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Discussion Forum

 

Feel free to comment on anything that we have published recently or add to existing discussions. We won’t assume that you want us to consider comments posted here for publication in the Journal; please let us know if you want us to do so. Letters we are unable to print in the Journal may be posted here instead (see Writing for the BJGP for letter submission guidelines).

 

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Date: 30 Apr 2012
Topic: Situating general practice training in the general practice context         
Comments by: John Goldie, Newhills Medical Practice, Easterhouse Health Centre, Glasgow
Jill Morrison, University of Glasgow, Institute of Health and Wellbeing, Glasgow
           
We are delighted that our paper has sparked discussion,¹ as was its intent. To answer some of the points made by Tom Pelly:
 
As we mentioned, Friedson^2,3 showed that the culture and values of institutions where doctors work are more important determinants of their behaviour than their experiences at medical school. Much of what takes place during socialisation is at tacit level. It is a process where what is seen as unusual, non-routine, or incongruous to the outsider becomes as commonplace and taken-for-granted as for those within the group they seek to join. It works best when it unfolds in a subtle and incremental manner. It is the taken-for-granted routine day-to-day activities that have most impact.⁴ While reflective spaces such as the ST groups you describe can mitigate some of the effects of socialisation during hospital posts, it cannot entirely counteract its effects.
 
Training for general practice is built on a continuum of learning experiences from the formalised educational experiences of undergraduate medical education to the foundation years, with its focus on experiential learning and generic skill development, to speciality training and continuing professional development. Undergraduate medical education and foundation training occurs predominantly in hospital settings allowing for experiences following a patient through a primary to secondary to primary care journey, understanding what makes a good referral from the hospital point of view, and viewing the primary care interface from the secondary care perspective. We would not advocate changing this. It is when our trainees enter their specialty training we believe that change is required.
 
The RCGP Curriculum document’s learning outcomes are comprehensive and wide ranging. Following the argument that working in hospital posts ‘allows the building of more specialist knowledge in commonly encountered general practice problems’ to its conclusion would mean GP trainees would require to rotate through numerous subspecialties extending training to an extent that is not feasible or desirable. Knowledge and skills gained in such posts are mitigated by their need to be re-contextualised to the general practice setting. These become rapidly out of date if it not regularly updated in the context in which they were learned. Indeed, as you point out, many training schemes have reduced their hospital component to 18 months in recognition of the importance of early experience in general practice to help contextualise learning during hospital posts. Our experience is that these trainees have benefited from having spent more time in general practice than their predecessors. Having the 3, soon to become 4, years of specialty training for general practice situated in general practice – during which there could be selected attachments to relevant hospital specialties according to their educational needs as outlined by Paul Main – would enable trainees to contextualise and update their learning over an extended time period and socialise to the community of practice that is general practice. After specialty training, learning will take place predominantly in the general practice context, with involvement of secondary care colleagues according to the learner’s educational needs. Situating general practice training in general practice is the logical extension of developments in training programmes.
 
References
1. Goldie J, Morrison J. Situating general practice training in the general practice context. Br J Gen Pract 2012: DOI: 10.3399/bjgp12X636245.
2. Friedson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Harper & Row, 1970.
3. Friedson E. Professional powers: a study of Institutionalization of formal knowledge. Chicago, IL: University of Chicago Press, 1986.
4. van Maanen J, Barley SR. Occupational communities: culture and control in organizations. In: Staw BM, Cummings LL (eds.). Research in organizational behaviour: vol 6. Greenwich, CT: JAI Press,1984.

 

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Date: 29 Apr 2012
Topic: Chronic kidney disease    
Name: Peter Toon, QMUL School of Medicine, Centre for Health Sciences, Kent
           
In the April edition of the Journal there was an editorial and paper on CKD,^1,2 which discussed the reluctance of doctors to make this diagnosis and share it with patients. One factor that may lie behind this is the bizarre nomenclature of impaired renal function. 
 
‘Stage’ implies a point of a scale of progression, and most people will have come across the term in relation to cancer, most commonly staged at 4 levels. Although prognosis varies enormously between different tumours, stage 3 is usually bad news, and stage 4 extremely bad news. This shapes their understanding of what stage 3 means.
 
Based on an estimate of GFR, renal function however is divided into five ‘stages’.³ Unless  there is other evidence of disease, renal function reported as stage 1 is normal, and stage 2 only minor impairment. In most cases only once we reach stage 3 is any intervention indicated. Even this is not a disease as most people understand the term, something that impairs health or longevity. It is an asymptomatic condition that may if untreated progress to chronic renal failure, more akin to a risk factor such as hypertension. Some of those at this level have impaired but stable renal function. For others the rate of decline that, as Professor Jones points out, accurately predicts the date of renal failure, indicates that this will occur some years after death is likely from other causes.
 
I once heard Iona Heath comment that the depression screening questions for patients with diabetes felt like saying ‘you have one chronic disease, would you like another?’. Telling patients with hypertension, diabetes or heart disease that they have CKD stage 3 feels very similar. A better way of describing the condition might make it easier to discuss, and for patients to get the benefits of intervention without being exposed to the anxiety which the present nomenclature generates.
 
References
1. Abdi Z, Gallagher H, O’Donoghue D. Telling the truth: why disclosure matters in chronic kidney disease. Br J Gen Pract 2012; 62(597): 172–173.
2. McIntyre NJ, Fluck R, McINtyre C, Taal M. Treatment needs and diagnosis awareness in primary care patients with chronic kidney disease. Br J Gen Pract 2012: DOI: 10.3399/bjgp12X636047.
3. National Institute for Health and Clinical Excellence. Chronic kidney disease: early identification and management of chronic kidney disease in adults  in primary and secondary care. London: NICE, 2008.

 

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Date: 23 Apr 2012
Topic: Caution in comparing waterpipe tobacco smoking to 100 cigarettes
Comments by: Husain Khaki, Imperial College London, Faculty of Medicine, London

Mohammed Jawad, Imperial College London, Faculty of Medicine, London
Fiona L Hamilton, Imperial College London, Department of Primary Care and Public Health, London

 

We thank Dr Masters and his colleagues for highlighting their efforts towards a practical equivalence between cigarettes and waterpipe tobacco smoking using pack-years.¹ A website used to estimate smoking pack years in niche tobacco products is laudable, especially at a time where alternate forms of tobacco smoking are increasing in prevalence.

 

However, we assert that there exists a common misinterpretation among healthcare professionals, the media, and the lay public about the World Health Organization (WHO)’s advisory note in 2005,² which compared an 80-minute waterpipe session to 100 cigarettes. It is our contention that the WHO report confusingly twice mentions that it is only the amount of smoke produced from a waterpipe that is equivalent to 100 cigarettes (comparing the 0.5 L of smoke produced by a cigarette to the 50 L produced by a waterpipe), and not the chemical composition. We believe that comparing cigarettes and waterpipes chemical-by-chemical is a better indicator of the adverse health effects of waterpipe smoking (and hence a more pack-year worthy comparison) than simply the volume of smoke. This permits an analysis of the nicotine, tar and carbon monoxide content of a typical waterpipe session and we prudently reached a midway figure of ten cigarettes to one waterpipe session.³

 

We commend Dr Masters and colleagues for stimulating discussion into an important and growing issue. We hope that their innovative website will continue to simplify the important task of pack-year calculations in light of this interpretation.

 

References
1. Masters N, Tutt C, Yaseen N. Waterpipe tobacco smoking and cigarette equivalence. Br J Gen Pract 2012; 62(596): 127.
2. WHO Study Group on Tobacco. Tob Reg Advisory Note. Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators. Geneva: WHO, 2005.
3. Jawad M, Khaki H, Hamilton F. Shisha guidance for GPs. Eliciting the hidden history. Br J Gen Pract 2012; 595(62): 66–67.

 

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Date: 23 Apr 2012
Topic: Response to ‘General practitioners at the Deep End’ 
Comments by: Joy Main, former principal in Hartcliffe and Withywood, Bristol, Honorary Research Fellow, Norah Fry Institute, University of Bristol.
Paul Main, former principal in Hartcliffe and Withywood, Bristol. Deputy Director, School of Primary Care, Severn Deanery

 

These 12 articles¹ and Watts’² concluding editorial have been inspirational, and for us, like others,³ have helped validate our experience over a professional lifetime of serving in a deprived post-war peripheral council estate where there were ‘very few easy cases’.⁴ We recognise each characteristic cited by Watts, as being a true reflection of issues faced by all patients at the Deep End, and the teams who serve them.

 

Watts et al convincingly make the case, again, for additional healthcare resources to deal with the number, severity, and complexity of health and social problems at the Deep End, which are difficult to address with standard resources and in standard consultation times.⁵ Despite the shorter life expectancies, and many more years in poor health before death, endured by Deep End patients, any additional healthcare resources directed to Deep End populations do not reflect the additional, potentially preventable, morbidity and premature mortality.

 

An answer to this mismatch of need and resource is to engineer longer consultation times in deprived areas, either with doctors, or with nurses able to handle the complexity of multiple morbidity, and this model would fit the opportunistic nature of the work. This requires political will and professional support, rather than opposition.⁶ It is telling that the Black Report, in 1980, was released in small numbers on a Bank Holiday weekend, and that this important series of articles from GPs at the Deep End has, to date, generated only three letters to this journal. The blind spot to which Watts refers is real. His point that Tudor Hart's Inverse Care Law is a man-made construct, that restricts access to care based upon need, is well made. The point, as he says, is not that poor areas get bad GPs while rich areas get good ones, but that good GPs in poor areas are prevented from maximising what they could do by failure of provision of the resource that would give the deprived ‘an average chance of health’. The issue is not doctor workload, but resource to reach all the potentially treatable morbidity.

 

Twenty-one years ago we wrote a series of articles for this journal (they appeared in Connexions) about the need to target resources to the ‘forgotten areas of deprivation’ to give our patients an ‘average chance of health’.⁷ Over 65 years, between us, of service within socio-economic deprivation, it was our clear experience that advocacy on behalf of the health resource needs of patients, needs to be a constantly repeated teaching theme. Resource providers start out not understanding, learn in dialogue, then move on and the educational process has to start all over again.

 

The mutual support that Deep End Group participants have experienced is relevant for Deep End workers everywhere. The involvement of policy advisers from the Scottish Government Health Directorate is important. We look forward to hearing more about the trajectory of this initiative. As Watt says: ‘addressing the Inverse Care Law is not rocket science’, but it is vital to the health of deprived patients. Would that a similar group could establish itself south of the border.

 

References
1. Watt G. General practitioners at the Deep End. Twelve articles in the Br J Gen Pract 2011; 61: 66-67, 146, 228, 298, 350, 407, 463, 519, 569, 629, 685 and 741.
2. Watt G. Reflections at the Deep End. Br J Gen Pract 2012; 62: 6-7.
3. McGinnity E. GPs at the deep End. Br J Gen Pract 2011; 61: 439.
4. Sambele P, Mandeville B. The Keppoch Medical Practice: reporting from the Deep End. Br J Gen Pract 2011; 61: 463.
5. Main JA, Main PGN. Jarman Index. BMJ 1991; 302: 850–851.
6. Main JA, Main PGN. Quality or inequality in health care? Br J Gen Pract 1991; 41(350): 388.
7. Main JA, Main PGN. A forgotten area of deprivation. Five commissioned articles in RCGP Connection (Membership Magazine) 1990 Issues 19–23 (July to November).

 

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Date: 22 Apr 2012
Topic: Response to ‘Out of hours primary care: closer and closer apart’
Comments by: Warren M Luke, RD, FRCGP, Ardgowan, Falkirk

 

John O'Malley’s interesting editorial¹ raises many good points and will, I hope, widen discussion about the entire provision of Out of Hours (OOH) care. I believe that the Government in 2004 gave away too much in reducing the 24-hour commitment at a time when locally organised co-operatives were already providing excellent care in many areas, tailored to the needs of those areas and not a national blueprint. I write as a former principal in practice for nearly 30 years and one now working limited sessions in OOH.

 

OOH needs to be seen as a distinct sub-speciality of primary care requiring tailored training and appraisal programmes. This is of especial importance at the outset of revalidation. ‘Audit’ (now an old fashioned word) is not really possible when the outcome of consultations and referrals is not available to the OOH doctor.

 

Member of the Faculty Board, West of Scotland Faculty RCGP and Sessional OOH Doctor Forth Valley Health Board
(these views are mine and not necessarily those of the above bodies).

 

Reference
1. O’Malley J. Out of hours primary care: closer and closer apart. Br J Gen Pract 2012; 62(597): 176–177.

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Date: 17 Apr 2012
Topic: Response to ‘Situating general practice training in the general practice context’
Comments by: Tom Pelly, training programme director, Bristol Vocational Training Scheme, Severn Deanery, Horfield Health Centre, Lockleaze Road, Bristol

 

While I understand and agree with the long-term aim of increasing training time in the GP setting for GP trainees, I am unable to agree with some of the conclusions drawn by Goldie and Morrison.¹
 
First, the training received in hospitals by GP trainees does not occur in isolation from the general practice setting. Within our vocational training scheme for example, during the time that our trainees are in their hospital placements our main focus is on putting their experiences into the general practice context. Furthermore, in our local deanery, all trainees do 6 months in GP practices prior to their final ST3 year, and this means that members of each small group are grounded with the perspective of the world they are preparing to enter. The socialisation and cohesiveness of the STs within their small group of GP trainees seems much more important than the more transient bonds formed while on hospital placements.
 
Second, obstetrics aside, I am sure that there is benefit to be gained by training in many hospital jobs as it allows the building of more specialist knowledge in commonly encountered general practice problems, for instance in sexual health, ENT, or dermatology. This knowledge is subsequently disseminated through peer learning to other members of their vocational training scheme small group and to the practices they work in later.
 
Finally, quality assurance of hospital posts means that the hospital leads for all our jobs are visited on a rolling cycle. We discuss with our hospital colleagues how our trainees can make the most of their time in hospital training experiencing, for instance, following a patient through a primary to secondary to primary care journey, understanding what makes a good referral from the hospital point of view, and viewing the primary care interface from the secondary care perspective. Given that commissioning is likely to lead to a more focused examination of the grey area between what can be done in primary or secondary care, fully understanding the boundary from all sides is likely to put us in a much stronger position to be able to mange it to the profession’s best advantage.
 
Leaving aside the economic and logistical arguments of how to base training fully in primary care, arranging service provision in hospitals, or longer training in GP, I strongly support extended training for GPSTs within a primary care setting. I would, however, anticipate that an extra training year in the GP setting after completion of MRCP would alleviate many of the concerns raised.
 
Reference
1. Goldie J, Morrison J. Situating general practice training in the general practice context. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X636245.

 

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Date: 11 Apr 2012

Topic: Author's response to Richard Smith (23 Mar 2012)

Comments by: Calum Paton, School of Public Policy and Professional Practice, Keele University

 

Richard Smith suggests that only communists and fantasists may detect a’neo-liberal London consensus’. He goes on to suggest that the BJGP is UK-centric. May I suggest that his US-corporate-for-profit-health-care-tinted spectacles have actually stopped him seeing the UK health systems in the round, from which perspective the English obsession with recycling increasingly surrealist versions of failed ‘market reform’ models is quite striking. First rule of comparative health care: use it to understand yourself better!

 

‘The London consensus’ was of course my tart take on the well-known coinage, ‘the Washington consensus’. Ironically, at a time when Obama has overcome at least some of the huge odds against humane health reform in Washington, Richard’s stay with UnitedHealth may have taken him more Rightwards than he has realised even by Washington standards!

 

In London, of course, there are enthusiastic neo-liberals (Tony Blair, for example: if you doubt me, just read his political autobiography, A Journey); and then there are fellow-travellers. The latter may or may not be enthusiastic, but they have accepted the terrain of neo-liberalism as the place for debate. I include the King’s Fund and the Nuffield Trust in this — pragmatists who have become just a bit too pragmatic.

 

And as Keynes knew, ‘practical men’ were often slaves to a defunct economist ... ‘pragmatists’ in London often fail to see the opportunity cost of both market reform and endless tinkering with market models, of which Lansley’s ‘La La Land’ is merely the most absurd yet.

 

And Richard, yes, power and responsibility should go together, for GPs as well as for all of us. My point was exactly that: if you don’t maintain the balance between the two, you’re in trouble. The government’s dishonesty — selling ‘100% the latter’ as ‘100% the former’ — is a sure way to disillusionment. Some GPs are often too trusting — at first — of reforms that promise to put them in the driving seat yet end up scorching their backsides in the hot seat.

 

And it’s not just this government: Alan Milburn did the same in 2001, in New Labour’s heyday. It’s called the London consensus, you know!

 

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Date: 10 Apr 2012

Topic: Response to 'Situating general practice training in the general practice context'

Comments by: Paul Main, Deputy Director, School of Primary Care, Severn Deanery

 

Goldie and Morrison¹ are right to emphasise the importance of the general practice context for postgraduate general practice training. In 1919 Sir James Mackenzie stated ‘the teacher of practical matters must be one who experiences what he teaches. We all recognise that the best teacher for one who wants to be a shoemaker is the man who is in the habit of making shoes. Unfortunately, this common-sense idea is rarely applied to medical education’.²

 

In 1952, the same year that our college was founded, the first integrated general practice training scheme pilot was set up in Inverness. Senior house officer level trainees had a 2-year contract to train concurrently in hospital and general practice. They were based for that whole period in one general practice. They started full-time in the practice for a few weeks and then spent 2–4 half-days every week in the same practice. The rest of the time was spent as a supernumerary experiencing different hospital departments and clinics according to their educational needs. They reported valuing the range and flexibility of the scheme.³

 

The compulsory postgraduate training for general practice that started in 1982, requiring at least 2 years post full GMC registration in hospital and 1 year in general practice, seems in retrospect, almost a regression from the Inverness scheme of 30 years earlier.

 

Goldie and Morrison make important and relevant contextual observations about reflective practice, being part of a community of practice, and progressing through the Dreyfus model of skill acquisition. Current trends moving the delivery of care formerly given in hospital, to the community, and the super-specialisation of hospital departments, make this an opportune time to remove GP training from hospital, where what can be learned becomes less relevant to the future GP.

 

If the proposed 4-year trajectory of training for general practice that is currently mooted, becomes accepted, then there will be a real opportunity for trainees to spend, at the very least, 2 years training within general practice, in the community of practice in which their futures will be spent.

 

References
1. Goldie J, Morrison J. Situating general practice training in the general practice context. Br J Gen Pract 2012; 62(597): 217–218.
2. Mackenzie J. The future of medicine. London: Henry Frowde, Hodder & Stoughton, 1919.
3. Horder JP, Swift G. The history of vocational training for general practice. J R Coll Gen Pract 1979; 29(198): 24–32.

 

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Date: 10 Apr 2012
Topic: Doctors’ behaviours with antibiotic prescribing
Comments by: Dr John Peters, Littlepace Medical Centre, Clonee, Dublin 15, Ireland
Clare Young, Littlepace Medical Centre, Clonee, Dublin 15, Ireland
Professor Tom O'Dowd, Public Health and Primary Care, School of Medicine, Trinity College Dublin, Tallaght Hospital, Dublin 24, Ireland

 

We read the study by Colin P Bradley et al¹ regarding the influence of patient payment on antibiotic prescribing in Irish general practice. The Republic of Ireland is one of three European countries in which antibiotic use in general practice is increasing1. Eligibility for Ireland’s primary care services is determined by a means test with General Medical Service (GMS) card holders having access to GP services and medications free of charge. The remainder are private patients who pay a fee to access GP services.

 

We retrospectively reviewed a 2-week period in September 2011 in a practice with predominantly children and young patients presenting with symptoms that indicated a probable RTI (as in the Bradley et al study). The results were presented to the practice GPs and nurse in October and then a second 2-week period in December 2011 was then reviewed. Our results are as follows:

 

Table: Comparison of consultations for September and December 2011

Parameter measured	September	December
% RTI presentations of total consults	22.7	35.8
% antibiotics given for RTI	67.8	60.0
% delayed antibiotics given for RTI	27.9	37.2
% GMS did get antibiotics	53.2	57.6
% PP did not get antibiotics	83.7	62.5

*GMS = public patients; PP = private patients

 

The representation of GMS and private patients in September and December was approximately equal. Our findings show that there were more RTI presentations in December with less antibiotic prescribing overall, fewer antibiotics prescribed to private patients, and higher use of delayed antibiotic prescribing.

 

As stated in many articles including the Bradley study, there are many external non-clinical factors that influence GP’s prescribing such as patient’s expectations, time constraints, patient volume, and mode of renumeration.^1,2,3,4 Our brief audit demonstrates that doctors’ behaviour can be changed by the use of data on their prescribing activities. The only intervention between September and December was a presentation of September’s results to the clinical staff. Whether this will be sustained or not will be the subject of another audit.

 

References
1. Murphy M, Byrne S, Bradley CP. Influence of patient payment on antibiotic prescribing in Irish general practice: a cohort study. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X593820.
2. Little P, Dorward M, Warner G, et al. Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study. BMJ 2004; 328(7437): 444.
3. Coenen S, Michiels B, Renard D et al. Antibiotic prescribing for acute cough: the effect of perceived patient demand. Br J Gen Pract 2006; 56(524): 183–190.
4. Geneau R, Lehoux P, Pineault R, Lamarche P. Understanding the work of general practitioners: a social science perspective on the context of medical decision making in primary care. BMC Fam Pract 2008; 9: 12.

 

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Date: 7 Apr 2012

Topic: Response to 'Not just another primary care workforce crisis'

Comments by: Dr David Berger, MRCGP, Exmoor Medical Centre, Dulverton, Somerset

 

There is a baffling disconnect in the position of Irish and Purvis on the primary care workforce crisis.¹ On the one hand, they say:

 

‘The supply of newly qualified GPs is unlikely to match demand without international recruits and returners to the GP workforce.’

 

On the other hand, many readers of this Journal will be astonished to learn the obstacles faced by UK-trained GPs who wish to return to England (but not Wales or Scotland, see below) after working as GPs for a period over 2 years in countries such as Australia, New Zealand, and Canada.

 

Briefly, they have to register for a local returners scheme, take a knowledge-based multiple choice question (MCQ) in London, wait for the results of that, then apply to do a basic objective structured clinical examination (OSCE) in London, wait for the results of that, then have a clinical interview with a regional educational supervisor and then, if all is deemed satisfactory, be signed off as fit to work, all the while idle at their own expense over a period of up to 6 months. This returners policy has been implemented by the Committee of General Practice Education Directors (COGPED), a body to that Irish and Purvis belong, with no attempt to distinguish at entry between a doctor who has been, say, on maternity leave and not working for 5 years and one who has been doing mainstream first world general practice in a comparable health economy. Arguments that the latter individual requires ‘refamiliarisation’ with the NHS are specious as no such ‘refamiliarisation’ is offered during the period they remain idle, their clinical skills atrophying. Further, knowledge of NHS procedures and protocols is not assessed by the MCQ and OSCE, which are basic clinical exams. Many would argue, too, that ‘refamiliarisation’ is not as complex a task as COGPED would have us believe and could easily be dealt with in many ways such as online learning modules or a short face-to-face course.

 

I suggest that Irish and Purvis reflect on the absurdity of COGPED’s position and that if they are serious about tackling the workforce crisis they put in place a workable scheme for experienced UK-trained GPs returning from working in comparable health economies. Meanwhile, both Wales and Scotland take a far more pragmatic approach and will assess returning GPs on their merits via a clinical interview and do not require the MCQ and OSCE, with the attendant period of costly, enforced idleness, as standard.

 

Either Irish, Purvis, and their colleagues on COGPED will put in place a more sensible regime to relicense UK GPs returning from abroad or we really will be in the workforce mire. In England, anyway.

 

Competing interests
I may wish to work abroad and may wish to return one day. I have had previous correspondence on this issue with Irish and COGPED.

 

Reference
1. Irish W, Purvis M. Not just another primary care workforce crisis … Br J Gen Pract 2012; 62(597): 179–179.

 

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Date: 5 Apr 2012

Topic: Editor's response to Richard Smith (23 Mar 2012).

Comments by: Roger Jones, Editor of the BJGP, London

 

Richard Smith’s editorial lineage goes back 25 years, and mine a bit longer, to the clinical editorship of World Medicine in the early 1980s — nothing like a bit of badinage between two old hacks.

 

We are aware of the demographic asymmetry in the editorial board and do our best by advertising nationally for new members — but as for sacking my splendid colleagues, this isn’t the BMJ!

 

Diagnostic safety-netting was a term coined by Roger Neighbour in his seminal Inner Consultation¹ and is a useful neologism which is firmly embedded in describing the diagnostic processes of primary care.²

 

Calum Paton can comment for himself about the neo-Liberal consensus and power vis a vis responsibility, but tighter editing by me would have stopped short at changing this sentence — general practice unfortunately has a long record of the exercise of power through claims to autonomy and clinical freedom without fiscal responsibility.

 

And finally all those terms missing from the cloud are very much on our minds, and all will appear in the titles of articles and papers to be published in the next few months.

 

References
1. Neighbour R. The inner consultation. 2nd edn. Oxford: Radcliffe Publishing, 2004.
2. Almond S, Mant D, Thompson M. Diagnostic safety-netting. Br J Gen Pract 2009; 59(568): 872–874.

 

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Date: 26 Mar 2012

Topic: Authors response to Peter Davies (24 Mar 2012)

Comments by: Mark Purvis, Yorkshire and the Humber Deanery, School of General Practice, University of Leeds, Leeds

Bill Irish, School of Primary Care, Severn Deanery, Academic Centre, Frenchay Hospital, Bristol

 

Thanks Peter.

Your point is well made. We have recognised the potential for extended roles of the GP, but the word limit was against us!
I think we could go further and point out that training too few/too many GPs is a binary decision but with unequal risk and consequence, in other words, too few GPs and the NHS implodes … train ‘too many’ GPs and the flexible, adaptable, entrepreneurial nature of GPs is that they add value through extended roles, enhanced roles, and intermediate care roles. So you can have too few GPs with apocalyptic consequences … but you can never really have too many GPs!

 

Hey, if we have enough GPs we may even be able to reconnect with urgent and unscheduled care out of hours.

 

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Date: 24 Mar 2012

Topic: Response to 'Not just another primary care workforce crisis'

Comments by: Dr Peter Davies, FRCGP, GP Keighley Road Surgery, Illingworth, Halifax

 

Irish and Purvis¹ have written a useful article summarising the imbalance between GPs entering and leaving the GP workforce, and indicate that this imbalance is likely to worsen in the next few years. The problems that the deaneries face now are acute and have serious implications for future recruitment of GPs at surgeries, and hence the viability of clinical services. There are two other dynamics in play that make the situation even more challenging than they describe.

 

First, many new roles are opening themselves up to GPs, and they currently sit somewhat uncomfortably alongside the traditional service roles of the general medical services and Personal Medical Services contracts. As a speciality we have accommodated training for many years. We have just about got enough appraisers. We have so far been able to recruit senior GPs to lead Clinical Commissioning Groups. We have medical directors who are system leaders but nearly all of them are coping with too much work (a lot of it protracted and complex) for the time they have available. All these additional roles are useful and interesting, and do contribute to patient care and safety. However, they all take GPs away from direct clinical work.

 

We have always seen some drift of GPs to post overseas, or moves sideways to other specialities such as occupational health.

 

So as a speciality we have many new roles opening up to all GPs, and we still have the patients to see. There may not be enough of us to go round all these roles.²

 

Second, we have a primary care service that is poorly configured in terms of its structures and processes to achieve the outcomes that both doctors and patients want and need. We have GPs working flat out in their surgeries coping with the daily treadmill of acute reactive demand. We know that there is much unmet need, but we feel so busy that meeting it can seem an impossible challenge. Our supposed 10-minute consultations already average 11.7 minutes, and still fail to fully address all the problems patients have, and the comorbidity that needs addressing. We can see the challenges of age, complexity, and comorbidity are going to increase, and we are not well set up even for current demands. The GP’s work is not well integrated with the specialist nurses available in primary care. Too often they are hospital outreach staff directed by consultants, rather than GPs. There are developing tools such as the Bolton Dashboard and the BUPA/Nuffield predictive risk management software that will in future allow us to ask ‘who needs to be seen today?’ as opposed to ‘who’s booked in today?’ But at present in our surgeries we are lumbered with the burden of acute reactive medicine and we struggle to see past our list of patients. And our work with our specialised nursing colleagues is not yet fully effective, and their work is not always best targeted.

 

So we see an ill-configured and specified primary care service with rising clinical and managerial demands on it, trying to meet it with too few staff. This scenario is intrinsically unstable, and a new settlement for primary care will soon become necessary.

 

References
1. Irish W, Purvis M. Not just another primary care workforce crisis … Br J Gen Pract 2012; 62(597): 179–179.
2. Davies P, Moran L, Gandhi H. What is the work of primary care? In: The new GP’s handbook. London: Radcliffe Medical Publishers, 2012.

 

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Date: 23 Mar 2012

Topic: The BJGP

Comments by: Richard Smith, 35 Orlando Road, London

 

One of the pleasures of being an honorary fellow of the College is that I receive a copy of the Journal, and, although deluged like everybody else with written material, I read it. I was an editor for 25 years, and as such I have a few observations on the Journal that may prompt some useful thoughts.

 

First, I notice that your editorial board has 17 members (assuming that you and your deputy are members), and yet there are only two women. Surely this is an embarrassingly low number. Judging by the names, I think that only one member comes from an ethnic minority. You are failing to reflect British general practice. I suggest that you scrap your board and make a fresh start. As I discovered, copying Margaret Thatcher in her abolition of the Greater London Council, it is easier to get rid of the whole lot than just one or two.

 

Secondly, I’m impressed that in your Editor’s Briefing you have managed to make safety-net a verb. Truly there is no noun that can’t be verbed.

 

Thirdly, what is the ‘neo-liberal London consensus’, which Calum Paton writes about?¹ This reminds me of my days as a communist, but I suggest that it is a figment of Paton’s imagination. He also refers to GPs being ‘sold the dream of power only to find it has become responsibility’. But did any GP think it possible to have power without responsibility? I can’t think so. In short, I think that this article would have benefited from tighter editing.

 

Fourth, the word cloud of the Journal contents is very interesting, but what may matter most is what’s not there. Rob Atenstaedt notices the absence of any mention of countries outside the UK,² and I noticed the absence of safety, internet, comorbidity, and commissioning.

 

References
1. Paton C. Competition and integration: the NHS Future Forum’s confused consensus. Br J Gen Pract 2012; 62(596): 116–117.
2. Astenstaedt R. Word cloud analysis of the BJGP. Br J Gen Pract 2012; 62(596): 148.

 

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Date: 19 Mar 2012
Topic: Response to ‘Service users’ views of moving on from early intervention services for psychosis: a longitudinal qualitative study in primary care’
Comments by: Dr Peter Carter, MBBS, MRCPsych, Consultant Psychiatrist, Waltham Forest EIP, London

 

Lester et al’s paper is timely.¹ Many Early Intervention in Psychosis (EIP) teams have been in action for over 3 years and are refining discharge pathways to primary care. This interface is not just with colleagues but now also with commissioners. While there is robust economic evidence for EIP, this perhaps sits outside the regular reading of most GPs.² This interface needs active management and should not be relied on to grow organically. Every interaction with GPs should name the team and provide opportunity for shared learning, enhanced by the many leaflets covering this area.³ There is a need to help GPs to understand what patients have been experiencing for the proceeding 3 years and not just to advise on subsequent management. In a world of ever changing services it is particularly important that they can be supported to navigate their way back in and EIP teams would tend to maintain responsibility for this, sometimes necessitating a brief period of re-engagement to do so. This is added value from an economically justified team. GPs are often left with a client who is still on medication and are quite reasonably asking for how long they might continue, when meds can be safely stopped, and what the considerations and risks in doing so might be. There is a concern that vocational aspects, which are particularly valued by clients, may be among the hardest to access from primary care.

 

References
1. Lester H, Khan N, Jones P. Service users’ views of moving on from early intervention services for psychosis: a longitudinal qualitative study in primary care. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X630070.
2. McCrone P, Knapp M, Dhanasiri S. Economic impact of services for first-episode psychosis: a decision model approach. Early Interv Psychiatry 2009; 3(4): 266–273.
3. Iris. Early intervention psychosis iris network.

 

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Date: 19 Mar 2012
Topic: Response to ‘Calling time on the 10-minute consultation: where are we now?’
Comments by: Greg Irving, Past Chair AiT committee, RCGP, London
John Holden, GP, Garswood

 

In their editorial, Silverman and Kinnersley present a strong case for moving on from the 10-minute consultation.¹ In 2011 an electronic ‘consultation length’ survey of all UK GP trainees (ST1–ST4) was undertaken by the RCGP Associates in Training committee. One of the key questions within the electronic survey was, ‘what consultation length does your trainer offer for routine booked appointments?’

 

A total of 1492 trainees completed the survey (~15.8% out of ~9451 trainees contacted) providing proxy evidence of current consultation lengths offered by their GP trainers. The results of the survey are presented in the table. 

 

Table. GP trainer consultation length for routine booked appointments and trainee preference

Consultation length (minutes)	Number of trainers	Trainee preference
<5	4 (0.3%)	0
5–9	32 (2.4%)	4 (0.3%)
10	1236 (82.8%)	187 (12.5%)
11–14	68 (4.6%)	404 (27.1%)
15	102 (6.8%)	834 (55.9%)
>15	22 (1.5%)	63 (4.2%)
No set time	28 (1.9%)	0

 

When asked ‘what would be the ideal consultation length be for routine booked appointments?’ only 12.5% of trainees thought that 10 minutes was adequate. In contrast 55.9% believed that 15 minutes was needed. Reasons for trainees selecting 15 minutes included: ‘time for preventative care’, ‘thorough exploration of presenting problems’, and ‘greater patient satisfaction’.

 

This survey suggests that even in those practices that meet the quality standards for GP training, 15 minutes is still far from the norm. Yet, at the same time, it would appear that the next generation of GPs would agree with Silverman and Kinnersley that we should indeed call time on the 10-minute consultation.

 

We are encouraged that trainees largely recognise that longer consultations are needed in general practice. This will undoubtedly need reorganisation within practices, but we have been able to offer 15-minute appointments as standard for eight years in our practice with huge benefits for ourselves, and we are confident, for patients’ too.²

 

There is now substantial continued evidence that longer consultations can improve quality of care.³ With evidence and the opinions of younger GPs coming together we believe the RCGP and other NHS policy makers should unequivocally advocate 15-minute consultations.

 

References
1. Silverman J, Kinnersley P. Calling time on the 10-minute consultation. Br J Gen Pract 2012; 62(596): 118–119.
2. Holden J, Brown G. The introduction of repeat dispensing for 600 patients in one general practice. Int J Pharm Pract 2009; 17(4): 249–251.
3. Howie J, Maxwell M, Walker J, et al. Quality of general practice consultations: cross sectional survey. BMJ 1999; 319(7212): 738–743.

 

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Date: 18 Mar 2012
Topic: Response to ‘Payment for Performance and the QOF: are we doing the right thing?’
Comments by: Dr Gerda Pohl, The Market Surgery, Warehouse Lane, Wath Upon Dearne, South Yorkshire

 

The authors seem to work under the assumption that there is a payment system for GPs that will not create a conflict of interest,¹ but I do not believe that this is the case: every payment system will have some negative impact on GPs behaviour: capitation based systems incentivise huge lists with little actual care, while systems that pay GPs for activity (such as, for example, in Germany or the US), create a bias towards ‘activism’, in other words, arranging lots of tests and investigations — and discourage spending time with patients for histories, examination findings, and explanations. Systems that pay every GP the same salary (as in Cuba or the former Soviet Union) are known to discourage doctors and can either lead to disengagement or to parallel earnings from private practice or non-medical activities.

 

Let’s face it: GPs are only human, and collectively will behave as humans do, and a good majority will always be motivated by financial gain — this doesn’t necessarily have to be selfish as such, but pressure to provide well for children and other dependants creates incentives of its own.

 

It can be argued that QOF could minimise the conflict of interest between professionalism and financial interest, by increasing pay for good practice and decreasing it for bad practice.

 

That this can’t always work perfectly is obvious, and one way to address this is to constantly adjust it, keeping indicators that seem to perform well and removing those that encourage ‘gaming’.

 

What worries me is that there is no systematic way of gathering opinion from working GPs as to which indicators perform well: every self-respecting GP knows which of the indicators motivate us to improve evidence-based care (in my opinion, asthma reviews, blood pressure targets, epilepsy reviews, and several others meet this), and which ones encourage ‘gaming’ (one of the worst, in my view, being PHQ–9 for depression).

 

Why are jobbing GPs not more involved in developing QOF?

 

Declaration of interest: In our practice, I am nominally responsible for the depression indicators, but we have given up trying to achieve them.

 

Reference
1. Kramer G. Payment for Performance and the QOF: are we doing the right thing? Br J Gen Pract 2012; DOI: 10.3399/bjgp12X630151.

 

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Date: 14 Mar 2012
Topic: Response to ‘The training capacity of general practice revisited: advanced training practices’
Comments by: Petre Jones, The Project Surgery, Plaistow, London

 

Dr Watton’s inspirational project in advanced training practice capacity faces an uncertain future and he raises important questions on the development of community-based educational funding.¹

 

The Project Surgery is a similar size practice, training 2nd and 5th year medical students, up to 3 VTS learners and some COPD work, with one partner also working as VTS programme director. We run this on mainstream funding only and also face a 20% cut in our core PMS budget. The future is unclear but such issues focus one’s mind onto priorities.

 

With the advent of Local Educational Networks commissioning education and the unification of undergraduate, postgraduate medical and dental, and nursing training budgets into one income stream we have an opportunity to press for funding to flow into primary care as community-based education increases. The challenge will be to stand up to large block funded institutions and traditions of menu driven course based training, to develop what is core community training.

 

Our educational leaders will only navigate this murky swamp if they develop a vision of what the future could be. The Whitehouse Surgery stands as a beacon of possibilities to draw from. Colleagues who are core to our teams and unable to be trained outside primary care are doctors, nurses, and administrators, and so multidisciplinary training for these roles at all levels, in educationally integrated practice training teams, must be our first priority.

 

We must establish what will be core activity for the future of primary care and secure its mainstream funding if we are to realise the prize of widespread, advanced, and multidisciplinary training.

 

Reference
1. Watton R. The training capacity of general practice revisited: advanced training practices. Br J Gen Pract 2012; 62(596): 135–154.

 

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Date: 9 Mar 2012

Topic: Response to 'Calling time on the 10-minute consultation'

Comments by: Thomas Round, Primary Care Clinical Academic Fellow, Kings College London, Primary Care and Public Health, London

 

I read with interest the recent BJGP editorial on ‘Calling time on the 10-minute consultation’.¹ As a recently qualified GP working in one of the most deprived and ethnically diverse areas of the UK the concept of a one size fits all 10-minute consultation seems woefully outdated. As an individual practitioner I of course vary the length of my consultations based upon a multitude of patient factors, but there is always the underlying time pressure of a full surgery of patients waiting to be seen and of course the ubiquitous QOF targets. There is an undoubted effect of this time pressure on the way I practice, utilising time and follow-up appointments for complex cases. However, I wonder whether this time limitation could potentially impact on the ability of primary care practitioner’s to make complex diagnoses early, a potential ‘achilles heel’ of general practice,² thus adding to diagnostic delay and error, the biggest cause of medicolegal claims against GPs.³ Recent research has shown that health systems with a gatekeeper function have lower cancer 1-year survival.⁴ Around 23% of patients consult three or more times with a GP before suspected cancer referral, with increased repeat consultations in those from ethnic minorities and for certain cancers before referral.⁵ A Cochrane review into the effects of changing the length of  primary care consultations found a lack of evidence, with only five UK trials meeting the inclusion criteria, with most having methodological weaknesses.⁶ They make the case for further research in this area, as without evidence the 10-minute consultation may still be the norm in 20 years time.

 

References
1. Silverman J, Kinnersley P. Calling time on the 10-minute consultation. Br J Gen Pract 2012; 62(596): 118–119.
2. Jones R. Diagnosis — still the achilles heel of general practice? John Fry Lecture. London: Royal Society of Medicine, 2011.
3. Kostopoulou O, Oudhoff J, Nath R, et al. Predictors of diagnostic accuracy and safe management in difficult diagnostic problems in family medicine. Med Decis Making 2008; 28(5): 668–680.
4. Vedsted P, Olesen F. Are the serious problems in cancer survival partly rooted in gatekeeper principles? An ecologic study. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X588484.
5. Lyratzopoulos G, Neal RD, Barbiere JM, et al. Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England. Lancet Oncol 2012; 13(4): 353–365.
6. Wilson AD, Childs S. Effects of interventions aimed at changing the length of primary care physicians’ consultation. Cochrane Database Syst Rev 2006; (1): CD003540.

 

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Date: 13 Mar 2012
Topic: COPD in primary care
Comments by: Noel Baxter, GP Southwark, LRT Co-lead and Stop Smoking as a Treatment for COPD Clinical Lead
Christopher Cooper, GP Islington, LRT GP and Earlier Diagnosis Clinical Lead

 

As GPs working for the London Respiratory Team, we were extremely pleased to see the high profile given to COPD in February’s BJGP^1–4 since we believe that primary care, as part of an integrated pathway, has a major role both in earlier diagnosis and continued management of this condition. We would like to highlight two concepts from our workstreams:⁵ first that COPD is as important as lung cancer (or TB or other serious illness) and second to view high quality stopping smoking support as the treatment for COPD. We are keen to promote straightforward techniques such as very brief advice on smoking⁶ and simple case-finding techniques⁷ that can be used even in time-limited consultations to provide systematic and opportunistic earlier diagnosis of COPD and maximally effective intervention.

 

Opportunities to signpost patients in primary care range from receptionists noticing insidiously increasing breathlessness in patients they may have known for years, through to practice nurses who are ideally placed to offer case-finding spirometry to patients at risk of COPD. Increasing fragmentation of care within the NHS often means that the patient’s registered GP may be the only healthcare professional in a position to spot recurrent chest infections, for instance, diagnosed out-of-hours or at walk-in centres, or to offer follow-up following an emergency department attendance. Earlier and accurate diagnosis in turn leads to proven interventions such as stopping smoking as a treatment and pulmonary rehabilitation. Per quality-adjusted life year, these treatments are highly cost effective at around £2092 and £2000–8000 per QALY respectively.^8–9

 

Within London, we’re making the case for change in respiratory services by advocating a value-based approach to COPD health care. Work is needed across the UK to get the best value from the respiratory programme spend. The coming months will be a key time for clinicians and commissioners to debate where there could be improvements within the existing respiratory budget by maximising the outcomes that people with COPD want through the use of therapies which have proven cost-effectiveness.

 

References
1. Broekhuizen B, Sachs APE, Verheij TJM. COPD in primary care: from episodic to continual management. Br J Gen Pract  2012; 62(595): 60–61.
2. Miravitlles M, Andreu I, Romero Y, et al. Difficulties in defferential diagnosis of COPD and asthma in primary care. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X625111.
3. Martin A, Badrick E, Mathur R, Hull S. Effect of ethnicity on the prevalence, severity, and management of COPD in general practice. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X625120.
4. Tsiligianni JG, van der Molen T, Siafakas NM, Tzanakis NE. Air travel for patients with chronic obstructive pulmonary disease: a case report. Br J Gen Pract 2012; 62(595): 107–108.
5. The London Respiratory Team. Workstreams. NHS London.

6. NHS Centre for Smoking Cessation & Training. Very brief advice on smoking. London: NCSCT, 2012.

7. Price D, Crockett A, Arne M, et al. Spirometry in Primary Care case-identification, diagnosis and management of COPD. Prim Care Respir J 2009; 18(3): 216–223.
8. Hoogendorn M, Feenstra TL, Hoogenveen TR,  Rutten-van Mölken MP. Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD. Thorax 2010; 65(8): 711–718.
9. Griffiths TL, Phillips CJ, Davies S, et al. Cost-effectiveness of an outpatient multidisciplinary pulmonary rehabilitation program. Thorax 2001; 56(10): 779–784.

 

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Date: 9 Mar 2012

Topic: Authors' response to Philpot et al (17 Feb 2012)

Comments by: Tom Brett, Professor and Director, General Practice and Primary Health Care Research, School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia
Diane Arnold-Reed, Associate Professor and Programme Coordinator, School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia

Max Bulsara, Professor of Biostatistics, The University of Notre Dame Australia, Fremantle, Western Australia

 

Philpot et al have done no more than reiterate (albeit in more detail) what we have already described and discussed in the paper.¹ The study design as outlined in the methods clearly states that the Fremantle Primary Prevention Study was ‘an open, prospective, pragmatic² randomised study in three practices’ involving 1200 participants with the aim of absolute cardiovascular risk reduction.

 

We sought to examine our intervention in the real life situation of busy clinical practices. We clearly stated that the study designated five visits for intensive group and two for the opportunistic group and, for ethical reasons, we placed no restrictions on routine attendances outside of planned study visits. We have no information on whether or not relative risk cardiovascular targets were discussed at unplanned visits. It is possible that the impact of the intervention on absolute risk reduction could have been more marked if visits were restricted.

 

Time constraints inevitably impact on busy GPs and practice nurses in clinical practice and need to be taken into account in the design of research studies. In our study, ethical practice necessitated that clinical judgements on the efficacy of introducing or altering pharmacological treatment, referrals to a dietician, exercise physiologist, or cardiologist, were at the discretion of the treating doctor. The practice nurses played key roles in recruitment, randomisation, and follow-up of participants.³ Whether health promotion messages are effective or not would depend on who delivers the messages and how they are delivered.

 

Effective translational research in a general practice setting requires a pragmatic approach which inevitably leads to complexity of study design. We were pleased that so many patients engaged in the study and follow-up discussions suggest their enablement benefitted from the experience.

All research can be improved as none is perfect.

 

References
1. Brett T, Arnold-Reed D, Phan C, et al. The Fremantle Primary Prevention Study: a multicentre randomised trial of absolute cardiovascular risk reduction. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X616337.
2. MacPherson H. Pragmatic clinical trials. Complement Ther Med 2004; 12(2–3): 136–140.
3. Young J, Manea-Walley W, Mora N, et al. Practice nurses and research — The Fremantle Primary Prevention study. Aust Fam Physician 2008; 37(6): 464–466.

 

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Date: 5 Mar 2012

Topic: The one and the many

Comments by: Peter Davies, FRCGP, GP, Member, Calderdale Clinical Commissioning Group, Keighley Road Surgery, Illingworth, Halifax

 

I welcome Kramer’s reflective paper¹ on our work and its funding. I think he asks the right starting question, and that the answering questions go deeper still. They are obvious to any astute observer of general practice, and they are begging to be answered in every surgery we each do. Medical and other politicians are begging not to answer them as they are too difficult, and so stop them being ‘pragmatic’.²

 

They centre around the old philosophical problem of how we balance the needs and wants of the one with the needs and requirements of the many. So for example in morning surgery should we give our first patient an excellent thorough consultation and then be playing catch up with subsequent patients? Should we be aiming at one excellent consultation or several reasonable quality ones? Can we set a clear standard of quality that does not collapse under the weight of quantity? Is running late a sign of good listening or poor quality?

 

In public health and evidence-based medicine we see these themes in the Rose Paradox.^3,4 This can be briefly stated as a small change in a modifiable risk factor (for example, reduction in population average blood pressure) will produce a major gain in public health outcomes (many fewer strokes and heart attacks) whereas a major change in the health of one individual (for example, after a heart transplant) is great for that individual, but makes almost no difference to overall population health. In terms of medical reward systems should we value doctors who do detailed operations (for example, a maxillofacial surgeon spending many hours taking out an oral cancer) more than those who persuade people not to smoke in the first place?

 

At the level of health economics or commissioning we then have to work out how many acts of individual good we can afford to allow our doctors to deliver. And the question is unavoidable as we only have a finite sized economy, and a finite sized budget to work with, and we are a finite workforce, of finite personal capacity. We cannot either individually or collectively do everything. How much is it reasonable to ask of us and the system we work in?

 

As a speciality and as a profession, and as the NHS as a whole system, we have not really acknowledged this tension between the deontology of each individual clinical interaction and the increasing utilitarianism that comes as we discuss the workings of the system.⁵ We still cling to the wreckage of Nye Bevan’s rhetoric of ‘all care necessary from the cradle to the grave’ and hope that we, whether individually or via the system, will be able to achieve this.

 

At some stage we will need to try and answer the questions of quality versus quantity and the question as to whether our activity and interventions are really aimed at individuals or populations. We may not get a perfect answer to these problems, but at least acknowledging that currently unstable, and often poorly considered⁶ balances are being struck would be a start.

 

References

1. Kramer G. Payment for Performance and the QOF: are we doing the right thing? Br J Gen Pract 2012; DOI: 10.3399/bjgp12X630151.
2. Davies P, Glasspool J. Patients and the new contracts. BMJ 2003; 326(7399): 1099.
3. Rose G. Sick individuals and sick populations. Int J Epidemiol 1985; 14(1): 32–38.
4. Davies P, Jenkinson S. Interpreting the evidence. Student BMJ 2008; 16: 26–27.
5. Davies P, Garbutt G. Should the practice of medicine be a deontological or utilitarian enterprise? J Med Ethics 2011; 37(5): 267–270.
6. Gubb J, Li G. Checking up on doctors. A review of the Quality and Outcomes Framework for general practitioners. London: Civitas: Institute for the Study of Civil Society, 2008.

 

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Date: 17 Feb 2012

Topic: Response to 'The Fremantle Primary Prevention Study: a multicentre randomised trial of absolute cardiovascular risk reduction'

Comments by: Benjamin Philpot, Statistician^, Greater Green Triangle University Department of Rural Health, Deakin University and Flinders University, Warrnambool, Vic 3280, Australia

Kevin McNamara, Research Fellow, Centre for Medicine Use and Safety, Monash University, Parkville, Vic Australia

James A Dunbar, MD, Professor, Greater Green Triangle University Department of Rural Health, Deakin University and Flinders University, Vic 3280, Australia

 

Brett et al recently described a randomised trial of cardiovascular disease (CVD) risk reduction in three general practices.¹ Suboptimal trial design may be a substantial contributor to concern about the efficacy and cost-effectiveness of such primary prevention interventions by health professionals.² We are concerned that such shortcomings also feature in their study.

 

The study aimed to measure the effect on CVD risk of more frequent GP visits. The number of study visits actually received was not specified, and is crucially important. Based on a small sample, opportunistic group participants received clinically, significantly more ‘non-study’ GP visits, ostensibly unrelated to the intervention but possibly not. Also, the study design did not allow an effect to occur between the final GP visit and data collection. Therefore, we estimate that they potentially compared a mean of 9.6 intervention group visits with a control group mean of 7.8 visits (and not 5 versus 2 visits, as claimed). Similar levels of care may explain a lack of between-group differences for the primary outcome.

 

Counseling provided was unclear. Apart from risk measurement and target specification, GP-counseling was simply deemed ‘individualised’ and ‘offered as appropriate’ — further details would be welcomed. No framework for behavioural change is specified, nor is any protocol for initiation or intensification of drug treatment, despite potential influence on outcomes.² A substantial practice nurse role is hinted at in the discussion section but never described.

 

We are also concerned by the authors’ conclusion that ‘the study demonstrates that absolute cardiovascular risk can be improved by primary prevention strategies’. This misinterprets minor (and occasionally significant) improvements to individual risk factors — there was no significant between-group reduction in overall CVD risk. The authors’ also conclude that a ‘targeted approach using absolute risk calculators can be used in primary care to modify global CVD risk assessment’ — given that risk calculators were employed for both study arms, it should not be implied that this was evaluated.

 

References
1. Brett T, Arnold-Reed D, Phan C, et al. The Fremantle Primary Prevention Study: a multicentre randomised trial of absolute cardiovascular risk reduction. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X616337.
2. Ebrahim S, Taylor F, Ward K, et al. Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database of Syst Rev 2011; (1): CD001561.

 

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Date: 10 Feb 2012

Topic: Response to 'Why bother talking to teenagers'

Comments by: Jane Roberts, Chair of RCGP Adolescent Health Group, and members of the group, Blackhall Community Health Centre, County Durham

 

We applaud Samir Dawlatly’s exhortation ‘why bother talking to teenagers?’¹ and would like to offer further commentary and clarity for those interested in working more effectively with young people consulting in primary care.

 

Dr Dawlatly refers to the RCGP Adolescent Primary Care Society. This group has been through numerous name-changes but is in fact known as the Adolescent Health Group (AHG [formerly the Adolescent Task Force]). The group has a long history upon that we build today. We are now part of the College’s Clinical Innovation and Research Centre and more can be found out about our activities at http://www.rcgp.org.uk/clinical_and_research/circ/priorities__commissioning/adolescent_health.aspx including accessing the brand new Confidentiality Toolkit and a summary of the recent symposium on young people’s mental health, a key priority area of the group.

Our three main areas of focus are education, informing policy development, and advocacy. The group’s members lead on a number of different initiatives around the country that think ‘outside of the box’ and seek to make primary health care more youth friendly.

Young people deserve a better deal from general practice. They visit us regularly: around half of Year 10 pupils (14–15-year-olds) had visited their GP in the 3 months preceding a recent survey² but 25% of the girls reported feeling uneasy when consulting with their GP.2 The health needs of young people are also rising; with increasing use of alcohol, rates of STIs, and obesity.³ In the last few decades it is only adolescents who have seen no improvement in mortality rates with an associated rise in long-term conditions.⁴ Health inequalities further complicate the picture and remain a significant barrier for all young people to enjoy better health.

While we accept doctors cannot overturn the structural obstacles and transform health through the practice of medicine⁵ we at the AHG are committed to making changes to improve the care of young people’s health in primary care. We invite you to learn more about us from our webpage and our chair’s blog.⁶

For those readers who are interested in joining the group please contact Jane Roberts.

 

References

1. Dawlatly S. Why bother talking to teenagers. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X6I2522.
2. The Schools and Students Health Education Unit. Young people into 2010. Exeter: SHEU, 2010.
3. Coleman J, Brooks F, Treadgold P. Key data on adolescence 2011. London: The Association of Young People’s Health, 2011.
4. Viner R, Barker M. Young people’s health: the need for action. BMJ 2005; 330(7496): 901–903.
5. Edgcumbe D. Good health has little to do with doctors, Mr Lansley. Br J Gen Pract 2012; 10.3399/bjgp12X625238.
6. Roberts J. Chair's blog for the RCGP Adolescent Health Group.

 

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Date: 9 Feb 2012

Topic: Water pipe tobacco smoking and cigarette equivalence

Comments by: Nigel Masters, GP, Highfield Surgery, Highfield Way, Hazlemere, High Wycombe

Catherine Tutt, Specialist Practice Nurse, Highfield Surgery, Hazlemere, High Wycombe

Nisar Yaseen, GP, Highfield Surgery, Hazlemere, High Wycombe

 

The authors of this editorial¹ on shisha (waterpipe) guidance tentatively offer 10 cigarettes as equivalent to a shisha session of 45 minutes. In our freely available smoking pack year calculator on the web² we have taken guidance from a World Health Organization study on waterpipe smoking.³ From this study an 80-minute session of such smoking was compared with 100 cigarettes and thus a 45-minute session would be around 60 cigarettes equivalence. As shisha smokers can use in both personal and group settings we have used a 20-minute session (25 cigarette equivalence) as our baseline in the calculator. Of course this is simply an approximation but hopefully helpful to all the health staff who need to calculate smoking pack years. Smoking pack years is a figure that combines smoking duration and smoking intensity, and one smoking pack year is defined as 20 cigarettes smoked daily for 1 year.

 

References

1. Jawad M, Khaki H, Hamilton F. Shisha guidance for GPs. Eliciting the hidden history. Br J Gen Pract 2012; DOI: 10.3399/BJGP12X625030.
2. Masters N, Tuttt C. Smoking pack years.

3. WHO Study Group on Tobacco. Tob Reg Advisory Note. Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators. Geneva: WHO, 2005.

 

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Date: 8 Feb 2012

Topic: Response to 'Tips for GP trainees working in general medicine'

Comments by: Dr Arun Khanna, Respiratory ST5

Dr Chris Whale, Respiratory Consultant, Derby Hospitals NHS Foundation Trust

 

We write to congratulate the authors on writing an excellent piece of work that GP trainees on general medical rotations should find very helpful.¹

 

Although the article provides good advice on commonly encountered medical problems, we would like to highlight issues relating to pleural problems (point 20: ‘Never let the sun go down on an empyema’).

 

Pleural intervention (including thoracocentesis and drain insertion) is associated with a range of potential complications, and each procedure should be performed by competent (or supervised) medical staff. These procedures are best avoided out of hours. We recommend that in most situations you can ‘let the sun set’ and defer the intervention until the next day.

 

1. The authors suggest that everyone with pneumonia-associated pleural effusion needs a pleural tap. Diagnostic pleural tap should be guided by clinical need. Up to 40% of pneumonias have associated para-pneumonic effusion (the most common cause of exudative pleural effusion in young patients)² and the vast majority will settle with antibiotic treatment. Pleural tap should be considered in the context of persistent sepsis despite antibiotics.
2. While we agree that pleural fluid pH <7.2 or aspiration of frank pus requires drainage of pleural cavity, we wish to point out that, in the majority of cases, this can be done safely by ‘specialist teams’ within working hours and does not require urgent out-of-hours chest drain insertions.³
3. The National Patient Safety Agency 2008 rapid response entitled Risk of chest drain insertion highlights the potential and sometimes fatal complications from implantable cardioverter defibrillator insertion.4 The current practice in most hospitals is to insert chest drains for pleural effusions using real-time pleural ultrasound guidance during normal working hours.

 

By highlighting the points above, we hope to emphasise the importance of patient safety in pleural intervention.

 

References

1. Saunders TH, Basford PJ. Tips for GP trainees working in general medicine. Br J Gen Pract 2012; DOI: 10.3399/bjgp11X613296.
2. Chapman S, Robinson G, Stradling J, West S. Oxford handbook of respiratory medicine, 2nd edn. Oxford: Oxford University Press, 2009: 50.
3. Akram AR, Hartung TK. Intercostal chest drains: a wake-up call from the National Patient Safety Agency rapid response report. J R Coll Physicians Edinb 2009; 39: 117–120.
4. National Patient Safety Agency. Chest drains: risks associated with the insertion of chest drains. London: NPSA, 2008.

 

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Date: 6 Feb 2012

Topic: Resposne to 'Evaluating the transferability of a hospital based primary care trial to primary care: a randomised controlled trial'

Comments by: Deborah J Sharp, Professor of Primary Health Care, University of Bristol, Academic Unit of Primary Health Care, School of Social and Community Medicine, Bristol

Jonathan Banks, Universtiy of Bristol, Academic Unit of Primary Health Care, School of Social and Community Medicine, Bristol.

Linda hunt, University of Bristol, School of Clinical Sciences, Bristol Royal Hospital for Children, Bristol.

Julian Shield, University of Bristol, Diabetes and Metabolic Endocrinology, Bristol Royal Hospital for Children, Bristol.

 

Thank you for inviting us to reply to the letter from Dr Tisi who is concerned that our conclusions are not justified by our results.¹ Taking the points he makes in turn:

 

1. There were not 152 eligible patients: 152 patients were referred by their GP for specialist obesity support. These children were screened for eligibility and 31 were not deemed suitable for the trial because of obesity related comorbidities. This left a further 45 who declined to participate in the trial for various reasons. These 76 patients did not provide trial data and will have received treatment in secondary care in the usual way. It is therefore erroneous to suggest that only 39 of 152 people made it through to the end of the trial. As we make clear in our consort diagram, 39 of the 76 who were randomised completed treatment but 52 provided outcome data and were included in an intention to treat analysis.
2. We have been explicit in our acknowledgement of the modest improvement in body mass index (BMI) standard deviation score (SDS) but as we point out this is still better than described in the recent Cochrane Review. However, the main aim of the trial was to establish the feasibility of running a fully powered trial in primary care and to this end we looked at a range of measures including: whether patients referred for obesity support were clinically suitable for primary care (121, 80% suitable); the willingness of families to be randomised to primary care (45, 30% declined trial participation); and the degree to which families randomised to primary care engaged with the service (measured with the main clinical outcome of BMI SDS change, patient satisfaction, and adherence rates, all of which are detailed in the article and comparable between the trial arms).
3. We recognise that in a full trial a longer- term outcome measure is essential but in a feasibility study such as this there were insufficient resources available and long-term efficacy was not an objective. However, this does not undermine the rationale for the study which was to assess the feasibility of running a specialist obesity service in primary care in order to proceed to a fully powered trial. Once such trials have been conducted and are open to scrutiny, we should be better placed to assess the value of realigning healthcare resources.

 

We hope that he will agree that our findings justify further research to develop interventions in the primary care setting that may assist families needing help with managing childhood obesity.

Reference

1. Tisi R. Obesity and chronic disease in younger people. Br J Gen Pract 2012;62(596): 123.

 

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Date: 5 Feb 2012

Topic: Response to 'How to afford a just health service'

Comments by: Dr Julian Tudor Hart, FRCGP, FRCP, honFFPH, Hon Research Fellow, University of Wales, Swansea Medical School, Gelli Deg, Penmaen, Swansea

 

David Jewell suggests means-tested direct charges to patients (co-payments) as ways to afford a just health service in times of austerity.¹ He had no need to search so far.

 

A best answer was provided 250 years ago by Adam Smith:

 

‘The subjects of every state ought to contribute towards the support of the government, as nearly as possible in proportion to their respective abilities; that is, in proportion to the revenue that they respectively enjoy under the protection of the state.’²

 

This is what we now call income tax. It was first instituted in 1799 to pay for our wars, but only became in any way socially redistributive in Lloyd George’s budget of 1909. It is, of course, means-tested. Means tests are costly to administer, and it seems pointless to do this more than once, except as an effective deterrent to a high proportion of people entitled to benefits. Of 30 countries for which The Organisation for Economic Co-operation and Development data were available in 2005, the UK ranked 11th lowest for personal income tax as a percentage of income, below every other European country except Ireland, Iceland, and Switzerland.³

 

Unlike any leading politician or most economists today, Adam Smith understood the function of the state as guardian of property. ‘Till there be property there can be no government, the very end of which is to secure wealth, and to defend the rich from the poor’, he said.⁴ The rich should pay more for every aspect of the state, because without it, our obscenely unequal society would fall apart.

 

That’s the closest one can get to the truth, looking from above. It’s much easier to see from below, as most still do in Wales, Scotland, and Northern Ireland. Here NHS care is seen as a progressive and civilising extension of care within families at home.  Both are social functions separated so far as possible from the commodity market.  They are both motivated by perceived needs rather than opportunities for profit, and are cooperative rather than competitive in nature. Neither can gain in effectiveness or efficiency by remodelling to an industrial or commercial pattern.

 

In dismissing co-payments as a principle conceded long ago, David Jewell reveals ignorance of history. Charges for prescriptions, spectacles, dentistry, and so on (to Chancellor Hugh Gaitskell, and a cabinet majority who agreed with him) led two ministers and one junior minister to resign from Attlee’s government in 1951 (Nye Bevan, Harold Wilson, and John Freeman). They understood that the NHS was founded on solidarity. Without this it can exist only in name. People may be slow to understand this, but when they do, there will be short shrift for such casuistry.

 

References
1. Jewell D. How to afford a just health service. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X625300.

2. Smith A. An enquiry into the nature and causes of the wealth of nations (1762). Oxford: Oxford University Press, 1993.
3. OECD. Organization for economic co-operation and development 2005 data.
4. Smith A, Cannan E. Lectures on justice, police, revenue and arms. Oxford: Kessinger Publishing, 1896: 15.

 

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Date: 31 Jan 2012

Topic: Predictive effect of heartburn and indigestion and risk of upper GI malignancy
Comments by: Julia Hippisley-Cox, University of Nottingham, Division of Primary Care, Nottingham

Carol Coupland, University of Nottingham, Division of Primary Care, School of Community Health Sciences, Nottingham

 

Further to our recent publication of two papers in the BJGP,^1,2 we have been asked to evaluate specifically whether dyspepsia is a significant independent predictor of upper gastro-intestinal malignancy (in other words, gastro-oesophageal and pancreatic malignancy) and to consider adding it to the models. These symptoms (heartburn or indigestion) were not included in the original analysis that had focused on more traditional alarm symptoms. We, therefore, undertook an analysis based on the original derivation cohort from the published studies and identified patients with new onset of (a) heartburn or (b) indigestion (other than where heartburn is explicitly mentioned). We determined the age–sex incidence rates. We added both factors to the Cox models and determined the hazard ratios adjusted for the factors in the original models. We tested for interactions between the new variables and age. We evaluated performance of the new models on the original validation dataset using published methods.

 

The crude incidence rate for new onset heartburn in patients aged 30–84 years was 130 (95% [CI] 128 to 133) per 100 000 person years for males and 196 (95% [CI] 193 to 199) for females. The incidence rate for indigestion in males was 680 (95% [CI] 680 to 693) per 100 000 person years for males and 844 (95% [CI] 836 to 850) for females. Both heartburn and indigestion were independently associated with risk of gastro-oesophageal cancer and also pancreatic cancer in both males and females. The adjusted hazard ratios associated with indigestion without heartburn were higher than those associated with heartburn. For example, females with heartburn had a 2.2-fold increased risk of gastro-oesophageal cancer and a 2.5 fold increased risk of pancreatic cancer. Females with indigestion without mention of heartburn had a 4.3-fold increase in gastro-oesophageal cancer and a 3.8-fold increase in pancreatic cancer. The pattern for males was similar. We therefore retained both heartburn and indigestion in both updated models for males and females. The performance of the updated algorithms on the validation cohort was equivalent to that of the original models for gastro-oesophageal cancer and marginally better for pancreatic cancer. The R², D-statistic, and receiver operating characteristic statistics for gastro-oesophageal cancer were 71%, 3.2 and 0.90 for females, and 71%, 3.2 and 0.92 for males. The corresponding values for pancreatic cancer were 62%, 2.6 and 0.84 for females, and 64%, 2.7 and 0.86 for males.

 

In summary, we have identified and quantified two additional symptoms (heartburn and indigestion) that are predictive of both upper GI cancers. We have now included both symptoms in updated  models at QCancer (www.qcancer.org). As with the other symptoms included in the models, it is important to remember that they represent symptoms that have been significant enough for a patient to present to their GP and for their GP to record. Not all patients with such symptoms will have attended their GP and not all such symptoms will be reported or recorded.

 

Competing interests and financial disclosures (as per original paper reproduced here)
All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: JHC is professor of clinical epidemiology at the University of Nottingham and co-director of QResearch® — a not-for-profit organisation that is a joint partnership between the University of Nottingham and EMIS (leading commercial supplier of IT for 60% of general practices in the UK). JHC is also a paid director and co-founder of ClinRisk Ltd that produces software to ensure the reliable and updatable implementation of clinical risk algorithms within clinical computer systems to help improve patient care. The software which implement the algorithms described in this paper are free for anyone to use under the terms of the GNU lesser GPL3. For those who wish to implement software in a closed source setting, then a license fee is payable to ClinRisk Ltd. CC is associate professor of medical statistics at the University of Nottingham and a paid consultant statistician for ClinRisk Ltd. This work and any views expressed within it are solely those of the co-authors and not of any affiliated bodies or organisations.
Acknowledgements
We particularly thank Professor Sir Mike Richards (Department of Health cancer tsar) and Ms Ali Stunt (CEO of pancreatic cancer action) for discussing and requesting the additional analyses.

 

References

1. Hippisley-Cox J, Coupland C. Identifying patients with suspected pancreatic cancer in primary care: derivation and validation of an algorithm. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X616355.
2. Hippisley-Cox J, Coupland C. Identifying patients with suspected gastro-oesophageal cancer in primary care: derivation and validation of an algorithm. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X606609.

 

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Date: 22 Jan 2012
Topic: Response to ‘Is health eating for obese children necessarily more costly for families?’
Comments by: Susan Martin, Saddleworth Medical Practice, Uppermill, Oldham

The paper by Banks et al¹ was music to my ears. As someone who has been jousting with a tendency towards obesity since my teenage years I am not only well aware of the ‘healthy food costs too much’ argument so beloved by patients, but the counter arguments. The one that seems to confound people most of all is ‘why don’t you just eat less of what you can afford to buy?’ I have not yet had a sensible answer to this: generally there is a knotting of brows for a few seconds as though I were speaking in tongues, before moving on to some other issue.

 

It seems to me that there are two main problems to be overcome in quashing the ‘healthy is expensive’ argument. First the cheapness of less healthy options: the often quoted discount ready-made lasagne, for example. Second is the idea that a diet is not healthy unless it contains a liberal sprinkling of exotic fruit and veg. We are surrounded by images of blueberries with our breakfast cereal, pak choi in our ‘10-minute’ supper, and kiwi fruit at just about any time of day. These images are propagated by magazines and diet clubs alike. Is it any wonder people think they can’t afford it?

 

Last year one of Britain’s leading supermarkets introduced menus that cost around £50 per week for a family of four. In some quarters this came under fire for such mundanities as toast for breakfast. There is nothing wrong with toast for breakfast. In many Mediterranean countries (whose diet is seen as the gold standard) it is common to skip breakfast altogether in favour of elevenses, or to take little more than bread and coffee.

 

By all means try to curb the purveyors of cheap, unhealthy options, but more importantly let us push a sensible, achievable alternative.

Reference
1. Banks J, Williams J, Cumberlidge T, et al. Is health eating for obese children necessarily more costly for families? Br J Gen Pract 2012; DOI: 10.3399/bjgp12X616300.

 

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Date: 18 Jan 2012

Topic: Response to 'Thirty-minute compared to standardised office blood pressure measurement in general practice'

Comments by: Akke Vellinga, Discipline of General Practice, National University of Ireland Galway, Ireland

Andrew Murphy, Discipline of General Practice, National University of Ireland Galway, Ireland

Eoin O'Conway, Institute of Biomolecular and Biomedical Research, University College Dublin, Ireland

 

We read with interest the study by Scherpbier-de Haan et al regarding the use of the 30-minute blood pressure measurement in dealing with the ‘white coat effect’ and the accompanying editorial by Wallace and Fahey.^1,2 Both highlighted the importance of having an office-based alternative to ambulatory blood pressure monitoring (ABPM). This is most topical as practices react to the 2011 National Institute for Health and Clinical Excellence (NICE) unequivocal recommendation that ‘ABPM should be implemented for the routine diagnosis of hypertension in primary care’.³

 

In the RAMBLER II study, we prospectively examined the use of ABPM in 114 Irish general practices over a 1-year period between 1 April 2009 and 31 March 2010. All practices used the dabl ABPM expert online software system (www.dabl.ie/en/prod_abpm.aspx), which provides online transmission of ABPM data for instantaneous reporting and storage of data. There were 13 303 ABPM recordings from 11 537 individual patients (47.9% female, average age 57.9 [standard deviation {SD} 14.6] years) with an average of 102 (SD 83, median 84) ABPM recordings per practice per year. With most practices having only one device, this suggests that many devices are being used close to capacity even before the revised NICE recommendation was made.

 

In 6224 (53.8%) ABPMs, the recommended minimum of 14 daytime and seven night-time measurements were obtained. In 8475 (73.2%) ABPMs, at least 13 daytime and six night-time measurements were obtained. The reasons for this shortfall need to be further examined. Having the recommended number of readings had a small but significant impact on both white coat and diastolic averages but not on systolic averages (data available from authors).

 

Mean systolic blood pressure (SBP) was 139.4 mmHg (SD 14.7 mmHg) and 121.5 mmHg (6.8 mmHg) for day and night respectively; mean diastolic blood pressure (DBP) was 80.8 mmHg (SD 11.1 mmHg) and 67.1 mmHg (10.7 mmHg) for day and night respectively. Mean blood pressure in the first hour of the ABPM (white coat window) was 158.8 mmHg (SD 21.7 mmHg) and 95.1 mmHg (SD 17.1 mmHg) for SBP and DBP respectively. These figures emphasise the real impact of the ‘white coat effect’ in routine practice.

 

This study emphasises the heavy current workload of ABPM devices, the importance of ensuring that the recommended minima of readings are obtained, and the importance of the ‘white coat effect’ in routine practice.

 

References

1. Scherpbier-de Haan N, van der Wel M, Schoenmakers G, et al. Thirty-minute compared to standardised office blood pressure measurement in general practice. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X593875.
2. Wallace E, Fahey T. Measuring blood pressure in primary care: identifying ‘white coat syndrome’ and blood pressure device comparison. Br J Gen Pract 2011; DOI: 103399/bjgp11X593749.
3. National Institute for Health and Clinical Excellence. The clinical management of primary hypertension in adults. London: NICE, 2011.

 

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Date: 7 Jan 2012

Topic: Response to Obesity and chronic disease in younger people

Comments by: Roger Tisi, GP, Audley Mills Surgery, Rayleigh, Essex

 

In your editorial on obesity,¹ Yates et al talk in apocalyptic terms about the rise in its prevalence. Their description of its ‘devastating consequences’ is amplified to an impressive degree by the repeated use of figures referring to relative rather than absolute risk. They propose an ‘urgent need for high quality research’ and go on to comment approvingly on the paper from the Bristol team,² concluding that it provides evidence that ‘primary care can be used to engage effectively with, and manage, childhood obesity’.

 

To be honest, I’m not that good at analysing research papers but I felt it would be worthwhile seeing whether the paper delivered on this promise. Unless I am missing something, the main results I can see from this paper are as follows:

 

1. Of 152 eligible patients at the start of the trial, only 39 of them (25%) made it through to the end of the 12-month intervention period.
2. Reductions in body mass index (BMI) seen in those who did last the course (in both the primary and secondary care groups) were modest to say the least — and the authors comment that the mean change in BMI ‘is too small to be certain of an improvement in metabolic health’.
3. There is no follow up beyond the 12-month trial period to see if there is any sustained reduction in BMI.

 

A more realistic conclusion, therefore, is that this model of an obesity clinic is equally ineffective in primary and secondary care. Something perhaps to bear in mind before we rush to provide such services as part of the ‘re-focusing of healthcare priorities’ that your editorial recommends.

 

References
1. Yates T, Davies MJ, Khunti K. Obesity and chronic disease in younger people: an unfolding crisis. Br J Gen Pract 2012; 62(594): 4–5.
2. Banks J, Sharp DJ, Hunt LP, Shield JPH. Evaluating the transferability of a hospital-based childhood obesity clinic to primary care. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X616319.

 

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Date: 5 Jan 2012

Topic: QOF should be more about disease and risk factors prevention

Comments by: Edoardo Cervoni, Tarleton Group Practice, The Health Centre, Tarleton

 

I urge a radical re-thinking of the obesity QOF system. QOF should be far more about disease and risk factors prevention. As there may be debate around the concept of obesity as a problem rather than a disease, there should be little doubt that obesity is a significant problem.¹ Obesity has been associated with cardiovascular disease, premature death, stroke, non-insulin-dependent diabetes mellitus, gout, gallbladder disease, GORD, asthma, joint problems, and several types of carcinomas. Abdominal obesity (increased waist-to-hip circumference ratio [WHR]) should be recorded as more closely correlated with metabolic disease and even malignancies.² Clinically I find it difficult to accept that patients may be diagnosed as obese without being first warned to be overweight and advised accordingly. Healthy lifestyle education should be a core activity of primary care workers and I am concerned that some non-profit organisations may be better at managing weight than GPs are.³ The paper from Phillips and colleagues told us that dietary counselling by clinicians in primary care is sub-optimal, and perhaps the same could be said about physical exercise advice.⁴ Bobbioni-Harsch and colleagues have shown how metabolically normal obese subjects could be at increased risk of cardio-metabolic diseases. Furthermore, their findings suggest that high BMI, alone or with fasting insulin, negatively affects the cardio-metabolic profile.⁵ Interestingly, patients may be more upset by being told that they are obese, or scared of having their weight checked, than being told about high cholesterol or abnormal glucose tolerance. GPs tend to avoid using the term ‘obese’ and often prefer to use a euphemism. They are aware that the term obese may upset the patient. It has been shown that the term obese makes patients believe that the problem has more serious consequences and makes them feel more anxious and upset than when the same symptoms are labelled using a euphemism. I strongly advocate for more regular use of the weight scale in primary care, as there is a continuum from normal body weight to obesity and the early identification of a trend of excessive weight gain may be both clinically more beneficial and less upsetting for the patient.

 

References
1. Heshka S, Allison DB. Is obesity a disease? Int J Obes Relat Metab Disord 2001; 25(10): 1401­–1404.
2. Björntorp P. The associations between obesity, adipose tissue distribution and disease. Acta Med Scand Suppl 1987; 723: 121–134.
3. Jebb SA , Ahern AL, Olson AD, et al. Primary care referral to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial. Lancet 2011; 378(9801): 1485–1492.
4. Phillips K, Wood F, Spanou C, et al. Counselling patients about behaviour change: the challenge of talking about diet. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X616328.
5. Pataky Z, Makoundou V, Nilsson P, et al. Metabolic normality in overweight and obese subjects. Which parameters? Which risks? Int J Obes (Lond) 2011; 35(9): 1208–1215.

 

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Date: 2 Jan 2012
Topic: Response to ‘From the European Definition as an advocate not a steward/gatekeeper’
Comments by: Francesco Carelli, EURACT Director of Communications and Professor of Family Medicine, Milan, Italy

 

In her editorial, Clare Gerada describes, in this dismantling situation for family medicine, the progressive shift for GPs from an advocate to gatekeeper role.¹ This is true and dangerous.

 

The role of advocate in our situation has not legal but medical roots, opposite thinking from John Matthews.² It comes directly from the European Definition where GPs’ characteristics contain comprehensiveness, community orientation, and holism (a biopsychosocial approach).³ So, nothing to do with legal roots but the real medical roots.  Advocacy in this context is not separated from decision making, on the contrary, the GP must be the advocate in the sense to stay by their patients, making decisions together with their patients in a difficult bureaucratic and cutting system. Just recently in the WONCA European Definition the characteristic of patients’ empowerment was added in all its significance.

 

It does not make sense for GPs to spend their time negotiating contracts with managers and hospitals, and even less to bear financial risk for their expensively ill patients, turning GPs into rationers of care and away from their professional role as patient advocates.

 

So, I totally agree with Clare Gerada’s editorial. She understands how this dismantling situation in primary care (where innovation is going to destruction and cherry picking patients away from their normal primary care provider, limiting referrals and treatments on financial rather than clinical grounds, and creating opportunities to control medical care before it is delivered, and creating perverse incentives) is really the transformation from human and clinical advocate to a cold gatekeeper, in this case for other and upper providers.⁴

 

I think all these will turn in a worsening of our role and the final assimilation by John Matthew with a steward (a gatekeeper even) is indicative how the situation is going to disrupt the  advocacy  just against our most important clients, our patients!

 

References
1. Gerada C. From patient advocate to gatekeeper: understanding the effects of the NHS reforms. Br J Gen Pract. 2011: 61(592): 655–656.
2. Matthews J. From patient advocate to gatekeeper: understanding the effects of the NHS reforms. Br J Gen Pract 2012: 62(594): 12.
3. Allen J, Gay B, Crebolder H, et al. The European definition of general practice/family medicine. Wonca Europe, 2002 and 2011.
4. vanWeel C, Carelli F, Gerada C. Reforming  primary care: innovation or destruction? Br J Gen Pract 2012: 62(594): 43–44.

 

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