The future of GP appraisal: Delivering consistent quality across the UK UK-wide standards for the quality assurance of general practitioner appraisal are to be set down by the RCGP as part of its preparations for revalidation. The standards will focus on agreed core information for appraisal – rather than attempting to unify documentation specific to particular countries – to ensure that systems of clinical governance and appraisal are developed and applied consistently across the four countries. The ‘core’ information will comprise:
q Demographic Data w Record of Discussion Summary of Appraisal discussion domain by domain l Review of the last year’s PDP l The current year’s PDP developed as a result of appraisal l Review of content of the current year’s PDP Personal Development Plan l
The proposals were developed at a meeting of country appraisal leads convened by the RCGP where the different country systems and documentations were reviewed. They build on the work set out in the RCGP policy paper Principles of Appraisal, published last year, which called for consistency across the four countries of the UK. The introduction of revalidation by the RCGP will be underpinned by a robust appraisal system and CPD strategy. The College will therefore need to have confidence in the Quality Assurance process of appraisal carried out by local organisations – including appraiser selection, training and support – and appropriate access to local QA processes in order to be satisfied that recommendations arising from it are reliable. It will also need to be confident that specific aspects of appraisal which are critical to the College’s decisions on revalidation – such as the model of multisource feedback used or the level and nature of CPD undertaken – will be effectively administered through the local process. Appraisal processes that are equivalent and interchangeable between each UK country will be needed. Appraisal methodologies will continue to be owned by employers and remain an NHS responsibility but the involvement of the Postgraduate Deaneries will be critical.
Quality Assurance of appraisal Before the RCGP will quality assure GP appraisal, key elements must be clarified: l The respective quality assurance responsibilities of the RCGP, GMC and other organisations. l Lay input into the process. l Quality assurance of local level processes. l The RCGP will support a panel system at local level. l Local panel/Responsible Officer sign-off procedures of revalidation evidence. l The UK structure for Responsible Officers (to be clarified by the Department of Health). l Best practice for appraiser selection and training will need to be maintained. Once these have been determined, the next steps will be to agree a system that allows appraisers to be selected and trained to a common
a The new RcGp standards will ensure consistency across the uK and provide added conﬁdence Professor Steve Field for patients and the public b
standard. This will involve the development of an accreditation scheme for initial and ongoing appraiser training to support appraisers and allow quality assurance and calibration. The process by which appraisees will collect and demonstrate their evidence within appraisal will also be agreed. RCGP Chairman Professor Steve Field said: “As GPs, we all want to continually improve the care we provide for our patients. Appraisal is a cornerstone of this activity in that it provides a point in time when we can look back on our performance during the previous year and plan for the year to come. “The new RCGP standards will ensure consistency across the UK and provide added confidence for patients and the public, as well as ourselves, that the system in which we are participating is fair and effective.” The RCGP has also joined forces with education leaders from CoGPED to bring about the development of a consistent appraisal system across England, building on the success of the processes already in place in Scotland, Wales and Northern Ireland. In a joint position statement, the two organisations recommend that : l The provision of and accountability for GP appraisal should remain a PCT responsibility l Employment, management and remuneration of local appraisers should be developed locally to a common national model l Postgraduate Deaneries should develop the strategy and local standards, working with PCTs, public and local stakeholders l Deaneries should be charged with providing a cost effective process to support needs of patients, service, professionals and revalidation The RCGP and CoGPED are concerned that while good appraisal systems do exist in some PCTs in England, provision is ‘patchy’ and the consistent quality of delivery that exists in Scotland, Northern Ireland and Wales is lacking. They argue that a robust and coherent system is essential if revalidation of GPs in England is to be successfully implemented and are hoping that this collaboration will encourage the involvement of the Department of Health in delivering a national appraisal system for GPs in England. Under the proposals, Postgraduate Deaneries would work as Commissioning and Quality Assurance organisations responsible for development of appraisal commissioning plans, contracts and standards. They would ensure appointment standards for appraisers, training and assessment standards of appraisers, feedback, reassessment and ongoing development. The model proposed is already in place in Scotland and Wales, with GP appraisers managed through the deanery. · GMC prepares for introduction of new licence to practise. See page 4
THE NEwSpApER OF THE ROyAl cOllEGE OF GENERAl pRAcTITIONERS
Inside this issue... A FIRST FOR JOHN HORDER New RCGP Award
AT HOmE wITH THE OSbORNES RCGP Wales Chair Bridget Osborne talks about her latest role
EGp upDATE Test yourself on clinical scenarios
pREDIcTING DEpRESSION Major study to help family doctors
Yes, Minister: Dr Agnelo Fernandes and his Croydon colleagues receive their award from Health Minister Ben Bradshaw, watched by comedian Dara O’Briain (far left) who compered the event
croydon Federation honoured for local diagnostics initiative A GP federation in Croydon is celebrating after winning a coveted Health Service Journal award for bringing diagnostics to patients in the local community. Led by RCGP Fellow Dr Agnelo Fernandes, the Croydon GP Federation was formed last year and is made up of 16 local practices, covering a population of 140,000 patients. The Diagnostics in the Community pilot has brought ultrasound, echo and direct access MRI diagnostics into the participating GP surgeries in South London and has been such a success that it is now being rolled out by the Primary Care Trust. Patients have the choice and convenience of having their diagnostic test at six sites locally in Croydon, as well as central London if more convenient. The HSJ Awards are held annually to celebrate NHS achievements and the Croydon Federation claimed the category for Improving Patient Access. Dr Fernandes said: “We were absolutely thrilled because it’s not often a GP-led practice project wins an HSJ award. “The pilot was a great success almost immediately. Our real aim was better access to diagnostics and care for patients, which we have achieved. Ideally no patient should have to travel more than 30 minutes for their test.
“We no longer need to refer patients to hospitals just for a diagnostic, and we are getting quicker results. From the time of first referral patients are receiving their test and report within two weeks, surpassing national targets by a long way.” The project is notable for being driven entirely by GPs with no external funding. All sites involved gave up their rooms and facilities for free in recognition of the importance of the project for improving patient care. “We had a vision and were determined to make this work for the benefit of patients. We project-managed it ourselves and overcame any problems that cropped up,” said Dr Fernandes. “We made this our priority in November 2007 and by February 2008 we were delivering it. It could be the fastest implementation of a major redesign project in NHS history!” Dr Fernandes says the HSJ award is recognition of the hard work and commitment of the federated practices in wanting to make a difference: “To have won and received the award from a Minister was just unbelievable. It was a real boost to our team.”
Gps key in communicating new grant to mothers-to-be GPs and midwives will be asked to sign claim forms for the new Health in Pregnancy Grant.
Dr John Horder with Jane Austin and her family at the presentation of his eponymous award
Jane Austin receives the ﬁrst John Horder Award Former RCGP President Dr John Horder has given his name to a new College Award recognising the contribution of College staff members. Dr Horder made the inaugural award at the Annual General Meeting to Jane Austin, former RCGP Director of Policy and Communications, who retired last summer after 18 years service. The citation was given by RCGP Honorary Secretary Dr Maureen Baker who said: “Jane
has worked tirelessly for the College in a variety of roles and the College would like to pay tribute to her dedication and significant contribution. It seems particularly fitting that this award should be associated with Dr John Horder, who has always been very involved and interested in staff welfare.” The prestigious Award will be made annually to a member of staff deemed to have given ‘exceptional service in promoting the objectives and values of the College’.
From April 2009, pregnant women throughout the UK will be eligible for the Health in Pregnancy Grant, a one-off payment of £190. The grant, administered by HM Revenue and Customs (HMRC), is available to pregnant women between the 25th week of pregnancy and their due date of delivery. The grant aims to provide flexible financial help to support the general health and wellbeing of women in the later stages of pregnancy, and to help them meet the wider costs in the run-up to birth. A doctor or midwife will be required to sign the claim form, meaning GPs will play a key role in ensuring that women receive the new grant. The grant, which is not means tested, is paid as a one-off lump sum. Payment will start from 6 April 2009 and will be paid directly to the pregnant woman. The mother will then be able to spend the money how she chooses, taking into account advice from her midwife or GP on lifestyle changes and healthy eating. The introduction of the grant forms part of the Health & Social Care Act 2008, and brings Britain in line with other European countries in recognising the need to provide additional support to help meet the extra costs associated with having a baby
Plus a celebratory dinner for your whole team
There is a long tradition of innovation in grassroots general practice but rarely have GPs been able to quickly take on board and replicate the ideas of colleagues from around the UK. That’s why the Enterprise Awards have been seen as such an important initiative for primary care. GP newspaper and the RCGP wanted to create an awards scheme that would showcase new ways of working that were easily replicable by other practices. And these awards are not just for the privileged few. The only work involved is telling us, in less than 500 words, what you did, why you did it and what you achieved. So just ask yourself whether your ideas are replicable. If the answer is yes, then we want to hear from you. And so does the rest of the profession.
Entry forms Proudly supported by
You can download an entry form now from: www.healthcarerepublic.com/awards
Award categories Practice team Innovative clinical care – general Innovative clinical care – specific Enterprising use of IT Primary care nursing Environmentally friendly practice Risk management
The MDU Enterprise Award The readers of GP newspaper will be invited to vote for an overall winner from the successful entrants in the seven categories. The winner of the overall award will receive a prize of £4,000.
Closing date: 26 January 2009 www.healthcarerepublic.com/awards
Does anything need to be sent with the claim form?
How long will it take before a decision is made on the claim?
Health in Pregnancy grant: key questions and answers
Win £4,000 in cash ENTERPRISE AWARDS
When can a pregnant woman claim the grant? From April 2009, when the grant is officially launched, a pregnant woman will be able to claim the grant from her 25th week of pregnancy. In addition, and in order to ensure as many women as possible are eligible, pregnant women whose expected delivery date is on or after 6 April 2009 can also make a claim from the 25th week of her pregnancy. This means the first claims can be made from January 2009; payment, however, will not be received until after the official launch of the grant in April 2009.
How will a woman claim the grant? Once a pregnant woman reaches the 25th week of her pregnancy, she will need to fill in a simple claim form, which will be made available to GPs and midwives before January 2009. A midwife or doctor will need to sign the form to confirm that the woman is 25 weeks pregnant, and that ‘appropriate maternal advice’ has been given. It will then be the responsibility of the woman to ensure the application form is sent to HM Revenue and Customs (HMRC), who are administering the grant, and that it arrives within 31 days of being signed by the midwife or doctor. HMRC will only supply forms to registered midwives and doctors; pregnant women cannot obtain the form directly.
london gets its own primary care journal An ambitious new project to promote learning amongst primar y care professionals has been launched by the three London Faculties of the RCGP. The London Journal of Primary Care is a webbased journal which will publish multidisciplinary grass roots innovations – with practical lessons for policy. The editor-in-chief, Professor Paul Thomas, said: “Different practitioners often need to work
No. HMRC will not usually require any additional information to be sent with the claim form.
Once a fully completed claim form has been received by HMRC, they will aim to give a decision in two weeks in most cases. Eligible expectant mothers (whose expected delivery date is on or after 6 April 2009) sending claims before April 2009 should wait until the end of April 2009 before following up claims.
What is appropriate maternal advice? This is the normal advice that midwives and doctors give to pregnant women to help them and their unborn baby stay healthy during pregnancy, for example advice on a healthy diet and lifestyle. The most appropriate advice varies for different women, and so there is no set rule on what this might be.
When will the grant be paid? Once HMRC has received that claim form (which must be within 31 days of it being signed by a midwife or doctor) it will be processed as soon as possible. If the woman hasn’t heard anything from HMRC within four weeks of posting her claim form, she should phone the helpline – the number for this will be available on the claim form. Pregnant women making claims prior to or immediately after the introduction of the grant in April 2009 might have to wait slightly longer to receive payment. Payments should be received by the end of May 2009, however.
What if the expectant mother is under the age of 16? There is no minimum age to claim the Health in Pregnancy Grant. Expectant mothers under the age of 16 should complete their own forms unless they are physically or mentally unable to claim themselves. A parent of the expectant mother cannot claim on their daughter’s behalf.
Will further information be available for healthcare professionals? Guidance notes will be available with the form to help answer any questions a pregnant woman or healthcare professional might have about the grant and the application procedure. A quick reference guide for healthcare professionals will also be made available for doctors to answer any specific queries about the grant. Further information is available at www.direct.gov.uk. In addition posters and materials for women will be distributed in clinics and waiting rooms, with advertising in the parenting press to ensure that as many pregnant women as possible hear about the new grant.
in partnership with each other and the journal will be open to all those who share this broad vision for healthy communities. It is aimed at all primary and social care disciplines and reflects the ambition of the three Faculties to promote modern, high quality primary care throughout the capital.” As well as the web version, there will be two print copies a year to feature the ‘best of the web’ and provide multi-disciplinary insights into important contemporary issues. More than just a traditional academic publication, the website features research and case studies of quality improvements, as well as search and discussion facilities to help practitioners and managers to promote collaborative developments. It has received the backing of many organisations, including the London Deanery, Healthcare for London and Primary Care Trusts. RCGP News • January 2009
INTERVIEW Dr Bridget Osborne, new Chair of RCGP Wales, talks about the priorities ahead and how ‘being interested in people’ attracted her to general practice
Rising to the challenges DR BRIDGET OSBORNE is a busy person, combining her role as a salaried GP with educational work and running an award-winning farm on her property in North Wales. On top of these responsibilities she can now add Chair of RCGP Wales, representing over 1,600 members. “I moved to live in Wales 20 years ago and decided then to get involved in the College as much as I could,” she says. “I like a challenge, and taking on the role of Chair is certainly that.”
Humble beginnings According to Dr Osborne, her parents were shocked when she decided to embark upon a medical career. “As a child whenever the cats brought stoats home I used to bury them in little coffins and dig them up later to mount skeletons! I certainly don’t come from a medical background – until my sister went to university, no one in my family had.” Bridget’s career began in hospital medicine before she made an important discovery. “After a while I realised that people are actually more interesting than diseases! “To me, the best part about being a GP is the people. I’m naturally nosey, and I love finding out about people and their lives.” After beginning her career at the Royal Free in London, Bridget has worked in Leeds, Newfoundland, Scotland and, for the last 12 years, as a sessional GP in Conwy, North Wales. “I’m a salaried GP by choice. I wanted the flexibility, and it has been much easier to raise a family. I’ve been able to centre my career around my three children (aged 23, 20 and 14), and still have the time to run our farm.” Winning an RCGP Faculty prize was the catalyst for Bridget’s
The different sides of Bridget Osborne: At home on her farm and, below, as Chair of RCGP Wales, presenting the Patient Nomination and Practice Team Awards Right: Where sheep may safely graze – the Osbornes’ ‘more easily satisfied’ flock
involvement in the RCGP. “I was an associate in training (now AIT) member of the College during my training year when I won the prize, and one of my first senior partners encouraged me to get more involved in the College.”
The big issues for Wales Bridget’s priorities for her term revolve around social issues. “Teen pregnancy is a big issue here in Wales, along with alcohol and drug misuse and supporting the work of the College’s Secure Environment Group.” RCGP Wales has already set up a national mental health network and disability awareness training. Another issue of concern will be the Welsh Government’s restructuring of the local NHS. The internal market has been abolished and seven new NHS local health boards will replace the existing structure of NHS trusts and 22 local health boards. “Luckily Wales is a small country so we are able to have an input into these debates. Members of Welsh Council recently met the Welsh Minister of Health, Edwina Hart, and will debate and make a submission to the review.” Bridget is also concerned at the ‘box-ticking’ mentality in parts of the health system. “Co-morbidity is a big issue for doctors in this area. Many of our patients have multiple health problems, which often makes it hard to tick the right boxes on a form. Sound guidelines are fantastic, but we have to rely on our judgment as well!” Another priority is encouraging council members to get involved in committee work. “I’d like to see them empowered rather than just attending meetings,” says Bridget.
Outside the College On top of her GP hours, Bridget serves as a Sessional Course Director and Clinical lead for the Retainer scheme for Cardiff University (PGMDE). She is also a GP advisor for the Primary care support service; a medical examiner for the Driving Vehicle and Licensing Authority and has given medical advice on the popular Jamie and Louise programme on BBC Radio Wales. Perhaps her greatest claim to fame outside medical circles is the small farm her family run on their property. Earlier this year the Osborne family was Welsh runner-up in the Nature of Farming Awards, organised by the Royal Society for the Protection of Birds and BBC Countryfile. “We live on a hill farm 800 feet above sea level which we’ve gradually expanded over the years. We now have 70 breeding ewes and a small herd of Welsh Black cattle, and two years ago we brought back the original farmland which had been sold separately from the farmhouse. “I love animals and being outside. Farming is not a complete contrast to medicine really – the principles of caring apply to both, but sheep are more easily satisfied!!”
a co-morbidity is a big issue for doctors in this area. many of our patients have multiple health problems, which makes it hard to tick the right boxes on a form. Sound guidelines are fantastic , but we have to rely on our judgement as well
patients applaud top doctors in wales Patients in Wales honoured their ‘exceptional’ GPs at a black tie function in Cardiff organised by the RCGP. The Patient Nomination and Practice Team Awards 2008 were held at Cardiff City Hall in the first of what will become an annual event for the College. Patients from across Wales were asked to nominate GPs from their local communities and a large number of nominations were received from across the countr y. Out of 11 finalists, the winner was Dr Martyn Davies MRCGP from Crwys Medical Centre in Cardiff, who was nominated by his patient Mrs Rosemar y Brown. The winning Practice Administration Team was The Vauxhall Practice from Chepstow. Dr Bridget Osborne, Chair of RCGP Wales, said: “GPs in Wales offer a ver y high standard of care. This award gives patients the opportunity to recognise and celebrate particular GPs who offer exceptional care and have made a real difference. I would like to thank all the patients who took the time to respond to the sur vey and nominate GPs.” Celebrating excellence: (l-r) Dr Tony Jewell, Chief Medical Officer for Wales, Rosemary Brown, Dr Martyn Davies and Dr Bridget Osborne RCGP News • January 2009
Gmc prepares for introduction RcGp joins forces with Age of new licence to practise concern over depression The General Medical Council is taking the first steps towards revalidation by contacting doctors about the new licence to practise, which will be introduced this autumn. A letter and leaflet entitled ‘Licensing and you: Information for registered doctors’ is being sent to all doctors on the medical register. Under the new system, doctors wanting to practise medicine in the UK must be licensed medical practitioners – which means they must hold both registration and a licence to practise with the GMC. Doctors will need a licence to practise to: l hold a position as a doctor in the NHS or independent sector, on a permanent or locum basis l write prescriptions, sign death certificates or exercise any of the other legal privileges currently reserved for registered medical practitioners
l if their employer or those who contract their services or another party requires them to hold a licence Doctors wanting to practise overseas will not need to hold a licence for the period that they are out of the UK. Sir Graeme Catto, President of the GMC, said: “This change in medical regulation next year will have important implications for doctors, employers and patients. It will be the first step towards the introduction of revalidation which will give patients regular assurance that their doctors are up to date and fit to practice. “The GMC will implement licensing next autumn. Our letter and leaflet to doctors is the start of a continuing campaign to prepare for this change.’’ n Further information about licensing is available from the GMC website www.gmc-uk.org
Save the date for the third RcGp conference... Excellence in Practice: winning ways for primary care – the third RCGP Annual National Primary Care Conference – will be held from 5 – 7 November 2009 at the Scottish Exhibition and Conference Centre, Glasgow. Watch out for the Conference website which goes live later this month.
...and the Sexual Health conference Enrol now for this year’s Sexual Health in the Surgery (SHINS) conference in Manchester on 27 February 2009. Not as hard as you think: Improving Pathways and Sharing Good Practice is organised by the RCGP Sex, Drugs and HIV Task Group. Keynote speaker is Baroness Gould and the programme includes Quality STI Management in general practice and new HIV testing guidelines. There are also practical workshops on sex workers and trafficking, sexual assault and commissioning services for sexual health. n Contact Irene Heaton for further information: email@example.com
ERIC GAMBRILL MEMORIAL FUND Applications are invited for the Eric Gambrill Travelling Fellowship to be awarded in April 2009. The value of the Award is £2,000. Those eligible for the Award will be fully trained and practising UK general medical practitioners. In recognition of Dr Eric Gambrill’s interest in general practice, education and travel, the successful applicants will be expected to undertake a study or project as part of his/her professional career development. The closing date for applications is 31 March 2009. Application forms and further information may be obtained from: The Honorary Secretary to the Trustees Eric Gambrill Memorial Fund Altyre House, Church Lane GRAYSHOTT Hindhead Surrey GU26 6LY email: firstname.lastname@example.org 4
New leaflets have been developed by Age Concern with the involvement of the RCGP to encourage older people with depression to discuss it with their GP. The four leaflets provide clear information to older people, their families and carers on: l spotting the signs of depression l discussing depression with your GP l coping with depression l caring for an older person with depression Age Concern’s Down but not out campaign is working with the College to improve the diagnosis and treatment of older people with depression. The campaign calls for increased support for older people with depression to seek treatment and includes a range of measures to improve diagnosis of depression by GPs. This campaign follows research in 2007 from the UK Inquiry into Mental Health and WellBeing in Later Life which found that despite being the most common mental illness in later life and being associated with increased mortality from physical illnesses, abuse and risk of suicide, depression continues to be underdiagnosed. Only one third of older people with depression discuss it with their GP, and only half of them are diagnosed and receive treatment.
A key barrier for many older people with depression is the reluctance to discuss mental health issues with heath care professionals. For many older people, and the wider public, depression remains a taboo subject and many people feel uncomfortable talking about sadness, stress and anxiety. When depressed, older people may present with somatic symptoms or the depression may be masked by long-standing physical or mental illness. Older people themselves may think that depression is a normal or inevitable part of ageing and do not recognise that depression is a manageable health condition. Age Concern is working to break down these barriers and encourage people to access the help and support they so desperately need. The new leaflets form the first phase of a public education programme to make sure that simple information about depression is readily available. These resources will make it easier for older people with depression to have the confidence and vocabulary to discuss depression and to access the treatment and support they need. n The free information leaflets about depression are available, along with more information about the campaign at: www.ageconcern.org.uk/downbutnotout
A major step forward for patients with learning disabilities The RCGP has welcomed the publication of a specification for a directed enhanced service in England: learning disabilities (Clinical directed enhanced services [DES] guidance for GMS contract 2008-09, Appendix 3). This follows the report of the Independent Inquiry into access to healthcare for people with learning disabilities (Healthcare for All, July 2008) and partly implements the recommendations of that inquiry; recommendation 8 called for regular health checks in this vulnerable group of the population. This will be an enormous step forward for both adults with learning disabilities and a challenge particularly for those practices which have not already implemented some regular structured review for their own patients with intellectual disabilities. However, the introduction of registers as a clinical indicator through QOF means that almost all GPs should have already identified their target population of approximately eight per practitioner. Last summer the DH published its LES framework for improving the quality of healthcare for LD; this now helpfully augments the guidance. www.pcc.nhs.uk/204.php The RCGP recognises its own responsibility that general practice needs to improve education and training of GPs in care of people
of learning disabilities and this is addressed in a dedicated statement in the GP training curriculum. We welcome the DH implementation of its stated commitment to the introduction of annual health checks in line with its obligations under the Disability Equality Duty. The guidance targets those more disabled as a priority (moderate and severe). The intervention of a fully comprehensive check can actually double the number of clinical needs identified and therefore addressable, compared to current standard GP care. (Cooper, SA et al., 2006, J.Intell.Dis.Res: 50(9) 667-677) The embedding of annual health checks in practices for this currently disadvantaged population will require much cooperative effort from all providers, particularly primary care and the community learning disability teams, but the rewards as far as the learning disabled population and their carers are concerned, should be significant. The RCGP believes that ‘All should mean All’ and not only those with moderate and severe disability should be entitled to a check. Stephen Field Matt Hoghton Graham Martin Jill Rasmussen
RCGP Postgraduate Training Board Vacancy for Board Member The RCGP Postgraduate Training Board covers all aspects of specialist training for general practice, assessment of trainees and certification of GPs. Members of the Board are drawn from the RCGP and from relevant external organisations. The PTB currently has a vacancy for an RCGP appointed member to join the Board. Applications are invited from members and fellows of the College. The appointment will be for a period of three years. Closing date for applications is 2 February 2009 Further information may be obtained by contacting the PTB Administrator, Kate Tunnicliffe Email: email@example.com Tel: 01925 242167 RCGP News • January 2009
updating EGp update
management of neuropathic pain in primary care Clinical scenario
Essential General Practice (EGP) Updates are now in the second stage pilot and will soon be going live as an ongoing, six monthly, electronic CPD learning programme. Meanwhile, another e-learning project aimed at GP trainees and funded by the Department of Health has also been launched under the banner of e-GP Learning for Healthcare. To avoid confusion between the two programmes, the College has decided to rename EGP Update in time for the official launch in April 2009.
The new title will be Essential Knowledge Update (EKU), with the linked Knowledge Challenge becoming Essential Knowledge Challenge (EKC). Both will sit under the umbrella title Revalidate (mirroring the InnovAIT resource for trainees) as follows: l Revalidate: Essential Knowledge Update (EKU) l Revalidate: Essential Knowledge Challenge (EKC) The Revalidate title will be used to similarly brand current and future CPD products.
In the meantime, here are a selection of Testing Times questions from the second stage pilot for you to assess yourself on...
Lawrence is 58 years old with multiple medical problems including poorly-controlled diabetes, COPD, poor renal function, erectile dysfunction and chronic low back pain. He presents to you with difficulty in walking due to pain in his feet. His BMI is currently 38. You take a full histor y and undertake a clinical examination. You note his previous drug histor y and look at his past medical histor y.
What do you do now? q What would you do next? Would you treat with simple analgesics and see if they work before going into the detail of assessing him for neuropathic pain?
w Your immediate diagnostic priority is to rule out
The diagnosis and management of chronic kidney disease in general practice Clinical scenario A 57-year-old Afro-Caribbean gentleman has been lost to follow-up for his hypertension. He comes to see you because he’s worried about his headaches and would like his BP checking. His BP is 165/95 mmHg. You do some blood tests, and the lab reports his eGFR as 55ml/min/1.73m2. He does not have diabetes.
What do you do now? q As he is Afro-Caribbean you adjust his eGFR accordingly. You now make it 66ml/min/1.73m2. Is that right?
w You find out that he had had bacon for breakfast and you want to recheck his eGFR. What instructions should you give him about coming back for the blood test? Will you tell him not to have eaten meat for six hours before the test?
e As you wish to check his urine, you ask him to bring in an early morning ‘first pass’ sample. As he does not have diabetes, is it sufficient for you to use a dipstick?
r He has a BP of 162/94 mmHg when it is repeated and his urine shows an ACR of 40 mg/mmol, and the corrected eGFR is 53 ml/min/1.73m2. Would you start an ACEI as the anti-hypertensive drug of choice?
t His creatinine remains reasonably stable and his K+ normal. After adding a thiazide and calcium channel blocker his BP remains stable at 127/77 mmHg. Will you review him and check his U&Es and ACR at an annual check in a year’s time?
Routine antenatal care of the healthy pregnant woman
Review of the health of britain’s working age population Clinical scenario It is Monday afternoon. James Start is 37 years old and works in a local baker y. Two months ago he was in an RTA and sustained a whiplash injur y. He seemed to have improved and the last entr y of his notes states that he had a good range of movement of his neck. He has had repeated sickness certificates and when you look back in his records you see that he has only been back at work for about a week. He comes to see you this time complaining of aching in his neck and a headache. On examination you find he is slightly tender over the back of his neck but does move his neck freely when distracted. You reinforce the fact that he has been fully investigated but it was clear that his injur y from the RTA was only muscular and that with time he should continue to improve. He then asks you for another sickness certificate because there is no way he can go back to work feeling as he does.
What do you do now? q Offer him an open certificate for another week and tell him you will review him after that?
w e Offer him a closed certificate for one week? r Offer him some advice about keeping himself mobile Ask if he has any concerns about returning to work?
and his posture; suggest he returns to work and you review him in a week if he is not recovered.
t Suggest he goes back to work and tell him that he needs to see his employer and tell them they will have to make changes to his work pattern and duties.
To ﬁnd out if your answers are corect, please go to: www.rcgp.org.uk/practising_as_a_gp/ distance_learning/egp2_update.aspx
What do you do now? (at ﬁrst contact, before she attends the booking appointment with the midwife)
q Would you simply make her a booking appointment with the midwife?
w Would you advise her to take 400mcg folic acid twice daily to make up for not having taken it since conception?
e Would you explore her lifestyle habits or leave that to the midwife?
r Would you ask about her mood? t Would you raise screening issues? RCGP News • January 2009
e You establish a working diagnosis of neuropathic pain due to his diabetes. He is anxious about the pain disturbing his sleep. Would your first line treatment be amitriptyline?
r Lawrence fractures a metatarsal and after a period of immobility his neuropathic pain worsens considerably. You examine both feet and see that his affected foot is swollen and the skin is reddened. Would you consider the most likely diagnosis to be a deep vein thrombosis?
t Despite the treatment his feet remain very sensitive (rather than just painful). What would you do next? Tell him to rest?
Irritable bowel syndrome in adults: diagnosis and management in primary care Clinical scenario Sally is a 28-year-old secretar y who has recently also started a part-time course in fine art. She consults you complaining of abdominal pain, bloating and increased stool frequency. She has had episodes similar to this since she came back from a holiday in India a couple of years ago. Her weekends are currently spent visiting her father who has recently been diagnosed with stomach cancer. Although she admits to skipping meals since she started her course she has not lost any weight. She in part attributes her static weight to going less often to the gym now that she has to visit her father. However she proudly tells you that, whatever meals she misses, she always has her breakfast of a bran-based cereal.
What do you do now? q Ask if her abdominal pain is relieved by defaecation or is associated with altered bowel frequency or stool form?
w Refer her to secondary care to have the possibility
Clinical scenario Julie is an obese teenager who returns from a holiday in Ibiza to find herself pregnant; she has just missed her second period. She comes to consult you with her stepmother, and is determined to keep the baby.
red flag pathologies. Would these include infection, severe nerve root entrapment, ischaemia.?
of inflammatory bowel disease or cancer excluded?
e Advise her to eat regularly and to take plenty of
The face behind EGp
fibre and fruit?
r Offer lifestyle advice and offer to see her in a few weeks?
t Refer for cognitive behavioural therapy (CBT)?
Dirk Pilat (left) is the new RCGP Development Fellow for Essential General Practice Updates (soon to become EKU). Currently working as a GP in the East End in London, he has been a College member since 2001. He graduated from the University of Köln (Germany) in 1996 and went through the Rural General Practice rotation of the University of Glasgow. From 2002 to 2008 he worked as a GP in rural New Zealand, receiving the postgraduate Diploma in General Practice from the University of Otago in 2007. He has a special interest in dermatology. In his leisure time, he “enjoys listening to jazz, funk, tinkering with my ever increasing pile of computers and tr ying to get to grips with my bass guitar”.
Antidepressants in pregnancy
SUMMARY POINTS l Depression in pregnancy is often underdiagnosed l Many women try and avoid antidepressants
during their pregnancy l Tricyclic antidepressants are usually used ﬁrst line
DR LOUISE R NEWSON GP in Solihull
Introduction DEPRESSION DURING PREGNANCY is still underrecognised and under-treated. Rates of depression in women are higher during the childbearing years than at any other time and women who are pregnant have higher rates of depression when compared to non-pregnant women. In addition, pregnancy itself is a major psychological life event and many women find the additional stress of pregnancy insurmountable. The biological changes during pregnancy have a direct effect on mood state. Concentrations of female specific sex steroids are raised during gestation and modify parts of the brain involved in mood regulation. There are also gradual increases in hormone concentrations within the hypothalamic-pituitary-adrenal axis; overactivity of which has been found in people with depression1. Depressive symptoms, particularly psychological symptoms of depression, during pregnancy should be taken seriously and not be dismissed as a normal part of the pregnancy experience. The NICE guidance on antenatal and postnatal mental health was produced in February 2007. It covers the care of women with anxiety disorders and depression both during pregnancy and after birth. Some of its content will be discussed in this article.
Problems with depression in pregnancy Studies examining obstetric complications in women who are depressed during pregnancy are difficult to interpret because the possible consequences of untreated depression are difficult to separate from the possible consequences of taking psychotropic medication. Child development can be affected by antenatal depression. A UK study found that the risk of delayed mental and physical development increased by up to 34 per cent in those children whose mothers had depression in pregnancy2. Limitations in this study, however, mean that there is no conclusive proof that depression in pregnancy can actually cause developmental delay. Severe depression is associated with an increase in: l Obstetric complications including preterm delivery l Suicide attempts l Stillbirth l Low birthweight infants l Postnatal specialist care for the infant3. Depression in early pregnancy may interfere with the neuroendocrine pathways and subsequently placental function, which play an important role in maintaining the health of the pregnancy and also determining the onset of labour.
Screening for depression during pregnancy It is important that health carers are to be alert for signs of depression and to also ensure mothers and their babies receive the full care and support they need. It is recommended that at a woman’s first contact with primary care at her booking visit healthcare professionals should ask these two questions to identify possible depression: l During the past month, have you often been bothered by feeling down, depressed or hopeless? l During the past month, have you often been bothered by having little interest or pleasure in doing things? A third question – Is this something you feel you need or want help with? – should be considered if the woman answers ‘yes’ to either of the initial questions.
Management of depression in pregnancy NICE guidelines recommend that treatment and care should take into account the woman’s individual needs and preferences. Women with mental disorders during their pregnancy should have the opportunity to make informed decisions about their care and treatment in partnership with their healthcare professionals. When a pregnant woman needs to be treated for major depression the possible risks and benefits of both receiving and not receiving antidepressant medication need to be considered on an individual basis. NICE recommend that healthcare professionals should: l acknowledge the uncertainty surrounding the risks regarding treatment l explain the background risk of fetal malformations for pregnant women without a mental disorder l describe risks using natural frequencies rather than percentages l if possible use decision aids in a variety of verbal and visual formats that focus on an individualised view of the risks l provide written material to explain the risks (preferably individualised) and, if possible, audiotaped records of the consultation. Many women with mild or moderate depression decide that the risk of taking antidepressant medication is too great and for
them, the first line of management is to stop antidepressants and try alternative, self-help therapies first. Alternatively, an antidepressant with a lower risk may be given. If a woman being treated for mild depression is already taking an antidepressant, the medication should be withdrawn gradually and the patient closely monitored. Antidepressants should ideally only then be considered if these alternative treatments do not work or the depression worsens. However, if a woman is taking an antidepressant and has suffered with severe depression, it may then be appropriate to combine drug treatment (even switching to an antidepressant with a lower risk) with psychological treatments.
Stopping antidepressants Although NICE recommends stopping antidepressants in all women with mild depression who become pregnant, many experts still feel that there may be some circumstances, such as a previous history of severe depression, when it is actually more beneficial to continue the antidepressant. Relapses after stopping antidepressant medication are common. One study of pregnant women with major depression, 26 per cent of women who continued their antidepressant medication throughout their pregnancy experienced a relapse compared with 68 per cent of women who discontinued their medication4. Similarly, two-thirds of women with a history of recurrent depression will relapse during pregnancy if they discontinue their medications after conception5. When stopping or reducing the dose of an antidepressant, some people experience discontinuation (or withdrawal) symptoms. To minimize these, the dose or frequency of antidepressant should be gradually reduced over at least four weeks.
Antidepressant choice Drugs with the greatest evidence of safety for both the mother and fetus should be prescribed, and at the lowest dose. Monotherapy is preferable to prescribing a combination of drugs. To prevent neonatal withdrawal at the time of delivery, a dose reduction or even withdrawal of the antidepressant is sometimes may be considered in the weeks before delivery. The safety of antidepressants is still not well understood and many trials involving the safety of antidepressants in pregnancy show conflicting and often confusing results. Many of the studies have been small, underpowered and also do not include long-term follow-up of exposed infants. One study following over 2,200 women found that treatment with either selective serotonin reuptake inhibitors or tricyclic antidepressants did not show a consistent link with congenital anomalies6. However, infants exposed to these drugs during pregnancy did have a significant increase in preterm delivery risk. All antidepressants carry the risk of withdrawal or toxicity in neonates; however, in most cases the effects are mild and selflimiting. There are many differences between the available antidepressants. Before stopping or switching antidepressant treatment during pregnancy, it is recommended that advice should be sought from: l The National Teratology Information Service (Tel: 0191 232 1525) l A specialist perinatal mental health team (where available) or from secondary psychiatric care.
Tricyclic antidepressants (TCAs) Tricyclic antidepressants have lower known risks during pregnancy than other antidepressants and are often used as first line choice of antidepressant. Although they are well established for the management of depression in pregnancy, their use can be limited by adverse effects, safety in overdose and also the need to titrate the dose. Amitriptyline, imipramine and nortriptyline are preferred tricyclic antidepressants. Many extensive epidemiological studies have shown no evidence that therapeutic doses of TCAs are associated with an in-
References 1) Wadhwa PD, Glynn L, Hobel CJ, Garite TJ, Porto M, Chicz-DeMet A, et al. Behavioral perinatology: biobehavioral processes in human fetal development. Regul Pept 2002;108:149-57. 2) The impact of maternal depression in pregnancy on early child development. BJOG 2008;115:1043-51 3) Bonari, L, Pinto, N, Ahn, E et al. Perinatal risks of untreated depression during pregnancy. Canadian Journal of Psychiatry 2004;49:726-735 4) Cohen LS, Altshuler LL, Harlow BL et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. Journal of the American Medical Association 2006; 295:499-507. 5) O’Keane V, Marsh MS. Depression during pregnancy. BMJ 2007;334:1003-1005 6) Davis RL, Rubanowice D, McPhillips H, et al. Risks of congenital malformations and perinatal events among infants exposed to antidepressant medications during pregnancy. Pharmacoepidemiol Drug Saf 2007;16:1086-94 7) Wogelius P, Norgaard M, Gislum M, et al. Maternal use of
l The risk of selective serotonin reuptake inhibitors
in pregnancy is still unclear l There is still limited evidence regarding the eﬃcacy of alternative treatments creased incidence of congenital malformation or other adverse pregnancy outcome. Chronic use, or the use of high doses near term, has been associated with short-term neonatal withdrawal symptoms (jitteriness, hyperexcitability, myoclonus, convulsions, difficulties in feeding), especially in premature or small-for-date neonates.
Selective serotonin reuptake inhibitors (SSRIs) The majority of studies have found no significant increase in congenital malformations after exposure to the SSRIs as a group and to the single drugs citalopram, fluoxetine, and sertraline. In 2005 several reports indicated that there may be an increased risk of congenital malformations, including heart defects, following prenatal exposure to SSRIs (paroxetine in particular). One study reported a relative risk of congenital malformations in babies born to women taking selective serotonin reuptake inhibitors, but not tricyclic antidepressants, during the first trimester of pregnancy7. This increased risk, however, has not been supported by other trials and meta-analyses. However, one large study did not show that there are significantly increased risks of craniosynostosis, omphalocele or heart defects associated with SSRI use. The authors concluded that any associated defects implicated with SSRIs are rare and the absolute risks are small8. Data on the effect of SSRIs on the incidence of preterm birth, spontaneous abortion and fetal death are still conflicting. A large Canadian study looked at outcomes from infants of depressed mothers treated with SSRIs and compared them with outcomes from infants of depressed mothers not treated with medication. Their results showed that taking SSRIs during pregnancy was associated with an increased risk of low birth weight and respiratory distress9. Some studies have indicated that the use of SSRI around the time of delivery has been associated with neonatal withdrawal symptoms and that these are most common and most severe with paroxetine. Fluoxetine appears to be the SSRI with the lowest known risk during pregnancy. However, a very recent study has suggested a possible association between cardiovascular anomalies and firsttrimester exposure to fluoxetine10.
Alternative treatments Many pregnant women, especially those with mild depression during their pregnancy may prefer to try alternative treatments to antidepressant medication. Some self-help strategies (guided self-help, computerised cognitive behavioural therapy or exercise) may be beneficial. Some women also find non-directive counseling delivered at home or brief cognitive behavioural therapy useful. However, there is still insufficient evidence specific to antenatal women to make any conclusions regarding the efficacy, or relative efficacy, of psychosocial or psychological interventions for treating antenatal depression. One Cochrane review concluded that the evidence is inconclusive to make any recommendations for interpersonal psychotherapy for the treatment of antenatal depression11. The evidence was also inconclusive for them also to make any recommendations for massage therapy or depression-specific acupuncture for the treatment of antenatal depression12.
USEFUL WEBSITES www.Depression-in-Pregnancy.org.uk: an online community forum for people affected by depression during pregnancy www.rcog.org.uk: Royal College of Obstetrics and Gynaecology
selective serotonin reuptake inhibitors and risk of congenital malformations. Epidemiology 2006;17:701-4. 8) Louik C, Lin AE, Werler MM, et al. First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects. N Engl J Med 2007;356:2675-83. 9) Oberlander TF, Warburton W, Misri S et al. Neonatal outcomes after prenatal exposure to selective serotonin reuptake inhibitor antidepressants and maternal depression using population-based linked health data. Arch Gen Psychiatry 2006;63:898-906 10)Diav-Citrin O, Shechtman S, Weinbaum D, et al. Paroxetine and fluoxetine in pregnancy: a prospective, multicentre, controlled, observational study. Br J Clin Pharmacol 2008;66:695-705 11)Dennis CL, Ross LE, Grigoriadis S. Psychosocial and psychological interventions for treating antenatal depression Cochrane Database Syst Rev 2007;(3):CD006309 12)Dennis CL, Allen K. Interventions (other than pharmacological, psychosocial or psychological) for treating antenatal depression. Cochrane Database Syst Rev 2008;(4):CD006795. RCGP News • January 2009
prediction of depression by the family doctor moves closer MAJOR DEPRESSION is now a leading cause of morbidity and social disability worldwide, and reducing its prevalence is one of the greatest public health challenges of the 21st century. Depression will rank second to cardiovascular disease as a global cause of disability by 2020. It occurs in up to a quarter of family practice attendees, relapse is frequent up to ten years from first presentation and both residual disability and premature mortality are common. Although a great deal is known about risk factors for major depression, effective strategies for prevention are hindered by lack of evidence about the combined effect of this large number of known risk factors and whether the risk for major depression can be quantified in the same way as other clinical disorders such as cardiovascular diseases. Professors Michael King and Irwin Nazareth from the Research Departments of Mental Health Sciences and Primary Care and Population Health (Division Population Health) at UCL have recently developed the first international risk instrument (predictD) for predicting the onset of major depression in European general practice attenders from six countries (UK, Spain, Portugal, the Netherlands, Slovenia and Estonia) and have tested its predictive power in general practice attenders in a non-European setting (Chile). Here they describe the process – and how their groundbreaking work could transform the diagnosis and treatment of depression in the future. THE STUDY was funded by the European Commission and involved the recruitment of 10,045 GP attenders in Europe and Chile and follow up at six, 12 and 24 months. The approach was modelled on risk indices for cardiovascular disease, which provides a percentage risk estimate over a given time period. The discriminative power of the algorithm compares favourably with risk indices that have been developed for cardiovascular events. Moreover, the risk predictor instrument for depression was found to have excellent validity in an external population (ie Chile). The results of this study were published in the December 2008 issue of Archives of General Psychiatry, the world’s leading journal in mental health (http://archpsyc.ama-assn.org). (Arch Gen Psychiatry. 2008;65(12):1368-1376) This is the first risk algorithm to be developed simultaneously in a number of cultures in one continent for prediction of new episodes of major depression in a general medical setting and validated in another continent. This is arguably the most rigorous test that can be applied to any prediction tool. We believe that the predictD instrument will be useful clinical tool for early detection of depression in family practice. The questions making up the algorithm are brief and easy to complete, making it potentially feasible to use in family practice. People identified as at risk on screening can be flagged on family practice computers to alert doctors when they consult. Recognition of those at risk may be helpful when it leads to watchful waiting or active support, such as re-starting treatment in patients with a history of depression. Advising patients on the nature of depression or on brief cognitive behaviour strategies they might undertake to reduce their risk could also be envisaged. We now plan to test the utility of this instrument in early detection of depression in randomised trials in Europe. We also plan to test the feasibility of using this instrument in China and to assess its application and predictive power in such a setting. The Medical Research Council has funded the UCL Division of Population Health and the MRC General Practice Research Framework to run a workshop in China to develop a research proposal for the prediction of depression in a Chinese community setting. This will be the first-ever research initiative of its kind to be undertaken in Asia.
The story: Depression is a common problem throughout the world. Although we know a lot about how best to treat depression we know very little about how to prevent its onset in the first place. The Departments of Mental Health Sciences and Primary Care and Population Health at UCL have recently coordinated a large international study to try to predict which people in the community will become depressed. Although there have been instruments developed in medicine to predict the onset of cardiac disease or stroke, none have been developed to predict people’s future risk of major depression. Risk tools such as this one are needed in order to focus our efforts on prevention of depression. The audience: This study was undertaken with approximately 10,000 people attending their general practitioners in six countries in Europe and one in South America. Thus it applies to general populations and should attract wide interest among professionals, voluntary organisations concerned with depression, general practitioners and ordinary people in the community.
Contact: Professor Michael King Professor of Primary Care Psychiatry, Research Dept of Mental Health Sciences, University College London, Royal Free Campus, London NW3 2PF email: m.king@ medsch.ucl.ac.uk RCGP News • January 2009
The Alexander Technique and back pain PROFESSOR PAUL LITTLE Medicine, Health and Life Sciences Faculty University of Southampton A RECENT STUDY in the BMJ1 has demonstrated significant long term benefits from the Alexander Technique for those suffering back pain. This article summarises the background to the study, the main findings and its relevance for GPs.
What exactly is the Alexander Technique? Originally developed by the actor FM Alexander, this is a technique to help people recognise, understand and avoid poor habits of body use which affect postural tone and neuromuscular co-ordination. It is widely used in acting and music schools and increasingly finding advocates in the health arena. The technique uses hand contact to observe and interpret subtle changes in muscle tone and co-ordination, together with oral and written advice to help practise and maintain better body use. It is active self-help rather than a ‘magic bullet’ – patients have to practise between lessons and apply it in everyday activities. We don’t fully understand the mechanism yet but would expect it to help by limiting muscle spasm, strengthening postural muscles, improving coordination and flexibility, and decompressing the spine. Preliminary physiological studies suggest the technique does modify postural tone and also the body’s dynamic adaptability to changes in load and position2-4. Prior to the trial there was suggestive evidence from a small trial that it could help in the short term, but no evidence of long term benefit5.
The BMJ study group involved those with chronic or recurrent back pain, rather than acute pain, and avoided cases with serious underlying pathology. The study provided robust evidence of benefit: l It involved dozens of teachers in a wide range of practices and followed up patients over a year, which suggests that the benefit is likely to be generalisable – not the effect of a particularly enthusiastic teacher. l There were lasting benefits after 24 lessons – a 45 per cent reduction in the Roland disability score compared with the control group, and 18 days fewer pain reported in a month compared with the control group. l There was additional Phase II type evidence for the effect of dose response: six lessons resulted in a 17 per cent reduction in Roland Disability score. l The trial also supported the additional effect of a GP prescription for aerobic walking exercise – an additional 17 per cent reduction in Roland disability score. l There was evidence that the effect was more beneficial in the long term than massage treatment.
n ENT and facial problems n Neurological problems n Skin problems
Until now the Alexander Technique hasn’t been available on the NHS, which is entirely appropriate given the lack of evidence behind it. It is important when advising patients considering private lessons for them to have a bona-fide practitioner. The best method is to look up the Society of Teachers of the Alexander Technique (STAT)(www.stat.org.uk), which lists registered teachers in each area. They are likely to charge about £35 for a lesson. It is important to be able to learn from a qualified and registered teacher – a good teacher is both good with their hands (in showing you what you are doing wrong) and can provide you with clear verbal explanation and instruction. Otherwise, your patients are probably wasting their money. Experienced teachers are needed to assess patients’ problems individually, which makes it difficult to incorporate the principles into a ten minute consultation. Only a fully-trained teacher will have the subtle hand skills required to assess the particular problems and to provide the nuanced, individualised advice. However there are some useful books that can be helpful pointers, such as Illustrated Elements of Alexander Technique by Glynn Macdonald or Body Learning by Michael Gelb. These can support lessons but realistically, based on the current evidence, your patients probably need to have one-to-one lessons from a good teacher to be significantly helped.
Applying the results
(1) Little P, Lewith G, Webley F, Evans M, Beattie A, Middleton K et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ 2008; 337: doi: 10.1136/bmj.a884. (2) Cacciatore T, Gurfinkel V, Horak F, Cordo P, Ames K. Alteration of muscle tone through conscious intervention: increased adaptability of axial and proximal tone through the Alexander Technique. Proc Int Soc posture and Gait Research 2007; 18. (3) Cacciatore T, Horak F, Henry S. Improvement in Automatic Postural Coordination Following Alexander Technique Lessons in a Person With Low Back Pain. Phys Ther 2005; 85:565-578. (4) Gurfinkel V, Cacciatore T, Cordo P, Horak F, Nutt J, Skoss R. Postural muscle tone in the body axis of healthy humans. J Neurophysiol 2006; 96:2678-2687. (5) Ernst E, Canter P. The Alexander Technique: A Systematic Review of Controlled Clinical Trials. Forschende Komplementärmedizin und Klassische Naturheilkunde/ Research in Complementary and Classical Natural Medicine 2003; 10(DOI: 10.1159/000075886):325-329.
The RCGP is looking to appoint Guardians for the following Interpretive Statements of the GP training Curriculum: n ENT and facial problems n Neurological problems n Skin problems The role of the Curriculum Guardians is to take responsibility for the content of a particular Curriculum statement and to ensure its quality. They are responsible for proposing editorial changes but may involve others in contributing to it. The Guardians work together in the Guardians’ Group, which is mainly web-based but also holds an annual meeting. Applicants should have up-to-date knowledge of the appropriate subject area, be familiar with the GP Curriculum and have experience as a GP educator. The role of Curriculum Guardian is an honorary position and is not remunerated. For further information, including the role description and person speciﬁcation, please contact Kate Tunnicliﬀe, PTB Administrator. email: firstname.lastname@example.org or telephone 01925 242167 Closing date for applications is Friday 23 January 2008
Dr Joanna Rose
Dr Alison Sneddon
Double top: Ken Lawton with the award-winning Bruntsfield Practice team
Double celebration as bruntsﬁeld receives the 100th QpA Award Dr Ken Lawton, Chair of RCGP Scotland, presented the 100th Quality Practice Award plaque to the Bruntsfield Medical Practice. To date, 84 practices in Scotland have been successfully awarded the QPA, with 16 gaining reaccreditation. It is the second time that the Bruntsfield Medical Practice has been awarded the QPA, having first achieved the award – which is valid for five years – in 2002. Dr Lawton said: “It is a great achievement for Bruntsfield Practice to receive the QPA award for a second time. All members of the practice team should be extremely proud”. The busy Edinburgh-based practice comprises eight GPs, a Practice Nursing Team and front-of-house and practice management staff. Bruntsfield is an excellent example of a modern medical practice that has embraced the arrival of new computer systems, electronic records and prescribing. The ethos of the practice is to constantly strive for excellence in continuity of care and lack of complacency.
To have reached a total of 100 awards across Scotland is a major achievement for QPA which continues to go from strength to strength. An avid supporter of the Quality Practice Award, Dr Lawton said: “Quality has always been high on the agenda of GPs in Scotland and RCGP Scotland recognises this with the Quality Practice Award for those that reach the highest standards”. The Quality Practice Award was first introduced in Scotland in 1996 by GPs from NorthEast Scotland as a practice-wide version of Fellowship by Assessment (FBA). QPA was designed to recognise the commitment of the entire practice team in providing quality of care for patients and staff. Set at a very high standard, the award is an excellent benchmark to set General Practice as the cornerstone of primary care. n For more information on QPA, please visit the website at: www.rcgp.org.uk/practising_as_a_gp/ team_quality/qpa.aspx
New faces on the 56th Scottish council The RCGP Scottish Council has welcomed two new members, Dr Joanna Rose and Dr Alison Sneddon. Both are practising GPs whose terms are set to last until 2011.
Dr Joanna Rose
Dr Alison Sneddon
Following training in England, Joanna moved to Scotland to start house jobs, went straight onto a General Practice Vocational Training Scheme and completed a variety of SHO posts in Fife. She then spent her registrar year in Dunfermline. Having worked a short time as a GP locum, she took a break for maternity leave and has been working as a GP Retainee in Livingston for the past six months, working four sessions a week. Kept busy by her one year old daughter, Jo is still able to find time to pursue her interests of walking and skiing with her family who are also active members of their local church.
A full-time partner at a practice in Aberdeen, Alison became a Fellow of the RCGP in November 2007. In her spare time she likes to escape to her farmhouse in Strathdon to enjoy time with husband Neil and her two teenage daughters.
What led you to become involved with the RCGP Scottish Council? I feel that as a young GP with the experience of being both sessional and salaried, I can reflect the views and enthusiasm of non-principals at a national level. It is important to me, as well as fulfilling the day to day role as a GP, that I also do what I can to improve General Practice for both patients and doctors. Do you have any specific areas of concern or interest (clinical or otherwise)? I am involved in teaching students within the practice context and am also interested in post-graduate training. Where would you like to see General Practice in five or ten years? I would like to see the great job that the vast majority of GPs carry out on a daily basis to be recognised as the real cornerstone of the NHS. I would also like to see a change in the attitude of the media towards General Practice. I would like students and junior doctors to be passionate about entering General Practice and for professional education to be easily accessible. The smooth introduction and running of revalidation would also be a positive.
Perfect partnership: Dr Susan Potter, Bryan Caldicott, John Hopkins, chairman of Moss Grove Surgery Patient Panel and Practice Manager Sonia Clark with RCGP President Professor David Haslam at the presentation of their award
patients with a winning way Patients from the Moss Grove Surger y in the West Midlands are the winners of this year’s RCGP Patient Participation Award. The Surgery in Kingswinford has had an active patient panel for eight years and now has over 50 members, as well as a satellite panel of 35 consultation members. They have organised a wide range of activities including the introduction of a patient library and quarterly newsletters and have also developed a home visiting policy.
The panel runs twice-yearly health awareness events and has focused its recent efforts on the dissemination of health awareness to teenagers, hosting a very successful event on healthy eating, sexual health, drug awareness, smoking and dealing with stress and bullying. The Patient Participation Award – which is sponsored by GP Update and Elsevier and carries a cash prize of £3,000 – will be used to develop the surgery’s work with teenagers, including the introduction of a confidential teenage health card system. Patients with a hearing impairment will also benefit from a new visual display board to complement the current loop system – the direct outcome of a recent patient survey. The Patient Participation Award was established by the RCGP in 1996 to recognise the contribution and encourage the involvement of patients in UK general practice.
What led you to become involved with the RCGP Scottish Council? I was first motivated to become more involved with the RCGP Scotland following my attendance at the first national RCGP Conference in Edinburgh in October 2007. I recognised the value of the work being done by the College in Scotland to promote excellence in general practice and felt that I wanted to get more involved at a strategic level, both locally and nationally. Do you have any specific areas of concern or interest (clinical or otherwise)? I have recently been appointed as Assistant Director for Postgraduate General Practice Education in the North Deanery with responsibility for Grampian and Moray and am due to take up this post shortly. As you would expect, I have a particular interest in GP training and education and am keen to promote closer partnership working between RCGP Scotland and NHS Education for Scotland both locally and nationally. Where would you like to see General Practice in five or ten years? My vision for General Practice in the next five to ten years is to see well-trained highly motivated individuals delivering the best quality patient care in the primary care setting. I am passionate about General Practice and believe it deserves to be championed and promoted.
TIpS ON TENDERING Sheffield Faculty representative Dr Janet Hall (pictured right), practice manager and RCGP Honorar y Fellow Sandy Gower and RCGP Vice Chair Dr Clare Gerada will be hosting a workshop for GPs and Practice Managers on How to Submit a Successful Competitive Tender on 12 March. Dr Hall said: ‘The tendering process can be daunting for practices and this will be an opportunity to share experiences, advice and useful information.’ The event follows the Faculty’s successful public meeting on the Darzi Review last year. Look out for further details in the next issue of RCGP News.
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RCGP News • January 2009