Abstract
Invitation to tweet
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GP Specialty Trainee Awards
The Roche Specialty Trainee Awards are open to current registrars and those within 1 year of having completed vocational training. Audits or other projects and educational innovations can be submitted. There are up to three major awards of £1000 and further awards of £400. Applications are limited to the first 100 with a closing date of 31 July each year. If you are interested, there are examples of previous winning awards on the College Awards section of the website. Submit electronic descriptions of your project or audit, up to 3500 words, to
www.rcgp.org.uk/news_and_events/prizes_and_awards/prizes_and_awards_details.aspx
It's mine
Whether you agree or disagree, appropriately trained UK nurses and pharmacists are now independent prescribers on the same basis as doctors for most medicines of the British National Formulary. There are indeed mixed views.
The old school of thought suggests that if nurses want to prescribe, they should go to medical school for 5 years. The current training of nurses in medicine prescribing involves 26 taught days plus 12 days of learning in practice with a designated doctor. Despite this abridged training, nurses (and pharmacists) have responsibly assumed their new prescribing powers: the rush of anticipated inappropriate prescribing and harmful drug interactions has not occurred.
Besides prescriptions being legible, the aims of nurse prescribing are quicker patient access to medicines, increased patient choice, more efficient delivery of services and better use of nurses' skills and knowledge. However, how far these aims have been achieved has not yet been demonstrated. Most studies have been narrative in design, focusing on experiences of doctors, nurses and patients, when in my view, non-political systems should be in place to measure outcomes such as curbing prescribing costs, alleviating doctor workload and limiting errors.
On a personal note, my real concern is not whether other health professionals are responsible prescribers, but whether there is sufficient know-how to make the correct clinical assessment, to interpret laboratory tests and to disentangle the multi-morbidity—before lifting the pen. Surely that is what you would do before prescribing?
Hawkes, N. Handing over the prescription pad. British Medial Journal (2010) 340: p. 73–5
‘Throwing a sickie’
Did you know that the annual cost to the UK economy of sickness absence is estimated to be 10 times more than our annual primary care prescribing costs? Yet it is one of the areas in practice that is poorly administered and hugely variable.
Under the Membership of the Royal College of General Practitioners curriculum, as new GPs, I am sure our trainers have spent time teaching us the Department of Work and Pensions (DWP) sickness certification guidelines. However, a recent survey questionnaire suggests that the majority of GPs in practice (63%) had received no training in sickness certification and that there was substantial variation even for fairly straightforward cases. True, the small study was more a perception of current practice as opposed to actual study of issued sickness certificates. One can only wonder what the variation might be for more complicated cases.
In future, proposed changes to UK sickness certification legislation would allow GPs the choice ‘you may be fit for some work now’, which gives the employer options (including altered hours, amended duties and workplace adaptations); a proposed computerized record of sickness certification should also allow research and comparisons between practices.
Roope, R., Parker, G., Turner, S. General practitioners' use of sickness certificates. Occupational Medicine (2009) 59: p. 580–5
Treatment of depression
Even having done, or perhaps because of having done, 6 months general psychiatry, I find diagnosing and treating depression difficult. Just as patients do not usually present with central crushing chest pain radiating down their left arms, so I find very few patients volunteer classic symptoms of depression. Most of my patients suffering from mild to moderate depression present with somatic symptoms and with an aversion to any suggestion that they might have any form of mental illness. It is widely reported that GPs regularly miss depression so it pays to have an open mind. Making sure that you can take an adequate mental health history, ask sensitively about suicidal ideation and be able to persuade a reluctant patient to accept a diagnosis of depression are useful techniques to practise for the Clinical Skills Assessment. National Institute for Health and Clinical Excellence (NICE) recently updated guidelines 90 and 91 on the treatment and management of depression in adults and in adults with a chronic physical health problem. The quick reference guide that summarizes the recommendations reads very clearly and would form the basis of a very useful tutorial on the management of depression.
NICE recommends a stepped treatment of depression. The College website has a 2 hour e-learning session on Improving Access to Psychological Therapies. There is a very long pre-course assessment but there are useful descriptions of the different types of psychological therapies available. It is not a detailed description of say cognitive behaviour therapy but gives overview and reference links that you could explore further if you wished.
7UP and safer lithium therapy
Did you know that one of the key ingredients in the popular soft drink 7UP was once lithium citrate? The beverage was initially marketed as a hangover cure; the name itself, 7UP, was derived from the atomic mass of lithium, 7. Lithium citrate was removed from 7UP's formula in 1950. But I am digressing.
We know that regular blood tests are important when it comes to lithium therapy as lithium has the potential to interfere with kidney and thyroid function. Clinically significant alterations in lithium blood levels occur with commonly prescribed over-the-counter medicines and are dependent on kidney function. Under current Quality and Outcomes Framework (QOF) Mental Health Indicators, patients on lithium therapy require measurement of serum creatinine and thyroid function tests (TFTs) in the preceding 15 months and also a record of lithium levels in the therapeutic range within the previous 6 months.
However, the National Patient Safety Agency (NPSA) has brought to our attention that our current monitoring of lithium therapy is inadequate. A recent audit demonstrates less than optimal monitoring of lithium and a failure to adequately prepare patients to recognize therapy-induced side effects or toxicity. The audit found:
One in 10 patients had no documented lithium blood level [National Institute for Health and Clinical Excellence (NICE) standard: one blood level measurement every 3 months. Not met for 70% of patients]
One in five patients had no renal function tests documented (NICE standard: assessment every 6 months. Not met for 46% of patients)
One in six patients had no TFTs documented (NICE standard: assessment every 6 months. Not met for 51% of patients)
Clearly NICE guidelines describe a pattern of monitoring that is more stringent than the current QOF audit standard. In addition, NICE also recommends yearly health checks and monitoring of weight. It would be interesting to see what your practice does. What standard do you think we should follow?
Child deaths
The standardized childhood death rate in the UK is 2.5 per 10 000, so it is rare in general practice. I can conjure up a list of the few deaths of children that have occurred in my practice over the last 20 years; I remember them all.
For the first time, the Confidential Enquiry into Maternal and Perinatal Deaths has been extended to include a pilot report into child deaths. The British Journal of General Practice report on this pilot makes interesting reading. Over 50% of the cases had primary care involvement. Reading a list of children who died because they had not been appropriately vaccinated validates the hard work we put into persuading parents to have their children immunized. One of the points made is that some of the deaths occurred in children who did not attend their hospital outpatient appointments. What systems does your practice have for dealing with hospital ‘DNA’ letters? How enthusiastically do you chase children who have not been immunized? It is useful to be reminded that some routine work may save lives.
Thrombolysis in acute stroke
National Institute for Health and Clinical Excellence (NICE) recommends thrombolysis in acute ischaemic stroke. Until I read the personal view of Dr Hyun Choi in the British Medical Journal recently, I had not realized that the treatment of acute stroke was another illness the treatment of which is subject to postcode lottery in the UK. It made me wonder how many other national programmes and recommendations vary throughout the country. Dr Choi is a specialist trainee year 1. Like many of his peers he moved from one part of the country to another. Perhaps specialty trainees, with your increased likelihood of moving from one area to another, are more likely to spot such differences. What will you do if you move somewhere where you feel the local patients are disadvantaged?
Choi, H. Thrombolysis in acute ischaemic stroke: example of a health divide? British Medical Journal (2010) 340: p. c45