Abstract
Fit for the future
The UK General Practitioner Committee of the British Medical Association has published a 50-point plan for the future of general practice in the UK. Fit for the future: the evolution of general practice gives views on the ways in which general practice is moving forward, including out-of-hours care, Quality and Outcomes Framework, workforce and information technology. The full document and the executive summary are available on www.bma.org.uk/healthcare_policy/fitforfuture.jsp. If you prefer a more digestible audio format, the same page has a link to a podcast by Dr Laurence Buckman.
RCGP AiT conference in Scotland
An Associate-in-Training (AiT) conference is due to be held in Stirling, Scotland, on 23 September 2010 with the theme of ‘Patient Safety’. The 1 day event will be dedicated to workshops with the central theme of patient safety as applied to the Clinical Skills Assessment (CSA) examination; there will also be keynote speakers on career progression from AiT to GP partner. Further details are available from Diane Rich:
Patient manifesto
As I write this, the politicians are debating the various compromises necessary to function after the election resulted in a hung parliament. Before the election the Royal College of General Practitioners (RCGP) produced a patient manifesto with recommendations for whichever party or group of parties that attained power.
Leading the way: high quality care for all through general practice made a number of proposals to produce a healthier society. Key points included
Longer training for GPs Continued support for the development of GP ‘Federations’ Better access to talking therapies Better and faster access to diagnostic tests Better services for socially excluded groups
There were also recommendations for society-wide action to promote healthier lifestyles including graphic warning labels and minimum price levels for alcoholic drinks, a ban on smoking in motor vehicles (including private cars) with young children and action to tackle climate change.
NICE education modules
The National Institute for Health and Clinical Excellence (NICE) has a series of education modules based on guidelines about common clinical topics, e.g. chronic kidney disease and children with urinary tract infections. There are a set of modules on applying evidence-based knowledge and audit that might be useful to complete gaps in your curriculum coverage for your ePortfolio. The modules are linked to the BMJ Learning website.
www.nice.org.uk/usingguidance/education/educational_tools.jsp.
Summer reading
Lionel Shriver (We need to talk about Kevin) has written another thought-provoking novel. So much for that deals with the American health care system (not far from the newspaper headlines about patients in the UK funding their own treatments), the issues produced during treatment of a terminal illness and the effects of serious illness on family relationships.
If you prefer a shorter read, Linda Kat describes her experiences of post-surgical brain injury in two pages of the British Medical Journal.
Kat, L., Scipper, K., Knibbe, J., Tineke, A.A. A patient's journey: acquired brain injury British Medical Journal (2010) 340: pp. 1029–30
Chocolate is good for you
I was enchanted to see a large study (nearly 20000) claiming that moderate chocolate intake in middle-aged adults significantly reduces the chance of heart attack and stroke. The theory is that flavanols in cocoa improve the bioavailability of nitric oxide in the smooth muscle cells of blood vessels causing vasodilatation and lowered blood pressure (BP). I would prefer to selectively ignore the definition of ‘moderate’ as being 7.5 g chocolate; my preferred intake is considerably higher than this.
Safeguarding children
This is an important topic in general practice. Many of us will never see the horrific cases that attract media attention but all of us should regularly wonder whether a child we have just seen is at risk in some way. Most Primary Care Organizations are now making regular completion of Safeguarding Children training part of the criteria for remaining on the Performers' List. I am a trainer in the London Deanery; for our specialist trainees, completion of Level 1 and Level 2 Safeguarding Children training is an essential criterion for being signed off at the end of the Specialty Training 3 (ST3) year. The Royal College of General Practitioners (RCGP) and National Society for the Prevention of Cruelty to Children (NSPCC) have collaborated to produce a training toolkit that was revised in 2009. The RCGP e-learning website has a session set at Level 1 and three sessions that combine to complete Level 2 training.
www.e-lfh.org.uk/projects/egp/index.html
DSM-V
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the basis of psychiatric diagnosis in the USA and is widely used around the world. The current version (IV) was published in 1994 and is due to be replaced in 2013. The first draft of DSM-V has already caused debate as the focus is on promotion of early diagnosis and broadening of diagnostic criteria to reduce reluctance to be treated. There are new diagnoses, e.g. binge eating and lowering of diagnostic thresholds for currently recognized illnesses, e.g. attention-deficit hyperactivity disorder. The media has already focused on potential ‘epidemics’ of new illnesses and you will have to make your own minds up about whether the benefits of early diagnosis outweigh the risks of diagnostic tests with high false positives.
Malaria in pregnancy
The Royal College of Obstetricians and Gynaecologists has produced two guides on the prevention and treatment of malaria in pregnancy (Green top guides 54A and 54B).
NHS blacklist
Post-election, I write this at a time when the UK has just found out who will be taking up residence in Number 10. Regardless of whether Tory, Labour or Lib Dem, as one editorial wrote, ‘the axe will fall upon the National Health Service (NHS), that's for sure’. In anticipation of this, many GP practices are already taking steps to save money.
The Blacklist [officially Schedule 1 to the National Health Service (General Medical Services Contracts) (Prescription of Drugs etc.) Regulations 2004] is a list published in the NHS Drug Tariff denoting medicines and/or specific brands of medicines that cannot be prescribed on NHS medical prescriptions. If such a prescription is dispensed, then NHS Prescription Services will refuse to refund the cost to the dispensing pharmacy. The current NHS blacklist has not been updated since 1985.
An interesting poll of just under 700 GPs suggests that this Blacklist should be expanded to include among others, homeopathic remedies, erectile dysfunction therapies, treatments available over-the-counter from pharmacies and oral paracetamol suspensions. Respondents suggested that the list should be extended to include treatments that do not offer the NHS good value for money.
The problem is illustrated by a consultation I had with a father and his two children. He brought them in as a double whammy (as is customary in general practice). Both had very non-specific viral-type illnesses to which I gave the usual advice about symptomatic relief, antipyretics if necessary, etc. He replied that I should prescribe an antipyretic as his children are entitled to free prescriptions. This is where the consultation was diverted. He rambled on about the taxes he paid and the entitlement to free care for his children. Although I could not dispute this, I tried to reiterate why I was being slightly obstructive to his demands and to make him realize that Calpol today means no Herceptin tomorrow. I wish I could have been Carol Beer in Little Britain and said ‘computer says no!’
Persistent dizziness among the elderly
Although dizzy patients are predominantly managed in primary care, most diagnostic studies on dizziness have been performed on referred patients in secondary care. Because of this selective referral, the distribution of diagnoses in secondary care patients is probably different from patients in primary care. This skewed distribution hampers the application of findings from secondary care research to patients in primary care.
A group of Dutch colleagues analysed 417 elderly patients aged 65–95 years, who consulted their family physician for persistent dizziness. Contrary to previous studies where vestibular disease was thought to be the principal cause of dizziness in elderly patients, cardiovascular disease was found to be the most common major cause of dizziness in elderly patients in primary care.
Presyncope was the most common dizziness subtype (69%); cardiovascular disease was considered to be the most common major contributory cause of dizziness (57%), followed by peripheral vestibular disease (14%) and psychiatric illness (10%). An adverse drug effect was considered to be the most common minor contributory cause of dizziness (23%). Sixty-two percent of the patients were assigned more than one contributory cause of dizziness. GPs should anticipate that many dizzy elderly patients have more than one cause of dizziness that may be amenable to treatment.
Maarsingh, O., Dros, J., Schellevis, F. et al. Causes of persistent dizziness in elderly patients in primary care. Annals of Family Medicine (2010) 8(3): pp. 196–205