N ews Partnership vs Salary:
THe NewSpAper OF THe rOyAl COllege OF geNerAl prACTITIONerS
MARCH 2009
Inside this issue... Health Inequalities – the next steps
the changing face of general practice Is the rise in salaried GPs a welcome sign of the times,
or the end of general practice as we know it? This is the big question posed by Changing Partnerships – a new RCGP discussion paper outlining how the employment landscape is changing for GPs and what this means for the future of general practice in the UK. Authored by RCGP Vice Chair Dr Clare Gerada, it questions whether the lack of partnership opportunities will eventually diminish the role of the GP in the local community and lead to fewer candidates choosing general practice as a progressive career. Up until the late 1990s most GPs working in general practice were in partnership arrangements, working as self-employed contractors. Today, a strong trend is emerging towards salaried positions, a fact borne out by a 2007 GPC survey where a third of respondents said they occupied a mix of different salaried positions. Young GPs are finding it increasingly difficult to move into partnership – there are now over 100 applications for each advertised partnership, and the vast majority of new positions are for salaried positions only. The discussion paper asks whether this is a permanent trend, opening the door to a privatised health system – or a minor re-adjustment, providing much-needed flexibility for a new generation with different expectations. It points out the benefits of partnerships, saying that they tend to encourage tenure, continuity of care and innovation – for example, the rise of practice nurses, nurses practitioners and primary care informatics have all come from innovative GPs committed to their local practice.
The Sheffield experience Sheffield GP Dr Janet Hall took on two new partners last year – a decision that has led to widespread benefits for patients and the practice. “It’s important that clinical leaders are committed and feel involved – but it’s also important that they are looked after and their futures protected, especially in the current economic climate. GP partnerships are the best way of ensuring this happens. “Partnerships increase flexibility and bring a broader perspective and shared responsibility. By employing two additional partners at our practice, we have been able to offer a higher quality of service to our patients, including improved access, a wider skill base and extended services. “We have increased our training capacity, increased our list size and we have more influence in the local community. It also provides us with more time to liaise with other practices on practice based commissioning
Clare Gerada: The loss of the traditional GP partner may diminish the role of the GP in the practice community It says that in the long run, the trend towards salaried positions may have a downside for patient care in practices where GPs do not have the time commitment or a personal and financial investment and that this could impact on the wider role GPs play in their communities. “The patient advocacy role of GPs, especially in deprived and vulnerable communities, is strengthened by independent contractor status and could be irrevocably lost with the expansion of the salaried model.” and the flexibility to plan more effectively for the future rather than dealing only with the day to day. We have become a more effective and supportive team. “Some practices seem almost scared of taking on taking on new partners but GP partnerships are essential for the quality and development of general practice. We must encourage and commit to them to safeguard the future of our profession.” Dr Hall: Partnerships are the way forward
But the paper is keen to dismiss any link between contractual status and individual GP performance: “There is no relationship between the contractual status of an individual and his or her performance, commitment or inclination to innovate.” The positive aspects of salaried positions are also emphasised: “A major attraction is the flexibility they offer for both parties which may help reduce the workload and burden on busy, pressurised practices. “The work-life balance may be an issue for younger doctors, who see how hard it is for partners to take time off, and the increasing number of women in the profession is also driving the trend. Around two-thirds of salaried GPs are now women and, as in other walks of life, there is greater demand for part-time, flexible and largely in-hours working patterns.” Said Dr Gerada: “There is no doubt that salaried GP positions will be an attractive proposition for some doctors and that they work well. But we are worried that as time goes on, the loss of the traditional GP partner may result in a gradual diminution of the role that the GP has in his or her practice community. “Perhaps most concerning though is the sheer lack of choice for new younger doctors, who may have lost the opportunity, perhaps forever, to become masters of their own destiny. Some are already talking about the ‘ladder being pulled up’. Not only could this frustrate young GPs and erode morale, but it could lead to fewer and less able candidates choosing to enter general practice in the first place.” The paper concludes that the solution may lie in a ‘third way’ approach, with practices working as federations. The federated model is being strongly promoted by the RCGP and favours the continuation of the independent contractor, but with a
Report from major RCGP conference
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A letter from America Harvard Professor Gordon Moore on how UK general practice gets it right
Broadening horizons GP trainees report back from Utrecht
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Health Secretary praises Federation Alan Johnson visits award-winning Croydon
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Clinical Update NICE guideline on Borderline Personality Disorder
Championing Headache Four ways to make a difference
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stronger focus on the role played by individual GPs rather than a ‘salaried’ or ‘partner’ division. By sharing overhead costs on IT, HR and back-office functions, GPs will be able to focus on three broad roles: ● Traditional GPs providing traditional, quality general practice ● GPs with other interests such as academia, commissioning or local leadership ● Primary care directors responsible for management and organisation The paper says directorship has “…traditionally been the responsibility of partners, but in this federated model there is no reason to exclude salaried GPs solely by virtue of their contractual status from assuming the roles of responsibility of management in these areas, recognising the professionalism of salaried GPs, and thereby fully utilising the wide range of skills and expertise that are available within the workforce. “This model aims to distinguish GPs by their role rather than level of importance, and provide better pathways for young doctors. It also goes some way to safeguard NHS general practice for future generations.”
COLLEGE NEWS
rCgp states its position on primary care for asylum seekers GPs should not have to ‘police’ or refuse healthcare for failed asylum seekers and vulnerable migrants, according to a new RCGP position statement The statement points out that General Practitioners have a duty of care to all people seeking healthcare and that GPs should not be expected to decide who has access to healthcare or to turn people away when they are at their most vulnerable. According to the Table of Entitlements to NHS Treatments (correct as of November 2008) GP practices have the discretion to accept failed asylum seekers as registered NHS patients. However, an appeal against the April 2008 review is due to be published imminently and the current situation could change as a result. In addition to failed asylum seekers, the College urges the Government to consider the health needs of other vulnerable migrant groups, who it feels should also be entitled to free primary care. The RCGP wants Government to: ● Commission independent and wide ranging social, race, health and impact assessments of the proposed changes before the current situation is changed. (These should include vaccination coverage; outbreaks of communicable diseases; antenatal, perinatal, infant and child health including mortality; maternal health and mortality; and the health and social wellbeing of women and men who are abused or exploited at home or elsewhere, sexually or in other ways. The assessments should also include effects on inequalities in health.)
● Examine the compatibility of the proposals with the international human rights obligations of the UK, including those, but not exclusively, covering children ● Re-examine the proposals in the light of the evidence generated by the above assessments ● Commission independent, continuous, monitoring of access to health care and the health needs of refugees and undocumented migrants ● Explore and implement modes of mitigating or reversing adverse effects of excluding migrants from free access ● Issue guidance to overseas visitor managers and similar officers in NHS organisations and general practices that they shall deal with vulnerable migrants in a sensitive way that will not undermine migrants’ health ● Monitor the approach of vulnerable migrants by health care professionals, other staff and overseas visitor managers and similar officers in NHS organisations and general practices ● Particularly commit itself to the protection of children and pregnant women The RCGP bases its position on the following: ● There is no evidence that asylum seekers enter the country because they wish to benefit from free health care ● Asylum seekers are exercising a legal right to seek refuge from persecution ● The Government’s policy has had the effect of leaving some vulnerable people in the UK without any access to health care.
Health inequalities: taking the next step
The next step Dr Mark Williamson, Associate Director of Primary Care at the Department of Health, shared a common belief amongst conference speakers: that primary care is the solution to tackling disadvantage. Delegates were challenged with his example of a desperately disadvantaged teenager. He asked delegates to consider the multiple needs of a 19-year-old solo mother, struggling with drug addiction, unemployment and domestic violence. “This is not an unrealistic example,” he warned. Dr Williamson set out some key features for the design and delivery of new services: ● PCTs need to assess the scale and nature of problems in their areas. ● They need to engage with socially excluded people – or their advocacy groups – in developing solutions. ● There needs to be better integration of social services; for example, GPs working with social workers.
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Regulations from the Department of Health (England) which came into force on 1 April 2004 identified groups who were not considered ‘lawfully resident’ in the UK and made them liable for National Health Service hospital charges. Subsequently, a consultation in May 2004 proposed to extend the charging regime to Primary Care, including access to GP services. The aim of the draft legislation was to restrict access to NHS care for overseas visitors with the declared intention of reducing abuse of the NHS by what are termed ‘health tourists’. Although there has been no published government response to the 2004 consultation, a recent cross-Government enforcement strategy has been published, Enforcing the Rules. This suggests that primary care be brought into line with the regulations that exist for secondary care. The Home Office document describes the purpose of the strategy as: ‘to ensure that living illegally becomes ever more uncomfortable and constrained until they leave or are removed’.
● There is an adverse effect on infant mortality and children’s health in particular ● Denying free access to primary care could increase the likelihood of serious communicable diseases not being detected ● There could be deleterious effects on the health care and support for exploited women ● Health inequalities policies could be undermined ● Additional stress would fall on A&E services if access to primary care is restricted ● Such a change in policy infringes the basic human rights obligations of the UK Pending further legal clarification, the RCGP reminds all general practitioners that failed asylum seekers are entitled to unrestricted access to primary care services
Protection from the elements: Department of Health speaker Dr Mark Williamson demonstrates how primary care is the ‘umbrella’ solution to tackling differences in quality of care
GPs need to become more vocal and force the issue of health inequalities onto the political agenda, according to speakers at a major RCGP conference More than 80 GPs from around the country braved blizzard conditions to reach the Addressing Health and Inequalities Through Primary Care conference in London in February. Delegates tackled the ‘next step’ of a serious problem: despite increased funding and awareness, many disadvantaged people in society still suffer from poor health and unreliable access to health services. RCGP Chair Steve Field opened the conference along with David Colin-Thome, National Clinical Director for Primary Care in the Department of Health. Professor Field said: “The College is becoming more active and assertive on these issues. We are advocates for the public and patients, especially those in need.” Professor Field welcomed the introduction of inequality measurements in QOF, but warned that this alone would not solve the problem. “We still need to get more GPs into working class areas,” he urged. The conference also saw the official launch of the RCGP publication Addressing Health Inequalities: A Guide for General Practitioners. The guide contains practical advice on how GPs can positively influence the health inequalities among their local population as practitioners, commissioners and community leaders. Both the conference and guide were produced by the RCGP Health Inequalities Standing Group, which campaigns to raise awareness of this issue.
Background
● Effective services need to be proactive and offer choice. They should be welcoming and non-threatening. ● The quality of care should be the same or better than that for the rest of the population.
How to tackle inequality Some of the liveliest discussions took place in the conference workshops on caring for patients with learning disabilities, the undergraduate curriculum, practice-based commissioning and how to set up and run a social inequality practice. Another session on workforce issues raised the debate over partnerships versus salaried positions, and which arrangement is more effective in tackling inequalities. Dr Jez Thompson and Dr Graham Oliver led a session on how to set up and run a social equality practice, aimed at the homeless, refugees, asylum seekers, and others who find it hard to access primary care.
A challenge for the next generation The conference was brought to a rousing close by Dr Julian Tudor-Hart, described by the organisers as a ‘national treasure’. Dr Tudor-Hart first came to prominence in the 1970s for his inverse theory of care, which argues those most in need of health care are the least likely to receive it. He warned delegates of the impact a declining economy will have on the NHS and health services, urging GPs: “Don’t moan, organise. We’ve got to get serious about health service unions. A very broad alliance we need, but we’ve got to have it.” He was impressed with the determination shown at the conference, noting that the delegates “didn’t just want to talk – they wanted to do something about it. “And they didn’t heckle me, which is always a bonus!”
QOF should remain national, say the College and gpC The Quality and Outcomes Framework should remain a national framework, with local priorities addressed through locally enhanced services, according to the RCGP The College made its comments in response to a Department of Health consultation on developing the QOF. It said that the Framework had been a successful system for quality improvement in general practice and an effective national incentive mechanism with a very high uptake rate. “QOF encourages GPs to see patients more often and to provide a higher level of service including health promotion and prevention,” says the response. But it goes on: “Many of our members have raised concerns at the management ability of PCTs to deliver local quality improvement. We are not convinced that local QOF could be managed by PCTs and it could adversely affect the consistence of care offered to patients.” ■ The full response is available at: www.rcgp.org.uk/ news_and_events/college_viewpoint/college_ responses/college_responses_on_key_issue.aspx RCGP News • March 2009
PROFILE
A message to president Obama gordon Moore has some good advice for Barack Obama as he sets about the enormous task of reforming the US healthcare system – look to general practice in the UK
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“Reimbursement is stacked against GPs, they are rewarded on a fee per service basis not per capita and the remuneration gap between generalists and specialists is widening dramatically. It’s a frantic situation. “Doctors are competing against each other and there’s no proper planning for the distribution of services which is leading to fragmentation. It’s like sending a GP to the Wild West with a gun to shoot other GPs down. “Our people recognise what’s happening but they seem almost incapable of doing anything to prevent it. If primary care continues to spiral downwards, other delivery mechanisms will fill the gaps – schools will take control of the obesity agenda and pharmacy chains will employ nurse practitioners to deliver immunisations and other preventative healthcare services in their stores.”
s a Professor in the Department of Ambulatory Care and Prevention at the renowned Harvard Medical School, Dr Moore plays a key role in developing the healthcare leaders of the future and is always keen to ‘talk up’ British general practice as an example of a system that works well. His views are based on his experience working in general practice and hospitals in London – as well as his direct dealings with the RCGP going back to the 1980s. Working on the non-profit Harvard Community Health Plan (HCHP) – of which he was appointed Medical Director and Chief Operating Officer in 1978 – he was keen to find out more about UK general practice as background for a conference speech on the strengths and weaknesses of primary care across the globe. He was introduced to former RCGP President John Horder and they forged a friendship that continues to this day. “A lot of questions were being asked about the future of general practice in the USA, similar to what UK general practice had experienced in the 1970s. You guys were already getting to grips with issues such as fragmentation and John talked to me about the work being done by the College to raise standards. “I was convinced that a primary care-led system was the key to successful healthcare and was hugely impressed with what John and the College had achieved, and so it remains today.” He became more and more intrigued by the role of the GP, not just in providing care, but in facilitating holistic healthcare services for patients with an emphasis on qualities such as thoughtfulness and sensitivity.
OVER THE YEARS, he has been able to observe how UK general practice has tackled real or perceived threats to its survival such as fundholding and constant NHS reform. “GPs might feel that they are constantly fighting fire but in the UK you stand firm against whatever is thrown in your direction, whereas US general practice has fought similar battles and lost.” Watching Lord Darzi’s most recent review of the NHS – and the advent of the polyclinic – from the sidelines, he says he has been impressed by the RCGP stance. “There is no doubt that in some urban settings, corporate polyclinics would make sense but the best solution for the vast majority of the population is the federated system as put forward by the RCGP. Having a GP-friendly, co-ordinated and standardised infrastructure, with easier access to diagnostics and tests, would allow surgeries to provide services closer to where patients work and live – and that’s a real strength.” However, it’s a different story in Dr Moore’s own country and he fears for the sustainability of the current US system, both for the patients who are finding it more and more difficult to access or pay for healthcare and for the primary care practitioners who face an increasingly uncertain future. With low morale and low pay making it difficult to attract good graduates into the profession, he is concerned that time is running out before primary care is carved up by consultants, pharmacists and other health professionals keen to provide ‘first contact services’, but at a premium. “Only five per cent of US medical school graduates are going into general practice – that’s shockingly low. Fifty million out of 300 million Americans can no longer get the care and aftercare that they need. It’s hard to explain to your excellent GPs who are delivering high quality care in the UK just how chaotic the system really is. RCGP News • March 2009
is no doubt that in some urban settings, corporate ❛ There polyclinics would make sense but the best solution for the vast majority of the population is the federated system as put forward by the rCgp. Having a gp-friendly, co-ordinated and standardised infrastructure, with easier access to diagnostics and tests, would allow surgeries to provide services closer to where patients work and live – and that’s a real strength
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GORDON MOORE Dr Moore is a Professor in the Department of Ambulatory Care and Prevention and has worked in managed care since 1972, ultimately becoming Medical Director and Chief Operating Officer of the non-profit, Harvard Community Health Plan (HCHP) in 1978. In 1983, Dr Moore became the Director of Teaching Programs at Harvard Pilgrim Health Care, now one of the major teaching sites for Harvard Medical School. He also designed and implemented the groundbreaking New Pathway project at HMS. Until this year, he directed Partnerships for Quality Education, a project funded by the Pew Charitable Trusts and the Robert Wood Johnson Foundation to help prepare primary care clinician trainees for delivering care effectively in resource constrained environments in the future. His research is in the areas of educational strategies in healthcare, management of health care organisations, ambulatory health services, health policy, and effectiveness of primary care.
WHEN ASKED how things could have reached such a state without the alarm bells sounding, he makes an interesting observation. “If you boil frogs and gradually turn the heat up, they don’t notice. You might figure out that there’s a threat but if it happens over time you’re less aware of the changes that are actually taking place until they’re upon you “There’s a lesion in power of structure of system. Without an agreed formal structure for selecting, training, distributing, and rewarding GPs, we have such strong and differing points of view that we seem unable to reach a political consensus. “If the NHS didn’t exist in the UK, you’d agree to invent it but the US mentality isn’t like that. We have not been as humbled or as willing to learn from the experience of others.” He hopes the election of Barack Obama will stop the rot and rejuvenate primary care by establishing a proper infrastructure and appropriate reimbursement for GPs. “General practice still has its advocates but we’ve had ten years of underfunding and undersupply and it depends how much importance Obama decides to attach to healthcare and whether there are enough good people in the government willing to try and reform the system. Hopes are high but healthcare is really messy and it’s not the only area that needs sorting out.” Meanwhile, the effectiveness of primary care – particularly the success of UK general practice – is something he will continue to hammer home to his audiences of young leaders at Harvard. “They’re big fish in their own ocean and they take a lot for granted without appreciating the threats and really understanding how powerful the primary care system can be.” ONCE OR TWICE a year, his teaching brings him into contact with RCGP Chairman Steve Field, who is a visiting Professor at Harvard. “The College is in good hands with Steve. I feel privileged to know him and the other greats and the goods of general practice. I need very little excuse to visit the College when I’m in England – or to promote its work around the world. “I use the UK as an example for two reasons: I’m confident that what you say you can deliver – and you have the evidence for this – and you have healthcare satisfaction measures that demonstrate the central role of primary care in successfully delivering services that improve the health of the population. “I can think of very few professions that intersect science, interpersonal care, culture and small business opportunities. General practice is hard work but it’s good work. UK general practice is stellar, it sets the standards for the world and I’m its greatest admirer.”
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INTERNATIONAL
going Dutch: A trans-europe express course in healthcare Three young doctors had their horizons broadened during the GPs in Motion programme in Holland Dr Luisa Pettigrew Salaried GP, London Dr Moontarin Ansar ST3, Dundee Dr Nicolle Green ST1, Manchester HAVE YOU EVER WONDERED what General Practice is like in our fellow European countries? Perhaps you want some inspiration and wish to bring home new ideas? During all the hard work and concentration required for vocational training in the UK, we rarely get the chance to think about how our colleagues in Europe are faring, or indeed, how they qualify to become General Practitioners. So as two GP trainees and a newly-qualified GP we were thrilled with the opportunity to have a first-hand experience of Dutch General Practice and to meet our European counterparts. During three days in January 2009 the Dutch GP trainee association (LOVAH) hosted 37 aspiring and young GPs from 18 European countries during an exciting exchange programme called Huisarts in beweging or, in English, GPs in Motion. We spent our first day shadowing an allocated GP trainee in a Dutch General Practice; our second day was an educational day at one of the GP training institutes across the country; and on the final day we attended the national Dutch GP trainee conference alongside more than 700 delegates. We all had a range of experiences from a bustling inner city Amsterdam GP practice to a rural practice with a very religious community. It was fascinating to learn about the Dutch health care system and GP training structure. Their GP training system is also three years long, however they have two full years in general practice, the first and last. Most GP trainees will have worked a year or two hospital jobs prior to this. Dutch trainees were surprised that psychiatry is not a compulsory specialty in the UK, as mental health problems are such a large part of a GP’s workload. Dutch GPs already have licensing in place. Similar to UK proposals, Dutch GPs need to gain CPD points to keep their licence to practice, but also work a minimum number of sessions per year. Some differences included that by law everyone must have basic health insurance. This costs around 100 Euros per month. There is even an excess to pay if you self-present to A&E! Although are exceptions to this if you cannot afford to do so, the aim is to encourage patients to see their GP as a first port of call. The insurance companies also provide economic incentives similar to our QoF indicators to GPs. They also cover most prescription charges, however recently introduced a small charge for benzodiazepines.
Cultural exchange: (left to right) Nicolle Green, Moontarin Ansar, Luisa Pettigrew with two LOVAH Dutch trainees
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The Utrecht canal with the transport of choice for home visits by many Dutch GPs in the foreground
❛ The Portuguese trainees defended the fact that their system still has a single named GP to care for a patient and his or her family, arguing that this is the essence of being a ‘family doctor’. Have we lost our ‘essence’, in exchange for ‘patient choice’? Dutch GPs already have email links with local dermatology consultants and can seek a second opinion at the touch of a button. At the GP practice reception, rather than receptionists, most GP practices have what are called Doctors Assistants. They have had three years of specialised training and so have not only administrative abilities, but can also give basic advice and even do cervical smears, among other skills. This means that most appointments and calls are triaged before reaching the GP or nurse. Although the majority of the consultations were in Dutch, it was truly surprising how much is understood of what is happening by focusing on the non-verbal communication. This in itself was an eye-opening experience. ON THE SECOND DAY we each attended a typical group teaching session that was run in English for the visiting doctors from across Europe. This day ordinarily forms a weekly part of the Dutch trainees’ training, when they spend time discussing guidelines, difficult cases and general issues around their training. On this occasion it was an excellent forum for the exchange of ideas and experiences between our European colleagues. Many pros and cons of health care systems were voiced. Although these were anecdotal and personal views, they gave a real insight to how other healthcare systems work and are perceived by those who work in them. Together we watched a video consultation by a Dutch GP trainee (recorded in English) that gave led to much discussion. There was debate on areas from consultation techniques, to seeking out the hidden agenda, to the positioning of the furniture! Delicate consultation skills play an important part in Dutch training. In contrast, a Greek GP highlighted that patients in Greece often walk in to the consultation room and go straight onto the examination couch to be examined. Many of the differences discussed during this session and at the conference made us, as young and aspiring GPs, raise questions about
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our own system. The Portuguese trainees were passionate and defended the fact that their system still had a single named GP to care for a patient and his or her family, arguing that this was the essence of being a ‘family doctor’. Have we lost our ‘essence’, in exchange for ‘patient choice’? The Greek trainee was impressed by the computerised records we have available in the UK and in the Netherlands. Yet Spanish GPs already have shared electronic patient records within each region. This means that patients can pop into a GP in a neighbouring town and the doctor will have their records to hand. How far should we go with electronic patient records? Will it really replace one on one continuity of care? Italian trainees expressed frustration at the lack of opportunities for young GPs to become partners. Drifting between locums many have too keep their fingers crossed for the early retirement (or worse!) of senior GPs. Will the twotiered system of GP partners versus salaried and locum GPs that appears to be developing in the UK, ultimately lead to a similar situation? What can we do about this? The Danish admired the use of audit and guidelines used in the UK and the Netherlands. Should we export our guidelines or could we import ones we do not already have? Do we run the risk of losing our clinical skills while memorising guidelines? German and Swiss trainees are expected to organise their own vocational training. This can last seven to eight years and includes learning skills from ultrasound scanning to acupuncture. What skills do we really need to be a General Practitioner? How flexible is our training? How flexible would we want it to be? With regard to consultation length, most were envious to hear the Swedish have a minimum of 15 minutes per patient and up to one hour for mental health issues. Is an average of 11.7 minutes today enough to manage multiple co-morbidity, tick QoF boxes, find the hidden agenda, follow guidelines and document thoroughly? On the other hand Croatian and Slovenian GPs face up to 60 patients per day. There was passionate debate on abortion and euthanasia with a diversity of opinions based on personal and professional experiences. These made us think, and challenged our own points of view. We heard how the law strictly guards euthanasia, in reality therefore making it quite difficult to fulfil the criteria. It seemed that on average GPs, who were willing to take part in euthanasia, would be involved in around five cases during their professional life. There is currently also a strong push amongst Dutch GPs to improve the standard of palliative care available to patients. Our final day of the exchange was spent alongside 700 Dutch GP trainees at their GP trainee conference. English sessions were held in parallel with Dutch workshops and lectures. We were given a talk on palliative care by a consultant from the UK. We explored the ins and outs of non-verbal communication with a Dutch life coach. Professor Chris van Weel, President of WONCA, ran a workshop called The Grass is
Greener. Here we debated the role of the GP in 24-hour care, obesity and how much a GP can actually do in primary care. It was interesting to learn that Dutch GP trainees now have the opportunity to do a sixyear combined PhD and vocational training scheme. The fact that there is much less published research in the primary care setting than in the secondary care setting highlights the value of such training posts. Although there are still only 40 posts like these available in the Netherlands, already around 20 per cent of their recent international publications have come from trainees in these posts. They hope to expand to have projects with international collaboration. Our own Dr Iona Heath gave an inspiring lecture on the ‘Courage and Joy’ needed for being a GP. There were ten points for courage and five for joy! Dutch and international GPs reflected on thought-provoking excerpts from art and literature that we can apply to our daily lives in General Practice. The conference closing ceremony was spectacular and involved a lone drummer together with a laser light display in the auditorium. The Dutch then rounded off the day with an evening of over 300 guests where a tapas dinner was served followed by a live band. We felt inspired on our return by what we had learned from our European colleagues. The experience highlighted to us what we do well, and it also made us take note of where we have room to build on. It gave us an opportunity to forge international friendships both professional and personal. The Dutch GP trainee organisation and the support they receive to run educational activities were impressive. IF YOU ARE KEEN to get involved in international GP activities there are increasing opportunities to become involved ventures like this, which perhaps have eluded British trainees for too long. The Vasco da Gama Movement, part of WONCA, aims to develop links between aspiring and newly qualified trainees across Europe. It has the specific aims of improving training, research and opportunities for exchange. The RCGP International Committee is currently seeking members to form a UK committee of GP trainees and GPs within five years of qualification to form a working party for the Vasco da Gama Movement. There is also a programme called Hippokrates that facilitates exchanges between foreign GPs. In addition there is the annual WONCA Europe conference, that takes place in Switzerland this year, as well as the WONCA world conference in Mexico in 2010. In summary, the possibilities for international involvement of GPs are growing, and rightly so; the success of the Dutch exchange highlights the huge benefits to be gained from participation in such schemes. ■ For more information please contact: international@rcgp.org.uk The following websites also provide relevant information: WONCA: www.globalfamilydoctor.com Vasco da Gama Movement: www.vdgm.eu European WONCA Conference, September 2009: www.woncaeurope2009.org
RCGP News • March 2009
NEWS
Health Secretary praises the Croydon Federation Health Secretary Alan Johnson saw the benefits of a GP federation at first hand on a visit to South London
Supporting genetics in primary care
The Secretary of State met GPs and patients from the Croydon Federation, made up of 16 practices providing care for 140,000 patients and led by RCGP Fellow Agnelo Fernandes. The Federation recently won a prestigious Health Service Journal award for its work in bringing diagnostics into local surgeries, providing ultrasound, echo and direct access MRI. Mr Johnson was unable to attend the award ceremony so made sure that he visited the Federation in person instead. “What’s happening here is really inspirational. You read about this kind of thing in briefings, but coming out and seeing it for yourself makes you really appreciate it,” he said.
“Working in primary care can be a hard job so it’s important that we reflect and celebrate when we get things right. The HSJ Awards are the health service equivalent of the Oscars and I’m awarding this to the Croydon Federation for all you’ve done – not just the doctors but all the staff who work here. As Secretary of State, I’m very proud of you.” Other guests at the celebration included Andrew Pelling, MP for Central Croydon, who said: “This is an enterprising practice here – it underlines how dynamic and effective GPs are. In terms of improved services, this is testament to local GPs and PCTs implementing ambitious Government policies in a realistic way.” “As a politician and local resident, I am glad the PCT backed this federation. There has been far too much focus on estates and buildings rather than services – thankfully that is starting to change.”
How the NHS National Genetics Education and Development Centre can help you Professor Peter Farndon Director Candy Cooley Centre Manager Michelle Bishop Education Development Officer NHS National Genetics Education and Development Centre
With a reported one in ten patients seen in primary care having a disorder with a genetic component, GPs play a key role in identifying and supporting patients and families who may benefit from genetic services Encouraging the acquisition of appropriate genetics knowledge, skills and attitudes during training will not only enhance current clinical management, but will also prepare GPs for the advances that will come from an increased understanding of the genetic contribution to common diseases and responses to medication. To support this process, the NHS National Genetics Education and Development Centre works with health professionals, trainers and educators to integrate genetics into pre-registration education, post-registration training, professional development and workplace learning. So far we have worked with practitioners to identify where and how genetics impacts on their role and define what health professionals need to know about genetics for their clinical practice. By working with practitioners, GP trainers, programme directors and geneticists, core genetic topics for GPs were identified, prioritised and developed into a set of learning outcomes for GP trainees. These learning outcomes nowform a curriculum statement Genetics in Primary Care, part of the new RCGP curriculum. The Centre has written a series a series of articles to support this curriculum statement covering topics such as core genetic concepts, communication and ethical issues. These were published in the August 2008 issue of InnovAiT, the monthly education journal for GP trainees. We are now in the process of developing a ‘genetics in primary care’ module for the curriculum-based online e-learning resource for GP trainees. As well as the resources to support the GP curriculum, the Centre has developed a series of resources that can be used by a range of health professionals including established GPs who wish to update their genetics knowledge and skills. One example is Taking and Drawing a Family History – a series of eight factsheets RCGP News • March 2009
covering topics such as: why taking a family history is important; the accepted international symbols used when drawing a family pedigree; pedigree drawing exercises; and safeguarding genetic information. This series has been published and can be downloaded, like all our resources, free of charge from our website (www.geneticseducation.nhs.uk). The Centre is currently developing a number of scenarios that link in with the Taking and Drawing a Family History including pedigree drawing exercises. Videos showing different health professionals, including GPs, taking a family history in practice are also in development. In addition to the resources the Centre has developed to support genetics learning, the Centre has also established a Supporting Genetics Educators programme to assist university-based educators and NHS based trainers who teach genetics. The Centre has carried out workshops in collaboration with the West Midlands Deanery to provide GP trainers with tips and tools to support teaching the RCGP curriculum statement Genetics in Primary Care. These workshops are now being rolled out nationally by the Centre’s regional Genetics Education Facilitators who are linked to Regional Genetics Centres throughout the UK. For more information about what the facilitators can offer in your area visit our website (www.geneticseducation.nhs.uk) or email us at enquiries@geneticseducation.nhs.uk The Centre is also aware that health professionals will meet patients with genetic conditions with which they are not entirely familiar, and would value a source of authoritative information about the condition and its management. It is the aim of the Genetic Conditions Specialist Library to provide this ‘just in time’ information (www.library.nhs.uk/geneticconditions). The Centre is responsible for the library and is hoping to link the information about genetic conditions and their management with that about the availability of genetic testing, through the UK Genetic Testing Network (www.ukgtn. nhs.uk/gtn/Home). The Centre’s website (www.geneticseducation.nhs.uk) can provide educators with freely available teaching tools, learners with structured genetics learning resources and clinicians with links to sources of up-to-date information about genetic conditions and their management. The Centre’s website also contains a glossary which presents succinct information about core genetic concepts and the definitions of genetics terminology, and has proved popular with health professionals wanting ‘just in time’ information. In future newsletters we will provide up-todate information about the Centre’s activities, including new resources available on the website, which will be relevant both now and in the future for primary care.
Alan Johnson with Dr Hina Ansari and Dr Agnelo Fernandes of the Croydon Federation
Trainers in Health and Work: GPs and OH Physicians wanted The RCGP is looking to recruit 12 GPs with an interest in Health and Work issues, and 12 Occupational Health Physicians, to deliver a series of workshops to GPs throughout Great Britain. The aim of the workshops will be to drive up clinical management in the area of health and work. The GPs & OH Physicians would work in pairs, mostly in a region around their base, and be expected to deliver between four and eight half-day workshops per year, over a period of two years. Applications are particularly sought from GPs based outside London. For more information and to request a role specification, please contact Sam McNabb at: RCGP 4th Floor, 31 Southampton Row, London WC1B 5HJ Tel: 020 3170 8254 smcnabb@rcgp.org.uk Please note, the deadline for applying for these positions is 4 March 2009 Interviews will be held on 12 & 13 March and successful applicants will be expected to attend a one and a half day training course on 20th & 21 April. 5
CLINICAL UPDATE
Borderline personality Disorder DR DAVID MOORE General Practitioner on behalf of the NICE Borderline Personality Disorder guideline development group. Borderline personality disorder (BPD) is a well defined and increasingly recognised diagnosis and although recorded statistics report the prevalence at approximately one per cent of the UK adult population, one could argue many patients remain undiagnosed. The two real-life accounts above go in some way to highlight not only the potential distress associated with the diagnosis but also that the natural progression of the disorder tends to be favourable, with the majority of patients not having the criteria for diagnosis after five years. The term ‘borderline’ was first used in 1938 describing a cluster of commonly found symptoms that were neither truly ‘psychotic’ nor ‘neurotic’ in presentation but sat in the margins of both. It is important to remember however that BPD is a distinct diagnosis of its own and is in no way marginal or ‘borderline’. The social and psychological dysfunction present in people with BPD accounts for significant morbidity and an increased lifetime suicide risk. It is relevant as patients with BPD traditionally utilise healthcare resources frequently, often in distress and occupy a significant proportion of out-patient psychiatric time. For a long time, these patients have been unjustly and unfairly labelled as difficult and demanding, with the stigma of personality disorder still implying that in some way the patient is at fault for their own behaviour. Personality disorder may also be viewed with suspicion of not being a real mental health problem. Borderline Personality Disorder is a diagnosis often made by psychiatrists and mental health professionals. The features of the disorder can be varied and whilst presentations to healthcare services and other agencies are common, without a knowledge of the diagnostic criteria the condition may not be considered. As most presentations will initially be to primary care the GP with a good awareness of the features will be able to signpost patients to appropriate services early and avoid potential deterioration or crisis.
Diagnosis The diagnosis of BPD is formally made following a structured assessment interview in mental health services using the criteria set down by DSM-IV or ICD-10; the latter classifying the diagnosis as emotionally unstable personality disorder, borderline type. Whilst differences exist between the two classifications the diagnoses are usually treated synonymously, with the DSM-IV criteria used widely in research psychiatry and consequently in clinical practice. The features of the diagnosis under DSM-IV are listed in Table 1 below. The new NICE guideline for Borderline Personality Disorder aims to bring together the current research and expert opinion setting out specific recommendations for primary care clinicians as well as secondary and tertiary/specialist services. It focuses on the importance of respect for the patient and patient-focused
Table 1: DSM-IV criteria for borderline personality disorder (American Psychiatric Association, 1994) A pervasive pattern of instability of interpersonal relationships, self-image and effects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: ● Frantic efforts to avoid real or imagined
abandonment ● A pattern of unstable and intense interpersonal
relationships characterised by alternating between extremes of idealisation and devaluation ●
Identity disturbance: markedly and persistently unstable self-image or sense of self
● Impulsivity in at least two areas that are potentially
self-damaging (for example, spending, sex, substance abuse, reckless driving, binge eating). ● Recurrent suicidal behaviour, gestures, or threats,
or self-mutilating behaviour ● Affective instability due to a marked reactivity of
mood (for example, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) ● Chronic feelings of emptiness ● Inappropriate, intense anger or difficulty controlling
anger (for example, frequent displays of temper, constant anger, recurrent physical fights) ● Transient, stress-related paranoid ideation or severe
dissociative symptoms 6
New report on Mental Health in primary Care
Table 2: Crisis Management in Primary Care ● Assess the current level of risk ● Enquire about previous similar episodes and
successful management strategies used in the past ● Help to manage the person's anxiety by enhancing coping skills and helping them to focus upon the current problems ● Encourage the person to identify manageable changes that will enable them to deal with the current problems ● Offer a follow-up appointment at a time agreed with the person
care. Using the strong doctor-patient relationship common in primary care, patients should be encouraged to make choices and find solutions to their problems in a supportive and positive environment. It is important that GPs are aware of the delicate issues around the diagnosis and stigma attached, but also to maintain optimism as the majority of patients do get better. Specific guidance is given to consider the diagnosis in patients presenting with persistent self harm, persistent risk-taking behaviour or marked emotional instability. Whilst GPs may consider the diagnosis, NICE recommends that patients are referred to local community mental health services for assessment, formal diagnosis and management.
Management Patients with established diagnoses of BPD may also present to primary care in crisis. Crises are often unforeseen but many do occur during particular ‘risk events’ including transitions in relationships, therapies and services. It is important for clinicians not to minimise the reasons for crisis but to try and see the situation from the persons perspective. The guideline provides simple advice for GPs to follow during crises that the author has found helpful and effective. This is summarised in Table 2 above. Further guidance is given on the use of short-term courses of medication in the management of crisis. While medications may be appropriate, it is paramount that care is taken in the choice and duration of therapy. Medication should not be used when other interventions may be more appropriate. A review should be planned and medication stopped when no longer required or when ineffective, always bearing in mind the need to avoid polypharmacy, which is very common in this disorder. It is important to involve the patient in the rationale for prescription, the intended effects and the duration of treatment. It is important to be aware that there are currently no drugs with a licence for the treatment of BPD. It is clear however that BPD often exists with co-morbid mental health diagnoses such as anxiety or depression. In these situations treatment for the comorbid diagnosis may be appropriate but that the recommendation that pharmacological therapies are reviewed and discontinued when no longer indicated. The fluctuating nature of BPD means that patients may present with episodes of brief psychotic phenomena, anxiety and depression during the course of the disorder. It is not uncommon therefore that patients collate a repeat prescription containing an antidepressant, antipsychotic and anxiolytic medication. The practice of poly-pharmacy in these patients is often associated with a less favourable outcome. The guideline discusses the available psychotherapies and how they can be applied to individuals with BPD. There is evidence that psychological treatments may benefit patients with BPD, but only when given in a structured format. Therapies should be offered by trained and supervised professionals and should include more than one modality; for example, one to one and group therapy. It is clear brief interventions (<3 months) are not helpful for treatment of the disorder or its individual symptoms and may even be associated with harm. There is no available evidence that cognitive behavioural therapy (CBT) benefits patients with BPD. The development of available specialist services is core to the guideline. These should have a training and supervisory role to develop local services. The specialist services would be able to cater for patients with particularly severe symptoms or those at high risk. These services can also see patients with complex personality disorders or those where the diagnosis may be in doubt.
Summary The NICE guideline provides clear advice to UK healthcare professionals on the diagnosis and management of borderline personality disorder. The need to develop awareness and skills in the management of BPD is clear, with emphasis on de-stigmatisation. Practical advice is available for professionals, patients and carers. The guideline steers away from reliance on pharmacological treatments and instead recommends specific, well organised and supervised services which include support, crisis management and psychotherapy. Further research is needed to establish the role of medication for the treatment of the disorder and appraise specific psychological treatments. ■ The full guideline on Borderline Personality Disorder can be downloaded from the NICE website: ww.nice.org.uk/CG78
The management of patients with physical and psychological problems in primary care is the subject of a new report produced by the RCGP and the Royal College of Psychiatrists General Practitioners are ideally placed to provide a patient-centred approach in the management of patients with chronic physical illness and co-morbid psychological symptoms. It is vital, however, that GPs have the necessary skills and the availability of appropriate resources to refer people to. This report outlines, in a series of short chapters, the evidence-base and practical suggestions for the management of patients with physical and mental health symptoms. It focuses on the patient, the practitioner and the doctor-patient relationship within the consultation, which enables a focus on areas for training and audit. This layout also enables the busy practitioner to delve in and out of the report, rather than needing to read it as a whole. The report should influence future training of medical students and both GPs and psychiatrists, as well as the commissioning of services. The Primary Care Mental Health Forum supported the development and launch of this report and would like to see it widely distributed to undergraduate deans of medical schools, training committees of all Colleges and to commissioners of services, both mental health and long term conditions. It will be vital that Practice Based Commissioning takes account of the importance of managing patients with chronic physical health problems and psychological symptoms in a holistic, rather than reductionist way. ■ The management of patients with physical and psychological problems in primary care: a practical guide (CR152) is available from the RCGP website: www.rcgp.org.uk
NCC-pC set for merger The National Collaborating Centre for Primary Care (NCC-PC) is to be merged with three other NCCs to create a major new guideline centre The NCC-PC will cease to be hosted by the RCGP from 1 April 2009. The NCC – which has been hosted by the College on behalf of NICE for eight years – will merge with three other NCCs to become the largest guideline producing centre in Europe. The other three centres making up the new Centre are: the NCC Acute Care, currently hosted by the Royal College of Surgeons; the NCC Chronic Conditions, currently hosted by the Royal College of Physicians; and the NCC Nursing and Supportive Care, currently hosted by the RCN. The new centre is to be called The National Clinical Guidelines Centre – Acute and Chronic Conditions, and will be hosted by the Royal College of Physicians. The merger of the centres was planned following a review by the World Health Organisation of NICE guideline development. The NCC-PC has been responsible for producing successful guidelines since 2001, with a mix of skilled professionals supporting the process through the development and validation phases. These include information scientists, research fellows, health economists and project managers. The Clinical Director for the Centre, Dr Norma O’Flynn, will be moving to the new Centre along with the existing staff. Chief Executive Nancy Turnbull, who established the NCC-PC, will be retiring at the end of March 2009. Successful guideline topics produced by the NCC-PC include the original Type 2 Diabetes guidelines, Anxiety and Familial Breast Cancer topics led by the former unit in ScHARR in Sheffield headed by Professor Alan Hutchinson; the Referral for Suspected Cancer and Epilepsy topics developed by the Leicester Unit under the leadership of Professor Richard Baker, and a large selection of topics from the NCC centre in London – MI, Lipid Modification, Familial Hypercholesterolaemia, CFS/ME, Postnatal Care, Obesity and Medicines Adherence. A guideline on the management of Low Back Pain is to be published in May 2009, and a number of other topics will be transferring to the new National Collaborating Centre. For details of the full programme please see www.nice.org.uk/guidance The new larger centre will allow a GP perspective from early development of a larger number of guidelines. GPs will continue to be required to contribute to the guideline development process in terms of representation, commenting on draft guidance and involvement in implementation. The RCGP Clinical Innovation and Research Centre will continue its role in co-ordinating some of these activities. If you wish to register an interest in contributing to this work please fill in the online registration form at www.rcgp.org.uk/expert The College will also continue to engage with NICE through a number of other routes. As well as participating in the Board of the new NCC, the RCGP will continue links with the Implementation team at NICE, through representation on NHS Evidence, and through other developing programmes such as QOF. RCGP News • March 2009
NEWS
Suffolk gps claim vaccine victory With Jade Goody’s battle against cervical cancer dominating the tabloids in recent weeks, the rollout of the national vaccination programme for teenage girls could not be more timely.
We found the idea of sending a girl away to wait for two years when she needed the vaccine now, and the vaccine was available and licensed – purely because the money for her vaccine was in the wrong place at the wrong time – to be morally repugnant, ethically indefensible and a complete breach of our duty of care
But for GPs at Christmas Maltings Surgery in Haverhill, Suffolk, the initial programme did not go far enough. Here, Dr Mary Selby (right) – a partner at the practice, GP magazine columnist and newly-elected member of the RCGP Council – recounts her local campaign to widen the take-up. As you know, the Government started to vaccinate girls aged 12-13 this year but decided that girls aged 13-18 would have to wait their turn for vaccination, giving some a wait of up to three years. This was despite the fact that we know the vaccine works best if given early, before girls are sexually active, and the course of vaccine takes six months to compete. Suffolk GPs, like many others, were told by their PCT that if girls came to the surgery asking to be vaccinated early, they should be turned away. Myself and my colleagues – Drs Servant, Lindford, Andrews and Lewis – thought this was wrong, and started to vaccinate our own patients on demand. We argued that if GPs were willing to vaccinate girls, and girls were entitled to the vaccine on the NHS as the government had already decided, then it was wrong to make them wait. We had a number of exchanges with Suffolk PCT. It was all very polite, but first the prescribing advisor told me the vaccine was not licensed, then that we were not allowed to prescribe it on an FP10, and then he suggested we ask patients to pay for it. We challenged him on ethics, and on the regulations around charging patients for vaccines when they qualify for an FP10, and pointed out that the inverse care law was alive and well and living in Suffolk! We hoped that the PCT would challenge the decision on the funding process, believing that they would care about our patients as much as we did. This resulted in my request being passed to the PCT’s Consultant in Public Health. He informed me that he personally felt the vaccine was not cost effective; that a few extra deaths a
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year was a defensible price for the delayed catch-up; and that the GMC would be interested in my actions if I continued to go against the PCT on this matter. I was slightly astonished to be threatened personally with the GMC, but said that I would be delighted to defend my actions before the Council. We believed that the PCT were morally and ethically wrong not to fight for our patients. Determined to continue the battle, we wrote to all our teenaged girls inviting them to come in and talk to us about the vaccine. Those who wanted it were given it, and all were encouraged to come. We felt free to look after our own patients, but we also felt this was not sufficient: we were creating our own pocket of inequality. Across the country some GPs were refusing vaccine; some were sending girls to other practices under reciprocal agreements for private treatment; and many were paying for their own daughters to be vaccinated. This painted a picture of a vaccine being made available mainly to the middle/professional classes. This, we thought, was awful. Cervical cancer is a social disease, predominating in the socially disadvantaged who are least likely to seek vaccination. We found the idea of sending a girl away to wait for two years when she needed the vaccine now, and the vaccine was available and licensed – purely because the money for her vaccine was in the wrong place at the wrong time – to be morally repugnant, ethically indefensible and a complete breach of our duty of care. Our patients are not generally a group who can afford to pay – nor are they generally a group who will come and ask for HPV vaccine.
leave your mark with a legacy A new guide to legacies has been published by the RCGP The guide outlines the three main types of gifts that you can choose to leave to the College, alongside practical advice on tax, specimen legacy clauses, a pledge form and a helpful jargon buster. RCGP President Professor David Haslam said: “Legacies are vital to the future of the RCGP and any gift, no matter how large or small, will make a difference to our various educational and training programmes, helping us to improve the standard of general practice in over 40 countries across the world. “Please be assured, we never take your support for granted.” ■ Copies of the Legacy Pack can be downloaded from the website, by e-mail at legacies@rcgp.org.uk or by contacting Faryal Awan on 0207 344 3167. Please state if you would like a hard copy or electronic pack. RCGP News • March 2009
We knew that unless we contacted them in a proactive manner they would ‘miss the boat’. We asked our LMC to help us in our quest to make the catch-up programme available immediately. The LMC discussed the matter but were not prepared to challenge government policy. We also contacted the strategic health authority on the basis that this situation constituted a health inequality. They never responded other than to acknowledge my emails. We were by now also vaccinating temporary residents who were being refused the vaccine elsewhere. (We were not making any profit nor charging any fee. As a PMS practice we don’t earn extra money if we acquire extra temporary residents.) We then involved our MP, Richard Spring, who came to hear the argument, then facilitated an exchange of letters between myself and the Health Minister. Initially she suggested that it was the joint committee on vaccination who had decided upon the catch-up programme being delivered in schools – a bit of a sidestepping of responsibility, we thought. Besides, when we read the joint committee’s report it seemed that this had been a suggestion only, not backed up by any evidence on cost effectiveness or practicality – and with no ideas given on timescale. We challenged her response, point by point, much to the delight of our MP who, I think, felt he had found a nest of potential opposition activists in a sleepy rural town; and at the same
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time GP magazine ran an article on the HPV situation. The minister did not respond again. Instead we were delighted to hear that policy had been changed! GPs are now allowed to offer the catch-up vaccine and the vaccine costs will no longer be taken out of our drugs budget, as they had been. We are waiting to hear exactly how the government will do this, and are keen that they should give us guidance on what to say to patients requesting Gardasil, which we have not been using (not wishing to muddy the ethical argument) but which some patients perceive to be superior and which is also prescribable on the NHS. We feel that this story represents a victory for ethical practice and good medicine. It is good news for teenage girls, and fantastic for this surgery, because it shows that if right is on your side, and you make a strong case, you can actually change things. We took this to the top, despite threats from our PCT and a woeful lack of support from them and from other organisations with patient advocacy responsibility, and we are delighted to have made a difference to national policy. We felt passionately that our patients were worth fighting for. We went past our PCT, our LMC and our SHA to central government itself. We think we succeeded because, in the end, health ministers looked at our argument and had the grace and common sense to backtrack and do the right thing.
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RCGP Chairman Professor Steve Field writes: This shows how determined GPs and their practices can influence policy. We need more GPs to stand up and get more involved with their PCTs. Local leadership is the key to change and we’d like to see more people with the energy of Mary Selby and her colleagues. We are also keen to hear other stories of how our Members and Fellows across the country have made a difference. E-mail us at rcgpnews@rcgp.org.uk
POSTBOX From Doctor to Master I thought this might be of interest to fellow members. At the age of 81, having retired from family practice, I decided to test my remaining Bedz cells by embarking on a two-year course at the University of Stellenbsoch (near Cape Town) leading to Master of Philosophy in Ancient Cultures. Much to my surprise I graduated Cum Laude!! This photo was taken after the graduation ceremony with the Vice-Chancellor of the University. Note that I am wearing the gown of a Fellow of the College. Norman Levy FRCGP MB ChB and now MPhil!
For it’s a jolly good Fellowship scheme As a recent (successful) applicant for Fellowship of the RCGP, I found the process very straightforward. The documentation describing what was required was very explicit and the Fellowship Unit at the College was very helpful in addressing the few queries I had. As to why I applied, I received a well-worded letter from the South London Faculty of the RCGP which said that they were familiar with my work and suggested coming to a meeting at the College to find out more about the new route to Fellowship. At the meeting it occurred to me that that my contributions to general practice and to the College over many years were at least comparable with those of other people who were applying. When asking people for references, several people remarked how surprised they were that I was not already a Fellow! All in all I think the new scheme is excellent, very fair and transparent. It is much better then the previous arrangement. Mar y Pierce London SE3
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NEWS
Four ways to make more headway with headache Dr David Kernick RCGP Clinical Champion for Headache
Celebrating success: (l-r) guest speaker David Pendleton, award winner Dr Joanne Walsh, event organiser Monika Lauder and RCGP chairman Professor Steve Field
report on gp burnout tips the scales at Dublin Meeting The achievements of GPs in the Republic of Ireland were celebrated at the annual Winter Meeting held in Dublin Leadership guru Dr David Pendleton and RCGP Chairman Professor Steve Field joined Provost and Republic of Ireland Faculty Chairman Dr Joe Martin (pictured right) and 50 GPs for the event which culminated in the presentation of two prestigious awards. The biennial Manne Berber Award goes to the best completed audit or research project and has a value of £1,000. The 2008 prize was awarded to Dr Joanne Walsh for her work on GP burnout, Are the Scales Balanced? Dr Walsh, a trainee GP from Sligo, assessed the work/life balance of 128 GPs – with worrying results. From an overall response rate of 70 per cent, 31 per cent reported working 60+ hours a week and 24 per cent did not take all their entitled annual/study leave. In their personal lives, 47 per cent said they did not have enough time with their family or friends; and 21 per cent reported not getting adequate sleep. In her conclusion, Dr Walsh called for greater awareness raising in addition to improved support and resources to ensure “a contented, balanced and burnout-free primary care workforce for the future”.
Sign up to climate pledge The Climate and Health Council is asking GPs to support its pledge to tackle global warming and help prevent a public health catastrophe. The Council is an advocacy group set up to co-ordinate the voice of UK healthcare organisations on climate change and is supported by the Faculty of Public Health. It aims to have 10,000 health professionals signed up to its pledge by the end of this month in order to influence the UN world conference on climate change in Copenhagen a year from now. Website: www.climateandhealth.org
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
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
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In the UK, headache impacts upon the lives of 20 per cent of adults, and four per cent of the population have headache on more than 15 days each month. The World Health Organisation ranks migraine in the top 20 of diseases in terms of disability and, if all other types of headache are considered, headache would be in the top ten. Despite this burden, evidence suggests that the needs of headache sufferers are poorly met. The majority use non-prescription medication and are reluctant to seek help. When they do seek help, a diagnostic threshold is only reached in 70 per cent of patients and in the remaining 30 per cent, the diagnosis is often incorrect. Migraine has been studied most extensively, affecting 15 per cent of adult females and eight per cent of adult males, usually at the age of maximum economic activity. Migraine is also common in children, however. The age of maximum incidence is 15 years and 10.6 per cent of children have migraine. Three per cent of children will have a very significant problem with headache, affecting them one day in four and losing 12 days of school each year as a result. As children are often unable to articulate their problem and seek appropriate help, the needs of this population are arguably even greater. Cluster headache is possibly the most painful medical condition known. Although it affects only 0.1 per cent of the population, it can take many years for the sufferer to achieve a diagnosis and even then, treatment is invariably suboptimal. Despite the impact of headache and the availability of simple evidence-based approaches to treatment, its management in primary care is less than ideal. The aim of the RCGP programme is to work with other professional and patient headache organisations to reduce the burden of this problem and improve its management. Four areas have been identified:
q Evidence shows that GPs educated about
w Runners up were Dr Patrick Breen and Dr Anne Marie Kavanagh. Dr Jonathan O’ Keefe was also awarded the Slaney Prize, presented annually to the Republic of Ireland candidate with the highest mark in the RCGP exam.
rCgp Chairman joins revalidation Board Professor Steve Field has been chosen to sit on the Revalidation Programme Board that will oversee the delivery of medical revalidation across the UK. The 13-strong board is drawn from across the healthcare sector and will give strategic leadership of the roll out of revalidation across the UK. Early tasks will be to agree a robust programme of project management and reporting arrangements for revalidation and to ensure an effective communications strategy so that the profession, the public and other key interest groups are able to engage with its work. Chaired by Sir Michael Pitt, it will meet approximately every two months and is accountable to the GMC’s governing body. Its work will be transparent, with agendas, minutes and papers made available on the GMC website: www.gmc-uk.org/about/reform/ revalidation_board/index.asp Professor Field said: “Revalidation is the big challenge for GPs and the whole of the medical profession and I intend to make sure that general practitioners, the RCGP and the other medical Royal Colleges have a very powerful voice at the decision-making table.”
headache can improve diagnosis and management. A number of educational initiatives will be introduced directed at GPs, trainees and medical students. The occupational health setting will be targeted. Migraine costs over £1billion a year in terms of lost work and reduced capacity at work. There is considerable potential for identification and signposting of relevant management in this setting.
Kernick: Headache sufferers’ needs are poorly met
e There will be an ongoing research agenda.
r
Current work is focusing on the recognition and management of headache in children, particularly in school and community settings. Evidence-based management guidelines will be developed. Guidance for GPs on who to image when tumour is suspected has recently been published (Kernick D, Ahmed F, Bahra A, et al. Imaging patients with suspected brain tumour: Guidance for primary care. British Journal of General Practice 2008;58[557]:880-5) and guidelines are nearing completion to support GPs on which children to refer with headache and the management of headache in sport respectively. The College will attempt to raise the profile of headache together with other key stakeholders through organisational and political lobbying. An All-Party Parliamentary Group on Primary Headache Disorders is already in existence.
■ If members would like to be involved in any way or have any further comments, please contact David Kernick su1838@eclipse.co.uk Dr David Kernick is the lead research GP in a research and development practice in Exeter, where he has worked for the past 25 years
Dr Agnes (Nan) Kennie MBe MD FrCp(glas) FrCgp Dr Agnes Kennie has died in her 100th year after a lifetime dedicated to the medical profession Born in Glasgow in 1909, Dr Kennie started her career as a physician and by 1937 was working at Glasgow Royal Infirmary and a Member of the Royal College of Physicians. Speaking to RCGP News in July last year, Dr Kennie described her duties as “attending daily ward rounds, teaching students, taking two outpatient clinics each week and doing research – all totally unpaid – it was considered an honour to have the post.” As a means of survival she set up a general practice in her parents’ home, and was eventually forced to choose between surgery and general practice when the NHS was established in 1948. “My whole outlook on my career had been changed. After much thought I realised that my heart was in general practice. I bought, in 1948, a practice in Devon.” Dr Kennie was a founding member of the RCGP in 1953 and became a Fellow in 1959. She was also heavily involved in the BMA, of which she was appointed Fellow in 1960. In 1964 she retired from general practice to be closer to her sister in Scotland but remained active in the medical profession. She was involved in establishing (and later upgrading) a Day Centre for the elderly in Paignton, and in setting up a new branch of the Parkinson’s Disease Society in Torbay. In recognition of her service, Dr Kennie was awarded the MBE in 1989 and the following year was made a Fellow of the Royal College of Physicians (Glasgow). Aside from medicine, Dr Kennie was passionate about gardening, needlework and walking on Dartmoor. She was a much loved aunt, great aunt and great-great aunt.
RCGP News • March 2009