Abstract
Website of the month
This website produced by First5® leads and supported by RCGP Wales, has been created as a resource for Welsh First5® members. However, the plethora of information would be useful for any GP. The website aims to help professional development and networking with peers by signposting to CPD (continuing professional development) sessions. It also helps support patients with links to useful online resources. The simple layout makes it a useful tool for use during consultations.
Green Dreams
Green Dreams is a social enterprise project founded by an East Lancashire GP, Dr James Fleming. Project managers liaise with local practices to help co-ordinate volunteering, food banks, development of derelict land and other activities that can improve the quality of life of local residents. All such projects start with small steps; perhaps there is one tiny area that you could change in your own practice.
Breaching confidentiality
A recent ethics discussion in the British Medical Journal focuses on scenarios surrounding breach of confidentiality to alert the partners of someone who is human immunodeficency virus (HIV) positive:
denies having sexual partners
refuses to disclose a sexual history
reveals the identity of his sexual partners but refuses to disclose his HIV status to them
says he has disclosed his HIV status to his wife but refuses to bring her in to the clinic
You could discuss these at a tutorial or vocational training session and then read the author's suggestions.
Chan, T. (2013). Doctors have a duty to breach patient confidentiality to protect others at risk of HIV infection. British Medical Journal, 346, 1471. doi:10.1136/bmj.f1471
My ageing parent
This website pulls together medical, legal and social care advice for people who are looking after an elderly relative. Recent topics include ‘A beginner's guide to dementia’, the extra problems caused when dementia and hearing loss combine and advice about getting a community care assessment.
Asthma quality standards
The National Institute for Health and Clinical Excellence has produced a quality standard for asthma. It contains 11 statements of which 10 are directly applicable to primary care. You could discuss this at a clinical session at your own practice, or perhaps at a vocational training session you could pool data about which statements are not met in the linked practices and then discuss possible reasons. The standards are:
People with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN (British Thoracic Society/Scottish Intercollegiate Guidelines network) guidance
Adults with new onset asthma are assessed for occupational causes
People with asthma receive a written personalised action plan
People with asthma receive a structured review at least annually
People with asthma are given specific training and assessment in inhaler technique before starting any new inhaler treatment
People with asthma who present with respiratory symptoms receive an assessment of their asthma control
People with asthma who present with an exacerbation of their symptoms receive an objective measurement of severity at the time of presentation
People aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation
People admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge
People who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within two working days of treatment
People with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service
Social problems and patients
Within your local area it might be useful to draw up a list of both national and local resources to help patients who attend to see you when filling their social needs.
Citizens Advice Bureau, Age Concern UK, workplace unions and the Shaw Trust are some of the organisations I sometimes discuss. In our local area counselling can be fast-tracked if there is an employment-related cause or to prevent/minimise time off work. We also have a Live at Home scheme that provides, among other services, befriending for the housebound.
You could ask around your practice team and draw up a list of resources for your area.
Aqueous cream warning
This warning from the Medicines and Healthcare products Regulatory Agency (MHRA) has made me more cautious when it comes to emollient prescribing. Aqueous cream is a widely used topical emollient for the symptomatic relief of atopic eczema and as a soapsubstitute.
An audit of 100 children attending a paediatric dermatology clinic reported that aqueous cream was associated with an immediate skin reaction (stinging, burning, itching and redness) within 20 minutes in 56% of exposures, compared with 18% with other emollients used. Furthermore, several studies reported thinning of the outermost layer of the skin and increased skin water loss following its application in adults, both with and without eczema.
The causative agent may be sodium lauryl sulfate (SLS), contained in emulsifying wax that is one of the ingredients of aqueous cream. If a patient reports skin irritation (burning, stinging, itching or redness) after using aqueous cream, discontinue treatment, and replace it with an alternative emollient that does not contain sodium lauryl sulfate.
Drug Safety Update. (2013). 6 8:A2 Retrieved from www.mhra.gov.uk/home/groups/dsu/documents/publication/con254819.pdf
Postnatal depression
An Australian study found 16% of women who brought their babies to the emergency room for treatment of ‘non-time-critical’ conditions were positive on the Edinburgh Postnatal Depression Scale. The most common presenting complaint was ‘crying baby’. Many of the mothers had never been screened for depression previously. Although this was not a study based in primary care, this correlates well with what I see in general practice. I think that once we have answered the question ‘Is this baby sick?’, perhaps the second question we should be asking is ‘Why has this mum come to us; is she looking for help for herself?’
Stock, A., Chin, L., Babl, F., Bevan, C., Donath, S., & Jordan, B. (2013). Postnatal depression in mothers bringing infants to the emergency department. Archive of Disease in Childhood, 98, 36–40. doi: 10.1136/archdischild-2012-302679
Ulipristal for heavy menstrual bleeding
Ulipristal is more commonly known for its use as emergency contraception. However, it is interesting to see that it is now recommended for use within NHS Scotland as pre-operative treatment of moderate-to-severe symptoms of uterine fibroids in adult women of reproductive age. Dosing is as 5 mg orally once daily for up to 3 months. Treatment should be started during the first week of a menstrual cycle.
Scottish Medicines Consortium. (2013). 834/13 Retrieved from www.scottishmedicines.org.uk/files/advice/ulipristal_acetate_Esmya_FINAL_January_2013_Amended_080213_for_website.pdf
Quality and Outcomes Framework
The indicators for QOF have changed again this year. There are now 900 as opposed to 1000 points (mainly through ‘retiring’ administrative points). There are differences across the four countries; mostly in the percentage achievements required to claim the points.
I think some changes, such as the requirement to put a depressed patient into context (a biopsychosocial history) and the recognition that patients with rheumatoid arthritis are at higher risk of cardiovascular disease are positive. However I am concerned that we are being pushed into spending time recording data on patients rather than on time spent listening to them. At our surgery we have put a huge amount of effort into maximising the clinical input by clinicians and automating the recording so that time spent on the administrative side of QOF is not subtracted from the patient's ‘10 minutes.’ I wonder when we concentrate on patients with these illnesses what will happen to our care of patients with ‘non QOF’ disease. I am starting to ask myself what would happen to patient care if we devoted the time and energy spent on achieving QOF elsewhere; listening to a depressed patient, giving advice to a new mum who no longer has easy health visitor access, accepting the cup of tea on a home visit for example. What do you think?
The Poetry of General Practice Seminar 28 September 2013, Oxford
This one-day small group seminar, primarily for GPs, is ‘a forum for discussing and illuminating the experience of general practice through literary texts’. Led by a general practitioner and an Oxford academic, the seminar welcomes both new and established readers. Aims include ‘to foster reflective practice and examine the ways we communicate, to broaden our appreciation of the experience of illness and well-being and to explore the more qualitative aspects of the Personal Development Plan (PDP)’.
Retrieved from www.lit-med.com/