Royal College of General Practitioners - Online Learning Environment

Written by Dr Toni Hazell

Pneumonia is defined as an infection of the lung tissue, in which the alveoli become filled with micro-organisms, fluid and inflammatory cells, affecting the function of the lungs¹. Community acquired pneumonia (CAP) has a mortality rate of around 1% in those who are managed in primary care, rising to up to 14% for those admitted to hospital and to 30% for those who need intensive care¹. GPs need to risk stratify and make logical decisions as to who can be managed in the community, and who needs referral and consideration of admission.

An experienced GP will be used to assessing severity of acute infection. We make a clinical assessment, starting with an overall look at the patient (do they look unwell or otherwise make our antennae twitch?), assessment of vital signs such as pulse, respiratory rate, temperature and oxygen saturations, and consideration of co-morbidities such as immunosuppression. The NICE guidance on pneumonia², published in September 2025, recommends the more formal CRB65 tool, once we have made a clinical diagnosis of pneumonia.

Technology is available to measure C-reactive protein (CRP) as a point of care test in primary care, to help support or refute a diagnosis of inflammation, as occurs in an infection such as pneumonia. A 2016 NICE MedTech innovation briefing³ noted that primary care CRP testing can reduce antibiotic prescribing and referrals for chest x-ray, but that the sensitivity did not rise above 55% (and could be as low as 20% depending on the threshold used). Specificity was better, ranging from 73 – 99%. In the nine years since that briefing, the test has not become widely available, with barriers including cost, lack of commissioning enthusiasm and concern about the evidence base for effectiveness and value for money. A 2025 qualitative review⁴ comparing the UK with Sweden, the Netherlands and Canada, found that uptake of primary care CRP testing was higher in the other countries, but that clinicians didn’t feel that it had made a huge improvement to their assessment of patients with possible pneumonia, with some saying that the introduction was a policy failure, and the test over-used. Other studies have shown that CRP use is associated with increased antibiotic prescribing, rather than helping to reassure that antibiotics aren’t needed, and that this is particularly associated with systems where a CRP is checked before the patient is seen, resulting potentially in spurious high results in those with a low pre-test probability of bacterial infection⁵. NICE does not discuss primary care CRP in its latest guideline², but where it is being used the Primary Care Respiratory Society suggests cut-offs of 20 and 40 mg/L – do not prescribe antibiotics with CRP<20, consider prescribing with CRP of 20-40 if there is purulent sputum, and prescribe with CRP>40⁶.

The CRB65 scoring system is outlined in the box below and the results predict the risk of death in the next 30 days. Zero is low risk (<1%), 1 or 2 intermediate risk (1 – 10%) and 3 or 4 high risk (>10%).

CRB65 score – one point for each of the following:

• Confusion (new disorientation in person, place or time, or a score of ≤8 on an abbreviated mental test).
• Respiratory rate ≥30.
• Blood pressure ≤60 mmHg diastolic or 90 mmHg systolic.
• Age ≥65.

NICE write ‘guidelines not tramlines’⁷, and this guideline acknowledges the holistic nature of our assessment, advising the use of clinical judgment along with the CRB65 score, which can be affected by other factors such as comorbidities or pregnancy. NICE advises considering referral with a CRB65 score ≥2, and that those with a CRB65 score of 1 might benefit from an assessment in a same-day emergency care unit (which is in any case often where those referred to hospital will end up) or by being referred to a virtual ward or hospital at home service. Those with a score of zero can be managed in primary care, with appropriate safety-netting to return if symptoms deteriorate. Any signs of significant complications, such as heart failure, would lower the threshold for referral. We should have a lower threshold for children and young people (those aged under 18), considering referral or specialist advice for every patient.

For those not admitted, we would usually treat pneumonia with antibiotics in the community, to be started as soon as possible after the clinical diagnosis has been made². Whilst some causes are viral, the majority of pneumonia has a bacterial cause¹, and we cannot reliably differentiate between the two. The commonest bacterial cause is Streptococcus pneumoniae, with other responsible organisms including Haemophilus influenzae, Staphylococcus aureus and the atypical Mycoplasma pneumoniae. Those who are immunocompromised, or who have had multiple recent courses of antibiotics, may be more likely to have an unusual or drug-resistant bacteria (or a fungal infection such as Aspergillus) as a cause for their pneumonia^8,9; pneumonia in those with an unsafe swallow may be related to aspiration of stomach contents¹⁰.

NICE emphasises the need for only a five day course of antibiotics for adults and three days for children aged up to 11, with a longer duration only when clinically necessary. This may be because they have had a temperature in the last 48 hours of the five day course, or that they continue to have a sign of clinical instability, such as (in adults) systolic blood pressure <90 mmHg, heart rate >100 bpm, respiratory rate >24 breaths per minute or oxygen saturations <90% on air. These parameters, if present after five days of antibiotics, might make us re-visit the decision to keep the patient at home. The suggested first-line antibiotic for low-severity disease is amoxicillin, with doxycycline or clarithromycin as second-line, and erythromycin for pregnant women. For moderate severity disease the choice is largely the same, although clarithromycin moves to first line if an atypical bacterial cause is suspected. Those with high-severity disease are likely to be in hospital, but if treated in the community then a combination of co-amoxiclav and clarithromycin are first line, with erythromycin in pregnancy and levofloxacin as an alternative for those with penicillin allergy (bearing in mind the MHRA advice on quinolones¹¹).

Distinguishing between typical and atypical bacterial causes without a sputum sample is by no means an exact science; those with an atypical bacteria may have more prolonged or prominent constitutional symptoms (headache, malaise, sore throat, fever) and may be less likely to have clear consolidation on auscultation of the chest. Atypical infection can come in epidemics, with many cases clustered together and then none for several years and is more common with increasing age and in those who live in enclosed spaces such as boarding schools or military barracks. Outbreaks of one particular atypical bacteria, Legionella pneumophila are associated with contaminated water and air-conditioning systems and another, Legionalla longbeachae is associated with exposure to contaminated soil mixtures¹². Consideration of an atypical bacteria should be given when the patient doesn’t respond to an apparently appropriate first-line choice of antibiotic, and where there is a history of staying in a hotel or resort where exposure may be more likely.

Further reading and useful resources

• RCGP eLearning modules on Aspergillus and pneumonia.
• NICE guidance on pneumonia.
• StatPearls articles on aspiration pneumonia, atypical pneumonia and pneumonia in the immunocompromised patient.
• Patient information leaflet and NHS webpage on pneumonia.

References

1. NICE CKS. Chest infections – adult. Jan 2025.
2. NICE. NG250. Pneumonia: diagnosis and management. Sept 2025.
3. NICE. MIB81. Alere Afinion CRP for C-reactive protein testing in primary care. Sept 2016.
4. Glover RE, Pacho A, Mays N. C-reactive protein diagnostic test uptake in primary care: a qualitative study of the UK's 2019-2024 AMR National Action Plan and lessons learnt from Sweden, the Netherlands and British Columbia. BMJ Open. 2025 Aug 31;15(8):e095059.
5. Payne R, Mills S, Wilkinson C et al. Point-of-care C-reactive protein testing in general practice out-of-hours services: tool or trap? Br J Gen Pract. 2025 Aug 28;75(758):388-389.
6. Primary Care Respiratory Society. The place of point of care testing for C-reactive protein in the community care of respiratory tract infections. Summer 2022.
7. Reeve J. Avoiding harm: Tackling problematic polypharmacy through strengthening expert generalist practice. Br J Clin Pharmacol. 2021 Jan;87(1):76-83.
8. Aleem MS, Sexton R, Akella J. Pneumonia in an Immunocompromised Patient. [Updated 2023 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
9. Assefa M. Multi-drug resistant gram-negative bacterial pneumonia: etiology, risk factors, and drug resistance patterns. Pneumonia (Nathan). 2022 May 5;14(1):4.
10. Sanivarapu RR, Vaqar S, Gibson J. Aspiration Pneumonia. [Updated 2024 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
11. MHRA. Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate. Jan 2024.
12. Nguyen AD, Stamm DR, Stankewicz HA. Atypical Bacterial Pneumonia. [Updated 2025 Apr 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.

Written by Dr Emma Nash

The Chief Medical Officer’s low-risk drinking guidelines recommend that adults do not drink more than 14 units of alcohol a week, spread evenly over three or more days.¹

Although around 20% of the population report drinking no alcohol at all, a significant proportion of adults regularly drink over the recommended amount, ranging from 9% of Northern Irish women to 32% of English men.² The consequences of excessive alcohol consumption are significant, with 10,473 deaths from alcohol-specific causes in the UK in 2023³; many more are alcohol-related.

The public health approach ‘Making Every Contact Count’ (MECC)⁴ promotes the importance of making the most of opportunities to effect behaviour change. It encourages the use of routine interactions with people to offer brief advice and support them in making positive changes to their physical and mental health and wellbeing. Alcohol brief interventions are one such example.

In the context of alcohol, a brief intervention can be described as: “a short, evidence-based, structured conversation about alcohol consumption with a patient that seeks in a non-confrontational way to motivate and support the individual to think about and/or plan a change in their drinking behaviour in order to reduce their consumption and/or their risk of harm”.⁵

Brief interventions take 5-15 minutes to deliver and are ideally reinforced over further sessions. Multiple models exist, but ultimately the purpose is to focus the person’s attention on their lifestyle, highlight the reasons for change and potential strategies to do it, and empower the person to make the change. Whilst time constraints make a GP consultation challenging to deliver this, even a very brief intervention, with follow-up to discuss further, is useful.

Enquiring is the first stage – simple questions about alcohol consumption, or something more structured such as an AUDIT-C – can help identify where there is a problem, or at least bring it to mind. Behavioural change is a process rather than an event and even moving from the pre-contemplation to the contemplation stage of change is positive.

The brief intervention itself varies in form and needs specific training dependent on the model used. However, a common theme is motivational interviewing. Key elements of motivational interviewing include an emphasis on patient autonomy and patient-centred collaborative approach built on acceptance. One model of motivational interviewing by Miller and Rollnick⁶ describes four processes:

The extent to which motivational interviewing features in the brief intervention depends on the particular model chosen.⁷

One example of a brief intervention tool is the FRAMES model.^8,9

What you are able to suggest in the ‘Menu’ section depends on what is available locally in terms of support. However, behavioural strategies may include setting personal drinking limits and sticking to it; alternating alcoholic drinks with soft drinks; switching to low alcohol drinks; having regular alcohol-free days; identifying high risk situations for heavy drinking and creating a management plan; engaging in alternative activities to drinking.

Whilst these interventions can appear complex or arduous, they are only brief and are designed to be delivered in snippets, with reinforcement. The evidence base for the use of brief interventions is good, particularly in a primary care setting^10,11 and have the potential to have a significant impact on the future health of our patients.

Further reading

Alcohol Change UK.

National Institute on Alcohol Abuse and Alcoholism. Conduct a brief intervention: Build motivation and a plan for change.

NHS England. eLFH - Alcohol identification and brief advice.

ScotPHO. Alcohol: treatment for alcohol misuse.

References

1. English, Scottish, Welsh and Northern Irish Governments. UK Chief Medical Officers’ Low Risk Drinking Guidelines. 2016.
2. Alcohol Change UK. Alcohol statistics. Updated 2025.
3. Office for National Statistics. Alcohol-specific deaths in the UK: registered in 2023. 2025.
4. Public Health England, NHS England, Health Education England. Making Every Contact Count (MECC): Consensus statement. 2016.
5. Scottish Government. Local delivery plan: Alcohol brief interventions. National guidance 2019-2020. 2019.
6. Miller WR, Rollnick S. Motivational Interviewing, 3rd ed. Helping people change. New York (NY): Guilford Press; 2012.
7. World Health Organisation. Alcohol brief intervention training manual for primary care. WHO, 2017.
8. Bien T, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction, 1993. 88(3): p.315-336.
9. Drug and Alcohol Clinical Advisory Service. Fact sheet. FRAMES – Brief intervention for risky or harmful alcohol consumption.
10. World Health Organisation. Global status report on alcohol and health 2014. Luxembourg: WHO, 2014.
11. Platt L, Melendez-Torres GJ, O'Donnell A, et al How effective are brief interventions in reducing alcohol consumption: do the setting, practitioner group and content matter? Findings from a systematic review and metaregression analysis. BMJ Open 2016; 6: e011473.

Written by Dr Dirk Pilat

There is no question that general practice is an increasingly stressful profession, with ever growing demands placed on GPs while battling with diminishing financial and staffing resources. Days at work that just won’t end, never-ending workload and little control over our working lives can affect even the most resilient of practitioners. Throw in the constant battle with complaints and medicolegal issues and it’s no wonder that the prevalence of burnout, depression, low self-esteem and anxiety are significantly higher in the medical profession compared with the general population¹. The numbers are startling: An MDDUS survey from 2024 reported 71% of general practitioners suffering from compassion fatigue and 65% suffering from burnout². A PULSE survey from 2025 found that more than 54% of primary care doctors had to reduce sessions due to stress³. Unfortunately doctors aren’t great patients: we tend to downplay the severity of our symptoms and under-diagnose conditions in ourselves and often ignore the fact that we should seek help⁴.

For some time now, but particularly during and after the COVID-19 pandemic, attempts have been made to prevent burnout syndrome through individual and systemic approaches within the primary care workforce. Various psychological interventions were developed to empower professionals coping with increasing stress and burnout. Mindfulness-based interventions (MBI) are effective in reducing stress and promoting self-care and wellbeing: there is a growing body of research evidence that these can increase job satisfaction and even improve patient outcomes. Mindfulness has a well-established evidence base showing efficacy in improving the psychological wellbeing in both clinical and non-clinical populations. Various MBIs exist, though mindfulness-based stress reduction (MBSR) is the most extensively reviewed. Originally designed for patients with chronic medical and psychological conditions, it improves quality of life via focussed attention exercises, cognitive restructuring and adaptive learning techniques⁵. A 2020 systematic review of mindfulness – based stress reduction interventions on the psychological functioning of healthcare professionals showed that this particular method reduced anxiety, depression and stress and increased self-compassion⁶.

A 2021 systematic review on the impact of psychological Interventions with elements of mindfulness for physicians came to a similar conclusion: the vast majority of studies showed a positive impact on empathy, well-being, and reduction of burnout⁷. Similarly, a 2016 mixed method study showed that general practitioners who learned mindfulness based stress reduction (MBSR) techniques as a part of their regular CPD programme showed a significant decrease in depersonalisation and an increase in dedication and mindfulness skills compared with the control group⁸.

Interestingly, a decline in empathy and an increase in stress levels is not only experienced by established general practitioners but also by medical students and young doctors during their training. At the Charité – the medical faculty of the Freie Universität Berlin and Humboldt-Universität zu Berlin - medical students can choose to take part in a voluntary course on stress reduction. Delivered over one semester, students are being taught methods of mindfulness and meditation with quantitative results showing a reduction in perceived stress and an increase in self-efficacy, mindfulness, self-reflection and empathy⁹, confirming previous results of similar interventions, including previously obtained long-term results of this course format showing effects on stress biomarkers¹⁰.

For those struggling to find the time to engage in MBI, the ubiquitousness of wearable technological devices such as smart watches and mobile phones can – rather counter-intuitively – help to take part in short activities helping to achieve emotional control in the middle of a busy day. An example for this is the ‘Mindfulness app’ on the Apple Watch (similar apps exist on Android-based devices). A small 2024 mixed method study invited participants to engage for 5 minutes daily with the application, trying to achieve 6 breaths per minute during usage. After two weeks the data showed this to result in a significant increase in participants’ coping skills and slight reduction in symptoms of depression and anxiety¹¹.

In these stressful days it feels important to identify strategies to the improve quality of life for the primary care workforce. For some, mindfulness-based interventions might be just the ticket, even when it’s only for 5 minutes a day.

References:

1. Society of Occupational Medicine. What could make a difference to the mental health of UK doctors? A review of the research evidence. 2018.
   
2. MDDUS. Compassion fatigue in healthcare professionals 2024.
   
3. Colivicchi A. More than half of GPs reduced their sessions due to work-related stress. Pulse Today. 2025. 
   
4. Best, Ho. What’s it like to be a patient as a doctor. British Medical Journal 2024 Oct 11; q1486–6.
   
5. Kabat-Zinn, Jon. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Books, 2013
   
6. Kriakous SA, Elliott KA, Lamers C, et al. The Effectiveness of mindfulness-based Stress Reduction on the Psychological Functioning of Healthcare professionals: a Systematic Review. Mindfulness. 2021 Sep 24; 12 (1): 1–28.
   
7. Tement S, Ketiš ZK, Miroševič Š, et al. The Impact of Psychological Interventions with Elements of Mindfulness (PIM) on Empathy, Well-Being, and Reduction of Burnout in Physicians: A Systematic Review. International Journal of Environmental Research and Public Health. 2021 Oct 25; 18 (21): 11181.
   
8. Verweij H, Waumans RC, Smeijers D, et al. Mindfulness-based stress reduction for GPs: results of a controlled mixed methods pilot study in Dutch primary care. British Journal of General Practice. 2016 Jan 28; 66 (643): e99–105. 
   
9. Brinkhaus B, Stöckigt B, Witt CM, et al. Reducing stress, strengthening resilience and self-care in medical students through Mind-Body Medicine (MBM). 2025 Jan 1; 42 (1): Doc7–7.
   
10. MacLaughlin BW, Wang D, Noone AM, et al. Stress Biomarkers in Medical Students Participating in a Mind Body Medicine Skills Program. Evidence-Based Complementary and Alternative Medicine. 2011; 2011: 1–8.
    
11. Wright SL, Bach E, Bryson SP, et al. Using an App-Based Mindfulness Intervention: A Mixed Methods Approach. Cognitive and behavioral practice. 2024 Apr 1.
    

Written by Dr Dirk Pilat

Learning disability (LD) is the preferred UK term for individuals who have a ‘significantly reduced ability to understand new or complex information, to learn new skills’ and a ‘reduced ability to cope independently which starts before adulthood with lasting effects on development’¹. Mencap estimates that there are approximately 1.5 million people with a learning disability in the UK (2.16% of adults and 2.5% of children)², but is likely that the number of LD diagnoses recorded in health and welfare systems is significantly lower than the actual number of people living with LD³. This group represent a widely heterogenous group of patients with a broad spectrum of diagnoses and comorbidities, and will include some without a firm diagnosis to explain their LD.

The life expectancy of people with LD is reduced compared with the general population, with only 37% of adults with LD living beyond 65 years of age, compared with 85% of the general population. These patients are at disproportionately higher risk of preventable deaths; this is often due to the underlying cause of mortality not being detected early and/or a delay in appropriate referral, and sub-standard management of conditions once they have been diagnosed. A recent review of deaths of people with learning identified 42% of deaths in this group as avoidable⁴.

The second commonest cause of death in people with LD is respiratory (14.6%, compared with 16.7% who died of diseases of the circulatory system) with influenza and pneumonia  being the most common infective causes. This clearly highlights the immense benefits this population would get from pneumococcal and influenza vaccination.

Evidence suggests that vaccine coverage rates are lower in those with learning disability than in the general population; in children  complete coverage rates were significantly lower for children with intellectual disabilities at ages nine months and three years⁵ and there is data to show that in the past, only half of adults receive a flu vaccination.

Pneumococcal vaccination is now part of the childhood vaccination regime and available for people in clinical risk groups as an additional vaccine depending on their age when they were diagnosed with a co-morbidity entitling them to the vaccination (see table).

In the risk group ‘chronic neurological disease’ (the category which includes those with LD), the mortality rate of influenza per 100,000 population is 37 times higher compared to those in no risk group. With annual influenza vaccination available for all people with learning disability since 2014, every general practice surgery has the chance to protect some of the most vulnerable people in their community,  but this has not led to an appreciable increase in uptake.

To improve vaccine uptake amongst people with learning disabilities it is important to improve recording and coding (“coding is caring”!), as this will make this population more ‘visible’, facilitating invitation to annual learning disability health checks. Fear of medical interventions, including needles, may be a barrier to vaccination uptake in people with learning disabilities.

During the COVID-19 pandemic, NHS England developed a guide on how to increase uptake flu-vaccination for people with learning disabilities, and their key messages for GP-Surgeries were:

• GP surgeries should give a clear message that people with learning disabilities and their carers (family member and support workers) are entitled to a free flu vaccination.
• People on the learning disability register should have it recorded in their notes that they ‘need a flu vaccine’ – there is a specific Read / SNOMED code for this, or be called for vaccination using searches and reports on the clinical system.
• Practices can use this easy read flu invitation letter template for people with learning disabilities.
• Talk to people at their annual health check about why it is important that they have the flu vaccination.
• Put reasonable adjustments in place to help people with learning disabilities have their flu vaccination. This could be extra time, photo cards or an accompanying friend.
• The person seeing the patient may need to assess the patient’s capacity to decide to have the flu vaccine. If they do not have capacity for this decision, then this should not be a barrier to the flu vaccination being given; there would need to be a decision taken by the health professional that this is in their best interests.
• Consider the nasal spray flu vaccine as a reasonable adjustment. PHE guidance outlines the nasal spray can be used for people with a severe needle phobia. The nasal vaccine is not as effective as the injection, but some protection is better than none.
• Capitalise on attendance and offer the pneumococcal vaccine within the same appointment.⁷

In addition, people might benefit from scheduling their annual review during flu-vaccination season to try to immunise them opportunistically.  The guide ‘Flu vaccinations: supporting people with learning disabilities’ from the UKHSA has a collection of resources on how to improve vaccine coverage for the target population.

Utilising these suggestions will increase vaccine coverage and improve health outcomes for one of the most vulnerable groups we look after in primary care.

References:

1. Department of Health. Valuing People; A New Strategy for Learning Disability for the 21st Century. 2001. 
2. Mencap. How common is learning disability in the UK? 
3. NHS England and NHS Improvement. Improving identification of people with a learning disability: guidance for general practice. 2019. 
4. LeDeR Autism and learning disability partnership, King's College London. Learning from Lives and Deaths - People with a learning disability and autistic people (LeDeR) report for 2022. 2023.
5. Emerson E, Robertson J, Baines S, Hatton C. Vaccine Coverage among Children with and without Intellectual Disabilities in the UK: Cross Sectional Study. BMC Public Health. 2019 Jun 13; 19 (1).
6. UK Health Security Agency. Pneumococcal: the green book, chapter 25
7. Learning Disability & Autism Programme Team – NHS England & Improvement, South West. Communications toolkit: Increasing uptake of the flu vaccination for people with learning disabilities. 2020. 

Written by Dr Emma Nash

Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as harmful or life threatening. Whilst unique to the individual, generally the experience of trauma can cause lasting adverse effects, limiting the ability to function and achieve mental, physical, social, emotional or spiritual well-being.¹

Most of us are aware of post-traumatic stress disorder, resulting from an acute, significant traumatic event, but less aware of complex trauma. Complex trauma is exposure to a harmful or threatening experience over a longer period, where the individual cannot escape and is particularly linked to interpersonal relationships in childhood. The concept of complex trauma specifically relates to the effect the exposure has on the person rather than the event itself. Common themes include feelings of being unsafe, trapped, powerless, ashamed, humiliated, abandoned, invalidated, rejected or unsupported. It is the effects of these emotions and experiences that cause difficulties going forwards – trauma is not about what happened, it is about how the experience affects the individual’s future. 

"Trauma is not what happens to you, but what happens inside you as a result of what happens to you" (Bessel Van der Kolk²).

The effects of trauma are multi-faceted and affect the way people manage perceptions and respond to the present. These effects are greatest in childhood trauma:

• Neurological: changes to brain structure and altered neurodevelopment.
• Biological: alterations to cortisol levels and the immune response.
• Social: interpersonal development is affected, with issues around trust and security.
• Psychological: impact on mood, anxiety, expression and regulation of distress.

Whilst trauma can occur at any age, childhood trauma is particularly important because of the impact of poor attachment on brain development and the development of resilience. A child develops a sense of safety through reliability. Unreliable, inappropriate or absent responses to need leads to altered neurodevelopment and an increased stress response. The consequence is negative for executive function: working memory (attention), inhibitory control (filtering thoughts/information to resist temptation/distraction and pause before action), and cognitive flexibility (apply different rules in different settings, think outside the box, problem solve).

The effects of trauma can look like other conditions – most commonly ADHD and personality disorder, but also autistic spectrum disorders, mood or anxiety disorders, and addictions. 

Symptom overlap
Complex trauma	Distorted beliefs about self. Affective dysregulation. Hypervigilance/reactivity or emotional suppression. Difficulties in sustaining relationships. Suicidal ideation & behaviour. Substance abuse. Depressive/psychotic/somatic symptoms. Dissociation. Executive dysfunction.
Personality disorder	Problems in functioning aspects of self (e.g. self-worth). Interpersonal dysfunction: developing & maintaining relationships. Maladaptive cognition, emotional experience, emotional expression, behaviour. Disproportionate negative emotions. Social/emotional detachment. Dissociative symptoms in high affective arousal.
ADHD	Impulsivity. Executive dysfunction. Difficulties with behavioural self-control. Risky behaviours. Interpersonal challenges.

Trauma-informed practice is an approach to health and care interventions which is grounded in the understanding that trauma exposure can impact an individual’s neurological, biological, psychological and social development.¹ Our experiences define our sense of self and our predictions about how people will behave towards us. Someone who has experienced trauma may have an uncertain sense of self, or struggle with interpersonal relationships as a result of inconsistent responses, lack of their needs being met, or other adverse responses to their emotional needs. As mentioned, it’s not the exact nature of the trauma that is important – at least at first – but to understand that it has happened and to recognise that it its impact. Neural network formation, and synaptic pruning (where unused connections are removed) are maximal in the first five years of life. This neuroplasticity means that the effects of trauma are easiest to reverse at this age, but harder as time goes on. By adulthood, significant investment in psychological interventions to understand the impact of trauma, and strategies to address it, is needed.

Trauma informed practice aims to create safety for patients by understanding the effects of trauma and its close links to health and behaviour. It is not about treating trauma – that is not the role of general practice – but about considering it. Applying a trauma-informed ‘lens’ can help reframe some of what you see, for example, ‘emotionally unstable’ may represent a heightened alert state, and ‘attention seeking’ may actually be ‘attachment needing’. Instead of asking ‘what is wrong with you?’, we should ask ‘what happened to you?’. It is important that we ask without re-traumatising, so don’t ask about details, you only need to know that something happened which was distressing and affected the way the patient sees themselves and their relationships with others. Applying a trauma-informed lens to patient behaviour can improve interpretation of underlying needs and emotions.  The needs of an individual result in emotions, which manifest through behaviours. By applying a trauma-informed lens, the interpretation changes. 

Behaviour	à	Meaning
Not engaging		Fearful
Self-harm		Ashamed
Attention-seeking		Connection-needing
Relationship issues		Let down by trusted people
Impulsivity		Hyper-reactive
Emotionally volatile		Hypervigilant
Emptiness		‘Freeze’ response
Aggression		Self-defence
Dissociation		Coping strategies
Poor concentration		Overwhelmed
Substance misuse		Seeking feeling

Governmental guidance identifies six components to trauma-informed care^1,3; fundamentally it is a thought process and attitude change. Try to have professional curiosity about the patient’s past and use that understanding to reframe their behaviour. 

The key elements are:

• Safety: the clinician needs to create emotional and physical safety, enable people to ask for what they need, avoid re-traumatisation (e.g. invalidation) and consider the impact of their own actions.
• Trust: explain what you are doing and why, be reliable, set expectations and be transparent, make the person feel they are being listened to.
• Choice: share decision making and offer choice when available, recognise that they may feel a lack of control, and validate their concerns.
• Collaboration: utilise peer support, ask what they need, direct to appropriate support, and empower them where possible.
• Empowerment: validate their fears, concerns and opinions, listen to their wants and needs, support them to take action themselves, and recognise low self-worth. 
• Cultural consideration: have self-awareness of cultural issues, bring cultural awareness and enquiries, and recognise the healing value of cultural connections.

There are multiple models for trauma recovery. Our role is in promoting safety and stability. This helps patients develop skills for managing distress and emotions, gives them control of their body and environment, encourages self-care and helps develop coping strategies. 

Although there are no national guidelines published on best practice in managing complex trauma, trauma-focused cognitive behavioural therapy and trauma-focused eye movement desensitisation and reprocessing (EMDR) are most commonly used. Grounding techniques are a useful strategy to help manage distress. Treating comorbid mental health conditions and substance misuse in line with best practice also needs to take place – complex trauma should not be a barrier to accessing other help.

Key messages for general practice:

• Consider trauma.
• Recognise behaviours as an adaptive response to experience.
• Understand that relationships are key in recovery.
• It can be challenging.

References

1. Office for Health Improvement and Disparities. Working definition of trauma informed practice. 2022. 
2. Van der Kolk, B. The Body Keeps the Score. 2015. Penguin, USA. 
3. NHS Education for Scotland. Transforming Psychological Trauma: A Knowledge and Skills Framework for the Scottish Workforce. 2017.
4. Herman, J.L. Trauma and Recovery. New York: Basic Books. 1992

Resources

• Mind. Complex PTSD.
• Penna, S. How to support children that have experienced household psychological or emotional abuse. Mental Health Today. 2019.
• PTSD UK. Complex PTSD.
• PTSD UK. Grounding techniques for PTSD and C-PTSD.
• Trauma Recovery UK
• UK Trauma Council
• University of Sydney. Grounding techniques self-help resource.

Written by Dr Toni Hazell

Shared care is defined by NHS England (NHSE) as ‘a particular form of the transfer of clinical responsibility from a hospital or specialist service to general practice in which prescribing by the GP, or other primary care prescriber, is supported by a shared care agreement’¹. Shared care drugs tend to be those which we would not start in primary care, but where ongoing prescription by the GP is felt to be safe. This makes life easier for the patient, who can get all of their medications in the same place but moves the medicolegal prescribing responsibility from the specialist to the GP. In order for this to be safe, there has to be a shared care agreement in place, with good communication between the specialist and the GP (in both directions). 

Most of the key references in this blog are from NHSE and therefore pertain only to England – shared care issues in the devolved nations of the UK are generally agreed by individual health boards (Scotland/Wales) or health and social care trusts (NI) and so equivalent information should be sought from them.

The NHSE list of shared care drugs² includes disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate and leflunomide, lithium, medications to treat ADHD in adults, sodium valproate for patients of child-bearing potential and ciclosporin for patients using it for a non-transplant indication. The NHSE list is not exhaustive and some ICBs have shared care protocols for medications which aren’t on the NHSE list, including testosterone as part of HRT³, denosumab for the prevention of osteoporotic fractures⁴, and cinacalcet for primary hyperparathyroidism⁵. The GP responsibilities will vary by drug; examples include 3-6 monthly height, weight, blood pressure and pulse for children on ADHD medication and monitoring bloods, usually every three months, for DMARDs. Some of these bloods can pick up potentially serious complications including hepatotoxicity, so it’s important that there is a clear and rapid line of communication for expert advice in the event of an abnormal test result.

Shared care can only start when the following criteria are met¹:

• The patient’s clinical condition is stable.
• The GP has freely agreed to take part in shared care; if the GP feels that it isn’t safe or adequately resourced, prescribing stays with the specialist on a long-term basis.
• There is an agreed, written, shared care agreement, which states how often the patient will be reviewed and gives a ‘route of return’ if their condition changes, allowing specialist review without the need for a new referral.
• The specialist has provided enough medication to cover the transition period.

It follows from the above, that all specialist clinics who manage patients on shared care medications need to be able to prescribe long-term, as there has to be an alternative for those whose GP doesn’t feel that the proposed shared care is safe or adequately resourced. NHSE¹ are clear that the specialist, patient/carers and GP all have to give ‘willing and informed consent’ before shared care can take place, which implies that a referral form cannot state that an agreement to shared care is a pre-requisite of the referral being accepted, because consent given at that point cannot be fully informed. The idea of informed consent would also suggest that shared care agreements should not contain words to the effect that if no response is received from the GP within a certain time period, the acceptance of shared care will be assumed. Good communication is a GMC obligation⁶ which applies to both the specialist and GP, so it would be reasonable to assume that a request for shared care would meet with a prompt reply from the GP, whether this was an acceptance of the shared care, a rejection, or a request for more information.

NHSE guidance on shared care does not explicitly state that the patient can never be discharged from their specialist team. However, the specialist obligations towards a patient for whom the GP is sharing care are harder to meet if the patient is discharged. These include the availability of care and advice without needing a new referral¹ (often impossible in the NHS outside of a defined period of patient-initiated follow-up⁷), and NICE⁸ or other guideline requirements which mandate regular specialist review for some shared care medications. Multiple ICB shared care protocols^9,10 state that the patient should usually stay under the care of both specialist and GP and individual practice should always keep patient safety at the forefront of their minds when deciding whether to share care with a specialist team who propose to discharge the patient.

References

1.    NHSE. Responsibility for prescribing between Primary & Secondary/Tertiary Care. March 2018. 
2.    NHSE. Shared care protocols. January 2022. 
3.    Bath and North East Somerset Swindon and Wiltshire Together. Shared care agreement. Off-label topical testosterone in adult women on HRT. Dec 2023.
4.    Derbyshire joint area prescribing committee. Shared care agreement - denosumab 60mg for the prevention of osteoporotic fractures in men and post-menopausal women aged 18 and over. June 2022.
5.    Hampshire and Isle of Wight ICB. Cinacalcet for patients within Adult Services (Primary hyperparathyroidism and other indications). Share Care Guidelines. Oct 2024.
6.    GMC. Good Medical Practice. January 2024.
7.    NHSE. Implementing patient initiated follow-up: guidance for local health and care systems. May 2022. 
8.    NICE. NG87. Attention deficit hyperactivity disorder: diagnosis and management. Sept 2019.
9.    Hertfordshire and West Essex ICB. A frequently asked questions document: Shared care for medicines and NHS shared care and specialist guided prescribing service specification. Oct 2024.
10.  Nottinghamshire APC. Frequently asked Questions about Shared Care for Patients and Carers. March 2022.

Written by Dr Toni Hazell

Stopping smoking is one of the most significant things that a person can do to improve their health. It is the second most cost-effective measure in COPD management (behind flu vaccination and ahead of all pharmaceuticals)¹ and is associated with later mortality, whatever the age of quitting. It is however not an easy thing to do, with multiple studies showing that most people will relapse after their first quit event^3,4,5 – encouragement to try again is therefore vital.

Smoking cessation is more likely to be successful with a combination of support and pharmacotherapy than when tried alone, or with just one of these modalities⁶. Our role as GPs is not usually to provide this support, but to signpost patients to stop smoking clinics and potentially to prescribe on the clinic’s behalf (depending on local commissioning arrangements). To do this effectively and safely, it helps to understand the principles of very brief advice (VBA), the basic biochemistry of smoking addiction and the pharmacology of the drugs currently available.

VBA is a NICE approved⁷ 30-second intervention which can be delivered in a normal GP appointment; there is evidence that it is acceptable to patients and can contribute to successful smoking cessation^8,9. VBA consists of three ‘As’ – ask, advise, act. Ask the patient if they smoke. Advise them how to stop smoking (by explaining that they are much more likely to succeed with support and pharmacotherapy than on their own) and advise them as to how they can access this support. This might be via referral, or by giving the patient details for the local self-referral scheme.

After attendance at a smoking cessation clinic, you may be asked to prescribe nicotine replacement therapy (NRT), or one of the three currently available drugs – varenicline, cytisinicline and bupropion⁷. These all act in different ways on the addiction mechanisms which keep people smoking. When a smoker inhales nicotine there is a rapid increase in dopamine¹⁰, causing an immediate sensation of pleasure; as nicotine and dopamine levels fall, the desire for the next cigarette increases. With long-term smoking, nicotine receptors are upregulated in both number and sensitivity¹¹, causing dependence; down-regulation after quitting takes 6-12 weeks¹². The table below gives brief information about what we can prescribe; more detail is available in our eLearning module, Essentials of Smoking Cessation, which also discusses e-cigarettes.

Smoking cessation drug	Mechanism of action	Use in pregnancy, breastfeeding and under 18s	Other information (non-exhaustive list; consult BNF before prescribing)
NRT	Stimulates nicotine receptors to release dopamine, reducing withdrawal symptoms13.	Yes (from age 12).	Nine forms available. NICE advice: Risks much lower than smoking. Combine short and long-acting forms. Can be used to prevent relapse after stopping.
Bupropion	Increases dopamine levels by reducing dopamine reuptake, reducing withdrawal symptoms14.	No	Contraindicated with CNS tumour, current/previous eating disorder, history of seizures or predisposing factors for seizures (see RCGP eLearning module on Essentials of Smoking Cessation for more on what these are)15.
Varenicline	Stimulates nicotine receptors to release dopamine and blocks the rapid dopamine increase from nicotine16,18,19.	No	Recently available in UK after many years without a licensed option. Weight gain possible. Previous concerns about mental health adverse effects have now been disproven17.
Cytisinicline	Stimulates nicotine receptors to release dopamine and blocks the rapid dopamine increase from nicotine16,18,19.	No	UK availability as of March 2025: Varies by ICB in England. Available in Wales20. Not yet assessed by Scottish Medicines Consortium21 and not available in Northern Ireland22.

References

1. Murphy PB, Brueggenjuergen B, Reinhold T, et al. Cost-effectiveness of home non-invasive ventilation in patients with persistent hypercapnia after an acute exacerbation of COPD in the UK. Thorax 2023; 78: 523-525.
2. Cho ER, Brill IK, Gram IT, et al. Smoking Cessation and Short- and Longer-Term Mortality. NEJM Evid. 2024 Mar; 3 (3): EVIDoa2300272.
3. Gorniak B, Yong HH, Borland R et al. Do post-quitting experiences predict smoking relapse among former smokers in Australia and the United Kingdom? Findings from the International Tobacco Control Surveys. Drug Alcohol Rev. 2022 May; 41(4): 883-889.
4. Lee SE, Kim CW, Im HB, et al. Patterns and predictors of smoking relapse among inpatient smoking intervention participants: a 1-year follow-up study in Korea. Epidemiol Health. 2021; 43: e2021043.
5. Feuer Z, Michael J, Morton E, et al. Systematic review of smoking relapse rates among cancer survivors who quit at the time of cancer diagnosis. Cancer Epidemiol. 2022 Oct; 80: 102237.
6. Stead LF, Koilpillai P, Fanshawe TR et al. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016 Mar 24; 3(3): CD008286.
7. NICE. NG209. Tobacco: preventing uptake, promoting quitting and treating dependence. Feb 2025. 
8. Cheng CCW, He WJA, Gouda H, et al. Effectiveness of Very Brief Advice on Tobacco Cessation: A Systematic Review and Meta-Analysis. J Gen Intern Med. 2024 Jul; 39(9): 1721-1734.
9. Papadakis S, Anastasaki M, Papadakaki M, et al. 'Very brief advice' (VBA) on smoking in family practice: a qualitative evaluation of the tobacco user's perspective. BMC Fam Pract. 2020 Jun 24; 21(1): 121.
10. Benowitz NL. Pharmacology of nicotine: addiction, smoking-induced disease, and therapeutics. Annu Rev Pharmacol Toxicol. 2009; 49: 57-71.
11. Govind AP, Vezina P, Green WN. Nicotine-induced upregulation of nicotinic receptors: underlying mechanisms and relevance to nicotine addiction. Biochem Pharmacol. 2009 Oct 1; 78(7): 756-65.
12. Cosgrove KP, Batis J, Bois F, et al. beta2-Nicotinic acetylcholine receptor availability during acute and prolonged abstinence from tobacco smoking. Arch Gen Psychiatry. 2009 Jun; 66(6): 666-76.
13. Molyneux A. Nicotine replacement therapy. BMJ. 2004 Feb 21; 328(7437): 454-6.
14. Warner C, Shoaib M. How does bupropion work as a smoking cessation aid? Addict Biol. 2005 Sep; 10(3): 219-31.
15. Bupropion SPC. July 2024. 
16. Singh D, Saadabadi A. Varenicline. [Updated 2024 Oct 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
17. Royal College of Psychiatrists. The prescribing of varenicline and vaping (electronic cigarettes) to patients with severe mental illness. Dec 2018. 
18. National centre for smoking cessation and training. Cytisine. 2024. 
19. Nides M, Rigotti NA, Benowitz N, et al. A Multicenter, Double-Blind, Randomized, Placebo-Controlled Phase 2b Trial of Cytisinicline in Adult Smokers (The ORCA-1 Trial). Nicotine Tob Res. 2021 Aug 29; 23(10): 1656-1663.
20. NHS Wales. Cytisinicline. July 2024. 
21. Scottish Medicines Consortium. Medicines Advice. 
22. Stop Smoking NI. 
23. National Centre for Smoking Cessation and Training (NCSCT). 30 Seconds to change a life. 

Written by Dr Dirk Pilat

It is part of our lives to be exposed to stressful events, none of us will be spared these. It is nevertheless human nature to adapt and adjust to these stressors and slowly recover. In general practice we regularly see people who seek solace, support or need help after distressing events in their life. These can be traumatic events, such as exposure to actual or threatened death, as well as nontraumatic events such as interpersonal conflict, unemployment, financial difficulties, or personal ill health. The majority of people suffering from these events don’t come to see us at all (the so called ‘symptom iceberg’), and those who see us often improve with empathetic and non-judgmental support, or benefit from appropriate signposting. Nevertheless, sometimes the stressful event can trigger a temporary episode that is more than just the normal reaction to distress. In this case it might be appropriate to consider the diagnosis of adjustment disorder. 

The term ‘adjustment disorder’ has been around since 1980, and is usually associated with the following presentation, as suggested by DSM 5 – TR:

Emotional or behavioural symptoms within three months of a stressful event:

• exceeding what is acceptable within a cultural or societal context or

• associated with significant impairment within the social or occupational environment and

• does not meet the criteria for another significant mental health disorder and 

• once the stressor is over, the symptoms do not persist.

Its prevalence is variable from country to country (particularly prevalent in those with current or recent conflict), and some papers suggest it is the seventh most common diagnostic category used by psychiatrists worldwide with a lifetime prevalence of up to 21%. 

A meta-analysis from 2022 that aimed to determine those most at risk showed that female gender, unemployed status, low income, low social support, and a history of mental health disorders predicted adjustment disorders compared with no mental health condition. Those with adjustment disorder had 12 times the rate of suicide compared to those without this diagnosis.

Due to its presentation, adjustment disorder has a range of more severe differential diagnoses: for instance the diagnosis of PTSD and acute stress disorder require the stressful trigger to be of a magnitude that would be traumatic for almost everyone and also have a different group of symptoms. If the initial symptoms are worsening after a period of watchful waiting, the patient might be developing a severe mental disorder such as depression or general anxiety, particularly if the stressor vanishes.

The diagnosis is often criticised as the medicalisation of problems of modern life, as it may pathologise a normal stress response. We nevertheless know in primary care that different individuals will develop different responses to the same stressors (as the COVID-19 pandemic so powerfully demonstrated): some people will have no issues, some people will develop minor symptoms and handle them easily, while some people will develop an adjustment disorder. The decision whether the symptoms of our patient represents an adaptive or abnormal response is therefore a clinical one: some authors suggest assessing whether there is functional impairment present, whether the trajectory of the patient’s symptoms shows adaptation and whether the trajectory demonstrates the patient's resilience.

If the decision is made that support from primary care will not suffice, the next treatment of choice for people with adjustment disorders is psychological therapy, so signposting to your local talking therapies team (or a referral, if necessary) would be an appropriate next step. If significant distress and/or insomnia is present, short term pharmacological management with benzodiazepines might be appropriate in extreme cases. As the condition by definition is self-resolving, the use of medication is controversial, and has the potential to cause harm through side effects or dependence. Some papers suggest the use of a sedative anti-depressant such as trazodone may be helpful but there are no universal recommendations. There are randomised, placebo controlled trials that have shown the benefits of herbal remedies such as valerian or kava-kava (though there have been reports about hepatotoxicity). When recommending herbal supplements, always suggest that the patient checks the product for the THR Certification Mark: this indicates that the herbal medicine has been registered with the Medicines and Healthcare products Regulatory Agency and meets the required standards relating to its quality, safety, evidence of traditional use.

Placed in the middle of the community and with intricate knowledge of our patients, primary care is well placed to support patients with adjustment disorders, as we are able to assess the severity of their symptoms over time and are aware of their social circumstances, coping skills, beliefs and attitudes. This will help us determine whether the period of distress is settling or whether is causing a more severe mental health problem.

References

1. Bachem R, Casey P. Adjustment disorder: A diagnosis whose time has come. Journal of Affective Disorders. 2018 Feb; 227: 243–53.
2. Casey P, Bailey S. Adjustment disorders: the state of the art. World Psychiatry [Internet]. 2011 Feb; 10(1): 11–8.
3. Geer K. Adjustment Disorder. Primary Care: Clinics in Office Practice. 2023 Mar;50(1):83–8.
4. Gradus J. Prevalence and prognosis of stress disorders: a review of the epidemiologic literature. Clinical Epidemiology [Internet]. 2017 May; Volume 9: 251–60.
5. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Kava Kava. [Updated 2018 Apr 10].
6. McAteer A, Elliott AM, Hannaford PC. Ascertaining the size of the symptom iceberg in a UK-wide community-based survey. British Journal of General Practice. 2011 Jan 1; 61(582): e1–11.
7. Medicines and Healthcare products Regulatory Agency: The Traditional Herbal Registration (THR) Certification Mark: Guidance for Business.
   

Written by Dr Toni Hazell

An ectopic pregnancy is one in which the fertilised egg implants outside of the uterus; around 95% are in a fallopian tube, but an ectopic can also occur on the ovary, elsewhere in the pelvis, and sometimes in the cervix or in a caesarean section scar.  Around 1% of all pregnancies are ectopic, with this figure at least doubling for pregnancies arising from in-vitro fertilisation (IVF)^1,2. Non-tubal ectopic pregnancies are associated with higher morbidity and mortality than tubal ectopics, often presenting late with a sudden onset of symptoms prior to rupture, collapse and death.

Bleeding from an ectopic pregnancy can be fatal and the numbers of deaths in the UK and Ireland increased between the 2018-20 and 2020-22 reporting periods (8 deaths in 2018-20 and 12 in 2022-22)^3,4, with the 2024 MBRRACE-UK report noting that there were learning points for both primary and secondary care and that improvements to care may have made a difference for nine out of the 12 women who died. None were judged to have received good care, with three cases where improvements would probably not have affected the outcome. Many of these were around the presentation of women who did not know that they were pregnant; the rest of this blog will focus on the lessons for general practice. Those wanting more information on lessons for secondary care or the ambulance service can find them in the 2024 MBRRACE-UK report⁴.

Always consider the possibility of pregnancy

Unless there is a clear history of a total hysterectomy and bilateral oophorectomy, always consider pregnancy in a woman of reproductive age. Women who have irregular periods, or who have bled at the time of implantation, may not realise that they have missed a period; those who are pregnant as a result of failed contraception might not consider it as a possibility. Pregnancies due to a failure of sterilisation or intrauterine contraception in particular are at higher risk for being ectopic.

Symptoms may be atypical

When presented with a woman who has pelvic pain and/or vaginal bleeding, with a delayed period, most of us would consider an ectopic pregnancy. This may not be the case if the presentation is more subtle. Symptoms can include breast tenderness, diarrhoea or vomiting, dizziness, shoulder tip pain and rectal pressure, and some women will collapse with no previous symptoms and no knowledge that they are pregnant^1,4. NICE gives the following advice: “During clinical assessment of women of reproductive age, be aware that they may be pregnant, and think about offering a pregnancy test even when symptoms are non-specific”⁵. If a home pregnancy test was done, consider whether it may have been done too early, such that a false negative result was obtained.

Do you know where pregnancy tests are kept at work?

General practice is not resourced to offer routine testing for confirmation of pregnancy, and this has in some cases led to tests being unavailable or locked away. It is important that all practices hold some easily accessible pregnancy tests so that they can be used when there is a clinical reason to do so. Women may not have done a test at home because they didn’t think pregnancy was a possibility, or because of issues with access or affordability; adolescents in particular are less likely to confirm pregnancy promptly with a test⁶.

There are issues with access to early pregnancy assessment units (EPAUs)

The MBRRACE-UK report⁴ described calls not returned, issues with language barriers, and waits of over 24 hours for an appointment. Clearly any woman who is haemodynamically unstable at presentation should be referred via the emergency department, rather than via EPAU, but a woman who is stable when seen by her GP, may not remain so over the course of a long wait for an EPAU appointment. Commissioning GPs reading this blog might want to reflect on EPAU access in their area; are women reliably seen within 24 hours, seven days a week, and does the service have access to enough people to answer the phone, and interpretation available in person and on the phone? As GPs, we should not be reticent in saying if we feel that a service for an individual patient isn’t good enough, and if an EPAU appointment isn’t offered in a reasonable timeframe then referral to the on-call gynaecology team may be appropriate. 

Health inequalities matter

Vulnerable women are over-represented among those who died from an ectopic in 2020-2022, with one-sixth having language difficulties and nearly half having either a mental health diagnosis or issues with substance use or domestic abuse. These inequalities may prevent women’s concerns from being heard; practices should consider how the care of women who may find it more difficult to get their message across can be optimised, even in the difficult, time-pressured situation of the current NHS. The RCGP’s Health Inequalities Hub has more resources in this area.

How do you manage a pregnant woman with a past ectopic, or who is at a high risk for ectopic pregnancy?

Almost one in five women who has had an ectopic pregnancy will have another one¹; this is largely unaffected by the mode of treatment for the original ectopic. Aftercare of a woman who has had an ectopic should include the fact that she needs a scan at around 6-7 weeks of gestation in any subsequent pregnancies, to ensure that the pregnancy is intrauterine¹. Depending on local pathways, this may need to be arranged by the GP, or the woman may be given open access to EPAU to arrange this. An early scan should also be arranged if there is a history of damage to the fallopian tubes (including in pregnancy after failed or reversed sterilisation⁷), and in women who become pregnant with an intrauterine device in place; up to 50% of such pregnancies may be ectopic.

Further information  

The MBRRACE-UK report emphasises the need to Think Ectopic, which aligns with a national campaign led by The Ectopic Pregnancy Trust, endorsed by the RCGP. At the heart of the campaign is an ectopic pregnancy biocard which reminds healthcare professionals about the signs of ectopic pregnancy and time critical next steps.

Figure: Think Ectopic Bio Card. The Ectopic Pregnancy Trust. Reproduced with permission.

Request free copies of the card from The Ectopic Pregnancy Trust.

References

1. NICE CKS. Ectopic pregnancy. Feb 2023.
2. Anzhel S, Mäkinen S, Tinkanen H et al. Top-quality embryo transfer is associated with lower odds of ectopic pregnancy. Acta Obstet Gynecol Scand. 2022 Jul; 101(7): 779-786.
3. MBRRACE-UK. Saving Lives, Improving Mothers’ Care. Nov 2022.
4. MBRRACE-UK. Saving Lives, Improving Mothers’ Care. Oct 2024.
5. NICE. NG126. Ectopic pregnancy and miscarriage: diagnosis and initial management. Aug 2023.
6. Ralph LJ, Foster DG, Barar R, et al. Home pregnancy test use and timing of pregnancy confirmation among people seeking health care. Contraception. 2022 Mar; 107: 10-16.
7. University Hospitals Coventry and Warwickshire NHS Trust. Laparoscopic sterilisation. Dec 2022.
8. FSRH. Intrauterine contraception. July 2023.

Written by Dr Toni Hazell

Please note: this document was last updated on April 15 2024

1. There are treatments available for community management of COVID-19

For most of the pandemic, the primary care management of those with COVID-19 was supportive – if the patients weren’t unwell enough to be admitted then we managed them in the same way as patients with other viral respiratory tract infections. This changed in early 2022 with the arrival of new community treatments, which can be divided into two groups – antivirals and neutralising monoclonal antibodies (nMABs).

NICE¹ has approved two drugs for use in the community. The first is nirmatrelvir plus ritonavir (an antiviral, given orally) and it is approved for adults who do not need supplemental oxygen for COVID-19 and have an increased risk for progression to severe COVID-19. The second option is sotrovimab (an nMAB, given intravenously), which is approved for adults and children who are at least 12 and weigh at least 40 kg, for whom nirmatrelvir plus ritonavir is contraindicated or unsuitable. They also have to have no need for supplemental oxygen and be in the group with an increased risk for progression to severe COVID-19.

2. Only the highest risk patients are eligible for these treatments

Patients who are a member of the ‘highest risk group’ should have all received a letter from NHSEI telling them about these new treatments. They were also initially sent a PCR test kit to keep at home so that they can test promptly if they have symptoms of COVID-19. Advice has now changed and they are advised to take a lateral flow test as soon as possible if they have any symptoms that could be COVID-19². If positive, this should be uploaded online.

The group of patients defined as being in the ‘highest risk group’ is given in the table below – it is not identical to the group who were asked to shield during the pandemic, nor is it the same as the group who are usually invited for flu vaccinations.

The following patient cohorts were determined by an independent advisory group commissioned by the Department of Health and Social Care (DHSC)¹.

Down's syndrome and other genetic disorders	All individuals with Down's syndrome or other chromosomal disorders known to affect immune competence.
Solid cancer	Metastatic or locally advanced inoperable cancer. Lung cancer (at any stage). People receiving any chemotherapy (including antibody-drug conjugates), PI3K inhibitors or radiotherapy within 12 months. People who have had cancer resected within three months and who received no adjuvant chemotherapy or radiotherapy. People who have had cancer resected within 3 to 12 months and receiving no adjuvant chemotherapy or radiotherapy are expected to be at less risk (and thus less priority) but still at increased risk compared with the non-cancer populations.
Haematological diseases and recipients of haematological stem cell transplant (HSCT)	Allogeneic HSCT recipients in the last 12 months or active graft versus host disease (GVHD) regardless of time from transplant (including HSCT for non-malignant diseases). Autologous HSCT recipients in the last 12 months (including HSCT for non-malignant diseases). Individuals with haematological malignancies who have received CAR-T cell therapy in the last 24 months, or until the lymphocyte count is within the normal range. Individuals with haematological malignancies receiving systemic anti-cancer treatment (SACT) within the last 12 months, or radiotherapy in the last 12 months. All people who do not fit the criteria above, and are diagnosed with: myeloma (excluding monoclonal gammopathy of undetermined significance [MGUS]) AL amyloidosis chronic B-cell lymphoproliferative disorders (chronic lymphocytic leukaemia, follicular lymphoma) myelodysplastic syndrome (MDS) chronic myelomonocytic leukaemia (CMML) myelofibrosis any mature T-cell malignancy. All people with sickle cell disease. People with thalassaemia or rare inherited anaemia with any of the following: severe cardiac iron overload (T2 * less than 10 ms) severe to moderate iron overload (T2 * greater than or equal to 10 ms) plus an additional comorbidity of concern (for example, diabetes, chronic liver disease or severe hepatic iron load on MRI). Individuals with non-malignant haematological disorders (for example, aplastic anaemia or paroxysmal nocturnal haemoglobinuria) receiving B-cell depleting systemic treatment (for example, anti-CD20, anti-thymocyte globulin [ATG] and alemtuzumab) within the last 12 months.
Renal disease	Renal transplant recipients (including those with failed transplants within the past 12 months), particularly those who have: received B-cell depleting therapy within the past 12 months (including alemtuzumab, rituximab [anti-CD20], ATG) an additional substantial risk factor that would in isolation make them eligible for monoclonals or oral antivirals. Non-transplant renal patients who have received a comparable level of immunosuppression. People with chronic kidney disease (CKD) stage four or five (an estimated glomerular filtration rate [eGFR] less than 30 ml per min per 1.73 m2) without immunosuppression.
Liver diseases	People with cirrhosis Child-Pugh (CP) class A, B and C, whether receiving immune suppressive therapy or not. Those with decompensated liver disease (CP B and C) are at greatest risk. People with a liver transplant. People with liver disease on immune suppressive therapy (including people with and without cirrhosis).
Solid organ transplant recipients	Solid organ transplant recipients not in any of the above categories. Immune-mediated inflammatory disorders (diseases in which autoimmune or autoinflammation-based pathways are implicated in disease, for example, inflammatory arthritis, connective tissue diseases, inflammatory skin diseases, inflammatory gastrointestinal disease). People who have received a B-cell depleting therapy (anti-CD20 drug, for example, rituximab, ocrelizumab, ofatumumab, obinutuzumab) in the last 12 months. People who have been treated with cyclophosphamide (IV or oral) in the six months prior to positive PCR or relevant COVID test. People who are on corticosteroids (equivalent to 10 mg or more per day of prednisolone) for at least the 28 days prior to positive PCR or relevant COVID test. People who are on biologics or small molecule JAK inhibitors. People who are on current treatment with mycophenolate mofetil, oral tacrolimus, azathioprine, mercaptopurine, or similar agents (for major organ involvement such as kidney, gastro-intestinal tract, liver, lung, brain), methotrexate (for interstitial lung disease or asthma only) and/or ciclosporin. No minimum dose threshold is suggested. People who are on current treatment (or within the last six months) with S1P modulators (fingolimod, ponesimod or siponimod), or alemtuzumab or cladribine within the last 12 months. People who exhibit at least one of: (a) uncontrolled or clinically active disease (that is, required recent increase in dose or initiation of new immunosuppressive drug or IM steroid injection or course of oral steroids within the three months prior to positive PCR or relevant COVID test); and/or (b) other high risk comorbidities (for example, body mass index [BMI] greater than 30, diabetes mellitus, hypertension, major organ involvement such as significant kidney, liver, nervous system or lung inflammation or significantly impaired renal, liver, nervous system and/or lung function).
Respiratory	Asthma in people on oral corticosteroids (defined above). Any asthma patient taking immunosuppressants for their asthma including but not exclusively methotrexate, ciclosporin. Frequent exacerbations requiring 4 or more courses of prednisolone per year, usually 40 mg per day for five days or more. COPD on long term home non-invasive ventilation (NIV). Patients on long term oxygen therapy. People with moderate or severe disease (FEV1 less than or equal to 50% predicted) who have required four or more courses of prednisolone 30 mg for five days or greater in last 12 months. Interstitial lung disease (ILD) – all patients with idiopathic pulmonary fibrosis. Sub-types of ILD, for example, connective tissue disease related, sarcoidosis, hypersensitivity pneumonitis, NSIP (non-specific interstitial pneumonia) who have received a B-cell depleting therapy in last 12 months, or IV or oral cyclophosphamide in the six months prior to testing positive for COVID-19. Any ILD patient on current treatment with corticosteroids, mycophenolate mofetil, azathioprine, tacrolimus, cyclosporin or methotrexate. No minimum dose criteria. Any people with any type of ILD who may not be on treatment due to intolerance but has severe disease with an FVC predicted less than 60%. NIV and tracheostomy ventilated – all patients requiring this type of support regardless of the underlying disorder (which might include COPD, obesity hypoventilation syndrome, scoliosis, bronchiectasis, neurodisability and genetic muscular diseases [refer to neurology section]). Lung cancer patients, refer to 'Solid cancer' section above. Lung transplant patients (refer to solid organ transplant section). Pulmonary hypertension (PH): groups one and four from PH classification.
Immune deficiencies	Common variable immunodeficiency (CVID). Undefined primary antibody deficiency on immunoglobulin (or eligible for Ig). Hyper-IgM syndromes. Good's syndrome (thymoma plus B-cell deficiency). Severe combined immunodeficiency (SCID). Autoimmune polyglandular syndromes or autoimmune polyendocrinopathy, candidiasis, ectodermal dystrophy (APECED syndrome). Primary immunodeficiency associated with impaired type 1 interferon signalling. X-linked agammaglobulinaemia (and other primary agammaglobulinaemias). Any person with secondary immunodeficiency receiving, or eligible for, immunoglobulin replacement therapy.
HIV/AIDS	People with high levels of immune suppression, have uncontrolled or untreated HIV (high viral load) or present acutely with an AIDS defining diagnosis. People on treatment for HIV with CD4 less than 350 cells per mm3 and stable on HIV treatment or CD4 greater than 350 cells per mm3 and additional risk factors (for example, age, diabetes, obesity, cardiovascular, liver or renal disease, homeless, alcoholic dependency).
Neurological disorders	Conditions associated with neuromuscular respiratory failure requiring chronic ventilatory support: motor neurone disease Duchenne muscular dystrophy. Conditions that require use of specific immunotherapies: multiple sclerosis (MS) myasthenia gravis (MG) other immune-mediated disorders. Dementia, neurodegenerative and neuroimmune disorders when associated with severe frailty (for example, levels seven or eight on Clinical Frailty Scale, as part of a personalised care plan): Alzheimer's disease, vascular disease, Lewy body disease, or frontotemporal atrophy Parkinson's disease Huntington's disease progressive supranuclear palsy and multiple system atrophy motor neurone disease multiple sclerosis and other immune-mediated neurological disorders.
Children and young people (CYP) at substantial risk	Complex life-limiting neurodisability with recurrent respiratory infections or compromise.
CYP at significant risk if 2 or more of these risk factors are present	Primary immunodeficiency: common variable immunodeficiency (CVID). primary antibody deficiency on immunoglobulin (or eligible for immunoglobulin replacement). hyper-IgM syndromes. Good's syndrome (thymoma plus B-cell deficiency) severe combined immunodeficiency (SCID). autoimmune polyglandular syndromes or autoimmune polyendocrinopathy, candidiasis, ectodermal dystrophy (APECED syndrome). primary immunodeficiency associated with impaired type 1 interferon signalling. X-linked agammaglobulinaemia (and other primary agammaglobulinaemias). Secondary immunodeficiency: HIV CD4 count less than 200 cells per mm3. solid organ transplant. haematological stem cell transplant (HSCT) within 12 months, or with graft versus host disease (GVHD). CAR-T cell therapy in last 24 months. induction chemotherapy for acute lymphoblastic leukaemia (ALL), non-Hodgkin's lymphoma, chemotherapy for acute myeloid leukaemia (AML), relapsed and/or refractory leukaemia or lymphoma. Immunosuppressive treatment: chemotherapy within the last three months. cyclophosphamide within the last three months. corticosteroids greater than 2 mg per kg per day for 28 days in last four weeks. B-cell depleting treatment in the last 12 months. Other conditions: high body mass index (BMI; greater than 95th centile). severe respiratory disease (for example, cystic fibrosis or bronchiectasis with FEV1 less than 60%). tracheostomy or long-term ventilation. severe asthma (paediatric intensive care unit [PICU] admission in 12 months). neurodisability and/or neurodevelopmental disorders. severe cardiac disease. severe chronic kidney disease. severe liver disease. sickle cell disease or other severe haemoglobinopathy. trisomy 21. complex or chromosomal genetic or metabolic conditions associated with significant comorbidity. multiple congenital anomalies associated with significant comorbidity. bronchopulmonary dysplasia – decisions should be made taking into account degree of prematurity at birth and chronological age.

Table 1: Patient cohorts considered at highest risk from COVID-19 and to be prioritised for treatment with nMABs. Nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19. National Institute for Health and Care Excellence (NICE) Technology Appraisal (TA), 878, March 2023, last updated: 13 March 2024.

3. Commissioning of these treatments in England has changed.

When these treatments were first offered they were centrally commissioned - a high-risk patient in England who uploaded a positive COVID-19 test would be contacted directly by a COVID-19 medicine delivery unit (CMDU). Commissioning is now done locally⁴ and patients need to make contact themselves. Depending on local arrangements, they may do this via the GP, via their hospital consultant, via 111 or by contacting the CMDU directly. As time passes, it may be that some areas choose to use a mechanism other than a CMDU to deliver care. It would be sensible to find out how care is offered in your area, before you need to signpost a patient to it. The provision of these medications is arranged differently in Scotland⁵, Wales⁶, and Northern Ireland⁷.

In April 2024, the BMA issued guidance in this area, in response to suggestions from some ICBs that COVID-19 therapeutics should routinely be given by GPs. The BMAs position is that provision of therapeutics for COVID-19 should not be done by primary care, unless this is part of an appropriately commissioned service⁹.

4. Some patients may not realise that they are at high risk.

COVID-19 and the shielding programme revealed some of the limitations of coding and it is likely that there will be patients in the highest risk group who are unaware of their risk, particularly if they have only recently acquired the condition which makes them high risk. If you speak to such a patient then you can let them know that they are at high risk and should have some COVID-19 tests at home, and how to access treatment in your area.

5. Referring to a CMDU should be easy

If you have a patient who you think needs to be seen at a CMDU then you can refer directly, via e-RS. Your local CMDU should be found within the infectious diseases menu. At the moment, none of these drugs can be prescribed by a GP or by any doctor outside of a CMDU and they are not stocked by community pharmacies. Some of them have significant drug interactions, so if referring from primary care it is important to provide a list of current medication.

6. The PANORAMIC trial⁸ is now closed

The Platform Adaptive trial of NOvel antiviRals for eArly treatMent of COVID-19 in the Community (PANORAMIC) was open to those with COVID-19 who did not fit the criteria for treatment from a CMDU but had a wider range of co-morbidities or were aged over 50. It offered usual care or usual care plus a COVID-19 therapeutic. The group eligible for this trial were more similar to the group who are routinely offered flu vaccination, than to the shielding group. The trial is now closed to recruitment but will continue to collect data until September 2024. It is hoped that the date from PANORAMIC will inform our understanding about longer-term COVID-19 symptoms, as well as the use of antivirals, as participants will be contacted for six months after their enrolment in the trial.

References

1. NICE Technology Appraisal. Nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19. March 2023, last updated March 2024.
2. Department of Health and Social Care and UK Health Security Agency. COVID-19: guidance for people whose immune system means they are at higher risk. Last updated May 2024.
3. Department of Health and Social Care. Independent report. Defining the highest risk clinical subgroups upon community infection with SARS-CoV-2 when considering the use of neutralising monoclonal antibodies (nMABs) and antiviral drugs. Last updated March 2023.
4. Powis S. Access to COVID treatments. NHS England, June 2023.
5. NHS Inform. Coronavirus (COVID-19): Treatments. May 2023.
6. Antiviral services across Wales – information for members of the public. July 2023.
7. Nidirect Government Services. Treatments for coronavirus (COVID-19).
8. PANORAMIC trial.
9. BMA. Guidance on Covid Therapeutics for GPs.