Abstract
Happy new year
The year 2011 will be one of change in UK general practice, with particular emphasis on the changes related to the White Paper. One of the advantages of having spent over 20 years working in general practice is that I have learnt that as a profession we are hugely adaptable that we take the change and make the best of it for ourselves and our patients and that many innovations come round again in a slightly different form. Many of you will sit examinations or complete your GP training in 2011. Oliver and I would like to wish you luck in all your undertakings.
Patient feedback
Payment-driven targets for patient surveys may disappear. For the ePortfolio, Associates-in-Training (AiTs) currently have to complete patient satisfaction questionnaires. Results in our surgery seem to be very positive. I am unsure whether this reflects nice patients, good registrars or bland questions. A recent pilot study looked at the use of realtime feedback to allow rapid response to findings. For example, one of the practices involved used questions about telephone access to change the way telephone calls were handled by the practice and another used questions about how far in advance patients would like to be able to make bookings to reorganize the appointment system. Findings were sometimes unexpected. For example, one practice discovered that their Gujarati-speaking patients were using the English language version as the written Gujarati format did not use the local version of Gujarati. It is easy for us to make assumptions about our patients; this is one way to try to ask the views of our patients.
www.practicemanagement.org.uk/realtime-patient-feedback [date last accessed 11.11.2010].
i-stethoscope
I read a snippet in the Minerva section of the British Medical Journal that mentioned an i-stethoscope application (app) and was then asked about it by a patient the next day. There is a free entertainment app that gives a mock heartbeat and also various paid apps that can be used to demonstrate heart and breath sounds. I noticed that one of the reviews mentioned using it to listen to foetal heart sounds and another suggested taking it to his GP to demonstrate. At our surgery, we keep a list of useful smart phone medical apps; what would you add to your list?
Wellcome Trust
The Wellcome Trust awards an annual prize for books with a medical theme. This year's awards were chosen from a shortlist of six books, perhaps you could choose to read one in 2011.
Ethics of the ordinary
It can be difficult to get around to writing ePortfolio entries on ethical issues, and usually entries are triggered by ‘headline’ issues such as assisted wills or treatment rationing. Andrew Papanikitas and Peter Toon wrote a brief article in the November edition of the British Journal of General Practice that focused on mundane events in everyday general practice. The ePortfolio entries do not need to be long; if you read this and wrote down some thoughts about its relevance to your own practice, you would have a high-quality ePortfolio entry that might help fill one of your curriculum gaps.
Papanikitas, A., Toon, P. Last but not least: the ethics of the ordinary. British Journal of General Practice (2010) 60(580): p. 863–864.
Veterans
Some of you will work in areas with a known ‘military’ tie. Many of you will work with veterans, but, unless you take an occupational history, you may not discover this. The Royal College of General Practitioners (RCGP), in conjunction with The Royal British Legion and Combat Stress, has produced guidance to help you to identify the health care needs of veterans and then find ways to meet them. No one expects you to be an expert on the management of prostheses or the rules about entitlement to priority medical treatment, but if you use the guidance, you will be able to help your patients with service-related medical problems.
www.rcgp.org.uk/PDF/Veterans-Sep2010_Online.pdf [date last accessed 11.11.2010].
Why do clinical trials in general practice?
This brief editorial caught my eye recently in the Australian Family Physician. General practice is in a unique position to participate in research for the following reasons:
We are able to identify eligible participants (patients) From a population perspective, the greatest number of patients at risk are in the primary prevention population We treat a different disease spectrum not treated in secondary care. If we don't research this, who will? We see conditions such as Bell's palsy that have a limited therapeutic window General practice trials demonstrate what works in the real world as opposed to the controlled environment of a clinical trials centre. It can be said that research can only be directly applied to the population it was conducted in.
But I think the greatest reward as GP researcher is that you can see the effects of your project or research on the lives of your patients.
However, what the editorial did not address was that there are strict caveats before contemplating any research in general practice. Any original research must have prior ethics permission. This includes those projects conducted in general practice. Failure to acquire prior research ethics approval is against General Medical Council (GMC) regulations. Research ethics rules apply to all human participants. That includes staff as well as patients. These rules even apply when the data are anonymized (i.e. even if patients cannot be identified). In reality, unless you are working within an academic department with its associated support network, it is easier to partake in ongoing research projects that have already attained research ethics approval.
Nelson, M. Why do clinical trials in general practice? Australian Family Physician (2010) 39: pp. 713.
Effect of home testing of international normalized ratio on clinical events
For those of us who have trawled through a patient's variable international normalized ratio (INR) outside the target range, this will be a welcome article. As compared with venous plasma testing, point-of-care INR measuring devices allow greater testing frequency and patient involvement. However, does this improve clinical outcome?
A group in the USA randomly assigned nearly 3000 patients who were taking warfarin to either weekly self-testing at home or monthly high-quality testing in a clinic. The primary end point was the time to a first major event (stroke, major bleeding episode or death). Although the INR in the self-testing group tended to be slightly more within the target range, there was no evidence to support the superiority of self-testing over clinic testing in reducing the risk of stroke, major bleeding episode and death among patients taking warfarin therapy. This calls into question two widely held theories that more frequent INR testing equates to better outcomes and that self-testing (as opposed to clinic-based testing) can reduce adverse events such as bleeding and thrombosis.
Matchar, D. B., Jacobson, A., Dolor, R. et al. Effect of home testing of international ratio on clinical events. New England Journal of Medicine (2010) 363(17): p. 1608–20.
New international guidelines on resuscitation
Cardiac arrest away from a hospital setting is a very different experience from being involved in a team-based resuscitation process. As a GP, you may be involved in resuscitation attempts in the patient's home or be called from the surgery into the street. The new cardiopulmonary resuscitation (CPR) guidelines continue the 2000 process of acknowledging that diagnosing cardiac arrest is difficult. The guidelines stress absence of normal breathing in an unresponsive patient should be interpreted as cardiac arrest. For the first time, there is acknowledgement of the use of chest compressions alone by untrained people or for people being given telephone advice by the emergency services. Gaps in the performance of CPR are of critical importance, so the emphasis is on giving good quality compressions and minimizing pauses. Compressions should be to a depth of 5–6 cm in an adult and at a rate of 100–120 per minute. Rescue breaths, if performed, should be over 1 second rather than 2. CPR should only be stopped if the victim starts to show signs of regaining consciousness and starts to breathe normally.
Even without changes to the guidelines, there is good evidence that we need regular refresher sessions on CPR. You will need an up-to-date CPR certificate to complete your training; it is also helpful to enter the world of independent practice with a recent certificate as finding update courses can be more difficult when you are no longer in a teaching environment with protected time for learning.
Cardiac rehabilitation
I wonder how many of your coronary patients participate in cardiac rehabilitation? (a structured programme of exercise and information, which helps patients to manage their condition after a heart event). The British Heart Foundation (BHF) has just published the fourth National Audit of Cardiac Rehabilitation. It shows that only 41% of heart patients from the target groups (heart attack, bypass surgery and angioplasty) took part during 2008–09. The National Institute for Health and Clinical Excellence (NICE) guideline on chronic heart failure (August 2010) recommends cardiac rehabilitation, but the audit did not show any increased uptake in this group. The BHF is also concerned that women are under-represented in the programme; they made up only 26% of participants.
www.bhf.org.uk/research_health_professionals/non-research_grants/cardiac_rehab_grants.aspx [date last accessed 11.11.2010].
New system of drug pricing
The government currently negotiates drug prices via the pharmaceutical price regulation system. Negotiations every 5 years allow drug companies to set their own prices but cap their overall profits. By 2014, it is planned that this scheme will be replaced by a value-based pricing scheme, where the government will negotiate the prices that the National Health Service (NHS) pays for drugs according to the clinical value. It is unclear what the role of National Institute for Health and Clinical Excellence (NICE) will be in this process. There are concerns that a postcode lottery may be created, with local GP consortia having to choose between high-cost drugs or other clinical priorities.
Many rationing decisions will be made at local level; you may want to think about how you would deal with them if you were involved in commissioning.
Kmietowicz, Z. Experts warn of drug rationing by GPs under new pricing scheme. British Medical Journal (2010) 341: pp. c6240.
www.nature.com/news/2010/101101/full/news.2010.574.html [date last accessed 27 November 2010].