News & Views

Royal College of General Practitioners priorities

The new RCGP chair, Dr Clare Gerada has listed her key priorities for her 3 year term of office.

http://cms.rcgp.org.uk/staging/policy/rcgp_chair_priorities.aspx

Thank you for life

The RCGP has produced a book of thank you letters written from organ recipients to the families of their donors. Proceeds from the sale of the book will go to promotion of organ registration.

www.rcgp.org.uk/bookshop/info_9781860164071.html

Thinking point for commissioning

A recent study looked at the rate of provision of total hip and knee replacement per thousand people in need throughout England. Overall, the study showed variation in provision according to geography and demographic status. Younger men in southern England (excluding London) who needed joint replacement were the most likely to be treated. Despite methodological flaws (particularly definition of ‘need for joint replacement’ and the failure to obtain data from the private sector), this made me wonder again how we are going to set priorities when we as GPs take responsibility for commissioning.

Judge A, Welton NA, Sandhu J, Ben-Schlomo Y. Equity in access to total joint replacement of the hip and knee in England:cross sectional study. British Medical Journal (2010); 341: c4092

Treating other doctors

I wonder if you have ever been a patient? Have you ever treated a patient who is also a doctor?

As a profession, we are at greater risk than many groups of drug and alcohol misuse. We have stressful jobs and may become depressed. We often treat ourselves, fail to register with a GP and use informal ways of getting medical advice. The RCGP has produced a series of e-learning modules on Practitioner Health, with the option to add further face-to-face training to obtain certificates in practitioner health. The e-modules are scheduled to be released in spring 2011 and the advanced course in autumn 2011.

Impact of computers in consultations

Researchers in the Netherlands have come to the conclusion that computers are impacting on the doctor—patient relationship. This is based upon videotaping over 1000 patient consultations with 35 GPs along with a patient questionnaire over two separate time periods. The study showed that GPs gave less information to their patients if they used computers while the patient was talking; computer use also resulted in less eye contact, more closed body posture and (interestingly) patients offering their GP less information. Have you noticed this in your clinical practice? It would be interesting to find out what your patients think of the computer in the room.

Noordman, J., Verhaak, P., van Beljouw, I., van Dulmen, S. Consulting room computers and their effect on general practitioner—patient communication. Family Practice (2010); 27(6): p. 644–51

Quantity Outcomes Framework?

Healthcare systems around the world endeavour to improve quality, safety and access and to reduce disparities and costs.

It has been almost 7 years since the Quality and Outcomes Framework (QOF) and thus pay for performance (P4P) was introduced. The QOF contained evidence-based indicators and was weighted according to anticipated workload demands that each indicator would place on an average general practice. Its introduction was associated with the general trend in the National Health Service (NHS) away from placing implicit trust in doctors and more active monitoring of their performance. Several achievements of QOF were anticipated such as improving primary and secondary prevention, e.g. angiotensin converting enzyme (ACE) inhibitor plus beta-blocker for patients with heart failure; others have been unexpected such as reducing inequalities in health outcomes.

As opposed to P4P, fee-for-service systems such as Australia's Medicare that pay for activity (not outcomes) are unsustainable and not surprisingly there has been some interest in QOF. So, what doubts about QOF remain?

The structure of QOF allows GPs to exclude certain patients from QOF targets (‘exception reporting’) and there is no incentive to go beyond predefined targets. This does allow patient choice (to accept or reject advice) but diminishes the potential for overall public health gain. Ashworth and Kordowicz reiterate that QOF may be at odds with the values of professionalism that the RCGP is keen to promote, namely emphasis on personal care, longer consultations, continuity of care and involvement in the healthcare needs of the socially excluded. QOF may defect GPs from providing holistic care promoting an emphasis on technical excellence and not necessarily quality in primary care. Many aspects of quality such as consultation skills and patient enablement are not covered in QOF.

QOF has been described as a short-lived bonanza for GPs that has not been generally shared with the rest of the team. QOF may have resulted in a lack of attention to training and practice development, which will put practices in difficulty in the medium term. Many evidence-based indicators are not included in QOF (e.g. cardiac rehabilitation) because these services are not available nationally, despite their proven effectiveness.

Saying all this, the achievements of QOF have been considerable and are here to stay for the foreseeable future. QOF indicators will undoubtedly need to be effective, cost-effective and also demonstrate the potential for health gain.

Ashworth, M., Kordowicz, M. Quality and Outcomes Framework: time to take stock. British Journal of General Practice (2010); 60: p. 637–8

Continuity of care with GP

Managing acute illness is bread and butter for GPs; up to two-thirds of the 280 million consultations that occur in general practice in England alone are for acute problems. Distinguishing those patients that need emergency admission is a core skill of GPs. A report examining the quality of care of acute illness by GPs in 2010 (as part of the Inquiry into the Quality of General Practice in England) highlights nine measures that will facilitate the care of acute illness. These include: good access, sufficient consultation time and facilities to assess the problems, accurate diagnosis, adequate patient information, symptom resolution, appropriate prescribing, cost-effective use of resources, patient satisfaction and appropriate referral.

A laudable list indeed. We can collect numerical data but there are real opportunities for general practice to develop measures to reflect patient-centred care, communication skills and other core values. Surely developing quality measures for acute illness that recognize a relationship between patient and an experienced trusted GP can succeed in reducing referrals and admissions where alternative services have failed?

Jones, R., White, P., Armstrong, D. et al. Managing acute illness. An inquiry into the quality of general practice in England (2010) The King's Fund.

Orphan drugs

I visited Canada recently and listened to a consultant oncologist expressing horror that a single supplier was using ‘orphan drug’ legislation to vastly inflate the price of thalidomide tablets in the treatment of myeloma. When I returned, the British Medical Journal (BMJ) had an article about similar problems in Europe. Orphan drug legislation offers a monopoly (10 years in Europe) to encourage drug companies to develop medicines for the treatment of rare diseases; often uneconomic because of the small number of patients likely to need them. A legal loophole allows manufacturers to apply for a licence for existing drugs (so avoiding large development costs) and gain the monopoly for a treatment that may well have been already happening more cheaply on an unlicensed basis. Once a licensed product is available, the Medicines and Healthcare Products Regulatory Agency (MHRA) rules are that clinicians should only use an unlicensed product if they can show clinical benefit; a difference in price does not provide justification. The BMJ article quotes the price of carbamylglutamate (used unlicensed for 10 years in the treatment of a rare genetic deficiency) increasing from £4000 to £95 000 a year and idursulfase (used in the treatment of Hunter's syndrome) generating sales of $353 million in 2009 for the treatment of 500 patients.

On a much smaller scale, we have been reviewing the use of ‘special drugs’ in our surgery. We have paediatric patients on tube feeds and patients on specific ophthalmic and rectal medications. Prices charged for the identical product vary 5- to 6-fold between local pharmacies. We have managed to save thousands of pounds just by asking patients to choose the pharmacies that have managed to find cheaper suppliers. Potentially, more money could be saved by persuading secondary care to avoid ‘specials’ if there are effective alternatives and by arranging one supplier for the whole area.

Hawkes N, Cohen D. What makes an orphan drug? BMJ (2010); 341: c6459

Screening for lung cancer

The National Lung Screening trial was terminated early because fewer deaths from lung cancer were reported in the screening arm than the control arm. This was a large US National Cancer Institute (NCI) study on over 50 000 heavy smokers who were offered annual computerized tomography (CT) screening FOR 3 years. It is always difficult when studies are terminated early; there may be as yet unknown confounding factors. Reports of the study now come high up on Google ‘lung cancer screening’ searches so patients may well approach us for advice. I doubt screening will be available on the NHS, but patients at high risk may wish to discuss private referral; you will need to be able to give some sort of answer.

NCI. Lung cancer trial shows mortality benefit with low-dose C T. Press release dated 4.22.2010. Accessed via: www.cancer.gov/newscenter/pressreleases/NLSTresultsRelease

Hypertension in pregnancy

A GP was on the guideline development group that produced the new National Institute for Health and Clinical Excellence (NICE) guideline on the management of hypertension in pregnancy. Although management of hypertensive disorders in pregnancy should be done in secondary care, a significant number of women with hypertension first present in primary care.

The guidelines differentiate between chronic hypertension (hypertension in a woman who is already hypertensive when she becomes pregnant), gestational hypertension (new hypertension in pregnancy) and pre-eclampsia (new hypertension and proteinuria). The guidelines give aspirin prophylaxis and preconception advice. There are very clear algorithms for referral during pregnancy and then for follow-up after delivery.

National Institute for Health and Clinical Excellence. Hypertension in pregnancy: the management of hypertensive disorders during pregnancy www.guidance.nice.org.uk/CG107