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N ews RCGP on the move: College

THe NeWsPaPeR Of THe ROyal COllege Of geNeRal PRaCTITIONeRs

APRIL 2010

signs deal on our new HQ The search for a new building is over – and the RCGP will be relocating from Princes Gate after 48 years. RCGP Honorary Treasurer Dr Colin Hunter reports on the historic move and how it will bring about a wider range of services and benefits for College members. The College has exchanged contracts on new premises. The building, which is anticipated to be ready by summer 2012, is situated at the corner of Melton Street and Euston Road, right next to Euston station. This is an ideal location and is only five minutes walk or one Tube stop from King’s Cross and St Pancras stations and four stops from Paddington. The building is in fact two buildings: a Grade 2* listed building on Melton Street dating from 1906 and a newer linked building which was added in 1924. The building was previously a social security office. The College has been able to take advantage of the downturn in the market to purchase a building that will be a good long-term investment for the charity. The building is freehold. Our new building will provide an enhanced facility for Members and patients. It will include a contemporary conference suite encompassing a 300-seat lecture theatre, break-out space and dining space. We will also relocate the Clinical Skills Assessment Centre (currently in rented space in Croydon). There will be state rooms similar in dimensions to those in Princes Gate, enhanced and better meeting space and open plan office space for our staff. Subject to planning permission, we also hope to include 40 study bedrooms with en-suite facilities. It will provide in excess of 100,000 sq ft of space, more than four times larger than Princes Gate. We have appointed a top team to take forward the refurbishment project, including Kathy Tilney of Tilney Shane as architect and designer. Kathy has been working with us for a number of years and has a philosophy of making the building really work for the organisation, so our move will be coupled with new ways of working. We are, as part of the project, investing in a state of the art IT infrastructure which will deliver our progressive digital strategy. In addition, we will work to a modern sustainability agenda and encompass environmental enhancement wherever we can. The refurbishment programme is due to be completed in summer 2012. How will it be funded and will the subscription rate be increased to pay for it? We have been fortunate to be able to tie the sale of our current building at Princes Gate to the acquisition. We have exchanged contracts on Princes Gate and that building is likely to return to residential use. Currently our staff are spread across three other sites in London in rented space which has associated costs. We are in a position to be able to meet the interest costs from any loan from our current budget by redirecting monies to pay our loan rather than other landlords. There will

therefore be no need to increase the subscription rate to pay for the building. The College continues to grow in terms of membership and activities. Membership income only accounts for 40 per cent of our annual income and so the College is not entirely dependent on membership fees. The new building will also afford us some greater commercial opportunity, not least the leasing of our ultra-modern conference facility at the hub of the London transport system. Immediate Past President David Haslam, together with our current President Iona Heath, will be heading up a capital appeal to help raise funds towards the venture. The Appeal will probably be launched later this year and will look at diverse ways of raising funds towards the project. The sale of Princes Gate will necessitate us moving into temporary accommodation from August. We have again been able to take advantage of the market conditions and we intend moving into temporary office space near the Tower of London. The space will provide modern office accommodation for all our staff in London (with the exception of London faculties who will remain at Leman Street) and meeting space. There will, however, be no residential element. This will allow us to trial new ways of working with staff and look to how best to configure staff when we move to the new building. Over the past few years, I have received letters of concern from members with regard to the accommodation review. These have had two main themes: firstly, the loss of our building at Princes Gate; and secondly, around whether a more geographically dispersed College strategy would be more appropriate and cost-effective. There is no doubt that Princes Gate is a lovely building. However, it is already too small and the conditions in which staff work on the

All change for Euston: The new RCGP building (above) is ideally situated close to national and international rail links and is more than four times the size of the current headquarters at Princes Gate with the potential for much improved facilities for our Members and staff. second and third floors, and particularly the basement, are very poor. It does cater for receptions, small dinners and the summer reception very well but it does not fulfil any other function effectively. The 11 letting bedrooms are mostly without en-suites. The new building will, I hope, provide a very different but equally prestigious and valued HQ for us. We will do our best to ensure the look and feel of the building are consistent with modern general practice and a forward-looking Royal College. With regard to a more geographically dispersed College, we did considerable work and study in relation to this in 2005. The conclusion was that, if it could be achieved, the best option for us would be a single large building in Zones 1 and 2 in London. Much of this is derived from the quality of the transport network to London (essential for examinations and conferences)

new building will, ❛ IThe hope, provide a very different but equally prestigious and valued HQ for us. We will do our best to ensure the look and feel of the building are consistent with modern general practice and a forwardlooking Royal College

❜ Dr Colin Hunter

and from experience of organisations working across many sites. The next two years will be an exciting and challenging time. Through the medium of RCGP News, I intend to keep you up to date on plans and to seek input from Fellows and Members. Meanwhile if you wish to contact me please email me on treasurer@rcgp.org.uk

Also in this issue... Countdown to appraisal e-Portfolio Progress report on new RCGP online tool

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How green is my family? GPs confront the sustainability challenge

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Reaching out GPs the key to quality care for everyone

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Work in progress RCGP support on health and work a great success

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Close-up on cardio Managing hypertension and heart disease in general practice

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NEWS

RCgP appraisal ePortfolio set for autumn launch Dr Cath Jenson RCGP Revalidation ePortfolio Clinical Lead and Bromley PEC/Board

Appraisal Preparation (since last appraisal) Appraisal

Revalidation

Item

The temporary shutdown of the NHS appraisal toolkit in February brought the issue of electronic recording of appraisal to the front of many English GPs’ minds. The RCGP is continuing apace to develop the College Revalidation ePortfolio and we can now announce that the appraisal function (phase 1) will be available UK-wide from autumn 2010. This will be provided to all College members as a new membership benefit and therefore part of their subscription. Consideration is being given as to how the ePortfolio can be made available to non-members. We believe the RCGP ePortfolio format will enhance the ability of PCOs and appraisers to ensure appraisal maintains its educational and formative benefits. Furthermore, the system is structured to create an appraisal file specifically tailored to the needs of GPs undergoing recertification and revalidation. We wish to ensure that the College Revalidation ePortfolio works seamlessly for trainees moving from their registrar ePortfolio into revalidation. It is also essential that there are no barriers to PCOs adopting the RCGP tool from the autumn. The ePortfolio has been designed to enable the College’s role in the quality assurance of the revalidation process.

Coming in 2011: Phase 2 of the RCGP Revalidation ePortfolio Further functions to support PCOs in managing appraisal and revalidation are currently being built into phase 2 of the ePortfolio. These are led by a RCGP Steering Group which includes representatives of several UK-wide PCOs. Phase 2 functions will map to the requirements stated in ‘Assuring the Quality of Medical Appraisal for Revalidation’ (Revalidation Support Team, May 2009). The need for the Responsible Officer (RO) to be provided with a succinct summary of the achievements of each GP has been given paramount importance, since the College is aware that Responsible Officers will be reviewing multiple portfolios and it is in the interest of all parties to facilitate efficiency! The information within the ePortfolio will be structured and summarised to facilitate efficient assessment by the RO. The proposed ‘dashboard’ summary is shown in the panel above. Each ‘area’ (row) turns from red to

Dr Cath Jenson: Developments continue apace amber then green as data is entered in accordance with the requirements for appraisal and (in future) revalidation. By late 2010 accredited formats for MSF and PSQ data will be agreed and revalidation pilots will shape the requirements for inputting data such as complaints and clinical governance. The option for ‘views’ of selected areas of the ePortfolio by PCO revalidation panels are also being planned.

Also in Phase 2: Appraiser management functions Of interest to PCO appraisal leads will be templates for appraiser development currently being planned for phase 2. These are proposed to include functions for logging of each appraiser’s training, CPD, feedback and complaints. This will allow appropriate PCO officers (which could include the appraisal lead) to see at a glance how each appraiser is performing, and track this electronically.

Phase 3: Linking the RCGP Revalidation ePortfolio to bodies external to the College The final (Phase 3) development of the RCGP Revalidation ePortfolio in 2011 will focus on the requirements of national bodies such as the GMC to view selected areas of the ePortfolio. Most of these requirements are not yet finalised (many pilots are underway across the UK) – the College is poised to proceed as soon as they are announced.

Requirement

Status

Requirement

Status

Area 1: Description of roles

1

0

1

0

Area 2: Exceptional circumstances

0

0

0

0

Area 3: Appraisal Form 4s

5

1

5

1

Area 4: PDP

1

1

5

1

Area 5: PDP review

1

1

4

1

Area 6: CPD credits

50

5

250

0

Area 7: Colleague feedback (MSF)

0

0

2

0

Area 8: Patient feedback (PSQ)

0

0

2

0

Area 9: Complaints/cause for concern

0

0

0

0

Area 10: Significant event audit

2

0

5

0

Area 11: Clinical audits

1

0

2

0

Area 12: Declarations

3

0

15

0

Area 13: Additional evidence

0

2

0

2

Phase 3 of the RCGP Revalidation ePortfolio will also include developing electronic interoperability both with existing RCGP electronic products (such as the trainee ePortfolio and online learning environment) and national interoperability – the sharing of information between different electronic systems. Most medical and surgical specialty colleges and faculties have formed groups to develop ePortfolios; the RCGP is part of the largest national cohort and is working with this group to develop the highest possible standards including for any necessary interoperability outside of the RCGP. Whilst committed to interoperability work, we consider the particular strength of our ePortfolio design is that it is an ‘end to end’ revalidation solution for anyone working solely as a GP, which means all data can be entered onto one portfolio, which minimises the risks and inefficiencies of sharing data across electronic sites and hosts.

Compliance with national security requirements The College is in close discussion with the Department of Health to ensure our ePortfolio will meet all aspects of the revalidation specification, including security requirements. We are drawing on our expertise with the trainee ePortfolio

The survey was carried out as part of a new campaign calling for better access to psychological therapies, spearheaded by economist Professor Lord Richard Layard and the mental health charity Mind, with support from the RCGP and the Royal College of Psychiatrists. Launched at Westminster, the campaign challenges all of the political parties to make a guarantee in their election manifestos to offer, within five years, evidence-based psychological therapies to all who need them within 28 days of requesting referral. The survey received more than 1,100 responses. In it, members were asked with what success they were able to access specialist psychological therapies, for both adults and children, within two months of referral. The survey revealed that while GPs experience a slightly higher success rate when re-

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questing referral for adults, more than 60 per cent of respondents said they could rarely access psychological therapies. In contrast, less than 15 per cent of respondents said they could usually access appropriate psychological therapies for adults, with less than 10 per cent saying the same for children. RCGP Chairman Professor Steve Field emphasised patients’ rights to ‘nationallyapproved treatments, drugs and programmes, recommended by NICE for use in the NHS’. He said: “We believe that there needs to be better access to psychological therapies and welcome the substantial investment that has been made over the last few years, and we support fully the campaign to ensure that adequate funding continues to go into training therapists, rolling out talking therapies across England and making provision for children. “Even if there is a financial squeeze, the evidence is there that the country will save money in the short and long term.” Professor Lord Layard, Programme Director for Wellbeing at the London School of Economics, urged the importance of improved access for patients. He said: “Mental illness is perhaps the greatest single cause of misery in our country. For those who experience it, the least we should offer is the same standard of care we would au-

GPs leading the way amongst the specialties We are one of very few Colleges already at the pilot stage for phase 1 of our ePortfolio, with phases 2 and 3 also on schedule to complete during 2011. We will be using the pilot to ensure the ePortfolio is user-friendly for grassroots GPs, and to develop various sources of help getting started with it (to include online video demonstrations). The College is exploring options to allow other colleges to use our ePortfolio format, which will be of particular interest to GPs working in a second specialty (to avoid having to use two different revalidation formats). The commercial value of sharing our ePortfolio will also help to ensure the ePortfolio can continue to be free to College members for years to come. The process of Revalidation is taking shape and by the end of this year will be finalised through the pathfinder pilots. The RCGP Revalidation ePortfolio has been designed to be adaptable to changing requirements as the Revalidation process evolves. We are determined to ensure this ePortfolio will be truly supportive for GPs in their preparation for revalidation.

Record your experience and be part of history

gPs call for better children’s services A membership survey conducted by the College has revealed that, in almost eighty percent of cases, respondent GPs are rarely able to get access to psychological therapies for children within two months of requesting referral.

and using independent IT advisors to ensure our ePortfolio is at the cutting edge of technology.

The RCGP is calling for entries for its annual diary project on GP training.

Professor Layard: Urging the importance of improved access for patients tomatically provide if they had a physical illness. Politicians who committed to this would receive a huge vote of thanks from millions of families in this country.” ■ For more information on the campaign, please visit www.mind.org.uk

GP trainers, trainees, programme directors, educational and clinical supervisors in general practice and hospitals, and others whose lives are impacted by the GP curriculum are being asked to submit diary entries describing one day’s experience of GP training. To take part, choose a day between 29 March and 25 April 2010 and e-mail your entry to diaryproject@rcgp.org.uk. Contributions are anonymous and the results will be published on the RCGP website. The RCGP Diary Project is now in its third year and aims to create a living history by capturing snapshots of the RCGP GP training curriculum ‘on the ground’. Charlotte Tulinius, RCGP Medical Director of Curriculum, said: “The diary entries provide us with useful feedback that we can incorporate into the changes we make to the curriculum to keep it fit for purpose. Your entries have given, and will give, key insights for the teams responsible for implementing and developing the curriculum. They will be a rich resource for future researchers to understand the experiences of working with the GP curriculum at this point in history.” RCGP NEWS • APRIL 2010


FOCUS

Making the case for sustainable general practice This year’s RCGP Annual Conference in Harrogate will be our first-ever low-carbon footprint event. The venue has been specifically chosen so delegates can easily walk between the hotels and the conference centre. There will also be locally sourced food, a policy to limit printing, and delegates will be encouraged to car-share and use public transport wherever possible. Here, RCGP Sustainability Lead Dr Tim Ballard explains why the sustainability agenda is so crucial to the future of the College and wider primary care. The statement by Margaret Chan of the World Health Organisation that climate change is the biggest threat to health in the 21st century was reinforced by the report of the UCL/Lancet Commission on climate change and health published in May last year, the summary of which can be found at www.thelancet.com/climatechange. There is now an overwhelming view from climate scientists that global warming is a reality and that mankind’s activities are significantly contributing to this process. Health is likely to be affected in many ways, most of them adversely. There are the obvious changes such as changing prevalence of endemic diseases, increasing incidence of skin cancers etc, but the

really big problems with health are related to human conflict triggered by resource issues and the health consequences of mass migration. In common with much that influences health, the poor will fare the worst. This will be most noticeable in the third world where many of the world’s biggest cities, already with massive deprivation, are at sea level on estuaries. Unchecked, the projected rises in sea level are set to flood these cities. The possible human response to the effects of climate change can crudely divided into the two broad areas of mitigation and adaptation. Mitigation involves action aimed at minimising the environmental consequences of human activities. The major greenhouse gas is CO2.

How green is your garden? Dr Keighley and family (and dog and hens)

This is due to the sheer volume that is being pumped into the atmosphere. Many activities, in our oil based economies, can be reflected as the net CO2 that is produced as a consequence. Adaptation covers the strategies aimed at minimising the anticipated adverse effects of climate change. Many individual doctors have recognised much of the above and have begun to change their personal behaviour in response (see our story on Dr Keighley below left). To date there has been little in the way of a cohesive professional stance. I suspect that many doctors believe that the moral value of their clinical activities in some way insulates them from the massive environmental challenge that faces us all. Medical professionalism has been defined as ‘a set of values, behaviours, and relationships that underpins the trust the public has in doctors’. It would seem that the public have a right to expect that we do our best to raise awareness of the impact on health of climate change. We also need to develop strategies aimed at decreasing the contribution of healthcare delivery to the problem, as well as beginning to think about how we can deliver effective healthcare to those in most need in a lower carbon economy. It is estimated that the activity of the NHS is responsible for the production of 20 million tonnes of CO2 per year. It was in response to all of this that the RCGP began to act. I was appointed as ‘sustainability lead’ in October 2008. The strategic plan that we are working on has many facets. At its heart is the aim of including ‘environmental probity’ in the core understanding of what it is to be a GP. There are several work streams that we are developing. The first is the inclusion of sustainability as it relates to primary care in the curriculum and assessment blueprints. I hope that we will be able to look at the activities of individual faculties. The carbon reduction that can be achieved with faculties is likely to be small in the great

scheme of things but will still be an important area to focus on. We have also developed an environmental practice award scheme and this is currently being piloted. It is a web-based carbon calculator specifically designed for general practice and will enable practices to input their activities and demonstrate to them where appropriate savings could be made. There will then be a link to the Carbon Trust – which has confirmed that its interest free loans scheme will be available to practices. These can be accessed to fund the introduction of schemes and technologies that will reduce the carbon footprint of a practice. The RCGP has also been working with other Royal Colleges to look at how this topic can be introduced into undergraduate and postgraduate training prior to formal inclusion in curricula. There are also plans for five sustainability ST3 scholars at the Severn GP School. These scholars will have an extra month of study leave to enable them to focus on environmental issues relating to primary care. GPs are ideally placed to bring about change in the environmental impact of healthcare in the UK, both by modifying their own behavior as well as using their influence in commissioning decisions. We are held in high esteem by society, as shown by IPSOS MORI polls and NHS patient surveys. Patients trust and believe their doctors. Following the Doll report in the early 1960s doctors were at the vanguard of those stopping smoking and this was noticed by others, resulting in wider smoking cessation. Doctors stopping smoking was obviously motivated by direct self interest. The approach to personal and professional carbon use needs to be motivated not only by altruism but also by an intergenerational self interest – concern for our children and grandchildren. Hopefully patients and others in society will be positively influenced by the positive actions of their family doctors.

E A R LY B I R D B O O K I N G D E A D L I N E 2 8 J U N E 2 0 1 0

going green: how one gP’s family is making a difference to the planet Dr Judith Keighley Former Partner, Broxburn, West Lothian now Locum GP As a family we have been selected as one of five UK finalists for the Environmental Award of Future Friendly Family 2010. I know some doctors feel that doctors should keep out of environmental issues. Sadly, it is clear that at some point soon, we will reach Peak Oil. Once we have passed this our current relatively cheap fuel will become much more expensive, having an impact on most aspects of daily life. It would seem that staying healthy and living sustainably go hand in hand. To be healthy we are advised to eat at least five portions of fruit and vegetables, limit our meat and alcohol intake and exercise at least 30 minutes five times a week. Fruit and vegetables per calorie need less farmland to be produced than meat does. If we walk or cycle all our short journeys we are fitter and use less fuel. The alcohol we drink has often travelled thousands of miles giving it a high embodied energy. So what did we do to get this far in the Award? Mainly the simple things. We insulated our house with additional loft insulation, double glazing, cavity wall insulation and a new boiler. This cut our space heating fuel usage to about one-sxth of its original level. To conserve electricity we have put in energysaving bulbs, we switch off appliances at the wall, don’t leave anything on standby and gradually replace old appliances with more energy efficient ones as needed. We recycle everything we can and once a year ‘audit’ our shopping and our waste to get an idea of where further improvements can be made. RCGP NEWS • APRIL 2010

When we were a two-income family I used to enjoy a bit of retail therapy. My shoe collection vied with that of Imelda Marcos. As many of these were rarely worn, I realised that the high of retail therapy is shortlived and addictive. I gradually stopped – wow! what a change to the bank balance. As the children started to grow up we began to walk to nursery, school, shops and for local visits. The car fuel bills dropped and kids’ shoe bills grew! Our diet has evolved from highly processed and pre-cooked one to fresh, largely vegetablebased. This came about as the children arrived and we prioritised time to cook for them – and us. We then worked in the garden with them growing bits and pieces of vegetables and fruit. Fresh raspberries just picked or peas out of their pods cannot be beaten. Are we perfect? Far from it – the TV still gets left on standby or we occasionally leave a light on in an empty room. We are, however, thinking about it and by definition that changes our behaviour, making us reduce, reuse and recycle. It is hard though when short of time and tired to think about anything. We have gradually made it easier to recycle and try avoid bringing things into the house which will end up in landfill. Added to sustainability and health going hand in hand, I feel we could also add financial stability. It’s cheaper to walk, buy locally (you don’t fall foul of all the offers) and just reducing what you buy makes life cheaper. This is so important but difficult for many people and patients trying to cope with the aftermath of the recession.

Sustainable

Primar Care growing healthy partnerships

■ Vote now for Judith and her family at www.futurefriendly.co.uk. The competition closes on Wednesday (31 March 2010).

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NEWS

Including the excluded in healthcare Cabinet Office Minister Angela Smith and National Director for Primary Care Dr David Colin-Thome joined RCGP Chairman Professor Steve Field for the launch of a landmark report on how to improve healthcare and services for socially disadvantaged and harder to reach groups. Inclusion Health – a joint initiative between the Cabinet Office and the Department of Health (England) – acknowledges the need for a greater primary care focus in addressing the needs of the socially excluded. It proposes a framework for action, including strong clinical leadership; responsive, flexible and joined-up services; innovation in service design and delivery and increased emphasis on health promotion and prevention. New analysis by the Social Exclusion Taskforce in the Cabinet Office and the Department of Health (England) shows that – despite the progress made in healthcare over the past ten years – the homeless, those with learning disabilities, people leaving prison and sex workers are still finding it difficult to access the services they need, often with life limiting results. A new National Inclusion Health Board – chaired by Professor Field – will now take forward a programme of work to provide stronger advocacy for the most disadvantaged and support for the health professionals who work with them. This will include the establishment of a dedicated Faculty of Inclusion Health. RCGP member Dr Sam Everington, whose work in Bromley-by-Bow is showcased as an example of good practice in the report, said that simple changes were often the most effective way of engagement.

RCGP Chairman Professor Steve Field says: “This agenda is part of my DNA. My reasons for wanting to be a GP are the same today as when I was at school – I wanted to make a difference and help people less fortunate than myself. “Working in a particularly deprived area of inner city Birmingham is so rewarding – but incredibly frustrating. We have lots of disadvantaged groups and I still feel we can do more to reach out and make sure we are providing the care they need and helping them live as long and healthy lives as possible.

A united front: (left to right) Angela Smith MP; Rolande Anderson, Director General of the Office of the Third Sector; Dr David Colin-Thome; Professor Steve Field and Rosemary Cook, Director of Queen’s Nursing Institute “Look at things like the design of your consulting room. We have curved desks so that GPs and patients are on the same level and we go out into the waiting room to meet our patients – it makes a difference.” Charles Fraser, Chief Executive of St Mungo’s charity for homeless people, said: “There are degrees of social exclusion and this is not just about accessing healthcare but using it. I feel more optimistic that something is being

done to tackle the healthcare of homeless people than I have in the past 30 years.” Angela Smith concluded: “GPs are doing good in their own areas around the country. We need to bring them all together to lead the way.” ■ Inclusion health: Improving the way we meet the primary healthcare needs of the socially excluded – www.cabinetoffice.gov.uk/ social_exclusion_task_force_force.aspx

“We’ve acknowledged the need for clinical leadership and I’m delighted to have been asked to chair the new National Inclusion Board. We need to think differently about disadvantaged groups and I’m determined that high quality general practice plays a key role in improving the health outcomes of all our patients. “This is not just a commitment for GPs but about inclusion across the entire healthcare spectrum. We need to build on the good steps we’ve already taken and work more closely with our secondary care colleagues to deliver more integrated care. We can’t wait for big investments, this is too important an issue to be lost in the politics.”

starting young is the answer How ‘frontline’ scottish gPs to tackling health inequalities are addressing the problem Dr Angela Jones Chair RCGP Health Inequalities Standing Group Research suggests that many GPs feel illequipped to manage people with complex and multiple needs, especially when these needs fall into the sociomedical domain, such as homeless people, refugees and asylum seekers, and other excluded groups. Delivery of primary care for excluded people has been under the spotlight more recently. A study by the Cabinet Office, which reported on 11 March this year, acknowledged the key role that primary care plays in addressing social exclusion through providing for health needs and helping to coordinate other elements of care. Furthermore, the Marmot Report on Health Inequalities has focused on primary care as a key area of medical provision which is in a position to address the woeful health inequalities which exist in our society. So how are we to ensure that we have a workforce, equipped in terms of knowledge, skills and attitudes, to tackle health inequalities and to provide real and meaningful universal access to healthcare for socially excluded groups? The current consensus is to start young! Undergraduate curricula need to include opportunities to learn how to engage effectively with people who are socially excluded, in order to avoid the further marginalisation that arises if people cannot access the healthcare that they need. This requires a combination of experiential opportunities and positive role modelling of inclusive practice during these very formative years. It has been acknowledged that there is a dearth of inclusive role models available to undergraduates. Curricula are already overcrowded and space for extra sessions is difficult to find. Perhaps it is among those GP practices

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that take medical undergraduates that many such teaching opportunities are to be found, and delivered inclusively and universally, as part of ‘normal’ practice rather than marking out such approaches as ‘extraordinary’ and only to be undertaken by specialists. It has also been acknowledged that public health teaching can be somewhat dry and lacklustre and fails to put across the immense opportunity that public health measures offer for making a difference to the lives of people and communities. Moves are afoot to allow more public health specialists to maintain a clinical role. However, thought is also being put into ways of making public health teaching ‘sexier’ and to inspire more undergraduates to look at their work with more of a public health focus than has been the case up to now. The Health Inequalities Standing Group (HISG) has put together a conference on 27 April 2010 in Liverpool to look at these themes and we hope that as many GPs involved in undergraduate education as tutors, SSMs or communication skills teachers as possible will attend. The aim of the day is to share experience and to produce a document, with the help of the undergraduate group MEDSIN, which encourages best practice in the training of undergraduates so that we can ensure that the doctors of the future enter the profession with the basic tools they need to practice inclusively and to tackle health inequalities in whichever field they ultimately work. ■ Health Inequalities on the Medical Undergraduate Curriculum is a one-day conference, taking place at the Liverpool Medical Institution on 27 April 2010. To book your place contact Jonathan Hamston at jhamston@rcgp.org.uk

Professor Graham Watt Professor of General Practice, University of Glasgow Co-Chair of the GPs at the Deep End Steering Group Health inequalities are a major concern in Scotland. An event was held in Glasgow in the autumn entitled General Practitioners at the Deep End: what can general practices in deprived areas do to improve their patients health? to look at tackling the problem. Arranged by the RCGP Scotland Health Inequalities Short Life Working Group, the primary purpose of the event was to inform the RCGP Scotland report on Health Inequalities (a key remit of the Short Life Working Group). Invitations were despatched to the 115 practices which serve the most deprived practice populations in Scotland (both urban and rural) and participation at the meeting was open to all practices, regardless of RCGP membership status. RCGP Scotland and the Scottish Government shared the funding. The meeting provided an unprecedented opportunity for engagement directly with the ‘frontline’ GPs who operate at the heart of deprivation in Scotland and the day was carefully structured to gather the views and methods of practice as well as soliciting suggestions for potential policy changes to create the beginnings of a GP-led support group that will have ‘one voice’ for tackling Scotland’s growing concern of inequalities in health. Due to the success of the event and the overwhelming sense of solidarity generated, a GPs at the Deep End Steering Group was conceived. Comprising GPs from the top 100 most deprived practices in Scotland, the initial perceived responsibility of this group was to continue to tackle the specific issues faced by general practitioners operating in these areas.

Initially funded by the Glasgow Centre for Population Health, the GPs at the Deep End Steering Group has met several times over the past three months. Membership is fluid, although always consisting of GPs derived from the ‘top 100’. The process has been very productive and three smaller meetings (with locum funding) based on the original Deep End format were arranged for January 2010. These events were designed to draw on the experience and views of the GPs on the topic of unmet need, vulnerable families and the Scottish Government’s Keep Well initiative. Reports of the original GPs at the Deep End event and the subsequent meetings described above will feature in the report of the RCGP Scotland Short Life Working Group on Health Inequalities – the final draft will be presented to Scottish Council members at the meeting on 5 June this year. Engagement from the Scottish Government has been present since the inception of the GPs at the Deep End Steering Group and a meeting was arranged on 3 February between the Chief Medical Officer, his colleagues and representatives from the Steering Group and the RCGP Scotland Short Life Working Group to discuss the way forward. An early issue identified was the need to support further meetings like the original event. This meeting was successful in gaining a level of support from the Scottish Government and sparked a further meeting to discuss how the Scottish Government can work in conjunction with RCGP Scotland and the GPs at the Deep End Steering Group to help influence policy. It has been proposed that the Scottish Government fund some events over the coming six months with an issue-specific focus to help inform their methods on tackling Health Inequalities. An exciting time lies ahead for healthcare delivery in Scotland. RCGP NEWS • APRIL 2009


NEWS

Health and work workshops are in great demand with gPs Over 1,000 GPs around the country have taken part in RCGP workshops to help manage patients with health and work issues – with hundreds more enrolled for the next round. The interactive half-day workshops are proving a resounding success. One participant in Edinburgh reported: “Excellent course, has definitely increased my confidence in assessing fitness to work and addressed several related issues that I previously struggled with. I believe my assessment of fitness to work will change as a result of today’s teaching.” Another in Oxford said: “Very relevant. Good mix of facts and consultation techniques. I will find the motivational, interviewing and confidence-building skills very useful.” As a result of attending the workshops a number of GPs have also expressed an interest in becoming workshop trainers. The workshops, which aim to increase GPs’ knowledge, skills and confidence in dealing with clinical issues relating to work and health, have recently been revised to include material on the ‘fit note’. The new content will provide further support and guidance to prepare GPs for the ‘fit

note’ which is due to come into effect on 6 April. The workshops were piloted extensively throughout 2007, with content developed and presented by Professor Sayeed Khan and Dr Debbie Cohen. An independent evaluation of the workshop was extremely positive and led led to the workshops being rolled out more widely. RCGP Chairman Steve Field said: “Tackling health inequalities is a major priority for GPs and helping people into employment is clearly one of the best ways of improving the mental, physical and economic well-being for our patients. “I am delighted that there has been such an excellent response to the workshops and that so many grassroots GPs are finding the training relevant and useful. I would urge all our members to take up this valuable opportunity and enrol. “My thanks go to Professor Nigel Sparrow, Professor Sayeed Khan and Dr Debbie Cohen for their commitment, energy and support on this project. It’s really heartening to see College Members taking the initiative and creating innovative programmes that support GPs and improve the lives of patients at the same time.” Dr Debbie Cohen said: “We knew from our research that there was a need for this support but we have been surprised by the response. We are now well on our way to achieving our target to provide training and support for between

3,000 and 4,500 GPs across Great Britain over the next two years. We were determined that the content of the workshops should reflect what we were hearing from GPs in their surgeries and it’s very reassuring that participants are telling us that they can apply their learning and strategies directly to their consultations back in practice.” ■ To make registration easier, the schedule of future workshops has now been uploaded to the online booking system on the RCGP Health and Work in General Practice website: www.rcgp.org.uk/healthandwork

APRIL 20 21 22 27 28 29

Dr Debbie Cohen: On target to provide training for 3,000 to 4,500 GPs in the next two years

MAY Best Western Royal Beach Hotel PORTSMOUTH Marriott Gosforth Park Hotel GOSFORTH Hilton Garden Inn Hotel Luton North, LUTON Holiday Inn Northampton West NORTHAMPTON The Hallmark Hotel, CARLISLE Prince Rupert Hotel, SHREWSBURY

4 11 13 18 19 26 27

Holiday Inn, LINCOLN Best Western Huntingtower Hotel PERTH Park Inn Hotel, LEIGH Highpoint Conference Centre LEICESTER Walnut Tree Hotel, TAUNTON Latton Bush Centre, HARLOW Windermere Hydro Hotel BOWNESS ON WINDERMERE

Being open on patient safety is crucial Christine Johnson FRCGP GP Adviser, National Patient Safety Agency

Communicating openly and honestly with patients is a key part of providing care. When a patient safety incident occurs, this open communication needs to continue. Being Open about what happened and discussing promptly, fully and compassionately can help patients and clinicians to cope better with the after-effects. Openness and honesty can also help to prevent such events becoming formal complaints and litigation claims. There are case studies which demonstrate how Being Open (or open disclosure as called elsewhere) and improving patient safety can have economic benefits. The programmes that appear to be most successful take a comprehensive approach to promoting Being Open and include all stakeholders in this. For example, the University of Michigan Hospital System has found that the

full-disclosure programme has halved the number of pending lawsuits resulting in a total average annual savings of US$2m 1. Being Open is when patients, their families and carer get an acknowledgement that the incident has happened, an apology, an explanation or an expectation that there will be an explanation following an investigation, and reassurance that lessons will be learned to prevent it happening to someone else. NPSA guidance on Being Open has been available since 2005 and this was updated in 2009. Many professional bodies support Being Open, including the Royal College of General Practitioners, the Medical Defence Union, the Medical Protection Society and the General Medical Council. It is a key objective in the MRCGP curriculum. Being Open is more than a one-off event; it is a communication process with a number of stages. The needs of the patients, their families and carers have to be central to this. The table below outlines what the stages are in the Being Open process. Throughout this communication, there should be no speculation, attribution of blame

OVERVIEW OF THE BEING OPEN PROCESS Incident detection or recognition

Preliminary team discussion

Initial assessment

Detection and notification through appropriate systems

Initial Being Open discussion Verbal and written apology

Provide known facts to date

Follow-up discussions

Provide update on known facts at regular intervals

Offer practical and emotional support Choose who will lead communication

Documentation

RCGP NEWS • APRIL 2010

Identify next steps for keeping informed Provide written records of all Being Open discussions

Discuss findings of investigation and analysis Inform on continuity of care Share summary with relevant people

Establish timeline Prompt and appropriate clinical care to prevent further harm

Process completion

Respond to queries

or provision of conflicting information from different individuals. Discussions should take place at the earliest practical opportunity and consideration of the timing and location of the meeting should be made based on the patient’s health and personal circumstances. The patient, their family and carers should be offered the opportunity to share their understanding of what happened and ask questions they have regarding the incident. Importantly contact details should be provided so that if further issues arise later the patient, their family and carers know who to address these to. Some of the main barriers to Being Open for clinicians include the fear of litigation, concern that it will not benefit the patient, having a lack of confidence in personal communication skills and shame or embarrassment about the incident 2. It’s important to remember that saying sorry is not an admission of liability and is the right thing to do. Patients have a right to expect openness in their healthcare. In fact this has been embedded and reinforced in the Putting Things Right project in Wales; and in the NHS Constitution for England which pledges to patients that ‘the NHS also commits when mistakes happen to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively’. Supporting staff when things go wrong is vital. Staff involved in an incident need a supportive team; they need help and advice on how to deal with it. These staff are often referred to as the ‘second victim’. In the guidance developed by the NPSA, it is suggested that all organisations providing care in the NHS should identify ‘senior clinical counsellors’ who can provide mentoring and support to their colleagues involved in an incident and in communicating with patients as a result of an incident.

Further information

Monitor how action plan is implemented

The NPSA provides guidance and support on when and how clinicians can communicate with patients and their carers in three of its activity areas, the Root Cause Analysis, Significant

Communicate learning with staff

References

Record investigation and analysis related to incident

Event Audit and the Being Open programmes. These alongside The Seven Steps to Patient Safety provide: ● Information and guidance for clinicians on how to investigate an incident ● How to acknowledge, apologise and explain when things go wrong ● How to communicate effectively to patients, their families and carers ● How to provide support for those involved to cope with the physical and psychological consequences of what happened To help clinicians and organisations, a range of resources have been developed by the NPSA and are available at www.nrls.npsa.nhs.uk/ beingopen. Here, a free e-Learning tool can be accessed to learn more about Being Open, including case studies. Being Open training workshops have also been developed that include interactive role play with actors and the technique of ‘forum theatre’. ■ Any queries about Being Open, or for more information on the National Patient Safety Agency, please contact Christine.johnson@npsa.nhs.uk

1. Boothman RC, Blackwell AC, Campbell DA Jr, Commiskey E, Anderson S. A better approach to medical malpractice claims? The University of Michigan experience. J Health Life Sci Law. 2009; 2: 125-159 2. Gallagher TH. A 62 year-old woman with skin cancer who experienced wrong-site surgery: review of medical error. JAMA. 2009; 302: 669-677 3. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000; 320:726-727.

5


CLINICAL UPDATE

Headache care in general practice The College has teamed up with GP newspaper to publish a series of five factsheets to support the diagnosis and management of headache in primary care. Written by RCGP Clinical Champion for Headache Dr David Kernick and leading headache specialist Professor Peter Goadsby, they are available from www.healthcarerepublic.com/go/rcgp

FACT FILE 2: HEADACHE HISTORY EXAMINATION AND INVESTIGATION WHAT DO PATIENTS WANT? ● To be taken seriously by sympathetic ● ● ● ●

doctor. To have their ideas, concerns and expectations explored. To have their problem explained in terms they understand. To be offered informed choice about treatment with a clear management plan. Not to be abandoned. Follow-up is important.

HEADACHE HISTORY

● ●

THE HEADACHE EXAMINATION Fundoscopy and blood pressure measurements are minimal. The panel below shows a simple examination proforma that would exclude most pathologies. Subtle neurological nuances are rarely helpful in headache examination. Headache diaries are invariably useful. Scores such as MIDAS and HIT can assess impact and monitor treatment.

A SIMPlE ExAMINATION PROFORMA ● Pupillary responses and fundoscopy ● Visual fields ● Eye movements (superior, inferior, lateral) ● Facial movements

(wrinkle forehead, grimace with teeth) ● Protrude tongue ● Outstretch arms, palms upwards ● ● ●

● ● ● ● ●

● ●

6

for palmar drift With eyes closed, touch nose with finger (upper limb pyramidal, posterior column) Finger dexterity (play piano) Rapid hand movement, tap fingers of one hand on opposite palm and vice-versa (cerebella co-ordination) Limb and plantar reflexes Standing – feet together and eyes closed for balance (Romberg’s test) Walk heel to toe along a straight line Walk on heels, walk on toes Check for trigger points particularly over occiput, posterior neck and upper shoulders Active neck movement (rotation, lateral flexion) In the acute setting, include temperature, rash, neck stiffness, temporal artery tenderness if over 50

SIGN guidelines: www.sign.ac.uk Excellent review of evidence-based headache care. The British Association for the Study of Headache: www.bash.org.uk Contains UK headache management guidelines from a more pragmatic perspective

Exeter headache clinic website: www.exeterheadacheclinic.org.uk Clinical guidance and patient drug information treatment sheets that can be downloaded. Information from patient support groups: Migraine Action: www.migraine.org.uk Migraine Trust: www.migrainetrust.org

INVESTIGATING THE HEADACHE IN PRIMARY CARE Blood tests

● Annual incidence in population – 6-10 per 100,000.

Primary investigations

● Headache presentation to GP – 1 in 1,000.

● Full blood count – anaemia, leukaemia

● Headache presentation to GP if migraine or tension type headache can be diagnosed – 1 in

● ● ● ● ●

● How many different types of headache

do you get? Patients can often identify a number of separate headaches. Examine each one in turn. Time questions. Why consulting now? How recent is onset? The temporal pattern? Character questions. Intensity; nature and quality; sight; associated symptoms (particularly nausea, phonophobia, photophobia, movement sensitivity). Cause questions. Predisposing or trigger factors; family history of similar headache. Response questions. What do you do when you get a headache? (tension-type headache keeps going; migraine wants to lie down; cluster headache wants to bang their head against the wall). What medication has been used and is being used? State of health between attacks. Concerns, anxieties, co-morbid anxiety, depression.

Useful resources

● ●

SOME TuMOuR RISkS TO BEAR IN MIND

2,000. ● Risk of tumour in isolated headache where diagnosis cannot be made after eight weeks – approx 0.8 in 100. ● Risk of discovering incidental abnormality on investigation – 0.6 -10 in 100 depending on age. ● Suggested risk of tumour for which investigation should take place – 1 in 100.

and infection can cause headache Thrombocytopenia ESR and CRP – if raised can indicate temporal arteritis or systemic disease Creatinine – renal failure can cause headache Calcium – to exclude hypercalcaemia Thyroid function test – headache can be associated with hypothyroidism Liver function test – could indicate metastatic disease Carbon monoxide level where relevant

GuIDANCE FOR INvESTIGATING FOR TuMOuR IN PRIMARy CARE RED FLAGS: Presentations where the probability of an underlying tumour is likely to be greater than one per cent. These warrant urgent investigation. Headache with:

Secondary investigations ● ● ● ●

● Papilloedema or focal neurological signs.

VDRL HIV Lyme antibodies Antinuclear antibodies, lupus anticoagulant, anticardiolipin antibodies

● Alterations in consciousness, memory, confusion or co-ordination. ● New onset cluster headache (imaging particularly of the region of the pituitary fossa

required but non-urgent). ● A history of cancer elsewhere, particularly breast and lung.

ORANGE FLAGS: Presentations where the probability of an underlying tumour is likely to be between 0.1 and one per cent. These need careful monitoring and a low threshold for investigation. Headache: ● Where a diagnostic pattern has not emerged after eight weeks from presentation. ● Is aggravated by exertion or Valsalva manoeuvre. ● Has been present for some time but has changed significantly, particularly a rapid increase in frequency. ● Headaches that wake from sleep. ● New headache in a patient over 50

Imaging ● CT is more accurate for haemorrhage

up to five days after the event but will miss approximately ten per cent of space occupying lesions particularly in the posterior fossa ● Ten per cent of patients will experience problems with claustrophobia with MRI ● Three per cent will show incidental abnormalities which invariably give cause for unnecessary concern

gPs urged to continue support for organ donation Lynda Hamlyn Chief Executive NHS Blood and Transplant The UK’s organ donation campaign already has high levels of GP support, with more than four million patients having joined the NHS Organ Donor Register through promotional leaflets picked up in waiting rooms and through the GP registration process. But with three patients dying every day in the UK for want of an organ transplant, a new national Prove It campaign has been launched to encourage more people to sign up, and GPs are being urged to continue playing their part in providing opportunities for the public to join. NHS Blood and Transplant (NHSBT) has enjoyed a long and successful relationship with GPs in promoting the importance of organ donation. Many practices provide invaluable support by simply displaying organ donation literature. Last year alone, 10,000 patients signed up to the Register as a result of leaflets they picked up at their surgery. People are now encouraged to sign up to the confidential computerised Organ Donor Register rather than the previous card-carrying system. Registering makes it easier for the NHS to establish a person’s wishes as cards can get lost or damaged. Currently there are over 16.9 million people on the NHS Organ Donor Register – 28 per cent of the population. The need for more people to join is borne out by the statistics – more than 10,000 people in the UK currently need a transplant. Of these, 1,000 each year will die waiting as there are not enough organs available. The number of people needing a transplant is expected to rise steeply over the next decade due to an ageing population, an increase in kidney failure and scientific advances resulting in more

people being suitable for a transplant. In meeting this need, NHSBT relies entirely on the generosity of donors and their families. One donor can save the life of nine people, restore the sight of two others and improve the quality of life of many more people. People can opt for any part of their body to be transplanted or for specific organs only – kidneys, heart, lungs, liver, pancreas and eyes. Tissues – including corneas, skin, bone, tendons, cartilage and heart valves – can also be donated. There is no upper or lower age limit to joining – the oldest recorded solid organ donor recorded in the UK was 84 years old. NHSBT has set itself a target of increasing the numbers of registrations to 20 million by the end of 2010 and to 25 million by 2013. As in past years, the NHSBT will be sending organ donation literature to all GP practices,

pharmacies and libraries. This is an important element of the Prove It campaign which will continue throughout this year. A black and ethnic minority-focused element of the campaign has just been launched to target sections of the population which traditionally have low levels of organ donor registration. In this year’s mailing, practices will find leaflets and posters for use in their surgeries. Further supplies and a wider selection of literature are always available, free of charge from the NHSBT website: www.organdonation.nhs.uk GPs everywhere are urged to support the organ donation campaign by making the material available. Together, more lives can be saved. ● The RCGP is to appoint a dedicated

clinical lead to champion the value of organ donation within primar y care.

Maudsley Prescribing guidelines – new edition Maudsley Prescribing Guidelines is the most widely-used guide to prescribing psychiatric medicines. The tenth edition has been revised and updated and is indispensable for the prescribing community. It provides practical advice for use in common and more rarely encountered clinical situations. Key sections include: ● Plasma level monitoring of ● ● ● ● ● ● ●

psychotropics and anticonvulsants Schizophrenia Bipolar disorder Depression and anxiety Children and adolescents Substance misuse Use of psychotropics in special patient groups Miscellaneous conditions and substances

Where possible, guidance has been aligned with the most recently issued guidelines from NICE and the latest Cochrane reviews. The book also anticipates new drug introductions and changes in Product Licences. ■ RCGP members can benefit from a 10 per cent discount and free delivery by visiting www.informahealthcarebooks.com/ maudsley.html Special discounted price: £45/€56.70/$90 Quote code HJMAUD at the checkout. Alternatively, if you’d like a copy for each GP in your practice order the special five-pack offer at £175/€219/$350 from www.informahealthcarebooks.com/ maudsley5pack.html ISBN: 9781841847108 RCGP NEWS • APRIL 2010


CLINICAL UPDATE

guidelines for managing hypertension Dr Ivan Benett FRCGP

Box 1: Initial investigations required of the hypertensive patient

(GPwSI in cardiology)

Primary Care Cardiovascular Society In 2008 the Department of Health launched its document Putting Prevention First1 The idea is to identify those at risk by creating vascular checks for all aged 40 – 74 years, including blood pressure measurement. Cardiovascular risk increases with increasing blood pressure levels > 115/752. The WHO estimates that raised blood pressure accounts for about two in three strokes, and half of all coronary events3. Treating hypertension reduces cardiovascular outcomes. The rule of halves, addressed by Dr Julian Tudor Hart4, asserts that for chronic diseases, only half the cases are ascertained; half of those are treated; and of those treated only half are treated effectively. The Quality and Outcomes Framework (QOF) has led to the prevalence of hypertension in English practices being recorded as 12.5 per cent in 2006/7, rising to 13.1 per cent in 2008/9. This is about threequarters of the estimated prevalence5. The percentage of people with hypertension seen in the preceding nine months actually fell from 92.4 per cent in 2006/7 to 91.9 per cent in 2008/9. The percentage managed to the target of 150/90 mmHg was 77.6 per cent in 2006/7 and 78.6 per cent in 2008/9 6. The threshold for diagnosis (BP>140/90) depends on repeated measurements after rest and with validated, well maintained and recently calibrated monitors. In the presence of end-organ damage, such as left ventricular hypertrophy or proteinuria, there is no need for repeated measures. ‘Masked’ hypertension, where the BP is normal in clinic but high at other times, and ‘white coat’ hypertension may not be as benign as once thought. High normal BP <140/90 but > 120/80 also carries a higher cardiovascular risk, and risk of developing hypertension7. Most secondary causes of hypertension such as renal and endocrine causes are rare and occur less than once in a clinical lifetime. History, examination, simple investigation (Box 1), or resistance to treatment can help identify them. The exception is hyperaldosteronism, which affects about one in eight of people with hypertension. Serum potassium is usually normal and the condition only becomes apparent when there is resistance to treatment. In these cases a small dose of spironolactone 25mg daily, with careful monitoring of serum potassium, will often produce dramatic improvements. Referral to secondary care, or a GP with an interest, should be made if there is resistance to treatment or a suspected serious secondary cause. Box 1 highlights the initial investigations required with the hypertensive patient. Lifestyle advice remains the cornerstone of initial and ongoing management. Smoking cessation is the most important of all. The benefits of physical activity are increasingly recognised. A diet rich in fruits and vegetables, with low-fat dairy products and reduced saturated and total fat, also significantly reduces blood pressure. This Dietary Approaches to Stop Hypertension (DASH) diet is even more effective if combined with weight loss and exercise8. We know that a high salt intake is associated with raised blood pressure and reduction of dietary salt intake lowers it. Reducing dietary salt by 3g per day, especially in people of African origin, is also likely to be beneficial at a population level. The National Institute for Health and Clinical Excellence (NICE) updated its advice on drug treatment of hypertension9. ß-blockers were dropped mainly following the publication of the ASCOT trial10. ACE Inhibitors are to be used first line in those under 55 years and white. The rest (most) should start with calcium channel blockers or thiazide diuretics. Large individual trials have given mixed messages about which drugs or combinations work best. A recent meta-analysis concludes that essentially all groups provide similar reductions in cardiovascular outcomes, with the exception of ß-blockers which are particularly protective after myocardial infarction11. Benefit is achieved down to BP 110/70 and combinations of low dose drugs may have greater effect than single drugs at maximum doses. Treatment targets vary slightly and are summarised in Box 2 RCGP NEWS • APRIL 2010

Test

Rationale

Bloods for U&Es, fasting glucose and lipids

High K+ indicates possible endocrine cause High or rising creatinine for renal impairment Raised glucose to identify diabetes Lipids for overall CVD risk

Urine for blood and protein

Parenchymal renal disease

ECG

High voltages indicate possible LV hypertrophy, or identify other changes

Box 2: Target blood pressure according to guidelines Guideline NICE

9

Blood pressure target

Special comment

< 140/90

SIGN12

<140/90

Older people > 60 years

NICE – Diabetes13

<140/80

<130/80 if evidence of end organ damage incl. microalbuminuria

NICE – Chronic Kidney Disease14

139-120/<90

120-129/<80 if diabetes or proteinuria and use ACEI

European15

< 130/80

Lower limit 120/70

American16

<140/90 - 130/80 for diabetes or CKD

Use ACEI/ARB if microalbuminuria

Making lifestyle changes and taking medication is important. Good communication must exist between the physician and patient. People must understand why they need to make these changes, and their ideas, concerns and expectations must be addressed. They have to buy into the changes. This is what GPs are good at, but perhaps need to do better when dealing with this symptomless disease. Box 3 indicates suggestions from SIGN for improving concordance. No discussion on Chronic Disease Manage-

ment is complete without an encouragement to audit the care provided to the whole population. My personal feeling is that QOF measures the appropriate domains but uses inappropriate criteria. I would suggest targets of <140/90 and 130/80 if they have diabetes or CKD. ACEI or ARB should be used if there is significant proteinuria, or microalbuminuria in people with diabetes. Implementation research is now also urgently needed. We know what to do, but we now need to know the best way of doing it.

Box 3: How to improve concordance 12

SUMMARY KEY POINTS

● Involve the patient in making treatment decisions ● Increase the patient’s knowledge about treatment regimens and the rationale for treatment ● Patient counseling and information leaflets ● The use of single-daily or (if not available) twice-daily dosing combination tablets ● Minimising poly-pharmacy ● Use of compliance aids (eg dosette box) ● Considering side-effects which may cause discontinuation of drug use and changing the drug regimen promptly.

● Much is known about what works to reduce cardiovascular outcomes in people with hypertension. ● Vascular checks should identify more people with hypertension. ● Improving concordance is key to maintaining life style changes and adherence to medication regimes. ● QOF criteria and standards need to change if we are to impact further on the rule of halves. ● We need to know the best systems for ascertainment and delivering interventions

References 1. www.dh.gov.uk/dr_consum_dh/groups/ dh_digitalassets/@dh/@en/documents/digitalas set/dh_083823.pdf 2. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Prospective Studies Collaboration Age-specific relevance of usual blood pressure to vascular mortality: a meta analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360:19031913 3. WHO. The World Health Report 2002. Reducing risks, promoting healthy life. 2002 www.who.int/whr/2002/en/ 4. Hart JT Rule of halves: implication of increasing diagnosis and reducing dropout for future workload and prescribing costs in primary care BrJGP 1992;42;116-119 5. Wolf-Maier K, Cooper RS, Banegas JR et al. Hypertension prevalence and blood pressure levels in 6 European Countries, Canada, and the United States. JAMA. 2003; 289:2363-2369. 6. www.qof.ic.nhs.uk/search.asp. 7. Franklin SS et al. Predictors of new onset diastolic and systolic hypertension. The Framingham Heart Study. Circulation 2005;111:1121-27 8. Blumenthal JA, Babyak MA, Hinderliter A et al. Effects of the DASH diet alone and in combination with exercise and weight loss on BP and CV biomarkers in men and women with high BP. The ENCORE study. Arch Intern Med 2010; 170:126-135. 9. NICE Clinical Guideline Group. Hypertension management in adults in primary care. NICE CG34 2006. 10. The ASCOT investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOTBPLA): a multicentre randomised controlled trial. Lancet 2005;366:p895-906 11. Law MR , Morris JK, Wald NJ, Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 2009338:b1665 12. Scottish Intercollegiate Guideline Network 2001. Hypertension for older people. SIGN Publication No. 49 ISBN 1899893423 2001. 13. NICE Clinical Guideline Group. The management of Type 2 Diabetes. NICE CG66 2008 14. NICE Clinical Guideline Group. Chronic Kidney Disease CG73. 2008 15. www.escardio.org 16. National Institutes of Health. The seventh Report of the Joint National Committee on Prevention, Detection and Treatment of high Blood Pressure. NIH 2003. www.nhlbi.nih.gov/guidelines/hypertension/ex press.pdf

a decade of progress on coronary heart disease Dr Mike Knapton FRCGP Associate Medical Director British Heart Foundation Last month marked the tenth anniversary of the publication of the National Service Framework for Coronary Heart Disease and the five-year anniversary of the additional Chapter 8 on Cardiac Arrhythmias. It is therefore a propitious time to take stock of the progress of cardiac services and, more importantly, look at those areas where there needs to be more effort. In England, there have been considerable achievements, particularly in improving the management of acute myocardial infarction with rapid access to thrombolisis and more recently primary percutaneous interventions. Prevention of cardiovascular disease, diabetes and chronic kidney disease is being addressed through the NHS Healthcheck programme. There has been a reduction in premature mortality from coronary heart disease by about 50 per cent on the 2000 baseline. This progress has been supported by policy and legislative change, notably the introduction of the smoking ban in public places. However, cardiovascular diseases still account for more deaths than any other set of con-

ditions and there are around 53,000 premature deaths in the UK, and progress has not been so marked in other areas and many of these are salient to the practice of primary care. The recent National Audit for Cardiac Rehabilitation suggests that only just over 40 per cent of eligible patients (that is patients following heart attack, angioplasty and cardiac surgery) receive cardiac rehabilitation. This is disappointing given the target set in the NSF was 85 per cent. Cardiac rehabilitation is an evidencebased intervention that at five years can achieve a 27 per cent reduction in mortality and improve quality of life. Further work also needs to be done to improve the management of heart failure. The British Heart Foundation (BHF) has invested heavily in specialist heart failure nurses to improve the management of patients with left ventricular systolic dysfunction. However, heart failure services have not received the same attention from the NHS as those for acute myocardial ischaemia and infarction. There are also several ‘open goals’ where the NHS could reduce the risk of large groups of people at particular risk of cardiac problems. An estimated 46 per cent of patients with atrial fibrillation are not currently receiving Warfarin

and are therefore at an unnecessarily increased risk of stroke. Similarly, implementing a cascade screening programme amongst the relatives of people diagnosed with familial hypercholesterolaemia would help identify the estimated 100,000 people living in the UK who are unaware they have this treatable condition. The BHF, in partnership with the Welsh Assembly government, has developed a cascade screening programme in Wales. We hope that this will act as an exemplar and a pilot site for the rest of the UK. The NHS is going to face considerable challenges over the next five years as public sector spending is likely to constrain investment. With the inevitable emphasis that this will put on reduction of waste, increases in efficiency and productivity, I think it is clear that the BHF will also want to emphasise the importance of quality evidence-based medicine and rational decisionmaking in the NHS. We are delighted to be working with the RCGP to review the BHF ‘factfile’ programme, which provides concise and authoritative updates to GPs on cardiovascular issues. I would be very grateful to have feedback on this series or other publication we produce. They are all available from www.bhf.org.uk

7


NEWS

RCgP manifesto puts patients first The RCGP has launched a uk-wide manifesto calling on all political parties to make patient care their top priority.

Patients in partnership: Members of the Patient Group are looking for a new voice to join them

RCgP Patient group seeks new lay member The College is seeking a new lay member to join its patient group, which meets four times a year to discuss issues regarding general practice and the NHS. The group also provides patient perspectives on College and government healthcare policy. ■ For further details please call 0207 344 3050 or e-mail jcheong@rcgp.org.uk. Closing date for applications is 7 April 2010.

Invitation to apply for the role of

MEDICAL EDITOR The Royal College of General Practitioners is searching for an enthusiastic clinician/medical editor to join the successful e-GP team. The responsibilities of this exciting and challenging new role will focus on the editorial review and quality assurance of the e-GP e-learning programme. This will involve performing the detailed editorial review and editing of the near-complete e-learning sessions and working with the content development and technical teams to develop these into engaging and high quality finished resources. Other responsibilities will involve evaluating, updating and improving current content and contributing to the creation of publicity and other project-related materials. This post holder will work under the guidance of the e-GP Clinical Lead and will report to the e-GP Executive Board. We anticipate a commitment of two sessions per week over a 12-month period in the first instance. In addition to the sessional reimbursement, travel and subsistence expenses will be reimbursed. The post is available for one year in the first instance. Applications should be submitted by 5pm on 9 April to Heidi Cook at the email address below. They should include a current CV and a covering letter outlining suitability for the role, based on the role description (available on request from e-GP@rcgp.org.uk). Although some familiarity with online educational technologies and approaches is desirable, advanced IT skills are not required for this role. However, strong writing and editing skills and an eye for detail are essential. Shortlisted candidates will be asked to complete some short editorial exercises. Contact details: Heidi Cook (e-GP Administrator) RCGP 14 Princes Gate London SW7 1PU Tel: 0845 456 4041 e-GP@rcgp.org.uk

Background to the e-GP project Launched in July 2009, e-GP: e-Learning for General Practice is a comprehensive, free-to-access, high quality programme of online learning sessions structured around the GP curriculum, developed in a collaboration between the Royal College of General Practitioners and e-Learning for Healthcare (Department of Health). Covering around 500 primary care topics, e-GP provides a comprehensive programme of e-learning modules to support specialty training for UK general practice. It also assists the continuing professional development of qualified General Practitioners and is of interest to other healthcare professionals working in primary care. Further information is available at www.e-GP.org 8

The manifesto, entitled Leading the Way: High Quality Care For All Through General Practice, makes a number of recommendations to raise standards of patient care and help produce a healthier society – whatever the result of the General Election. It is divided into three sections, with calls for action under each heading: q High-quality GP care for all w Care for patients closer to home e Improving the health of the nation Central to the RCGP manifesto are : ● Longer consultation times ● Longer training for GPs ● Better round-the-clock care ● Continued support for the development of GP Federations ● Improved and faster access to diagnostic tests ● Better services for socially-excluded groups ● GPs to continue playing a key role in the care of patients from cradle to grave The manifesto supports action to tackle smoking and alcohol misuse, including minimum price levels for alcoholic drinks and a ban on smoking in motor vehicles (including private cars) with young children. Tackling climate change also takes priority. RCGP Chairman Professor Steve Field said: “Any political party coming into power in any of the countries of the UK faces enormous, unprecedented financial pressures. “Our health service faces a huge challenge: how to respond to reduced funding without reducing the quality of the services we provide, or the quality of the care our patients deserve.

Professor Steve Field: Strong general practice, delivering healthcare that patients need and want is the way forward “GPs and their primary healthcare teams are part of the solution. Strong general practice, delivering healthcare that patients need and want is the way forward. The RCGP is up for the challenge and is already leading the way in showing how high-quality, cost effective care can be available to all.” ■ For more information visit www.rcgp.org.uk

Better leaders, better doctors Sign up now for the RCGP leadership programme 2010/2011 Designed specifically to help GPs develop as leaders in the ever-changing NHS, the Leadership programme provides opportunities to meet and debate with a number of leading figures from the fields of healthcare, government, industry and leadership development. ■ For more information contact Katie Hopkins at leadershipprogramme@rcgp.org.uk

NI tackles VTe

gP expertise needed

RCGP Northern Ireland will provide a primary care perspective on venous thrombosis at its 2010 Symposium on 28 April.

The National Clinical Guidelines Centre for Acute and Chronic Conditions (NCGCACC) is looking for a GP to help develop its clinical guideline on Rehabilitation after Stroke.

Speakers include Professor Beverley J Hunt, Professor of Thrombosis and Haemostasis at King’s College London. Jointly hosted with the Royal College of Nursing, the seminar will address epidemiology, prevention, monitoring and treatment in light of the recently published NICE guidelines on VTE. The venue is the Royal College of Nursing, Windsor Avenue, Belfast from 1pm – 5.30pm and costs £10 for RCGP members. ■ For further details please contact Angela McLaughlin on 028 9023 005 or e-mail amclaughlin@rcgp.org.uk ISSN 1755-7720 © Royal College of General Practitioners. All rights reserved. Published monthly by the Royal College of General Practitioners 14 Princes Gate, London SW7 1PU email: rcgpnews@rcgp.org.uk website: www.rcgp.org.uk

Guideline Development Group members are expected to attend meetings every six to eight weeks for approximately 18 months from the last week of April 2010. Previous experience of guideline development, working with committees and knowledge of NICE and guideline development process, critical appraisal methods and the role of health economics are desirable ■ Further details and application form from NICE website: www.nice.org.uk/ getinvolved/joinnwc/join_a_nice_ committee_or_working_group.jsp

RCGP News invites your comments or letters... Please write to: The Editor RCGP News Royal College of General Practitioners 14 Princes Gate Hyde Park London SW7 1PU email: rcgpnews@rcgp.org.uk RCGP NEWS • APRIL 2010

http://cms.rcgp.org.uk/staging/PDF/RCGP_News_Apr10  

http://cms.rcgp.org.uk/staging/PDF/RCGP_News_Apr10.pdf