Abstract
Too much of a good thing?
Alcohol-related discharges in Scotland are said to have hit an all-time high of over 42 000. This, however, represents only a third of the estimated consultations in primary care for alcohol misuse in 2006–07. Industry sales data show that enough alcohol was sold in Scotland in each of the last 3 years to enable every man and woman over 16 to exceed the sensible male weekly guideline each and every week (The Scottish Government, 2009). Alcohol misuse is no longer a marginal problem, with up to 50% of men and up to 30% of women across Scotland exceeding recommended weekly guidelines.
In March 2009, the Scottish government announced a package of measures including establishing a minimum price per unit of alcohol. This together with drink-driving measures and alcohol brief intervention (ABI) for risky drinkers remain the most effective policies.
ABI in primary care has been discussed in InnovAiT (February 2008). The purpose of ABI is not simply screening, but to attempt to reduce total alcohol consumption and episodes of binge drinking in ‘risky drinkers’ by motivating individuals to think about and/ or plan a change in their drinking behaviour.
An excellent training event run by RCGP Scotland on ABI highlighted that unlike people who smoke, many people who drink alcohol have no idea that their consumption level is harmful. It stressed the importance of clearly describing the patient's drinking level compared to the drinking limits (screening feedback), explaining what this means for the individual in terms of health risk (i.e. hazardous, harmful or dependent drinker), eliciting readiness to change and choosing a suitable strategy. One of the key elements throughout ABI, however, remains personal responsibility of patients for their decisions on drinking.
The Scottish Government. Changing Scotland's relationship with alcohol: a framework for action (2009) Accessed via www.scotland.gov.uk/Resource/Doc/262905/0078610.pdf [date last accessed 09.03.2009].
Screening
Screening and the breadth and quality of information given to patients have been in the news. It is easy just to accept that antenatal screening for Down’ s syndrome or the breast screening programme is beneficial. You probably covered Wilson's criteria for a good screening programme at medical school. There is now a variety of screening programmes embedded in the NHS. It might be worth reflecting on some of them and making up your own mind as to whether you believe they are beneficial. Gotsche et al. [British Medical Journal (2009) 338: p. b86] have produced an evidence-based leaflet giving women what they believe to be is a more balanced view of the benefits and harms of the breast screening leaflet. Read their leaflet, compare it with the current breast screening leaflet www.cancerscreening.nhs.uk/breastscreen/publications/ia-02.html and make up your own mind. You may wish to discuss with your trainer, others in your practice or other registrars. Once you have done that you might want to go on to read a recent British Medical Journal editorial on prenatal screening for Down’ s syndrome [British Medical Journal (2009) 338: p. b140] where the confusion caused by some recent papers on Down's syndrome screening programmes are discussed. The final screening issue you could consider is how you will answer questions from under 25-year olds who have been triggered to attend for smear tests by the news about Jade Goody.
Rights of asylum seekers
The RCGP has issued guidance about the care of failed asylum seekers. The College position is that GP practices have the discretion to accept failed asylum seekers as registered NHS patients and that GPs have a duty of care to all people seeking health care, including these and other vulnerable migrant groups. Currently, groups who are not ‘lawfully resident’ in the UK are liable for NHS hospital charges. Legal review may change the position in primary care. The inverse care law of health care (those who need health care the most get the least care) seems to apply here. Ask yourself, as a doctor and a taxpayer what you believe. You may find a breadth of opinion even within one practice.
Advanced care planning
The Royal College of Physicians has produced guidance about Advanced Care Planning (ACP). At 19 pages long, the document is densely packed with information, so heavy going. The document is more broad based than shorter articles about ‘living wills’ and includes up to date information about the practical implications of the Mental Capacity Act. If the whole document is too daunting, try reading the three green summary boxes which look at how to make valid clinical decisions, how to have an ACP discussion and how to make decisions in the best interests of seriously ill adult patients. www.rcplondon.ac.uk/clinical-standards/organisation/Guidelines/concise-guidelines/Pages/RCP_ConciseGuideline_AdvancedCarePlanning.aspx.
Safeguarding children and young people
Baby P is still hitting the news. Has it made a difference to the way you or your practice looks at safeguarding issues? There is a Safeguarding Children and Young People Toolkit on the Clinical Innovation and Research Centre section of the RCGP website (www.rcgp.org.uk/clinical_and_research/circ/safeguarding_children_toolkit.aspx). As well as information about the subject, there are some learning modules (you will need to log in as a College member to get access to these). Although designed to allow the practice lead to facilitate teaching within the practice, you could adapt to use in a small group or at a Vocational Training Scheme (VTS) session.
Health in pregnancy allowance
There is a new one-off lump sum payment for pregnant women due to be available from April 2009. Your practice should have obtained a supply of the relevant forms. The health professional who signs the Health in Pregnancy grant form will be asked to confirm that appropriate maternal health advice has been given. You might want to think about what might be ‘appropriate advice’ (www.direct.gov.uk/money4mum2be). If you have not done an obstetrics job or if your practice still has a midwife-led service, you may need to work out how you are going to get enough exposure to antenatal care during your training.
Childhood immunisations
Measles cases rose from 990 confirmed cases in 2007 to 1348 in 2008 (Health Protection Agency figures). Measles is no longer a disappearing disease in the UK. It is worth asking yourself whether you would recognize a case of measles or whether you would be able to reassure the worried parents of a child with a rash. We all need to be able to give advice about vaccination; do you feel able to discuss the pros and cons of measles, mumps and rubella vaccination? You may find that the nurses or health visitors in your practice know a great deal about this topic. Achievement of childhood immunization targets not only represents good medical care but also earns money for the practice. It might be worth finding out who is responsible for collating the quarterly data in your practice, and what action is taken if uptake diminishes.
Salaried GPs handbook
In February 2009, the British Medical Association (BMA) released a new Salaried GPs’ Handbook. It gives information on the statutory and contractual rights of salaried GPs, how to become a salaried GP and how to get involved in local and national representation. Copies will be sent to all salaried doctors who are BMA members or you could look on the website (www.bma.org.uk). For those of you coming towards the end of training, a salaried post may be one of the options. Once you have cleared the various exam and Workplace-based Assessment hurdles, tutorial topics could include preparation for working as an independent GP, e.g. writing CVs, how to stay up to date and negotiating about pay and conditions. Some training schemes run ‘after the VTS’ courses.
Probity and ethical issues
The latest Ipsos MORI survey named doctors as the most trusted profession (out of 16 types of profession) (www.ipsos-mori.com/content/home-page-news/doctors-once-again-the-most-trusted-profession.ashx). Ninety-two per cent of over 2000 adults surveyed trust doctors to tell the truth. Do you find this flattering or a burden? Ethics and probity feature as components of the nMRCGP exam assessments and as a section of the current NHS Appraisal Toolkit. Think about aspects of your work where you are trusted to behave in an open and honest way. The Appraisal Toolkit has a structured reflection tool to help you think about probity issues.
Have you decided where you stand on the relationship between the medical profession and the pharmaceutical industry? British Medical Journal (2009) 338: p. b211, 232, 252, 222 and 234 pull together five different views on how the relationship between doctors, patients and industry should develop. As a GP, you will have to decide whether to see drug reps and whether to attend pharmaceutical company-sponsored meetings. This article may help you reflect on the subject.