Last year, HEPI recommended letting students register at two GP surgeries – one for where they are during term and the other for the rest of the year.
Many people welcomed the idea but, Dr Dominique Thompson, Honorary Secretary of the Student Health Association, argues in this guest blog that there are better ways to support students’ mental health.
In a recent report for HEPI, The invisible Problem? Improving Students’ Mental Health, Poppy Brown makes several recommendations, the first of which is ‘dual registration’ in general practice: ‘Allowing students to be simultaneously registered with a general practitioner (GP) at home and at university.’
This may seem like a sensible solution, but my experience suggests it is not so simple when looked at closely.
First, we must ask what is the problem that simultaneous (or dual) registration is trying to solve? Students move between different geographical areas during the academic year. The HEPI paper argues, ‘If care is needed from a doctor during this [holiday] time, students must register as a temporary patient, which provides only limited access to care.’
But this would only be necessary for emergency care in holidays, such as for sudden onset abdominal pain. For this, the student can be seen as a temporary resident. All routine care, follow up, medication and new non-emergency problems can be dealt with, and managed by, the term-time GP. Once a student registers with a GP practice at university they can remain registered with them all year round until they leave.
Continuity of care is at risk if students attempt to move backwards and forwards between their home GP and their student health GP. This is because it would cause fragmentation of care, rather than better care. Continuity of care is crucial in managing patients well, and is one of the great strengths of NHS primary care and general practice. This is particularly important with the increasing numbers of students who have complex medical (physical and mental) health histories.
Students can be followed up by the university GP in the holidays by telephone, in person if they wish, and by secure email or even using technologies such as Skype, if the practice uses it.
Advances such as WebGP and AskMyGP, are online, 24/7 programmes that allow non-urgent queries to be sent from anywhere in the world and at all times of day for answer by the GP team, often within 48 hours.
The transfer of electronic medical records can in many cases be done instantaneously, but only if the GPs use the same system, which Is far from guaranteed. There is a risk of delayed transfer of paper notes if the student keeps registering in different places. Handover of care, and responsibility for follow up would also risk being blurred.
The lack of a universal GP electronic record system is another reason why simultaneously being registered in two places is not practical, as there is be no way for GPs to access each other’s records. Two practices cannot access records simultaneously.
This would risk repeated tests and referral, and, more worryingly, medication above prescribed levels. The ‘stockpiling’ of medication could potentially become easier for high risk students.
Moveover, university GPs are experts in young people’s care and so may be better placed to advise young people about their health in many cases. They also understand about exam pressures, timetable issues and letters to departments, as well as other higher education related queries.
Follow up from secondary (hospital) care could also be at risk of loss of continuity if the hospital team are unsure where to send letters from clinics or after discharge from hospital. It is vital that students have an identifiable GP practice for co-ordinated care, as well as a single continuous NHS record for patient safety. Loss of secondary care information, or its lack of availability to the GP seeing the patient, could have dangerous consequences. Over-investigation, both of those who have physical symptoms, but also those who have health-related anxiety and seek repeated reassurance, would be a risk.
Electronic prescribing allows us to prescribe and send the prescription online to any UK pharmacy, so the student can phone us in Bristol from, say, Scotland, request their medication and collect it that same afternoon from their local pharmacy.
It is very difficult for us as university GPs to follow up other GPs’ advice or requests for investigations and suggestions when we have not been party to the discussion, and this can set up many unrealistic expectations from a student of what may happen next with their care. The home GP may also not give full consideration to the potential financial impact such recommendations might have on the university GPs’ local health budget.
It is also important to mention other aspects of the financial impact. At present, GPs are paid per capita and each student brings in two-thirds of what the average registered patient brings to a practice’s income. In other words, at Bristol we have 18,000 students registered with the Students’ Health Service but are paid for only 11,000 (Carr Hill Formula weighting calculation). If the students were registered in two places at once, who would be paid and would we have to divide the funding? These issues are unclear, but could lead to destabilisation of university GP practices.
What other solutions exist for providing care to mobile students? It is not unreasonable, with the current technological advances available, to suggest that students should register on arrival at university with their specialist university GP practice for expert clinical care and stay registered whilst at university. Secondary care teams can then liaise with the university GP. The GPs should use telephone consultations, email if secure, and online programmes such as WebGP to ask about routine care.
Electronic prescribing allows for prescriptions to be issued all over the UK A student would then only need to register as a temporary resident at home on the rare occasions that emergency ‘hands on’ GP care was required the same day. These GP notes could then be forwarded to the university practice for scanning into the university GP notes system, to ensure a complete record.
In this way we would support our students with specialist clinical expertise, throughout their university careers, maintain continuity of care, and minimise risks associated with replicating clinical workload.
Dual registration could in fact work least well for those complex students who might need the most GP care.