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.
Good article. You point out the complexity of dividing up the funding for GP services between two practices. In fact there is a much bigger point here, as the vast majority of NHS services are commissioned through clinical commissioning groups (CCGs). These are groups of GP practices which commission other NHS services (acute, mental health, community, etc.) for the patients registered in their practices. If a patient needs hospital care (or mental health or community services, etc.) they can be treated by any provider anywhere in the country and the provider sends the bill to the patient’s CCG. Dual registration raises difficult issues about how to divide up the budget between CCGs and which CCG a provider should bill. E.g. if a student from Birmingham who is studying in London has to visit A&E while on holiday in Cornwall, who should the Cornish hospital send the bill to?
None of this explains what I’m supposed to do if I require ongoing secondary care. Say I’m put on new medication(s) by the consultant during the third term of the year, and need seeing once a month to check how it’s going and increase/decrease/discontinue/augment. Then the summer vacation starts. That’s 3½ months. The other two holidays are each 1½ months long, too. No GP would be (or should be) happy to oversee that process, let alone one seeing me as a temporary resident. And I can’t access secondary care at home unless I’m registered with a GP there. Am I just supposed to travel several hours back to my uni town once a month for a twenty minute medication review? Or change GP and secondary provider six times a year? That’s twelve times notes have got to change hands, for only a couple of months at a time, mostly. Every time, it takes absolutely ages.
The only sensible way to deal with this is somehow, in some way, sort out a shared care agreement. I don’t care how it’s done.
Now let’s consider this through the eyes of a student or carer or concerned parent. For, lets say, 30 weeks of the year the stduent gets GP, Community and possibly hospital support fo ran enduring mental illness which requires a range of ongoing medication and other therapeutic interventions. The student then moves back home for periods – say 4 weeks at Christmas, 4 weeks at Easter and then 14 weeks during the summer with 2 weeks of that abroad. The student needs ongoing community psychiatric support and some hospital support throughout the year as well as regular ongoing engagement with GP Services. How do we solve this from a patients or worried parent perspective? Neither are really that interested in the mechanics they just want assurance that care will be available and information will be shared. They also expect it to be seamless in delivery.
Steven, that’s exactly my situation (except my holidays are six weeks, six weeks and 16 weeks). I’m bipolar, and the only ongoing care I have in the holidays is a big pile of prescription meds from my uni GP, and a private therapist I’m lucky to be able to afford to see. No mental health team.
Well, without the two weeks abroad part. If only 😀
I agree with earlier comments. This doesn’t take into account the actual view and individual experience of each student. I have found being registered in one place and not the other extremely inconvenient and difficult. Especially during this pandemic where being at home changes and fluctuates according to government guidelines. My local GP do not take emergency patients at all and thus I have to call my university gp- which in my case is 4 hours away, so there’s not really the option of ‘popping over’ for an appointment. It also can be off-putting to even contacting them, because you know they can only offer so much help being so far away. So I’m stuck in a catch-22, where there are people who could help me just 10 minutes away but there’s not really a point in registering because I would be back at uni in a few weeks, but the only people who are ALLOWED to help me, cannot because I cannot actually go and see them. I think this is both deconstructive and a dangerous place to be(health wise). I think the actual lived experiences of student should be taken into account and steps taken to move systems forward to facilitate that, rather than leaving them as they are and saying students (who are all human beings) have to just suck it up and get used to them. A more secure way of data transfer should be developed if that is the case.
I desperately need to know: “How or Why” would a student who had been registered (all their life) with 1 GP in: “London” would be taken off with no explanation, only due to seeing another GP only temporary whilst at college in: “Bristol”.
Also why would one, on returning to the same address in: “London” have to or need to re-register a new registration with that very same GP???
Would that be the only way or is it because the GP’s are being awkward???
Please, please please reply asap, thanking you in advance.
I have ongoing mental health problems as well as fibromyalgia and I am having tests for my nerve pain to see if it is part of my fibromyalgia or there is another course. I am at uni for around 30 weeks a year. This leaves me with 22 weeks at home without access to proper care. I can become a temporary resident but they don’t offer full services. As my medical problems are complex, it would be better for my care to be through one person – my GP for several years at home. At uni I often get a different GP if I can get through at all. I often feel stuck in limbo. It would be so much better if I could stay registered at my home GP but be able to access care from my uni GP. The system now is designed for people who have no long term medical problems and only visit their GP for an acute needs such as a rash. For people like me who need continuous care you feel like you are being tossed around and not getting the best care from home or uni. I realise that the current system works for the majority of students as they are young so less likely to need lots of care but for anyone with underlying medical conditions it is a nightmare. It’s hard enough being at uni without having to spend hours on hold, months on waiting lists and explaining again and again my medical conditions. My home GP is excellent and some uni GPs have also been good but I have no continuity of care – contrary to what the system is aiming to do. It would be so much better to remain registered at home but also register with a specific university practice with both having access to my notes and updated when I get care from either. Surely a system like the current electronic prescription system for notes would be possible.