Abstract
White Paper update
I think it likely that we will write many pieces entitled ‘White Paper Update’. Even if management does not appeal, this is going to affect every single one of us, so we do need to be aware of what is happening.
Primary Care Trusts will cease to exist by 2013 and every GP practice will be expected to join a consortium; these will commission:
Elective hospital care Rehabilitation care Urgent and emergency care (including out-of-hours services) Most community health services Mental health and learning disabilities services The National Health Service (NHS) Commissioning Board will have the power to assign a practice to a consortium so there is no ‘opt-out’ option.
The main financial change to directly affect practices is that a proportion of GP income will be linked to outcomes that practices achieve collaboratively through the consortia. Coupled with this will be a reform of Quality and Outcomes Framework payments to remove many of the payments that involve ‘recording’, e.g. maintenance of disease registers and recording of blood pressures or cholesterol level, and to focus instead on ‘health outcomes’.
The timetable is short when one thinks that the changes are major and that there has been no piloting:
This means that all of you will see the preparation for the process and will move into the world of independent practice during a period of massive change. You might wish to discuss at your vocational training sessions whether, particularly at the end of your training, you will need to add to your skill set.
Continuing medical education
The British Medical Journal (BMJ) is producing a set of learning modules linked to BMJ research articles, about one a week. Registration through BMJ Learning will allow you to access the research article and information, complete a set of multiple-choice questions (80% pass rate with scope to resit) and receive continuing medical education credits. The questions will be drafted by the article authors, with educational input from the Cleveland Clinic (a large provider of free medical education with visible distinction between sponsorship and educational content) educational experts.
First avoid unkindness
A ‘Personal View’ article from a recent British Medical Journal caught my eye. Angela Jones, a portfolio GP, described her concern about the lack of caring in the NHS. Like Angela, I have seen elderly patients describe their humiliation at being ignored when asking for help with simple bodily functions and parents of mentally ill teenagers crying with frustration when unable to get the help that they believe they need.
The Patients Association produced a report, Patients not Numbers, People not Statistics, where both patients and relatives describe such episodes. Angela asks whether ‘universal avoidance of unkind acts’ would be possible in the NHS. Perhaps, we could all ask ourselves whether we are always kind to our patients, whether we ever challenge the system that challenges them.
www.patients-association.org.uk/research-Publications/297 (You may want to look in the library for a copy as there is a £15 charge for non-members.)
Jones A. Could kindness heal the NHS? (2010) British Medical Journal (2010) 340: pp. c3166
Cervical polyps
When I first started as a GP, I frequently removed polyps that I spotted at cervical smears. After a few years, I then started sending the specimens to histology for review. I have never found anything other than benign lesions. A paper in the British Journal of Obstetrics and Gynaecology analysed the histology results of 1366 polyps removed over a 4 year period in primary and secondary care in Oxford; no malignant polyps were found. Costs for the hospital removal for about a 1000 of these were over £120 000, as opposed to £6000 for the removal of 287 polyps in primary care. I shall be more relaxed about my discussion of polyps with my patients and wonder at least whether more of them should be observed or treated in primary care.
Mackenzie, I., Naish, C., Rees, C.M.P., Manek, S. Why remove all cervical polyps and examine them histologically? British Journal of Obstetrics and Gynaecology (2009) 116: p. 1127–9
Dietary advice in diabetes
I spend a lot of time persuading patients who I treat medically for conditions such as hypercholesterolaemia or diabetes that my tablets do not replace, but complement, their lifestyle efforts. Our diabetic nurse and I spend time discussing these ‘difficult’ patients to encourage ourselves to go on trying different approaches to encourage them to help themselves.
A small study in New Zealand has shown that intensive dietary advice to patients with poor diabetic control, despite maximal drug treatment, improved both control and lifestyle measures. Although it involved just under a hundred patients and only lasted for 6 months, I will use this paper to encourage myself to go on ‘chipping away’ at these patients' lifestyles.
Coppell, K., Katakoa, M., Willimas, S., et al. Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimized drug treatment-Lifestyle Over and Above Drugs in Diabetes (LOADD) study: randomized controlled trial. British Medical Journal (2010) 341: pp. c3337
From Terra Australis
I am writing to you from Melbourne for the next 12 months, accompanying my other half on a secondment there. It is fortunate that medical skills are so transferable over the world. My first thoughts of Melbourne: cosmopolitan, foodie-haven and sports-mad. I went to my first Aussie Rules game—a mixture of volley/basketball played with a rugby-esque ball (in fact it is smaller) in a massive Quidditch-like stadium. Score 151–57!
I am teaching on the undergraduate curriculum in General Practice at Monash University in addition to doing some clinical sessions. We have been running various objective structured clinical examination-type stations with simulated patients on cases one might be seeing in General Practice. Even though these are undergraduate students, we have also not shied away from those difficult encounters such as domestic violence and medically unfit-to-drive scenarios [all potential Clinical Skills Assessment (CSA) cases]. I have been thoroughly impressed at the professionalism shown by some undergraduates coming through. The future does look bright, not orange—but green and gold (national colours of Australia). So, I will keep you posted on further developments.
Stage-3 chronic kidney disease and its relevance
Rummaging through my daily workflow of patients' results, sorting out the potential abnormal results, I still find it difficult to convey the true significance of stage-3 chronic kidney disease (CKD 3) to patients, in part, because we (collective medical field) are still unsure. Yes, there is a well established link between CKD and cardiovascular disease (CVD) with a high prevalence of atherosclerosis, arteriosclerosis and left ventricular hypertrophy in patients with early CKD as well as in patients with endstage renal disease, attributed to the same traditional CVD risk factors. However, the high prevalence of reduced estimated glomerular filtration (eGFR) in the elderly has led to speculation as to whether it should really be regarded as a disease at all. It remains doubtful whether labelling all elderly CKD patients with a ‘disease’ confers any additional benefit.
CKD 3 is the first stage that is identifiable from a blood test alone. In the UK, it accounts for the majority of people on primary care CKD registers. Approximately 9% of the English population are thought to have stages 3–5 based on recent estimates from the NEOERICA project. It also represents a group of people who, in the past, would have gone unnoticed clinically.
A recent review in the BJGP has tried to clarify the natural history of CKD 3 (in terms of numbers) in order to describe all cause mortality, cardiovascular morbidity and mortality and renal outcomes. Thirteen studies were identified including a total of over 700000 people. The all-cause mortality rate varied from 6% in 3 years to 51% in 10 years and was higher in stage-3B CKD (4.8 per 100 person-years) than stage-3A CKD (1.1 per 100 person-years). The relative risk of mortality (all-cause mortality or CVD mortality) was higher in stage-3 CKD compared with no CKD, but the increase was small for those with stage-3A CKD [hazard ratio (HR) 1.2–1.7] and greater in stage 3B (HR 1.8–3.3). End-stage renal disease was rare (4% in 10 years) and renal progression was evident in less than 20% of patients after 5 years.
What CKD registers do provide is an opportunity for GPs to assess the risk of patients developing CVD. Death from CVD is far more common than progression to renal replacement therapy in the elderly. Factors that increase the risks of progression to endstage renal disease include younger age, proteinuria and diabetes. Although the elderly have high rates of cardiovascular death, comparatively younger patients with CKD have substantially increased relative risks of death and these patients should be targeted for specialist renal review.
Sharma, P., McCullough, K., Scotland, G., et al. Does stage-3 chronic kidney disease matter?: a systematic literature review. British Journal of General Practice (2010) 575: p.266–76
Clark, L.E., Khan, I. Outcomes in CKD: what we know and what we need to know. Nephron Clinical Practice (2010) 114(2): p. 95–102
Intrauterine contraceptive devices and human immunodeficiency virus disease progression
Highly effective contraception is essential to reduce unintended pregnancies and the effect these have on individuals, society and public health resources. Intrauterine devices (IUDs) and depot progestogens are two commonly used long-acting reversible contraceptive methods with different risk and benefit profiles. A recent Cochrane review compared the contraceptive and non-contraceptive benefits and risks of these two forms of contraception.
Overall, the copper IUD was more effective than depot progestogens at preventing pregnancy [risk ratio (RR) 0.45; 95% confidence interval (CI) 0.24–0.84]. Interestingly, human immunodeficiency virus (HIV) disease progression was reduced in the IUD group (RR 0.58; 95% CI 0.39–0.87); however, there was no significant difference in pelvic inflammatory disease rates between the two groups. The significant point here, as one author suggests, is that the copper intrauterine contraceptive device (IUCD) has better efficacy with no additional risks, a fact of which most practitioners are unaware.
Hofmeyr, G.J., Singata, M., Lawrie, T.A. Copper containing intra-uterine devices versus depot progestogens for contraception. Cochrane Database of Systematic Reviews. 2010 16 (6): CD007043.