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Primary care

The General Medical Services (GMS) contract was introduced in 2004 and is the contract
between general practices and NHS England for delivering primary care services to local
communities. Around the same time the government introduced the Quality and Outcomes
Framework (QOF) which rewards GPs for the provision of quality care and helps to
standardise improvements in the delivery of primary medical services throughout England.
Participation in QOF is voluntary. The framework includes quality markers, and associated
financial incentives, for the management of conditions, including epilepsy. For epilepsy, GPs
can accumulate points for which they receive payment by demonstrating that they maintain
a register of adults receiving drug treatment for epilepsy (read code EP001).

Until 2014, practices also received funding for recording those aged 18 and over who were
seizure free (EP002) and the number of women of childbearing age who had received
information and counselling about reproductive issues (EP003) in the previous 15 months14.
Intuitively it would seem that improved-record keeping would translate into improved quality
of care, and thence into improved quality of life for people with epilepsy; there are no
randomised controlled trials available to support or refute this notion. The way in which the
review was performed is likely to have impacted on the effectiveness of the process. If the
activity was seen merely as a ‘tick-box’ exercise, then little would change for the better for
people with epilepsy. If, however, GPs undertook proper reviews and reacted to the problems
they encountered, this may have improved the lives of people with epilepsy.

Revised indicators for QOF 2014/15 became effective on 1 April 2014. Practices are required
to establish and maintain an epilepsy register, but quality indicators EP002 and EP003 have
been retired15.

GPs often perceive their knowledge of epilepsy as inadequate and barriers to implementation
of effective epilepsy review in primary care include: lack of incentivisation; the small
numbers of people with epilepsy attending GPs leads to a perception of deficient knowledge
and expertise; and poor access to secondary services. The Department of Health Action Plan
suggested a specific framework to help develop more GPs and nurses with a special interest
in neurology16. There have been GPs with a special interest in epilepsy for some time in parts
of the UK17, and there are around 40 to date. There is, however, no accredited qualification
for GPs with a special interest in epilepsy.

New diagnosis
The diagnosis of epilepsy is largely based on the history of seizures3, and the GP may well
be the best person to take a detailed history from the patient and any eye-witnesses before
salient features are forgotten. A GP with an average sized list can expect to see one or two
people with new-onset epilepsy each year18. Because of the potential problems of diagnosis,
it is recommended that a consultant neurologist, or other specialist with an interest in
epilepsy, should see people with a possible diagnosis of epilepsy promptly. The 2005 SIGN
and 2012 NICE guidelines both suggest that the diagnosis should be made by an epilepsy
specialist, and that patients should be seen within two weeks3,19. The SIGN guidelines also
suggest that the ‘shared care management system’ should ‘provide appropriate information’
once a provisional diagnosis has been made, and the individual referred to a specialist centre3.
The individual should be fully informed of the specialist’s findings, as should the GP18.

The Epilepsy Needs Revisited document20 suggested that GPs should not usually initiate
treatment. This is reinforced by national guidance stating that the decision to start AEDs
should be made by the individual and the epilepsy specialist. The NICE guidelines suggest
that an epilepsy specialist should recommend the appropriate treatment, and also plan its
continuation in partnership with the individual. Once the diagnosis has been established, the