Life stages topic guides

These Topic Guides each explore part of the RCGP curriculum, Being a General Practitioner.

Each Topic Guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of each clinical topic. It should therefore be considered in conjunction with other Topic Guides and educational resources.

They also contain tips and advice for learning, assessment and continuing professional development, including guidance on the knowledge relevant to this area of general practice.

Children and young people

This Topic Guide will help you understand important issues relating to the care of children and young people by illustrating the key learning points with a case scenario and questions.

The role of the GP in the care of children and young people

As a GP, your role is to: 

  • Provide the majority of care to children and young people in primary care. GPs are usually the first point of contact for the unwell child 
  • Be responsible for ensuring high quality evidence-based care for children and young people with both acute and chronic conditions, and demonstrating appropriate competence in child safeguarding 
  • Make every contact count, with opportunistic interventions during scheduled and unscheduled contacts in Primary Care 
  • Play a key role in coordinating truly holistic care through multi-professional conversations with services across health, social and educational sectors. This will have a crucial impact on the adult health and life chances of children and young adults1 
  • Identify and support at-risk children, and adolescents who may fall through the gaps in services, particularly in the context of safeguarding and mental health. Identify vulnerable children when seeing adult patients who have experienced their own health and social problems such as domestic violence or substance misuse.  

Emerging issues in the care of children and young people

The NHS has identified Child Health as a key area for education and training in General Practice. The role of the GP in commissioning, as well as coordinating services, has also recently been highlighted. Providing the best care for child health services requires collaboration between professionals. The traditional separation of primary and secondary care services needs to be replaced by multi-professional working across well-defined clinical sectors, enabling care closer to home. Integration with adult services is also a challenge, particularly in the context of mental health, drugs, alcohol, and safeguarding. The transition to adulthood is a time of risk and consideration should be given to health promotion in adolescence, which encourages greater autonomy and ownership of future health, for example diet, exercise, and obesity. Social determinants of health are particularly important in vulnerable sectors of society, especially with rising incidences of child poverty and inequality. GPs need to engage in reducing inequality of access to services and integrating health with social care.

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and a typical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care 
  • Prognosis 

The normal child

A very important element of child health in general practice is the recognition of the range of normality in physical, psychological and behavioural development. These include: 

  • Normal developmental milestones and assessment of development delay, including language, gross and fine motor and social development 
  • Normal growth including interpretation of growth charts 
  • Normal maturation including puberty 
  • Normality in the neonatal period including screening (for example, phenylketonuria, hypothyroidism, cystic fibrosis) 
  • Normality of physical development with normal variations (for example, orthopaedic variations such as genu valgus/varus and plagiocephaly) 
  • Normal development of emotional and psychological maturity and normal variation in childhood behaviour 
  • Awareness of norms and referral standards when undertaking Newborn and Infant Physical Examination Programme (NIPE) examinations

Symptoms and signs

A key feature of knowledge about child health is the interpretation of common symptoms and signs in different age ranges.  For example, back pain or abdominal pain in childhood, adolescence and adulthood are likely to have different underlying causes and natural histories.  This can have significant and potentially serious consequences if not fully recognised when considering differential diagnoses. 

Attention should also be paid to specific paediatric themes, such as: 

  • Behavioural problems 
  • Developmental problems 
  • Faltering growth 
  • Features of the acutely unwell child including fever, rashes, irritability, breathing and circulatory signs 
  • Mental health problems including bullying, stress and suicide
  • Adolescents and Young people aged 10-25yr as a distinct group with respect to brain development, physiology and pharmacokinetics  
  • Adolescence as a developmental stage and its particular issues, in particular the importance of being opportunistic in assessing mental well-being
  • Gender identity issues. Lesbian, gay, bisexual and transgender (LGBT+) patients face inequalities in their experience of NHS healthcare

Common and important conditions

Many of the problems and diseases are classified by body system, reflecting the wide scope of general practice in the United Kingdom. There is inevitably overlap between system classifications and generic areas such as child health.

  • Early and undifferentiated presentations, and recognition of a seriously ill child (and urgent intervention when appropriate) 
  • Acute paediatric emergencies (for example, febrile convulsions, anaphylaxis, asthma, septicaemia, meningitis, surgical conditions) 
  • Urgent resuscitation in line with Resuscitation Council (UK) guidelines 
  • Appropriate acute and repeat prescribing and reviews  
  • Behavioural problems (for example, enuresis, encopresis, eating disorders, tantrums) 
  • Childhood infections including exanthemata (for example, mumps, measles, rubella, chickenpox, herpes simplex, parvovirus, Coxsackie, Kawasaki, and other infections listed under dermatological disorders below) 
  • Childhood malignancies (for example, leukaemias, lymphoma, brain tumours, retinoblastoma, neuroblastoma, nephroblastoma, sarcoma) 
  • Chromosomal disorders (for example, Down syndrome, Fragile X, Klinefelter's syndrome, trisomy 18, Turner's syndrome) 
  • Congenital abnormalities (for example, congenital heart disease, hypothyroidism, musculoskeletal, neurological abnormalities and sensory impairment) 
  • Dermatological disorders in childhood (for example, seborrheic dermatitis, atopic eczema, infections such as impetigo and fungal infections especially tinea capitis and kerions, alopecia areata, vitiligo and infantile haemangiomas) 
  • Diagnosis and management of diseases relating to children (for example, asthma, diabetes, epilepsy, respiratory infections such as pneumonia, bronchiolitis, croup) 
  • Disease prevention, well-being and safety including in the following areas:  
    • prenatal diagnosis; 
    • health benefits of breastfeeding; 
    • infant feeding, effective milk transfer, and breastfeeding substitute guidelines 
    • healthy diet; 
    • social and emotional well-being; 
    • immunization; 
    • smoking; 
    • avoiding the use of volatile substances and other drugs; and  
    • minimising alcohol intake 
  • Faltering growth and underlying causes, including ineffective intake (for example, due to lack of breast milk), chronic diseases (for example, cystic fibrosis, coeliac disease), chronic infection, non-medical causes such as abuse or neglect 
  • GI conditions that present in childhood (for example, appendicitis, Meckel's diverticulum, intussusception, malabsorption such as coeliac disease, cows' milk protein allergy, cystic fibrosis and the risks/treatment of iron deficiency. Inflammatory bowel disease and other chronic malabsorption conditions which might be confused with other conditions such as eating disorders)  
  • Immunisation in children (routine primary schedule and other immunisations, contraindications to immunisation) 
  • Learning disabilities in children (for example, cerebral palsy, disorders with developmental delay, autism, dyslexia, dyspraxia, autistic spectrum disorders including Asperger's syndrome) 
  • Behavioural and mental health problems (for example, attention deficit hyperactivity disorder (ADHD), depression, eating disorders, substance misuse and self-harm, autistic spectrum disorder and related conditions (see also RCGP Topic Guides on Mental Health and Alcohol and Substance Misuse). Risks and consequences of bullying including cyberbullying. 
  • Musculoskeletal problems relevant to children (for example, inflammatory arthritides (infective, autoimmune), osteochondritis, Osgood-Schlatter's, Perthes' disease, slipped epiphysis, injuries such as greenstick fractures, pulled elbow)  
  • Neonatal issues: 
    • Congenital abnormalities as above 
    • Feeding problems (breast and bottle feeding), gastro-oesophageal reflux, hypoglycaemia 
    • Jaundice (for example, breastfeeding, haemolytic and haemorrhagic disease of the newborn, biliary atresia) 
    • Respiratory problems (for example, respiratory distress syndrome, sleep apnoea) 
    • Skin disorders for example, birthmarks, erythema neonatorum, miliaria and neonatal acne) 
    • Complications of prematurity such as chronic lung disease, cerebral palsy 
  • Neurological problems relevant to children including seizures (for example, febrile convulsions, epilepsy and their overlap in presentation with cardiogenic causes), awareness of rare degenerative neurological diseases (for example, Rett's syndrome, Battens)  
  • Sleep physiology and pathology of sleep disorders in infants and adolescents 
  • Obesity in childhood: long term health effects and interventional strategies for weight reduction 
  • Poisoning: accidental ingestion, iatrogenic, overdose and deliberate self-harm, and deliberate harm by carers 
  • Renal diseases relevant to children (including recurrent urinary tract infections, structural anomalies posterior urethral valves, renal pelvic dilatation, haemolytic uraemic syndrome; nephrotic syndrome and glomerulonephritis) 
  • Safeguarding children: 
    • Recognition of non-accidental injury including physical, emotional and sexual abuse, and appropriate actions 
    • Maltreatment and neglect, parental problems including domestic violence and abuse, substance and alcohol misuse and mental health problems 
    • Recognising the significance if a child is not brought to an appointment and taking appropriate action 
    • Balancing children's rights and wishes with professional responsibility to keep children safe from harm 
  • Sex identity and intersex, appearance of genitals including fused labia, hypospadias, clitoral hypertrophy. Risk of Female Genital Mutilation 
  • Teenage pregnancy, risks of sexually transmitted infections, and Child Sexual Exploitation
  • Transitional issues from child to adolescent and from adolescent to adult. This applies to all children but especially those who are vulnerable such as those with gender identity issues

Examinations and procedures

  • Age-appropriate clinical examination and normal variation in biometrics 
  • Informed consent and assessment of competence 
  • Perform accurate measurements including peak flow and blood pressure 
  • Appropriate use of and techniques for venesection in children and young people
  • Indication and administration of injections and immunisations

Investigations

The decision to undertake investigations in children can be complex. It needs to take account of the emotional and physical impact in the context of the probability and possibility of detecting significant underlying disease. 

  • Appropriate investigations for common diseases need to be clearly understood (for example, asthma, urinary tract infection) 
  • Prenatal diagnosis including screening available in UK for disorders such as Down syndrome, spina bifida, and structural defects (for example congenital heart disease, renal tract abnormalities) 
  • Liaison with specialist colleagues when considering invasive or complex investigations and their correct interpretation 
  • Appropriate use of sedation and pain relief and managing anxiety of the child undergoing investigative procedures

Service issues

  • Respect for the sensitivities of young people regarding their health attitudes, behaviours and needs; impact of attitudes to treating children and young people equitably, with respect for their beliefs, preferences, dignity and rights; issues of confidentiality and consent and sharing information with other agencies  
  • Appropriate autonomy and involvement of children, carers and families in care-planning and delivery; Parental responsibility and who can make decisions for a child; confidentiality balanced with the parents' need for information and shared decision-making with you as their GP, and awareness of the legal framework for consent in children and young people  
  • Prevalence and incidence of illness in the community and the specific circumstances of the patient and family; health care needs of the paediatric population of your community and the socio-economic and cultural features that might affect health  
  • Workload issues raised by paediatric problems (for example, the demand for urgent appointments and the mechanisms for dealing with this) 
  • Organisation of care, including care pathways and local systems of care; child-focussed clinical governance and risk management such as safety of treatment and care, safeguarding, the use of evidence-based practice, clinical audit, effective prescribing and referrals  
  • Multiagency working (working across professional and agency boundaries) and the principles of information sharing, including the role of the health visitor in child health surveillance 
  • Appropriate use of referrals. Co-ordination of care with other primary care professionals, paediatricians and other appropriate specialists, leading to effective and appropriate care provision
  • Taking an advocacy position for the child, young person or family when needed, balancing the child's rights and wishes with the professional responsibility to keep them safe from harm. This will include complex situations such as safeguarding issues and end-of-life care  
  • Information, advice and support to enable them to manage minor illnesses themselves, using community pharmacists and triage services where appropriate and access appropriate services when necessary 
  • Legal and political context of child and adolescent care. Delivering services for young people relating to access, communication, confidentiality and consent

Additional important content

  • Childhood immunisation schedules. These should be kept under review as they can frequently change
  • Communication skills specific to child and adolescent health and 'three-way consulting' (consulting with both parent and child); recognition and assessment of behaviour as a form of communication; recognition of the importance of seeing adolescents alone; use of tools for structured psychological assessment in adolescents such as HEADSS 
  • Prescribing and advising appropriately about the use of medicines in newborn, children and young people, being competent at calculating drug doses, understanding the risks and benefits of medicines in relation to children, and cultural differences in beliefs about illness and the use of medicines. Best evidence in clinical management and prescribing of medicines for children and licensing implications 
  • Pain management in children  
  • Co-morbidities in the child, young person and family with additional vulnerability or special circumstances 
  • Access for young people to confidential contraceptive and sexual health advice services that are tailored to meet their needs

Case discussion

James, a 14-year-old boy, attends your morning surgery with his parents. On reviewing his record, you discover that he has been diagnosed recently with Juvenile Idiopathic Arthritis (JIA) affecting both his knees and hips.  

His parents are seeking further information from you regarding the condition, management and prognosis, as the shock of the diagnosis during their initial hospital consultation meant that they could not take in much information at the time of diagnosis. James asks you if the illness will affect his ambition to become a professional footballer – before he became unwell, he had just been selected to play for the county junior team but is now struggling to walk because of his joint pain. James' parents tell you they have stopped him from playing any sport, fearful he will damage his health. 

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.  

 

                              Core Competence           
                         Questions                          
Fitness to practise  
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
What are my own personal values and assumptions regarding this young person's diagnosis and how might these affect my judgements and behaviours? 

How would I manage a family complaint if they were unhappy with my support? 
Maintaining an ethical approach 
This addresses the importance of practising ethically, with integrity and a respect for diversity. 
What happens if there is a conflict between the child's and parents' wishes? What are the ethical dilemmas? 
Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 
How might I adapt my consultation to take account of the differing needs of James and his parents? 

How confident am I in explaining prognosis? 

Which consultation models would help to improve my skills in managing this case? 
Data gathering and interpretation
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 
How should I investigate early childhood arthropathy? 

Could there be a genetic element to this?  

What is the prevalence of early childhood arthropathy in primary care? 

Could I detect an arthropathy at an earlier stage?  

What do the terms 'sensitivity' and 'specificity' mean in the interpretation of laboratory investigation? 
Clinical Examination and Procedural Skills
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 
What investigations such as blood tests would be appropriate to undertake in primary care? 

How do you assess functional impairment in this age group? 
Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 
How would I diagnose and manage JIA (perhaps bringing in the principle of recognising acutely ill children/rare diseases)? 

Should I advise James to stop playing football? 
Clinical management
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches.
How confident am I to prescribe in this age group?  

How does JIA present? 

How do I manage patients in the long term? 
Managing medical complexity  
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation.
What are the risks of prescribing and monitoring disease modifying drugs in primary care? 

How will care be coordinated with other professionals in the practice and in other services? 

Would any other interventions be helpful for James at this stage? 
Working with colleagues and in teams  
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development.
Which other members of the multidisciplinary team would I involve (for example, school nurses, faith organisations, psychologist and family counsellors)? 

How can I work with my local paediatric services to manage a child with newly diagnosed JIA? 

How do we coordinate care and maintain shared responsibility rather than simply handing over care to the specialist team? 
Improving performance, learning and teaching  
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
What mechanisms exist in my practice to ensure that I am kept up to date with a diagnosis of JIA?  

Should I be doing more to promote an awareness of JIA in my clinical practice and how do I do this?  

How might resource constraints prevent me from providing the best-quality care to patients with this diagnosis? 

What might be important to consider when thinking about managing long-term illness in a child? 
Organisational management and leadership 
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
What mechanisms are in place in my practice to ensure that JIA patients and their relatives are reviewed on a regular basis? 

How might I use my leadership skills to act as an advocate for James?  
Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 
How do I plan to follow up James and his family? 

How might I manage the psychological impact of his disease on James and his family? 

How can I manage issues around potential school absence? 

How do I manage the James' and his parents' ideas, concerns and expectations? 
Community orientation  
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare.
Which voluntary sector and support organisations might be helpful to James and his family? 

What are the care services available in my area for children? 

What psychological support services are available locally to children and adolescents? 

Who can advise on benefits if one parent gives up working to become a 'carer'?   

How to learn this area of practice

Key knowledge areas in child health include child development (starting with normality), diagnosis of acute and serious illness, and prescribing for children. Be aware of your potential lack of knowledge around minor conditions commonly seen in the community, which you may not have previously encountered in hospital settings (good examples are molluscum contagiosum, ringworm and head lice). Many conditions may not require significant intervention and it is important to recognise normal childhood findings and know when to appropriately reassure parents. 

Work-based learning

Learning together to improve child health - A joint position paper on inter-professional training by the Royal College of General Practitioners and the Royal College of Paediatrics and Child Health (May 2016) suggests that trainees in general practice and paediatrics will gain from training in each other's environment, for example in joint primary care clinics. 

The focus of the clinics is around a sharing of ideas and learning in both directions. The GP trainee leads the consultation for some patients; in other consultations, the child health related experience of the Paediatric Specialty Registrar allows them to be the natural lead. This balance helps to foster a culture of peer-learning. 

Learning occurs on a number of different levels (for example, clinical management of the condition, public health aspects, health promotion, case management, working with primary care nurses, etc.).  

In addition to gaining experience and building competencies in consultation and clinical skills, these clinics gave trainees the opportunity to develop new insights and perspectives into the challenges and opportunities of seeing children and young people jointly within a primary care setting.  

Learning together in paediatric services

Appropriate management of emergencies supported by focused learning allows acquisition of skills and some confidence in this area.  

Community-based paediatrics offers a great opportunity to learn about a wide range of conditions ranging from the long-term needs of the child with complex problems, to safeguarding, neurodisability and health promotion.  

Learning with other healthcare professionals

Much of the care of children in the NHS is provided by nurses, health visitors, social workers, pharmacists, physiotherapists and many others. Learning arises directly from clinical contact with these professionals – such as with midwives delivering antenatal and postnatal care, health visitors visiting children at home, or with specialist nurses managing young patients with chronic diseases. Many hold skills which should at least be understood by the doctor and not infrequently acquired in the context of multi-professional learning.  

The shared experience of training and learning encourages better communication and working relationships between the members of the health care teams and will create better health care outcomes.  

Structured learning

The RCGP and RCPCH provide a selection of courses across the UK in both child and adolescent health, including child health issues, child protection, immunisation and child development. This will stimulate reflection on real cases seen in your work and help you as a professional to develop the knowledge, skills and attitudes required for high-quality, collaborative care.  

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Recognition of normal stages of child development 
  • Current immunisation schedules  
  • Shared protocols for treating ADHD with methylphenidate 

Clinical Skills Assessment (CSA)

  • A 15-year-old girl requests the contraceptive pill 
  • Phone call: a health visitor is concerned about the welfare of a baby in a vulnerable family. You are due to see the baby's mother later that day. 
  • A mother expects her three-year-old son to be potty-trained and wants to discuss why he is not

Workplace-based Assessment (WPBA)

  • Case-based Discussion (CbD) about a mother who is very emotional about her young son's diagnosis of a brain tumour when he is also in the room 
  • Log entry reflecting on a consultation with a teenager who appears uncooperative  
  • Log entry about attending and contributing to a case conference for child safeguarding  
  • Clinical Examination and Procedural Skills (CEPS) demonstrating a competent 6-week baby check.  

References

1 Commissioning a good child health service. RCGP Publications. 2013 


People with long term conditions including cancer

This Topic Guide will help you understand how to provide care for people with long-term conditions, including those living with and beyond cancer, by illustrating the key learning points with a case scenario and questions.

The role of the GP in caring for people with long-term conditions including cancer

As a GP your role is to: 

  • Work with patients, their families and carers in a collaborative manner that supports patient activation; encouraging individuals to develop the knowledge, skills and confidence to take an active role in their own self-care 
  • Work collaboratively with people living with long-term health conditions to agree goals, identify support needs, develop and implement plans, and monitor progress 
  • Move away from a disease-based model of care towards a person-centred system that takes a biopsychosocial approach, considering each person and their family holistically 
  • Involve the whole Multi-Disciplinary Team (MDT) to facilitate person-centred approaches to care, including the systematic gathering of information about an individual’s personal experience of living with their conditions and an organisational approach to collaborative care and support planning 
  • Proactively encourage lifestyle changes that will reduce the risk of other health problems in those who have already developed long-term conditions, cancer or multi-morbidity. 

Emerging issues in caring for people with long-term conditions, including those living with and beyond cancer

The increasing number of people living with long-term conditions is one of the biggest challenges facing our health and social care systems. GPs have a vital role to play in caring for those living with long-term health conditions and supporting those who care for them.  

The increasing health burden of single and multiple long-term conditions has created the need for improved prevention and proactive models of care. It also highlights why and how people should be given greater control of their own care and the importance of breaking down the barriers to how care is accessed and provided. GPs must become familiar with evidence-based techniques and processes to enable this within their everyday practice and their teams, such as Collaborative Care and Support Planning (CC&SP).1 

Around half of those people in the UK found to have cancer today will live for at least 10 years after diagnosis.2 As cancer survival rates in the UK improve, new healthcare challenges are emerging. GPs need to recognise and address the ongoing needs of the growing number of people living a substantial part of their lives with and beyond cancer. The role of the GP is wide-ranging and spans the management of physical, social and psychological factors, from healthy lifestyle promotion and help with financial problems through to dealing with fatigue and detecting recurrence of disease. 

The provision of truly person-centred care for patients with long-term conditions and cancer requires a whole-system approach. For this to be successful there needs to be: 

  • Engaged, informed individuals and carers 
  • Health and care professionals committed to partnership working 
  • Organisational and supporting processes in place 
  • A whole system approach which is broader than ‘medicine' alone 

Knowledge and skills guide

A long-term condition is defined here to mean any medical condition that cannot currently be cured but can be managed with the use of medication and/or other approaches and therapies.

This is in contrast to acute conditions which typically have a finite duration, such as an upper respiratory tract infection. There are likely to be many different interpretations of what constitutes a long-term condition. Ultimately, the best means of defining what is and isn't a long-term condition, and making decisions about care requirements, is as part of a conversation between an individual and their healthcare professional. 

In relation to the care of people with long-term conditions and those living with and beyond cancer, consider the following areas within the general context of primary care:

  • The natural history of the untreated condition(s) including whether acute or chronic
  • The prevalence and incidence across all ages and any changes over time
  • Typical and atypical presentations
  • Recognition of normal variations throughout life
  • Risk factors, including lifestyle, socio-economic and cultural factors
  • Diagnostic features and differential diagnosis
  • Recognition of 'alarm' or 'red flag' features
  • Appropriate and relevant investigations
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care and, chronic disease monitoring
  • Patient information and education including self-care
  • Prognosis 

For people with long-term health conditions, the interactions between and cumulative effects of multiple conditions, treatments and therapies must be considered, as well as the needs of the individual and their carers/relatives based on their circumstances. These interactions bring additional complexity to care, beyond the biomedical aspects of the specific health conditions.

Common and important conditions

Long-term conditions cover a wide range of health conditions (see definition above), including but not limited to any condition or combinations of conditions in the categories listed below: 

  • Non-communicable diseases (for example, cancer and cardiovascular disease); 
  • Communicable diseases (for example, Human Immunodeficiency Virus (HIV) / Acquired Immunodeficiency Syndrome (AIDS)); 
  • Certain mental health disorders (for example, schizophrenia, depression) and
  • Ongoing defined impairments (for example, blindness, musculoskeletal disorders)

Examples of common long-term physical health conditions include: 

  • Diabetes 
  • Cardiovascular (for example, hypertension, angina) 
  • Chronic respiratory (for example, asthma, Chronic Obstructive Pulmonary Disease (COPD)) 
  • Chronic neurological (for example, Multiple Sclerosis) 
  • Chronic pain (for example, from arthritis) 
  • Other long-term conditions (for example, Chronic Fatigue Syndrome, Irritable Bowel Syndrome (IBS), cancer) etc. 

Consider the following areas in the context of long-term conditions and cancer: 

Natural History of the Condition(s)

  • Different trajectories of illness commonly seen in long-term conditions and cancer. These take many forms, but common trajectory patterns include stepwise (for example vascular dementia), exacerbations (for example COPD), gradual decline (for example frailty) and relapse/recurrence (for example breast cancer).
  • Conditions which may become chronic through treatment or through the natural process of the disease

Service Issues

  • Whole system approaches to care, including integrated care models with GPs working in multidisciplinary teams alongside secondary care, social care and others 
  • Active identification, surveillance and follow up 
  • The importance of continuity of care within organisations, teams and with individual health professionals 
  • The important role of third-sector providers (such as voluntary organisations, community groups and social enterprises) which can provide tailor-made support and interventions for people with certain long-term conditions (LTCs) 
  • Identifying and supporting unpaid carers of people with long-term conditions 

Multi-morbidity

Multi-morbidity refers to the presence of two or more long-term health conditions. This includes physical and mental health conditions, ongoing conditions (for example learning disability), symptom complexes (for example frailty or chronic pain), sensory impairment (for example sight loss) and alcohol and substance misuse. In patients with multi-morbidity, consider: 

  • Opportunistic and proactive identification of polypharmacy and multi-morbidity 
  • Reducing the burden of multi-morbidity and treatment, including appointments, on the quality of life of the patient and their carers/family 
  • The possibility of coexisting mental illness such as depression and anxiety 
  • The possibility of one or more long term conditions disguising other conditions including cancer 
  • The patient's needs, preferences, priorities and goals including the role of carers and family 
  • Providing whole person care taking into account a patient's social, mental and physical wellbeing
  • The benefits and risks of guidelines addressing single health conditions 
  • The benefits of an agreed personalised management plan to coordinate care 

Cancer

One in two people in the UK now develop cancer at some point in their lifetime, and GPs play a vital role in preventing, diagnosing and caring for people with cancer. For examples of references to cancer across the whole curriculum, please see the Cancer in the Curriculum: Map. 

Cancer in the curriculum diagram

Living with and beyond cancer

More patients are living with and beyond a cancer diagnosis (cancer survivorship) and as a result live with the long-term effects of cancer and its treatment. These effects are wide-ranging and include, but are not limited to: 

  • Physical (for example long-term effects of surgery, chemotherapy, radiotherapy, hormone treatment, etc.) 
  • Psychological (for example adjustment, depression, anxiety, post-traumatic stress) 
  • Financial (for example loss of own/partner’s job, costs of care, costs of unfunded treatments)
  • Social (for example loss of role, educational impacts, relationship breakdowns) 

Other important issues include: 

  • The recognition of signs and symptoms of recurrence and relapse 
  • Continued health promotion relating to future cancer and other health risks 

Collaborative Care and Support Planning

The RCGP has endorsed Collaborative Care and Support Planning as an effective approach to increase patient activation, health literacy and self-management whilst improving some patient outcomes and health professionals' job satisfaction.

Care and Support Planning (CSP) is a systematic process, which replaces current planned reviews for people with long term conditions, and is focussed on a 'better conversation' between the person with LTC/s and a healthcare professional, enabled by preparation. The CSP begins with an information gathering appointment in which tasks and tests are collected ahead of the CSP conversation. The results of any information gathered, together with reflective prompts, are sent to the person 1- 2 weeks before the CSP conversation (preparation). The CSP conversation itself has a solution-focussed and forward-looking approach which acknowledges the experience and expertise of the patient and brings together traditional clinical issues with what is most important to the individual, supporting self-management, coordinating complex care and signposting to social prescribing. Organisational processes, practice care pathways and staff/team roles and support are redesigned to achieve this.

To apply this approach successfully, a GP requires a working knowledge of: 

  • The benefits of the Collaborative Care and Support Planning process 
  • The factors influencing the relationship and dialogue between the professional and the person/carer and the core principles of communication (for example a partnership approach, goal setting and action planning) 
  • The factors that should be considered in care planning (for example multi-morbidity, support networks, cultural background) 
  • The phases of the care planning process 
  • The ethical and legal issues (for example autonomy, consent and capacity) 
  • The issues around personal budgets and personal independence payments 
  • The organisational barriers to effective Collaborative Care and Support Planning and how these impact on quality of care, including:
    • Limitations on the time available in GP appointments
    • Local/national policies and targets 
    • Public sector funding policies, in particular those relating to health and social care 
    • Local policies (for example the management of Individual Funding Requests and how this differs in the four UK nations) 
  • Shared decision-making processes and their application to select tests, treatments, management or support packages, based on clinical evidence and the patient's informed preferences 
  • Tools which can be used to measure the spectrum of skills, knowledge and confidence of individuals and the extent to which they feel engaged and confident in taking care of their condition (for example the Patient Activation Measure (PAM)) 
  • Techniques and frameworks for enabling behaviour change and their application to interactions with patients with diverse backgrounds (for example Health Coaching).

Case discussion

Rose is 72 years old and has osteoarthritis, Type 2 diabetes and COPD. She is cared for by her daughter, but Rose also takes significant responsibility caring for her grandson, who has behavioural difficulties.

Rose's daughter makes an appointment with her GP, Dr Patel, because Rose's breathing has been 'a bit up and down'. Rose understands the importance of controlling her medical conditions but finds it hard to prioritise this when her daughter and grandson also need her support. During the consultation, Dr Patel notices that Rose's mood seems low, but the limitations of the 10-minute consultation mean she is only able to discuss this briefly.

Six months later Rose sees a different GP, Dr Price. Dr Price discovers that Rose frequently attends for emergency appointments and has missed her last two routine reviews because she had to look after her grandson.  After surgery, Dr Price speaks with Dr Patel about how they can best help Rose. Their practice is implementing Collaborative Care and Support Planning, and both agree that Rose could benefit from this approach and they identify one of the team to act as Rose's Care Coordinator.

The Care Coordinator contacts Rose and books two appointments at times convenient for her. During the first appointment, a Health Care Assistant collects all the information required in advance of the second appointment and performs relevant tests.

Rose and her daughter both attend the second appointment with Dr Patel. This is a 30-minute care planning appointment. Dr Patel facilitates the conversation to help them prioritise their goals and targets for the next year. Rose admits her mood has been low for many months and that improving her mood is her first priority and this would help her to better look after her grandson and manage her other health problems.

Dr Patel explains that a local talking therapies service is now available and Rose decides to try this. Rose feels that her breathing is currently manageable, so they make a shared decision to focus on her diabetes.

Dr Patel generates a Care Plan which Rose can take home with her. They agree on a convenient time for a follow up appointment.

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive. 

                                    Core Competence      
                              Questions                            
Fitness to practise    
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients.  How do I feel about relinquishing control to my patients? 

How will I manage my own emotions and involvement with the intensity and intimacy of long appointments? 

How would I deal with the frustration of patients who do not follow through with their own goals and actions? 
Maintaining an ethical approach 
This addresses the importance of practising ethically, with integrity and a respect for diversity. 
How do I ascertain how much information Rose is happy for me to share with her daughter or with other agencies? 

How might the approach change if Rose suffered from dementia? 

How might individuals of different ages and cultures respond to this approach which shifts the balance of power towards the patient? 
Communication and consultation
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 
How can I encourage Rose to lead the conversation in defining her own goals and targets? 

How can I encourage self-management? 

What might be the impact of third-parties on the consultation?  
Data gathering and interpretation
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 
What information should be collected during the initial collaborative care and support planning consultation? 

How can we support Rose in interpreting information to best aid decision making? 
Clinical Examination and Procedural Skills 
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 
What structured tools am I able to utilise in assessing anxiety and depression?  

Can I accurately perform and interpret FEV1 measurements? 
Making decisions
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 

How can we support Rose's autonomy in decision making? 

How can I ensure that Rose remains the priority when her daughter is also in the room?  
Clinical management 
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 
How do I balance the patient's wishes with what I perceive to be medical priorities in management? 
Managing medical complexity
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation.
Thinking about similar patients, how do I assist a patient in managing the psychological burden of chronic disease and cancer?  

How do I make a holistic, whole person approach to disease management work in a specialism driven secondary care system? 
Working with colleagues and in teams  
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 
How can I ensure collaboration between different agencies including health, social and the voluntary sector? 

How can I effectively communicate this process with patient groups? 

How could I best involve other primary care professionals in the collaborative care and support planning process? 
Improving performance, learning and teaching  
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
What training will I and other professionals require to deliver patient-centred care? 

How can I improve my knowledge of local services to support patients and their families? 

How might I evaluate my current care for people with long-term conditions and audit the impact of a more structured and collaborative approach?  
Organisational management and leadership 
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
How can I involve patients and carers in service redesign?  

What are the advantages and potential challenges of involving patients in the design of the process? 

How can I use my clinical leadership skills to bring about improved care for people with long-term conditions? 

How do I overcome the barriers to changing my practice's current approach? 
Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 
How do I support the patient's family? 

What impact would Rose's social circumstances have on her health and wellbeing? 

When is it appropriate to involve a patient's relatives?  

How might I manage concerned relatives who take control of the conversation away from the patient? 
Community orientation
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 
How can my team balance the requirement for availability of appointments with the need for longer appointments? 

How can I support the provision of community based services to support healthy living? 

How do I balance the needs of patients with long-term conditions against the wider issue of limited NHS resources? 

How to learn this area of practice

Work-based learning

As a GP, you should develop a flexible partnership-based approach, to agree shared goals, identify support needs, develop and implement action plans, and monitor progress.

To be effective as a GP, you should become familiar with approaches to enable better health and wellbeing outcomes for these patients, including the Collaborative Care and Support Planning process. This should include leading and working within the multi-disciplinary team to implement and facilitate the process for the benefit of patients and their families/carers.

It is also important to reflect on positive and negative experiences recounted by patients with long-term conditions and use this to consider how your own practice and attitudes as a clinician impact on these experiences.

You should get actively involved in cancer care reviews, health promotion and recurrence detection. Follow up patients with a new cancer diagnosis to ensure continuity of care and in order to understand their journey through the cancer care pathway – including the effects that the diagnosis, the disease and treatments have on them and their family.

Self-directed learning

You can find e-Learning module(s) relevant to this Topic Guide at e-Learning for Healthcare.

There are many structured courses available to facilitate the delivery of Collaborative Care and Support Planning. Related to this, the Year of Care partnership is a quality assured national programme offering a range of support and training options including many resources to support all elements of the House of Care.

National voices have produced a guide to care and support planning to help healthcare professionals and people with need to understand and take part on the process whilst NHS England has released a handbook aimed at commissioners and care practitioners to set out what personalised care and support planning is, and how to deliver it.

Cancer

MacMillan Cancer Support

downloadable booklet outlining the long-term consequences of cancer treatment. 

RCGP Toolkits

The RCGP toolkits are regularly updated.

Collaborative Care and Support Planning (CCSP)

RCGP – Collaborative Care and Support Planning

RCGP endorses CC&SP as core business for general practice highlighting that it is an effective way to manage multi-morbidity. It has published a number of documents outlining specific recommendations and supporting commissioners and practices to implement CC&SP as a tool for supporting people with long-term conditions.

Coalition for Collaborative Care

The Coalition is an alliance of people and organisations committed to making personalised care and support planning the norm as a means by which people can be full partners with health and care professionals. 

The King's Fund

The King's Fund has published many papers on CC&SP including one describing a co-ordinated service delivery model – the 'house of care' – that aims to deliver proactive, holistic and patient-centred care for people with long-term conditions

Think Local Act Personal (TLAP)

TLAP have developed a range of materials to support councils and other people and groups to put the Care Act into practice. The Personalised care and support planning tool formed part of this. 

NHS England

NHS England has published a series of handbooks for commissioners and care practitioners setting out what personalised care and support planning is and how to deliver it.  

Person-centred care and shared decision-making

The Health Foundation

The Health foundation has developed a 'person-centred care resource centre' which provides a starting point for planning and funding (commissioning) shared decision making and self-management support

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Risk of second malignancies after treatment for cancer 
  • Prescribing in patients with multi-morbidity 
  • Entitlement to statutory benefits

Clinical Skills Assessment (CSA)

  • Man who had leukaemia as child, attends frequently for apparently minor conditions 
  • Woman with Ehlers-Danlos syndrome is struggling to manage her work as a primary school teacher  
  • Home visit to a bedbound woman with a spinal injury who has become mildly confused. She has had treatment for repeated UTIs. 

Workplace-based Assessment (WPBA)

  • CbD (Case Based Discussion) with a woman who cares for her frail elderly blind father with dementia, who is also your patient. She is asking for your help as she can no longer cope with him 
  • Learning log on a man living in a nursing home on dialysis who wants to stop treatment 
  • Learning log on a young adult with cerebral palsy who has epilepsy. 

References

NHS Data Dictionary

1 RCGP toolkits
2 Macmillan Cancer Support. Living with and Beyond Cancer 


Maternity and reproductive health

This Topic Guide will help you understand important issues relating to maternity and reproductive health by illustrating the key learning points with a case scenario and questions.

The role of the GP in maternity and reproductive health

As a GP, your role is to:  

  • Provide pre-conception advice and endeavour to optimize the health and wellbeing of women trying for pregnancy 
  • Work with midwives to provide antenatal care including routine antenatal care, and shared care with secondary care for more complicated pregnancies 
  • Provide postnatal care including support for breastfeeding, post-natal monitoring and medication management, detection and management of post-natal physical and mental health problems, and postnatal contraception 
  • Provide care for medical problems that are present in pregnancy – this may include physical or mental long-term health conditions that may pre-date the pregnancy, or that develop during pregnancy 
  • Provide care and support for women, and their partners, affected by pregnancy loss and infertility

Emerging issues in maternity and reproductive health

  • Increasing numbers of women are putting off having a child until later in their reproductive years. In addition to reduced rates of fertility, advancing maternal age is associated with an increased miscarriage risk and a higher risk of pregnancy complications 
  • Smoking, obesity and lack of exercise remain large, modifiable, risk factors for a range of poor pregnancy outcomes 
  • The diminishing role of the GP in routine antenatal care provides challenges in ensuring women receive continuity of care from pre-pregnancy through to after delivery. This is a particular challenge in relation to providing holistic care for women with underlying medical, psychological or social difficulties where the GP's knowledge of the wider situation can be invaluable. Good information sharing between GPs and other health professionals is essential in these circumstances 
  • The delegation of routine antenatal care to midwives is leaving many GPs with reduced experience of caring for pregnant women 
  • Developments in antenatal testing including pre-implantation genetic screening and Non-Invasive Prenatal Diagnosis (NIPD)

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care:  

  • The natural history of the untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care 
  • Prognosis 

Symptoms and signs

  • Normal pregnancy symptoms and signs 
  • Abnormal pregnancy symptoms and signs, including abnormal abdominal palpation (fetal size and lie), bleeding, hyperemesis, pain (abdominal or pelvic), pre-eclampsia symptoms and signs, pre-term labour, reduced fetal movements, symptoms of venous thromboembolic disease, symptoms suggestive of exacerbation of co-existent medical conditions 
  • Perinatal mental health symptoms 
  • Postnatal symptoms including abnormal bleeding and symptoms of breastfeeding problems 

Common and important conditions

  • Perinatal mental illness (PMI) including adjustment disorders, antenatal depression, baby blues, chronic mental illness in the perinatal period, OCD, paternal PMI, postnatal depression, post-partum psychosis, post-traumatic stress disorder and tokophobia 
  • Pre-conception care and advice including health promotion advice (for example, smoking cessation and weight loss), medication adjustments, optimisation of pre-existing medical conditions, rubella immunisation, supplementation 
  • Pregnancy with social complications – such as domestic violence, drug and alcohol misuse, homelessness, safeguarding concerns, teenage pregnancy 
  • Prescribing pre- and perinatally, including teratogenesis

Antenatal care

  • Principles and guidelines for routine antenatal care including recommended supplements, dietary and lifestyle advice, immunisation in pregnancy 
  • Antenatal screening for fetal and maternal conditions  
  • Pregnancies complicated by pre-existing medical conditions including asthma, cancer, cardiac disease, diabetes mellitus, epilepsy, hypertension, HIV infection, mental health conditions, obesity, thyroid disease and venous thromboembolism 
  • Indications for aspirin prophylaxis 
  • Antenatal complications, such as: 
    • Bleeding and pelvic/abdominal pain in pregnancy 
    • Congenital abnormalities 
    • Early pregnancy loss: miscarriage, ectopic and molar pregnancy 
    • Growth problems: abnormal symphysial fundal height 
    • Haematological problems for example, haemoglobinopathies (including sickle cell disease and thalassaemia), haemolytic disease (including rhesus incompatibility and prophylaxis) and thromboembolism 
    • Infections for example, urinary tract infection, asymptomatic bacteriuria, group B streptococcus, chicken pox, chorioamnionitis cytomegalovirus, hepatitis, herpes simplex, HIV, listeria, parvovirus and rubella 
    • Intrauterine death and stillbirth 
    • Mal-presentation including breech and transverse lie 
    • Metabolic problems arising in pregnancy for example hyperemesis, gestational diabetes, jaundice, obstetric cholestasis 
    • Multiple pregnancy 
    • Pregnancy induced hypertension, pre-eclampsia and eclampsia 
    • Reduced fetal movements

Delivery

As a GP you should understand this aspect of maternity care and women's experiences of the common types of delivery, but in general a GP is not expected to be able to provide intra-partum care. 

  • Normal labour and common problems of labour including premature labour, prolonged pregnancy, induction of pregnancy 
  • Caesarean sections: indications and associated complications, options for subsequent deliveries including vaginal birth

Postnatal care

  • Normal postnatal care including routine 'neonatal examination' and 'maternal six-week check' 
  • Infant feeding including breastfeeding. (Please also see Topic Guide on Children and Young People) 
  • Postnatal problems including breastfeeding problems, bladder and bowel problems, mental health problems, retained products, uterine infection, wound problems. 
  • Providing contraception advice postnatally and after pregnancy loss. 

Unwanted pregnancy and termination of pregnancy are covered in the RCGP Topic Guide Sexual health.  

Examinations and procedures

  • Antenatal examination including abdominal palpation, assessment of symphysial fundal height and fetal heart rate, blood pressure and urinalysis

Investigations

  • Pregnancy investigations, including: 
    • laboratory tests to evaluate gestational diabetes, obstetric cholestasis and pre-eclampsia
    • screening and prenatal diagnosis for congenital abnormalities including: 
      • amniocentesis and chorionic villus sampling
      • antenatal screening including triple test, quad test, nuchal test, haemoglobinopathy screening and anomaly ultrasound scan
    • tests for infection including asymptomatic bacteriuria, HIV, syphilis
    • ultrasound for dating, growth and fetal well-being; and 
    • urinary and serum β-HCG  
  • Primary care investigation of female subfertility including blood tests and ultrasound
  • Semen analysis

Service issues

  • Local arrangements for fertility treatments, antenatal care and delivery including shared care with midwifery services and with secondary care 
  • Local services to support women who are breastfeeding 
  • Local support and services for women with perinatal mental health problems, including strategies to identify these women 
  • Maternity rights, benefits, schemes and associated administration for example, Healthy Start, MatB1, maternity exemption from prescription charges 
  • Safeguarding of unborn children and neonates 
  • Screening for domestic and intimate partner violence in the context of antenatal care 
  • Strategies to reduce teenage and unplanned pregnancies 

Case discussion

Sabrina is a 40-year-old mother of five girls who comes to see you to tell you that she has found out she is newly pregnant with her sixth child. She has type 2 diabetes and has a BMI of 42. She speaks poor English and her husband translates for her. He tells you she is 'fine' except for some achy joints and asks how soon they can find out the sex of the baby. Saleem looks downcast and close to tears. Her medical records show that she had an emergency caesarean at her last delivery due to fetal distress. The health visitor had suspected that she suffered from post-natal depression after this child was born and arranged for Saleem to see you when the baby was two months old, but despite your best efforts to explore this she was very reluctant to talk to you about how she was feeling.  

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.  

 

                      Core Competence               
                                  Questions                                    
Fitness to practice
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
If I or my partner are personally struggling with infertility or recurrent miscarriage, how would I react when consulting women for whom getting pregnant seems easy, or who have an unwanted pregnancy? 
Maintaining an ethical approach
This addresses the importance of practising ethically, with integrity and a respect for diversity. 
How do I explore the couple's reasons for wanting to know the gender of the baby How do I react to families from cultural settings where female babies are less valued than males? 

How do I respect a patient's choice not to discuss personal matters such as their emotions with me? How do I know when to press them harder on this and when to step back? 
Communication and consultation
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 
What are the issues around use of interpreters, particularly if they are a family member or intimate partner? 

What alternative interpreting services are available in my locality? 

How can I develop my non-verbal communication skills? 

How do I explore the couple's reasons for wanting to know the gender of the baby? 
Data gathering and interpretation  
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 
How do I assess her diabetes control? 

How do I try and assess whether or not she is depressed? What tools can I use for screening for postnatal depression? 
Clinical Examination and Procedural Skills 
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 
How do I assess the gestation of a pregnancy? 

Am I proficient at carrying out a routine ante-natal check? 
Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 
What would make me decide I needed to arrange to see Sabrina without her husband present? How would I communicate this to them? 
Clinical management 
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 
What do I know about the management of diabetes in pregnancy? How can I advise her on this at the initial consultation? 

What pre-conception advice should be given to women with diabetes planning a pregnancy? 

What are the local arrangement for care of pregnant women with diabetes? 

What are the local guidelines on delivery for women who have had a previous caesarean section? 
Managing medical complexity
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation.
 How do I manage her multiple risk factors for pregnancy complications? 

How do I address my concerns that this baby might be at risk of gender-based abortion? 

How do I evaluate whether her 'achy joints' may have an underlying physical cause or whether they might be somatisation? 
Working with colleagues and in teams
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 
How do I ensure Sabrina has co-ordinated care with community teams including GPs, midwives, health visitors and secondary care antenatal services?  

How do I raise any safeguarding concerns that might relate to this pregnancy? 
Improving performance, learning and teaching 
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
How do I keep up to date with the latest guidelines and recommendations for conditions that I might see infrequently (such as diabetes in pregnancy)? 

How do I maintain my skills in providing antenatal care for uncomplicated pregnancies when it is increasingly common for women to be cared for almost exclusively by midwives? 
Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 

How does my organisation ensure that all women who are of child-bearing age and have diabetes receive appropriate pre-conception advice? 

What are the different systems of record keeping used in antenatal care and how are they co-ordinated? 

Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 
How can we promote mental and physical well-being in the perinatal period?   

How can we tackle the stigma around perinatal mental illness? 

How much do I understand about different cultural attitudes to childbearing? 
Community orientation 
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 
What services are available locally to support women struggling with perinatal mental health problems? 

In what ways can we develop services to help patients for whom English is not their first language? 

How to learn this area of practice

Work-based learning

Primary care placements are the ideal opportunity for a GP specialty trainee to learn how to manage maternity and reproductive health because it is where the vast majority of patients with these concerns are cared for.

Some GP specialty training programmes contain placements of varying length in obstetric and gynaecology units. These will give you exposure to patients with obstetric concerns including possibly experience in day assessment units or outpatient clinics for women with complicated pregnancies. It is also a good opportunity to observe deliveries including normal deliveries, assisted deliveries and caesarean sections.

Self-directed learning

Reproductive health is part of normal life experience for many specialty trainees and reflecting on your own, or family and friends, experiences of this area of health care can provide valuable insights. The RCGP Women's Health Framework is a library of educational resources and guidelines on women's health, including maternal health accessible to RCGP members and non-members. The RCGP have a perinatal Mental health toolkit

You can find e-Learning module(s) relevant to this topic guide at e-Learning for Healthcare and at RCGP Learning

Learning with other healthcare professionals

As a GP specialty trainee, it is essential that you understand the variety of services provided in the community. Working with community midwives will give an insight into community antenatal care. Health visitors have a key role to play in supporting women in the post-natal period and time spent shadowing them can give valuable insight into how they provide this support. Learning how to work with these professionals is an essential aspect of being able to provide holistic care.

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Primary care investigations for failure to conceive 
  • Prescribing in pregnancy and breastfeeding 
  • Routine antenatal screening tests

Clinical Skills Assessment (CSA)

  • Woman in early pregnancy requests an abortion. She describes risky sexual behaviours associated with alcohol 
  • Woman in stable same-sex relationship requests referral to the assisted conception clinic 
  • Woman who is 10 days postnatal attends with flu-like symptoms and a painful breast

Workplace-based Assessment (WPBA)

  • Case-based Discussion (CbD) about a woman who is Hepatitis B positive on routine antenatal testing and her husband is her only sexual partner 
  • Learning log on a couple who have had a recent stillbirth  
  • Clinical Examination and Procedural Skills (CEPS) – competent examination of a pregnant woman in the 3rd trimester of pregnancy

Older adults

This Topic Guide will help you understand important issues relating to the care of older adults by illustrating the key learning points with a case scenario and questions.  

The role of the GP in the care of older adults

As a GP, your role is to: 

  • Diagnose, investigate and manage older adults taking into account theories of ageing, differences in epidemiology and risk factors of disease in the elderly population. Consider the physical, psychological and social changes that may occur with age 
  • Communicate appropriately with patients, their families and carers, recognising potential challenges in communicating with older patients. When necessary, balance confidentiality with the need for information and shared decision making 
  • Coordinate with other organisations and professionals (for example community nurses, social services, rehabilitation, care homes, voluntary sectors) whilst taking an advocacy position for the patient or family when needed, including for palliative and end-of-life care planning 
  • Review medications and repeat prescriptions effectively, potentially working with pharmacists. Consider the factors associated with drug treatment in the older adult (for example changes to the physiology of absorption, metabolism and excretion of drugs and the hazards posed by multiple prescribing, non-compliance and iatrogenic disease) 
  • Offer advice and support patients, relatives and carers regarding prevention, monitoring and self-management. Ensure care promotes patients' sense of identity, independence, personal dignity and that the patient is not discriminated against as a result of their age. 

Emerging issues in the care of older adults

  • A demographic shift in the UK population has resulted in a rapid increase in the number of older people. Over the next 20 years, the number of people aged 85 and over is set to increase by two-thirds, compared with a 10 per cent growth in overall population1 
  • Risks of long term conditions and cancer in older adults are exacerbated by increasing lifestyle factors such as obesity, alcohol and other substance misuse problems 
  • Social care services to help people stay safe and independent at home (for example home carers, meals on wheels, day care) are mainly arranged by local councils whose budgets have been significantly reduced. The resulting lack of support in the community means there is little provision for preventative services, so when care is required, it is often urgent and unplanned2
  • Older people are increasingly admitted to hospital more frequently, with longer lengths of stay and occupy more bed days in hospital compared to other patient groups3 
  • There is an increase in the number of carers aged 80 and over. Over half are caring in their home for more than 35 hours a week. It is estimated that there will be more than 760 000 carers aged 80 and beyond by 20304 
  • Concept of 'living with frailty' as not an inevitable or irreversible part of getting older and that it is possible to maintain independence by engaging with strategies and services5

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care  
  • Prognosis 

Symptoms and signs

Consider the normal physical and psychological changes that can occur with age and relate them to the adaptations older adults make and to the breakdown of these adaptations (for example when hearing, vision or cognitive function continue to worsen). 

Common and important conditions

  • Cancer: recognise the common, early, 'red flag' symptoms and signs of malignancy (for example weight loss, dysphagia, melaena, diaphoresis etc.), many of which may be non-specific if taken in isolation. Many cancers are more prevalent in the elderly population and may be insidious 
  • Cardiovascular: atrial fibrillation, heart failure, hypertension, ischaemic heart disease, risks for stroke and dementia
  • Co-morbidity, difficulties in communicating, polypharmacy, malnutrition, social isolation and the need for additional support for the increasingly dependent patients in general practice are important issues and can delay the early recognition of adverse clinical patterns in older people
  • End-of-life care: moral, ethical and emotional issues relating to the end of life as well as after death (for example living wills, palliative care) (see also RCGP Topic Guide on People at the End-of-Life)
  • Musculoskeletal: falls, fractures, gait disorders, osteoporosis, osteoarthritis
  • Neglect and abuse (emotional, mental and physical) in the elderly
  • Neurological: Parkinson's disease, stroke and confusion 
  •  Psychiatric: anxiety and depression, delirium (hyperactive, hypoactive or mixed) and dementia (including vascular, Alzheimer's and Lewy Body and the importance of avoiding antipsychotics with the latter). Early use of anticholinergics where appropriate. The effects of these conditions on the person, the family and community, and the effects of physical function on the patient's mental state (See RCGP Topic Guide on Mental Health)
  • Renal: chronic kidney disease (CKD), hydration
  • Respiratory: COPD
  • Skin: pruritus, ulcers, skin malignancies, lichen sclerosus, benign lesions associated with ageing
  • Urogenital: infections, incontinence, LUTS, benign prostatic hypertrophy 

Examinations and procedures

  • Consider any adjustments that may be needed to examine appropriately and the normal variation in biometrics 
  • Informed consent and assessment of capacity 
  • Accurate measurements including dementia screening and assessing for arrhythmias  
  • Appropriate monitoring and use of investigations  
  • Indication and administration of vaccinations (seasonal flu, pneumococcal, shingles)

Investigations

  • Changes in the normal range of laboratory values that are found in older people 
  • Interpretation of ECG (for example diagnosing AF) 
  • Blood pressure (for example risk of hypertension and also postural hypotension)

Service issues

  • The care of older people may be a significant proportion of general practice workload (for example the requirement for routine appointments for reviews and monitoring, urgent appointments and the mechanisms for dealing with this). Increasing use of tools on frailty to identify populations that need increased support and management 
  • Increasing use of community teams and services to support patients at home and avoid admissions to hospital 
  • Inequalities in healthcare provision can be particularly significant in older persons (for example learning, physical disabilities, access to care). This can be limited by ensuring easy access to the primary healthcare team, appropriate timing of appointments, sign-posting to appropriate team members, and the systematic management of chronic conditions and co-morbidities  
  • The positive and negative ways in which socio-economic and health features inter-relate (for example poverty, ethnicity and local epidemiology) and the importance of this within the community 
  • Respect for the sensitivities of older adults regarding their health attitudes, behaviours and needs; impact of attitudes to treating older adults equitably, with respect for their beliefs, preferences, dignity and rights; issues of confidentiality and consent and sharing information with other agencies  
  • Increasing numbers of older adults do not have English as a first language for example those who are migrants or living with family and do not speak English at home 
  • Access to social services, rehabilitation, nursing homes, residential homes and various statutory and voluntary organisations for support of older people in the community, (for example podiatry, visual and hearing aids, immobility and walking aids, meals on wheels, home care services). Note that patients may have pre-conceived ideas of what 'support' can mean and may not identify themselves as needing support 
  • Differences when working with care homes including continuity, medicines management and the use of care home advocacy and Deprivation of Liberty orders (DoL) 
  • Advance care planning and Advance Directives (including Do Not Attempt Resuscitation (DNAR) forms) and the need to involve relatives and carers as well as the individual.  
  • Patient held records can support appropriate decision making in the context of long term conditions' management and end of life care (see RCGP Topic Guides People at the End of Life and People Living with Long Term Conditions) 
  • Ensure the appropriate use of screening and case-finding programmes. Note the potential challenges for example auditing the quality of care in varying forms of residential accommodation. 

Additional important content

  • Co-morbidity and physical factors – particularly diet, exercise, ambient temperature and sleep – disproportionately affect the health of older people and will influence the management of existing disease  
  • A problem-based approach is important, taking in the 'big picture', rather than a disease-based approach to the care of older people, who often have complex physical, psychological and social problems  
  • The distinction between physiological and natural ageing processes, and pathology/disease
  • Risks of poly-pharmacy (including the increased risks of significant cross-reactions and side effects)
  • Legal and ethical issues may arise (for example confidentiality, the Mental Health Act, the Mental Capacity Act, power of attorney, court of protection applications, guardianship, living wills, death certification and cremation) 
  • Difficulties in designing ethical approvable research studies with frail and elderly patients and extrapolating evidence from research to older populations 
  • Issues related to carers, in particular the positive and negative impact of being a carer on their health and your holistic duty not to overlook these issues

Case discussion

Ashok, an 80-year-old man, attends the surgery in winter after having been discharged from hospital following treatment of a femoral fracture. He has severe back pain and a raised prostate-specific antigen (PSA) level. He has vascular dementia and was being cared for at home by his wife although she is finding it hard to cope. They have family overseas but no local support network.  

Ashok has multiple other medical problems including type-2 diabetes and hypertension. His prostate cancer was thought to be in remission. They live in a two-storey property with an upstairs toilet; he is the registered owner of the house. He is now unable to climb the stairs.  

His wife, another patient of yours, has a right cataract impairing her vision and has previously made some minor errors when administering his medications. She also has poor mobility and is due to have a left hip replacement for osteoarthritis. She has been receiving a 'carer's allowance' and wants to continue to care for her husband at home.  

You make a home visit after Ashok's hospital discharge to find him unkempt, in soiled bedding in a cold house. There has been inadequate discharge planning and little assessment of his home situation to help him or his wife cope with his new immobility. 

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.  

                              Core Competence            
    Questions                                           
Fitness to practise
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
What are the personal challenges I face in my working life when caring for my elderly patients?  

How do my personal attitudes and biases to the elderly, to the processes of growing old, becoming frail and to dying affect my practice?  

How would I manage this complex scenario during the working day while also maintaining my performance elsewhere? 
Maintaining an ethical approach
This addresses the importance of practising ethically, with integrity and a respect for diversity. 
How might I address concerns about the inadequate discharge planning?  

How can my patients retain autonomy in this situation? 

What is my role in safeguarding the needs of the demented man while also respecting his wife's wishes? 
Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters.
What problems might I face in communicating with this couple? 

In the scenario described, who is my patient? 

How might I respond to apparently dated social and health beliefs and cultural traditions? 
Data gathering and interpretation  
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 
Where can I access information on the management of vascular dementia? 

How do I balance the use of intensive or invasive tests and treatments and the use of limited healthcare resources in the care of the elderly? 

What other information about the family would be useful? 
Clinical Examination and Procedural Skills  
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills.  
Can I perform an accurate assessment of cognitive function using formal tools? 
Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 
What are the most appropriate options for managing a situation where there is no clear clinical need for hospital admission?  

How much should Ashok's wife influence this? 

How could the consultation encourage a shared decision-making process? 
Clinical management
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches.
What are the immediate medical and social problems that I need to manage? 

What is the treatment of choice for Ashok's hypertension?  

How can I ensure my personal biases regarding the management of risk factors in the elderly do not influence management decisions? for example the cardiovascular risk factors of smoking, obesity, exercise, alcohol, age and race 
Managing medical complexity  
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 
How might I describe the complexity of this episode of healthcare provision? 

How would I make a risk assessment of this couple's situation? 

What are the possible supportive organisations and potential referral routes in this case? 
Working with colleagues and in teams 
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 
What arrangements would I make to improve continuity of care? 

If I was concerned there was a safeguarding issue in this case, how would I manage this? Who else might be able to help me?  

What processes are important for continuity of care in the out-of-hours setting? 
Improving performance, learning and teaching
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
What do I know about residential and care homes in my practice area? 

What can be identified as areas of personal educational need? 

What areas could be explored further for potential improvement for colleagues managing similar cases? 
Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
How can I retain patient confidentiality when recording information about this couple in the notes?  

What information would I normally expect to receive following a hospital admission?  

What can my practice do to improve the support for similar patients? 
Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 
Considering Ashok's wife, what might be the consequences to her if her husband goes into a care home? 

What sort of discussion should I be having with this couple regarding long-term care and placement? 

How can I manage this couple's ideas, concerns and expectations?  

How might the practice team have anticipated the problems identified in this scenario? Which problems, if any, do I think might have been prevented? 

What other services may be available to carers in my practice? 
Community orientation
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare.
How common is this type of problem in my practice population? How would I try to find out? 

What voluntary support services are available to my patients? 

What support can be offered by the primary care team and/or hospital outreach services? 

How to learn this area of practice

Work-based learning

In general practice you will have the opportunity to care for many elderly patients with physical and mental conditions who live at home or in a residential care home. As a GP trainee you should be encouraged to look after some of the practice's older patients throughout your placement. As you follow them along their journey you will gain a better understanding of their problems and of the social and medical care they receive. Case conferences and multi-professional assessments of your older patients will give you a better understanding of disease processes and their functional consequences.

A placement in a care of the elderly medicine (geriatric) department offers you the opportunity to learn how to manage complex co-morbidity, interact with inter-professional teams, experience interagency work, and work closely with the voluntary sector. You should also take the chance to expand your knowledge and skills in end-of-life care and advance directives. Take the opportunity also to attend day hospital and clinics, as well as to accompany your consultant on any domiciliary visits.

Self-directed learning

Older patients often have many complex psychological, social and physical problems that provide rich subjects for tutorials and case-based learning.

Learning with other healthcare professionals

The discipline of care for older adults involves huge numbers of professionals, each with their particular areas of expertise. These include community nurses, physiotherapists, occupational therapists, speech therapists, opticians, audiologists, palliative care nurses, physicians and social workers, to name but a few. You should endeavour to spend some time with these colleagues to ensure you understand the breadth and frequency of input that can be provided to the older adult, the effectiveness of such input, and the appropriateness of referral to these agencies. You should also take the opportunity to visit patients at their homes with other members of the primary healthcare team and to accompany the occasional patient to hospital clinics to gain a better understanding of the 'patient's journey'.

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Diagnosis of frequent falls 
  • Tools for assessing cognitive impairment 
  • Use of advance directives

Clinical Skills Assessment (CSA)

  • Elderly man requests more analgesia for advanced hip osteoarthritis. He has declined a hip replacement because he is the sole carer for his disabled wife. 
  • Woman with heart failure is dyspnoeic but cannot cope with the incontinence when she takes her diuretic medication 
  • Phone call: Adult son is concerned that his elderly father is no longer coping safely with living alone. 

Workplace-based Assessment (WPBA)

  • Log entry about attending a multidisciplinary team meeting planning the hospital discharge of an elderly woman with dementia 
  • Log entry about completing a care plan for a nursing home resident whose daughter has unrealistic expectations 
  • Data gathering in a consultation with a garrulous patient giving an inconsistent and vague history 
  • Mini-Mental State Examination

References

1 Quality Standards for the care of older people with urgent & emergency care needs: The "Silver Book" (2012) 
2 www.ageuk.org.uk
3 Quality Standards for the care of older people with urgent & emergency care needs: The "Silver Book" (2012) 
4 www.ageuk.org.uk 
5 Frailty: Language and Perceptions. A report prepared by BritainThinks on behalf of Age UK and the British Geriatrics Society (2015)  


End of life

This Topic Guide explores part of the RCGP curriculum, Being a General Practitioner. It will help you understand important issues relating to end-of-life care by illustrating the key learning points with a case scenario and questions.

The role of the GP in end-of-life and palliative care

As a GP, your role is to: 

  • Enable early identification of patients and their carers 
  • Holistically assess the needs of the patient, family and carer  
  • Understand diversity of need across age, gender, diagnosis, disability, sexuality, culture and spirituality to enable individualised care 
  • Identify reversible conditions or deterioration and proactively plan for anticipated changes in capacity 
  • Recognise common themes and consideration required for sensitive communication  
  • Manage the general medical care and support the needs of patients with advanced serious illness and end of life care  
  • Understand the purpose and function of the multidisciplinary team (MDT)  
  • Liaise and work in partnership with specialist palliative care and MDTs-  to optimise care
  • Understand the benefits of Personalised Care and Support Planning  
  • Understand how to reliably meet Five Priorities of Care for people in the last days of life, to ensure the best care and death possible. (Recognise, Communicate, Involve, Support, Plan & Do) 
  • Deliver care with compassion, so that the person can die with dignity, with individualised care and minimal distress. 
  • Ensure timely and regular review of the person’s needs and wishes, and revise care and support plans accordingly 
  • Understand your role in care after death, including health promotion advice and support of normal and complex grief responses 
  • Understand the importance of reliable processes in place, such as best practice coding and documentation, required to support patients and those important to them  
  • Participate in reflective practice to learn from deaths and improve your practice 
  • Understand the public health compassionate community approach and the GPs role within this.  

Emerging issues in end-of-life care

General practitioners play a key role in caring for people with advanced serious illness and those who are nearing the end of their life. But providing that care at a consistently high level of quality can often be challenging. The use of voluntary quality improvement standards for GPs, can help assess and improve end of life care. They might include:

  1. Professional and competent staff  
  2. Early identification  
  3. Carer support - before and after death  
  4. Seamless, planned, co-ordinated care  
  5. Assessment of unique needs of the patient 
  6. Quality care during the last days of life  
  7. Care after death  
  8. General practices being hubs within compassionate communities  
  • A Compassionate Communities, Public Health Palliative Care Approach can improve quality and meaning in life, experience, outcomes and the ability to mobilise the community to help develop supportive networks.  
  • Improving communication and coordination of important information between health and social care professionals from different care settings, including the use of Electronic Palliative Care Co-ordination Systems (EPaCCS).  
  • Documentation including Treatment Escalation Plans, ‘Do Not Attempt Resuscitation’ (DNAR), Deprivation of Liberty Safeguards, Advance Decision to Refuse Treatment (ADRT) and Lasting Power of Attorney (LPA). There is a range of relevant documentation, which can vary by region across the UK 
  • Application of an early palliative care approach and integration of proactive care planning into the management of all patients with advanced serious illness, including frailty, multi-morbidity and non-malignant disease. 

Knowledge and skills guide

The General Medical Council defines people as ‘approaching the end of life’ when they are likely to die within the next 12 months. This includes: patients whose death is imminent (expected within a few hours or days); those with advanced, progressive, incurable conditions, general frailty and co-existing conditions; life-threatening acute conditions or deterioration caused by sudden catastrophic events. Palliative care is a broader approach that improves the quality of life of patients and families facing the problems associated with life-threatening illness; physical, psychological, cultural, social and spiritual.

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition, including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations  
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of ‘alarm’ or ‘red flag’ features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including, self-care, initial emergency and continuing care, chronic disease monitoring,  
  • Patient information and education including self care 
  • Prognosis, and management of uncertainty 
  • Benefits of non-health based support for the patient, family and carer 

Symptoms and signs

  • Pain 
  • Gastrointestinal symptoms (for example nausea and vomiting, oral symptoms such as ulceration, constipation, diarrhoea, ascites, hiccupping) 
  • Cachexia, anorexia and fatigue 
  • Psychological problems (for example insomnia, anxiety, depression, delirium, restlessness and terminal agitation)  
  • Neurological symptoms (for example Headaches, Fits, limb weakness)  
  • Respiratory symptoms (for example breathlessness, excessive secretions, cough) 
  • Skin symptoms (for example pruritis, lymphoedema, prevention of pressure sores) 
  • Signs and symptoms of dying may include an exacerbation of those listed above 
  • Anticipatory grief (patient and carer) and bereavement support (carer) 
  • Care giver ‘pressure points and distress’ 
  • Recognition of complex grief signs and symptoms (to align with changing ICD code) 

Common and important conditions

Pain is a common symptom in palliative care. Recognition of the type, expression and possible causes of pain and its management are important (physical, psychosocial, cultural and spiritual)  

Emergencies in palliative care include:

  • haemorrhage
  • hypercalcaemia
  • superior vena cava obstruction
  • spinal cord compression
  • raised intracranial pressure
  • sepsis
  • pancytopenia and 
  • venous thromboembolic events (for example pulmonary embolus or deep vein thrombosis). 

Examinations and procedures

  • Assessing and diagnosing the cause of symptoms through appropriate targeted examination 
  • Pain and symptom management including knowledge of therapeutic procedures 
  • Psychological support 

Investigations

Investigations may be aimed at the underlying condition itself or checking for reversible conditions when appropriate. The rationale for investigations should be carefully considered and agreed with patients and those important to them.

Service issues

  • Palliative and end of life care takes time and planning. The number of people who die each year is rising. 
  • There is an increasing demand for specialist palliative care services, which are commonly supported by funding from charitable organisations. 
  • Optimising links between health and care services with de-medicalised support from voluntary sector and community development. 
  • Inequities in access and provision of palliative care services including 24/7 specialist palliative care support.  
  • Patient preference for place of death may be their home, which may require significant support and planning. 
  • Difficulties of prognostication and managing uncertainty. 
  • The importance of palliative care meetings and training within primary care teams for good service provision. 
  • Achieving reliability of care and experience for all patients who have an expectable death. 
  • Financial implications for patients and their carers including access to benefits (for example DS1500). 
  • Timely, death verification and certification.  

Additional important content

  • An increasing number of children and young people are living longer with life-limiting and life-threatening conditions and may require the support of the GP at times through their illness, including at transition from paediatric to adult services. The GP has a key role, providing general medical care and holistic care and support to the family. A GP may be involved in the care of a dying child only a few times during their career, and will require access to the wider MDT and knowledge of local services for help and support in this circumstance.  
  • Approaches to supporting families and carers after bereavement need to take into account religious, spiritual and cultural beliefs and practices 
  • A GP needs to be aware of ethical considerations in palliative care and the use of GMC guidance (for example autonomy, beneficence, non-maleficence). 

Case discussion

Mr Singh is 82 years old and the head of a large Sikh family. He had a haemorrhagic stroke two months ago which left him bed-bound with a reduced consciousness level and unable to communicate, although he can swallow soft food. He is cared for at home by his daughters and granddaughters.

Over the past week, his conscious level has declined and he is choking on his foods. He is having difficulty swallowing and you suspect that he has had further cerebral bleeding.  The family would like to continue to care for Mr Singh at home, in line with their cultural practices and beliefs.

You make a referral to the District Nursing team and perform a thorough assessment at home. You also contact the local Specialist Palliative Care team for expert advice regarding end-of-life care and psychological and spiritual support for the family.

A week later, you are asked to make an urgent home visit to Mr Singh. He has deteriorated further, is tachycardic and has coarse crepitations in his right lung. You make the decision to arrange admission to hospital where he is treated for an aspiration pneumonia with IV antibiotics and a drip is inserted to provide hydration while further assessment of his condition is made.  Further tests indicate that he has had more cerebral bleeding.

He is discharged home, and you note on the discharge summary the intravenous drip he had in hospital has been stopped after a discussion of risks and benefits before his transfer home. Sensitive DNACPR discussions have taken place with Mr Singh and his family and a form completed and sent to the local ambulance service and the family take a copy home with them.

Mr Singh is discussed at the practice palliative care meeting. The District Nurses have arranged for Mr Singh to have a hospital bed downstairs in his house. They are concerned that he appears to be agitated at times and that his breathing has become noisy due to respiratory secretions. His family are finding his slow decline traumatic. They feel that the goals of care should focus on symptom management and comfort. Mr Singh dies peacefully five days later.

You are able to issue Mr Singh’s death certificate the next day, which helps the family to arrange his cremation in line with their spiritual beliefs. The family are supported by the Specialist Palliative Care team’s bereavement service.

(Source: This is a modified version of the GMC End-of-Life Care illustrative case.)

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.  

 

                                  Core Competence            
                   Questions                                           
Fitness to practise  
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
What are my personal feelings about advance care planning and adhering to my patient's requests? 

How do we respect other people’s views and shared decision-making? 

How do we make time for sensitive and difficult conversations in a busy GP working day?  
Maintaining an ethical approach 
This addresses the importance of practising ethically, with integrity and a respect for diversity. 
What is the GMC's advice on end-of-life care? 

What are the ethical principles relevant to care planning and end of life care? Are there cultural beliefs that need exploring?  

When would I need to consider the Mental Capacity Act?  
Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 
How would I explain disease progression, variation and uncertainty around death and dying in this case? 

How could I start a discussion about end of life care planning?  

How would I handle issues such as distress or different opinions between family members? 
Data gathering and interpretation 
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations.
What are the challenges in identification of reversible causes of deterioration and whether investigation and / or hospital admission is necessary and appropriate? 

Am I aware of important psychosocial factors including the patient’s occupation?  
Clinical Examination and Procedural Skills 
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills.  
What symptoms might be problematic towards the end of life?  

What other potential palliative care emergencies might arise in this situation and how would I manage them? 

What are the indications for a syringe driver?  
Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 
Which specific problem-solving elements are demonstrated in the case study?  

How can the MDT support decision-making, information-sharing, peer support and education? 
Clinical management  
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 
How would I manage distressing symptoms towards the end of life? How might these present? 

Am I aware of where to find information and support for anticipatory prescribing and prescribing a syringe driver if necessary?  
Managing medical complexity  
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 
 How do I involve patients in assessing risks and benefits when deciding on care at home for patients with complex clinical needs? 

Do the family have the necessary information, knowledge and skills to support care?  

Can the family recognise distress and / or pain and are they aware how they can help including, giving medication that will help? 
Working with colleagues and in teams 
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 
As the patient’s GP, where in this case study am I demonstrating my ability to function as both leader and member of end-of-life teams?  

Who should the other members of this team be? 

How will I communicate with out-of-hours providers, district nurses and the wider practice team? 
Improving performance, learning and teaching  
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
What educational resources, especially locally, can I access for palliative and end-of-life care?  

What is the evidence-base for end-of-life care and what are the difficulties associated with research in this area? 
Organisational management and leadership 
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
What is the importance of documenting key decisions about preferences, ceilings of care and DNACPR?0 

What are the out-of-hours care arrangements? How can this help be accessed quickly if necessary?  

Am I familiar with the legal and statutory reporting obligations on death and cremation certificates, and the criteria for referral to the coroner? 

How can I reflect on and learn from deaths? How can I be involved with shared learning, across sectors?  

How do I achieve reliability of processes to enable high quality and safe care for all patients affected by end of life care? 
Practising holistically, safeguarding and promoting health
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 
How could I support the grieving process in Mr Singh's family? 

On what occasions in this case study have the spiritual and cultural needs of my patient and his carers been identified and attended to? 

Community orientation  
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 

What social benefits and services might be available to my patient and his carers? 

What support has the patient and main caregiver got available to them in a crisis – from health/care services and also within their supportive community networks? 

How to learn this area of practice

Work-based learning

Learning about palliative and end-of-life care occurs most effectively when you are actively involved in caring for a patient in the last year(s) of life, including when they are dying. This can be in the patient’s own home, or in a hospital, hospice or nursing home. You will find yourself surrounded by many health and care professionals from whom you will learn how to become better at this very difficult but rewarding aspect of being a GP. It is worth noting the role that every member of the MDT plays, and what is important to the patient and their family. It is also important to note how the patient and main caregiver(s) gain and build support and resilience from networks with their community.

Try if at all possible to follow a patient at the end of life and build a case study with suitably anonymised clinical detail, accompanied by your reflections. Working alongside your GP trainer can help in the day-to-day debriefing and managing your own beliefs and emotions. When death happens, ask if you and your trainer can visit the family and discuss their opinions of the care they received. Listen, reflect and share with your colleagues. Training practices usually have regular palliative care meetings where there is opportunity to discuss and learn from deaths with MDT members.

It is interesting to reflect on your observations and experiences of palliative and end-of-life care in hospital and the community, and how these may differ. Consider visiting a hospice if you do not have a clinical placement there, as this will provide another insight. You may witness varying attitudes to death including team members who see dying as a failure of their care and ability to cure, and others who view it more openly as a part of life.

Self-directed learning

There are many structured learning events, especially in local hospices and courses run by the major charities. There is a growing body of e-Learning to help consolidate and build on knowledge gained in the workplace. You can find an e-Learning module(s) relevant to this topic guide at e-Learning for Healthcare. For GP trainees, your specialty training programme should offer case-based discussions where end-of-life care can be shared. You can find an e-Learning module(s) relevant to this topic guide at e-Learning for Healthcare.

Deaths in our own life can affect the way in which we manage the deaths of others. Consider your own feelings, emotions and beliefs about death and dying. Be open about this with your supervisors. It is possible to read about experiences of other people to help widen your own understanding of how different people can respond to death and dying, helping also appreciate variation across age, gender, diagnosis, disability, sexuality, culture and spirituality to enable individualised care.

Consider people’s supportive network available to help increase their resilience and wellbeing, whilst they are not in direct contact with health and care professionals.

Furthermore, be cognisant of your own wellbeing, resilience and compassion needs. Dealing with distress and dying can be very rewarding but also emotionally draining. Explore options of how you debrief, distress and handle professional grief to help support your own resilience. This can be particularly important if you are dealing with illness, loss or grief in your own life, so get to know your own ‘warning signs’. Talk about coping strategies with your trainer and peer-groups.

There are valuable resources in the arts, including fiction and non-fiction books, theatre and films, which provide ways of considering the human experience and can be used in groups to supplement case-based discussions.

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT) 

  • Recognition of emergencies in palliative care 
  • Entitlement to statutory benefits such as DS1500
  • Management of types of pain, for example  neuropathic pain and metastatic bone pain

Clinical Skills Assessment (CSA) 

  • A man with metastatic bowel cancer wants to discuss his on-going care 
  • Phone call: District nurse requests medication to control nausea in a dying patient 
  • A Muslim woman seeks reassurance that her husband’s end-of-life care and funeral arrangements will comply with his religious traditions which she describes when asked.  

Workplace-based Assessment (WPBA) 

  • Log entry reflecting on organising home oxygen for a patient with end-stage COPD 
  • Consultation Observation Tool (COT) of a discussion with a patient about DNACPR  
  • Log entry about chairing the practice palliative care meeting, contemporaneously updating the patient record and ensuring communication with the wider MDT, including out-of-hours providers.  

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT) 

  • Recognition of emergencies in palliative care 
  • Entitlement to statutory benefits such as DS1500
  • Management of types of pain, for example  neuropathic pain and metastatic bone pain

Clinical Skills Assessment (CSA) 

  • A man with metastatic bowel cancer wants to discuss his on-going care 
  • Phone call: District nurse requests medication to control nausea in a dying patient 
  • A Muslim woman seeks reassurance that her husband’s end-of-life care and funeral arrangements will comply with his religious traditions which she describes when asked

Workplace-based Assessment (WPBA) 

  • Log entry reflecting on organising home oxygen for a patient with end-stage COPD 
  • Consultation Observation Tool (COT) of a discussion with a patient about DNACPR  
  • Log entry about chairing the practice palliative care meeting, contemporaneously updating the patient record and ensuring communication with the wider MDT, including out-of-hours providers  

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