http://www.rcgp.org.uk/pdf/RCGP_News%20Issue_Oct08 by Royal College of General Practitioners

News

The Equalisers: GPs take the lead in delivering quality healthcare for all A major new guide to help GPs reduce health inequalities has been published by the RCGP Addressing Health Inequalities demonstrates how GPs can positively influence health inequalities in their local populations as practitioners, commissioners and community leaders – as well as offering practical examples of how doctors can address the issue of health inequalities in their daily working lives. It encourages GPs to recognise that inequality issues can arise in every area due to a wide range of determining factors and presents integrated care and partnership working as the key to tackling the issue. It will be sent to all practices and Primary Care Organisations in England and Wales but should be a helpful reference point for all GPs in ensuring that patients receive the standards and services of healthcare they deserve, regardless of their personal circumstances or where they live in the UK. Produced by the College’s Health Inequalities Standing Group (HISG), the document is the culmination of a workshop hosted by the RCGP in April last for primary care practitioners, central Government, Primary Care Trusts, academics and other parties interested in the health inequalities agenda. It is divided into six sections:

● GPs and individuals ● GPs and the primary care team ● GPs and Practice-Based Commissioning ● Influencing the National Agenda ● Partnership Working ● Engaging with the Primary Care Trust As well as national guidance, the HISG was keen to back up their arguments with evidence so the book contains several case studies of good practice and links to a wide range of other useful resources. The publication has been co-edited by Nat Wright, immediate past Chair of the HISG, and Dr Ayesha Ali from the Department of Health in England,

which funded the project in line with the Government’s high prioritisation of the Health Inequalities agenda.* RCGP Chairman Professor Steve Field said: “When Dr Julian Tudor Hart formulated the inverse care law in 1971, I’m sure he didn’t expect that nearly 40 years later there would still be patients in the UK who miss out on health services due to their postcode or circumstances. “Everyone has the right to quality health services and, as GPs, we have unrivalled access to the heart of communities and an important role to play in reducing health inequalities for our patients. “I’m delighted that the RCGP has published such a user-friendly publication which will hopefully help all GPs achieve this for our patients.

GPs we have unrivalled access to the heart of ❛ Ascommunities and an important role to play in reducing health inequalities for our patients. I’m delighted the RCGP has published such a user-friendly publication which will hopefully help all GPs achieve this for our patients Professor Steve Field

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THE NEWSPAPER OF THE ROYAL COLLEGE OF GENERAL PRACTITIONERS

OCTOBER 2008

Inside... ESSENTIAL GENERAL PRACTICE What you think

YOUR RCGP Get involved with the Nominations Committee

INTERVIEW Health Minister Ben Bradshaw answers to the RCGP

NEWS New frameworks for Special Interests I would like to thank Dr Nat Wright and his team for their work in bringing all this information together ‘under one roof’ and for making it a riveting read as well as an informative one.”

INTERNATIONAL

■ Addressing Health Inequalities: A guide for general practitioners is available from the RCGP website www.rcgp.org.uk

CLINICAL UPDATE

*In June 2008, the Department of Health published Health Inequalities: Progress and Next Steps, outlining its approach to achieving the 2010 Health Inequalities Public Service Agreement targets and assessing what has and has not been successful.

Views from WONCA

Salmeterol in asthma Glucose lowering

SPOTLIGHT ON... Informatics

4 4

5 6 6

IAPT: What does it mean for GPs and Primary Care staff? Dr Alan Cohen National Primary Care Advisor IAPT programme Improving Access to Psychological Therapies is a Department of Health project aimed at doing just that – for all patients who might benefit. It is a commissioner led, outcome focussed programme that will ensure ‘stepped care’ – as recommended in the NICE guidelines – is implemented in your area, with patients being given the choice of psychological therapy in addition to ‘care as usual’. ‘Psychological therapy’ describes those interventions recommended by NICE, which include, but are not limited to, Cognitive Behaviour Therapy (CBT). Psychological therapies have been shown to be an effective intervention

for people with common mental health problems – depression and anxiety disorders, including PTSD and OCD. These therapies will be delivered by either a low intensity worker, or a high intensity worker.

High Intensity Workers

Low Intensity Workers

● High intensity workers spend between 12 and 20 sessions with people.

● This will be provided initially using the stepped care principle of initially offering the least burdensome treatment – ‘low intensity’ Cognitive Behaviour Therapy – supervised by an appropriate worker ● This may be face to face or over the telephone (working over the phone is an established, safe method) ● It usually does not exceed five sessions

● This will be delivered by workers trained in CBT techniques, and supervised by experienced therapists

Long Term Conditions and Medically Unexplained Symptoms CBT has been shown to improve outcomes in long-term physical conditions, such as CHD, diabetes and COPD (start by referring those who screen positively for depression in these groups – using the ‘two questions’ as in QOF). Treating those dia-

‘Happiness Economist’ Lord Layard (centre) joined RCGP Chairman Steve Field and representatives from leading mental health organisations for the signing of a consensus statement on improved access to psychological therapies for patients. The statement – supported by eight organisations – was accepted by DH Lead on Mental Health Kathr yn Tyson on behalf of Health Secretar y Alan Johnson. betics with depression can result in the population in your practice with wellcontrolled diabetes increasing by 40%. Every pound spent on CBT for

those with COPD can potentially produce a benefit of £3.00 in admission prevention for exacerbations of COP. Continued overleaf ➧

NEWS

Early success for Essential General Practice Update programme Professor Ruth Chambers Clinical lead EGP Update Programme Jacqui Smith RCGP Information Scientist EGP Update 1 was launched as a pilot in May 2008. Over 600 GPs registered to take part in the pilot having seen a flyer or read the articles in RCGP publications such as Seven Days and RCGP News. (The participants are listed in the table on the right.)

What the EGP Update programme is about EGP Update 1 gives the option for GPs to complete one or all of 20 items relating to new/ changing information relevant to a GP’s practice and substantiated by national authorities – prioritised from the 500-plus items of information identified in the searches conducted by the RCGP Information Scientist. The programme presents new and changing information to encourage GPs to apply the learning in practice; and compare their own performance against recommended best practice. GPs will be guided as to how they can rate the impact and challenge of the CPD element of future EGP Updates – for review at their appraisal as part of their future recertification.

Initial feedback Feedback from GPs who have participated in the first pilot shows how enthusiastic most GPs are about having this EGP Update programme to help them to keep up to date (see box). The varied sections (key points, practical tips, practical application in everyday practice, e.g. audit, clinical scenarios, further reading etc) seem to appeal to most GP users – there being something for every GP – catering for individual GP’s different preferences for type of learning.

What do GPs like particularly about the EGP Update programme? What GPs appreciate about the EGP Update programme according to the feedback seems to be: ● The varied format of the EGP Update programme – key points summarising theory, exercises to guide application in practice, opportunities for selfassessment etc – to match a range of learning styles. So respondents tend

Type of GP employment/partnership* of GP participants in the pilot (n=634) Partner

401

Salaried/sessional

125

Locum/freelance/portfolio

Retainer

GP in training

Retired

Occupational medicine only

Armed Forces

( where a GP gave salaried/locum this was counted as ‘salaried GP’)

to praise or criticise the formats of different sections of the EGP Update items accordingly. ● Being able to print off results of selfassessment. ● The range of fields covered by the EGP Update items was valued – reflecting the generalist nature of a GP’s work; and forcing a focus on areas of practice that the GP seldom (but sometimes) met or was less certain of. ● The focused articles summarising key information, aiding a busy GP in keeping up to date with options for further reading if they want more depth or to read more widely about the context of the particular guidance or clinical topic.

Is it too easy? Some GPs reportedly found the EGP Update 1 pilot too easy. Reading their responses made us realise that their different learning needs suggest varied levels of knowledge and skills/competence amongst GPs. Thus individual GPs vary in their satisfaction with the level of complexity, depth of information given, brevity/magnitude of items etc in the EGP Update items. The Applied Knowledge Test (AKT) team led by Dr Carol Blow are developing a knowledge challenge that focuses on the content of EGP Update 1 – as a parallel development to the EGP Update programme. This will be available as a pilot in Autumn 2008. The linked ‘knowledge challenge’ may fulfil the desire of some GP respondents for more in-depth challenge.

What does IAPT mean for GPs and Primary Care staff? ➧ Continued from page 1 CBT is also effective in depression, panic disorder, generalised anxiety disorder, obsessive compulsive disorder, post traumatic stress disorder and phobias It can also help those with ‘medically unexplained symptoms’, which account for up to 50% of acute OPD referrals. Consultation rates decrease and there is evidence that the effects of treatment are more enduring than after termination of medication, and that relapse from depression is less likely.

Outcome Focussed Routine assessment is an integral part of the programme, so patients who fail to improve will be ‘stepped up’ to more intensive treatment A minimum data set has been described which is an integral part of the IAPT programme. Data is collected by the service provider, in a consistent fashion by all providers, so that outcomes for both an individual and the service can be compared, and used to commission effective services.

Commissioning These services can be delivered through Practice Based Commissioning In a stepped care system such as the one being delivered by the IAPT Doncaster Demon-

stration Site which covers a total population of approximately 300,000 (accepting referrals for anyone older than ‘CAMHS age’) you should expect the system to manage 300 referrals a month. Of these, between 750-850 people at any one time will be receiving low intensity treatment and 45 to 65 people will have been stepped up to high intensity treatment, principally formal CBT. This level of activity is achieved within six months of the stepped care operating start date for low-intensity treatments and within a year for high intensity CBT. IAPT will be commissioned as a team that incorporates the required supervision and training, although provision may be ‘closer to home’ in rooms in primary care or via a ‘call centre’. The location of the service, and the service provider, is for local determination, depending on local circumstances. It must, however, have the elements of the IAPT programme: ● A stepped care approach to service delivery ● Outcomes are measured using at least the minimum data set The need for ‘conventional’ CMHTs will remain and provision of this stepped care system will help you manage many patients that previous service structures may have expected primary care to manage alone with medication.

Typical comments from those GPs submitting feedback about their experience with the pilot of EGP Update 1 ● Long overdue, well done! ● All very straightforward to use and ‘pithy’. ● Very informative and easy access for updating latest changes. ● Very good quick learning resource. ● Concise, up to date and quick to do. ● I enjoyed doing the programme. Well constructed and laid out. Easy to use. ● Left looking for more. Useful summaries but not as interactive/ informative as some other learning modules. ● Wide range of topics. ● A good way of updating quickly and efficiently without being swamped in detail. ● Tutorials based round the curriculum seem a very attractive idea; excellent links for tutorials and teaching as well as my own learning. ● Different to expected. This format encourages learner directed learning. ● Finding the time to take learning further will be a challenge to undertake in so many areas.

How relevant is the EGP Update programme for all GPs? There seems to be an appropriate mix of GPs who have undertaken the pilot programme as regards those who live and work in England, Scotland, Northern Ireland and Wales; the proportion who are principals or partners; salaried GPs; locum GPs and others such as retainers or trainees, or who work outside the UK. About half of those registering for the pilot have an educational post and/or are a GP appraiser. In general most of the content of the EGP Update programme seemed to succeed in being relevant to all GPs, whatever their work setting, or employment status or country of residence in the UK. There was an occasional remark by a GP locum that the ‘compare your practice’ section of one or two of the 20 EGP Update items was not applicable to them as a locum doctor. And a few respondents from Scotland highlighted the item on the Mental Health Act in England & Wales as not being relevant to them

● Overall very good. Brief and to the point. I like the practical tips for busy GPs. ● This is a useful programme to check knowledge, for revision and to learn new facts. ● Format a bit ‘clunky’. Some topics not that relevant though interesting. Self-assessment questions too brief and straightforward. ● Excellent – topical, enough info but not overwhelming. Really liked suggestions for application to own practice. Particularly useful for portfolio/GP locums where can be hard to find audit and other activity. ● Good way of helping me assess how much I have remembered of the latest guidelines. ● Found it helpful to do self-assessments and then look at the guidance. ● Useful summaries which I have put on a shared folder on the practice computer for whole team to share. Useful for GPR tutorials. ● It is a good initiative but I would have liked it to be more interactive and case based. (though we had signposted current legislation in Scotland and Northern Ireland and did not go into further detail as there was no new legislation in either of these countries).

Where next? The EGP Update 2 pilot will be released in October 2008 and be freely available to all GPs, whether or not they are members of the College. It has a different design with seven major items in a similar format to the 20 items of EGP Update 1 and 20 ‘minor’ items as brief paragraphs focused on substantiated new and changing information and guidelines. ■ The EGP Update 1 pilot programme is available at: www.rcgp.org.uk/ Practising_as_a_GP/distance_learning/ egp_update.aspx If you’ve not looked at it yet, do have a go and let us know what you think.

Energy, insight, skills and enthusiasm Dr Philip Evans Chair, RCGP Nominations Committee Over the last two years the College has reviewed its structure and governance and a number of important changes are being implemented. One of the first of these has been the establishment of a Nominations Committee. This has been appointed by Council with a mixed membership drawn from council members, the wider membership and a representative of the Patient Partnership Group. Essentially, the role of the Nominations Committee is to review internal College appointments and key elected positions, search for and identify candidates and produce a list of appropriate individuals for election. For each position clear procedures for appointment are established with both role and person specifications. At times, over many years, concerns have been Dr Philip Evans: expressed that the College tends to be run by a small Your College needs your involvement group of insiders. One of the aims of the Nominations committee is to dispel any such concerns. The College is the largest of the medical Royal Colleges and to be effective needs to make use of the energy, insight, skills and enthusiasm of its members at all stages of their careers. In practice the College is surprisingly open to new blood whether this is at district, faculty or national level. There is a wide range of activities in which the College needs to encourage and develop the interests and involvement of its members. These range across the fields of Education, Research, Assessment, Publishing, International activities, Writing, and the Academic/Political interface. The Nominations Committee wants all members to be aware of the opportunities that are available to contribute to the work of the College. It will regularly advertise all vacant and forthcoming positions, on the College website, in the Journal, through the Faculty and national newsletters. Full information about the nature of the different positions will be detailed and described with democratic and transparent appointment processes. If you have particular interests or skills and wish to be involved, feel free to apply for vacancies; or if at some stage in the future you think you might be interested in contributing, please let us know your particular area of interest. RCGP News • October 2008

INTERVIEW Health Minister Ben Bradshaw addresses the concerns of RCGP Members on targets, tensions and trust…

always had ❛theI have utmost respect for GPs – they are the foundation of the NHS... I strive to encourage new outlooks, new effective ways of working and an environment which puts GPs at the heart of developing local health care

Some doctors feel that the 18 Weeks target is rather arbitrary. How was it decided on and is it not just a reaction to the 18 month waiting lists faced by patients under the Tories? The 18 Weeks target – that no patient should have to wait longer than 18 weeks from referral to start their treatment, unless they choose to wait longer or it is in their clinical interests that they do – was agreed following consultation and by looking at international comparisons. When it was set (in 2004) it represented a radical change to the previous approach to reducing waiting because, for the first time, it set a maximum wait from referral to treatment. All previous targets had been for individual stages of a patient’s journey. In that sense, it was a completely fresh approach, not a response to the position inherited. Eighteen weeks is a maximum, and many patients, especially those with more clinically urgent conditions, are treated much more quickly than this.

GPs are concerned that 18 Weeks targets will lead to ‘gaming’ to make it appear that the target has been met. If patients decline one date, will they be bounced off the list and will GPs then have to spend even more time getting patients back onto the list with the result that the waiting time is actually much longer? No, there is no reason why patients should be ‘bounced off lists’ in this way. Where a patient is on an inpatient or day case waiting list they can agree the date for their admission from amongst those offered by the hospital. If the patient doesn’t want to accept an early date for personal reasons, then the hospital can ‘pause’ the waiting time clock until the patient makes themselves available for admission. This effectively removes any incentive for patients to be discharged back to their GP to ‘game’ the system. There are circumstances where patients do not attend outpatient appointments and fail to communicate with the hospital. We know that missed appointments are a real drain on services, and for that reason all trusts have been encouraged to agree policies with their local PCTs on how best to handle these circumstances and reduce ‘DNAs’ in trust and interface services where many GPwSI provide services. The national guidelines that we have published on this subject are based on the principle that policies must safeguard vulnerable patients, and must strike a reasonable balance between the rights and responsibilities of patients. Some patients will be discharged back to their GP.

How will you guarantee treatment as opposed to assessment? Can we assure patients that they will be receiving care from a consultant within 18 weeks rather than being seen by a member of the healthcare team and then given a further referral? You can assure patients that if they need treatment they will start that treatment in a

Question time maximum of 18 weeks, unless they choose to wait longer or it is in their clinical interests that they do. Clearly, in order to decide about treatment many patients will need to be assessed and have diagnostic tests. If, to start that treatment, a patient needs to have tests, this falls within the 18 week period and the 18 week clock stops only on treatment and not at assessment. As part of good practice, many teams are now multi-professional so patients may well receive treatment by other members of the consultant team. Referrers will have made their own initial assessment as part of the process to decide whether to refer or not. Good practice is to provide GPs with direct access to many diagnostic tests to support their own management of patients.

Shouldn’t we have learnt by now that targets distort everything? The 18 Weeks target is supported by the overwhelming majority of NHS staff as they believe that it improves the care that they can provide for their patients. This is true for both clinical and non-clinical staff alike. At the Department of Health the 18 Weeks programme has worked very closely with the Royal Colleges and the NHS to ensure that clinical care and the service that patients experience is improved by delivering the target. Deliberately, the way that the target has been defined provides for a tolerance to allow for clinical and patient driven exceptions. 18 Weeks was first mentioned in the NHS Improvement Plan (2004) and the NHS has been working towards this since then. The fact that the NHS has had four years to plan and bring waits down has enabled a measured approach to the changes needed.

❛ 18 Weeks sets a maximum wait from referral to treatment... and many patients, especially those with more clinically urgent conditions, are treated much more quickly than this

RCGP News • October 2008

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These factors together mean that the potential for distortion has been minimised. The NHS is also moving forward since the introduction of 18 Weeks and with the Next Stage Review, Ara Darzi has rightly suggested that introducing new targets is not necessarily the most effective way of delivering change.

Why does the DH think that quick treatment is always better? There are lots of decisions where there might be an advantage to taking your time. The way that the target is framed recognises that it can be in a patient’s best interests to wait longer than 18 weeks for treatment to start. If a clinician recommends a period of waiting for a patient (so-called ‘active monitoring’) this can stop a patient’s 18 week clock – with a new 18 week pathway starting when the period of active monitoring ends. These are decisions in the hands of clinicians, which is where they should be. However, we make no apology for bearing down on unnecessary delays for patients. Waits measured in years not weeks were not uncommon. This was unacceptable treatment and apart from often being a symptom of inefficient processes, meant patients waited in sometimes a distressed, painful, immobile state. 18 Weeks has been the opportunity for many services to review how they deliver care, review process inefficiencies and put in place new ways of working which many clinicians have been struggling to do for some time.

Much of the delay in achieving the 18 Weeks target is GP access to diagnostics. How do you plan to address this? It is true there have historically been major delays for patients waiting for diagnostic tests. 18 Weeks has allowed the NHS to focus attention on this area and has achieved major leaps in clearing large backlogs of diagnostics, including in audiology and the fitting of hearing aids. The vast majority of patients now receive their test within six weeks and average waits are lower still – under two weeks. Looking to the future, we know that good

access to diagnostics for GPs with fast turnaround of results, can cut out unnecessary steps in the patient journey or can even prevent the need for a referral to hospital. We will continue to disseminate evidence of this kind of good practice, and support its adoption. However, the vital key to developing good direct access services lies with Primary Care Trusts and practice based commissioners working with providers.

How can Government manage the tension between professing locally responsive services and the habit to micromanage everything from the centre? Government is committed to ensuring that local health communities have the resources and support to develop and deliver high quality health care. While there was previously a need to implement reform alongside unparalleled investment in the NHS this had to be co-ordinated nationally to ensure large scale change. While there is still more to do the management of change has shifted and whole professional disciplines are now embracing future change and champion this. There is no longer a need to do this centrally. The World Class Commissioning (WCC) agenda is also proving grounded support for local heath communities to ensure improved elective care. Supporting the concept of practice based commissioning WCC empowers GPs to effectively commission patient pathways.

Your outspoken comments about GPs haven’t made you very popular with the profession. Has your work on the NHS review given you a better insight into our role and have you changed your views? I have always had the utmost respect for GPs – they are the foundation of the NHS and the relationship between the GP and the patient is the backbone to delivering comprehensive, modern community based healthcare. It is because of that relationship that I strive to encourage new outlooks, new effective ways of working and an environment which puts GPs at the heart of developing local health care.

NEWS

CLINICAL REVIEW

A new era for practitioners with a special interest From April 2009 General Practitioners with a Special Interest (GPwSI) in a clinical area will have to be accredited in line with new competency frameworks, launched by the Department of Health, the RCGP and the Royal Pharmaceutical Society. The skills and competences GPs are required to demonstrate in order to fulfil the GPwSI role vary according to individual specialty and the nature of the locally commissioned service – but they will have to be met in order for GPs to continue to practise as a GPwSI. Practitioners need to be assessed by either their PCO or Special Health Authority. The new and updated frameworks are renamed ‘Practitioner with the Special Interest’ (PwSI) to reflect those new frameworks which are now applicable to Pharmacists (PhwSI), who are also developing roles in this area. The 2008 Frameworks are in response to the reorganisation of services in line with ‘Care Closer to Home’, and to formalise and develop existing arrangements. The frameworks have been developed and badged jointly across the RCGP, the Department of Health and the Royal College of Pharmacists. The development has been led by a clinical lead (either GP or Pharmacist, as appropriate) and they have been through a rigorous and transparent development process. The new frameworks are listed in the panel on the right.

Development of the Frameworks Development of each GPwSI framework was led by its own GP Clinical lead and group of stakeholders relevant to the specialty. Stakeholders included patient and professional organisations with pharmacists and commissioners. Other stakeholders were sought as necessary, and a total of 200 stakeholders were involved. Each draft framework underwent a stakeholder consultation, followed by further amendments. The framework clinical content was signed off for the RCGP by the Chair of the Clinical Innovation and Research Centre and the education and accreditation aspects by the Professional Development Board.

Summary of development process The ten month process of developing the frameworks involved: ● Initial literature search ● First draft developed by Clinical Lead ● First stage consultation – face to face, teleconference, virtual ● Second draft ● Second stage virtual consultation ● Third draft ● Signed off by the: ● RCGP Professional Development Board ● CIRC Chair ● Royal Pharmaceutical Society of Great Britain

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

GPs and GP Registrars Pharmacists Consultants Nurses RCGP Patient Partnership Group Specialists such as: Geriatricians, Psychiatrists, Paediatricians, Endoscopists, GPwSI networks Genetic Counsellors etc Other Royal Colleges: Paediatricians, Psychiatrists, Physicians, Community Matrons Community Liaison Pharmacist GP Educators Primary Care Trusts 16 Primary Care Societies Policy advisors Commissioners GP advisors DH Public Health Unit Clinical Programme co-ordinators Private Providers, e.g. Out of Hours Medical Directors

Palliative care Sexual Health

Cardiology Drug misuse Epilepsy Learning Disability Older People Respiratory Pain Management Diabetes Urgent and Emergency Care Headache Mental Health

GPwSIs only:

Charities/Health Organisations also involved include: ● ●

The Consultation process was led by 16 Clinical Leads who involved:

Specialist frameworks for GPwSIs and PhwSIs:

● ● ● ● ● ● ● ● ● ● ● ●

Diabetes UK MedFASH Macmillan Cancer Support BUPA Foundation The Sainsbury Centre for Mental Health Epilepsy Action Asthma UK National Treatment Agency Faculty of Sexual and Reproductive Health British Association for Sexual Health and HIV (BASHH) Terrence Higgins Trust London Ambulance Service Association of British Clinical Diabetologists British Association for Community Child Health (BACCH)

Pharmacists only: Anticoagulation therapy Skin disease (to follow later in 2008)

WHY FRAMEWORKS ARE IMPORTANT Collaborative working has produced 16 individual frameworks that:

Inform… All practitioners need to know the extended knowledge and skills they will require to provide services as a PwSI

Assist... Commissioners need to identify the specific competences (Chapter 3) required by their practitioners in order to meet the specifications of their local services

Remind... Commissioners and practitioners need to be aware of the necessary support and infrastructure required for different PwSI services

Advise... Everyone should be aware of the best methods of acquiring and maintaining the competences required or the delivery of different PwSI services

A PwSI is a GP or Pharmacist who: ✔ Is first and foremost a generalist ✔ Is able to act without direct super vision ✔ Has a level of skill or competence that exceeds the core competences of the individual’s normal professional role ✔ Is accredited to deliver specialist clinical ser vices directly to patients

Left: Welcome to WONCA

The world organisation of family doctors European conference 2008 was held in Istanbul from September 1-4 on the theme of Overcoming the Distance. In three accounts, RCGP members and trainees relate their experiences with surprisingly similar results... Dr Mbang Ana MRCGP The 2008 conference can be summed up in two words ‘thoroughly enjoyable’. Over the three days of conference I attended several insightful and original lectures and workshops. It was a truly international affair and I met doctors from all corners of Europe and even some from Australia and South Africa. The days were long but interesting. My favourite lecture was given by Professor Michael Weingarten from Tel Aviv University and questioned ‘the ethics of preventative medicine’. His presentation and stimulated much debate amongst the audience. I had the opportunity to attend two workshops. The first concentrated on the care of refugees and undocumented migrants in primary care. Interestingly, the results of the topics discussed during this workshop are going to be used to create a proposal to form a WONCA special interest group for this group of patients. The second workshop was for the Vasco da Gama Movement (VdGM). Vasco da Gama is the junior doctor branch of WONCA Europe founded by a group of Dutch junior doctors during the 2004 WONCA Europe conference. It aims to act as a platform for recently qualified GPs and vocational trainees to exchange clinical information, ideas, research and experiences. Since its inception VdGM has held a two day pre-conference meeting which involves junior

doctor representatives from most European counties. During this year’s pre-conference meeting (which I unfortunately was unable to attend) the following subjects were discussed: the importance of trainee involvement in curriculum development; the importance of vocational training within a primary healthcare setting (believe it or not some trainees do not have the privilege of working in general practice as part of their Vocational Training); and encouraging academic general practice. The Hippocrates program was also discussed. This is an exchange programme that appears to be greatly encouraged in other European counties, particularly the Nordic states. Its aim is to give GP registrars the opportunity to experience general practice in another country during their general practice post for a maximum of two weeks. Like many others, I was completely unaware of this programme. However, I was informed that at some point it was in existence in the UK. Among others at the conference, I would like to see this opportunity revived. The VdGM do acknowledge funding is the main obstacle that needs to be overcome. The conference provided a great opportunity to reinforce old knowledge and also to acquire knew information. It also served as an amazing opportunity to network; I met many esteemed doctors – including RCGP President David Haslam.

PETER BURRILL MB, ChB, MRCGP, MD

Endoscopy Dermatology (published April 2007) Child Protection Genetics

Views from WONCA

More data on the safety of salmeterol in asthma Specialist Pharmaceutical Adviser for Public Health Derbyshire County PCT

In 2006, a meta-analysis(1) was published that examined questions about the safety of long-acting beta-agonists (LABAs). They found that LABAs significantly increased asthma-related hospital exacerbations, lifethreatening exacerbations and asthma deaths. An analysis of data from RCTs conducted by GlaxoSmithKline has recently been published(2) in an attempt to alleviate concerns regarding the safety of salmeterol when used in the recommended manner in combination with inhaled corticosteroids (ICS). It found no clinically significant effect of salmeterol on asthma-related hospitalisations. A subgroup of trials found that severe asthma exacerbations were less frequent by a statistically significant – albeit small – amount in patients taking salmeterol. Asthmarelated deaths in either group were too infrequent to provide useful information. The National Prescribing Centre (NPC) blog(3) that accompanies the paper comments: ‘In view of the limitations of the study, the results should be interpreted cautiously. The study suggests that if salmeterol is used in combination with inhaled corticosteroids according to British guidelines, then the incidence of serious adverse events arising from the use of salmeterol in asthma are likely to be very small, at least over the short term. ‘The study does not by itself alleviate the concerns over the long-term safety of LABAs when used in routine clinical practice, and clinicians should continue to bear in mind the possibility of serious adverse events arising from their use, and to advise patients of the risks and monitor them accordingly. LABAs should only be used in patients with asthma whose symptoms are uncontrolled by inhaled corticosteroids alone. Stepping-down therapy should be considered when good long-term asthma control has been achieved.’ The editorial(4) that accompanies the paper comments: ‘Because we cannot expect any more new data, how should physicians and patients use combination therapy? Perhaps the best advice is to consider using combination therapy only for indications that accord with nationally

Right: RCGP delegates at WONCA

And there was some time for socialising... (l-r) Dr Rowan Lanton, Dr Cliona Doyle, Dr Luisa Pettigrew, Dr Anita Koruth, Dr Pusbar Grocock, Dr Mbang Ana and Dr Liz Brown on the sunset boat cruise on the Bosphorus As a result during the trip I started to wonder why junior doctors are not getting more involved with the International department of the RCGP. The opportunity to meet colleagues from other counties has been invaluable. I now know that it is not only British doctors who are frustrated by government policy. I’ve learnt that in Portugal all GPs use the same computer system, which seems sensible. I’ve learnt that the UK model of general practice and vocational training is highly regarded amongst

Cliona Doyle (Severn) Pusbar Grocock (Mersey) Anita Koruth (Mersey) Rowan Langton (Sheffield) Luisa Pettigrew (London) our European colleagues – and as such we should be proud to be a part of it. I have come to realise that medicine is not just what I practise here in the England, but a global community of doctors that can motivate, inspire and educate one another regardless of geographical location. Maybe this is what WONCA means by ‘Overcoming the distance’. My account of the conference can be viewed online. If you have time, take a look: http://www.nduk.org/blog/?p=208 RCGP News • October 2008

WONCA EUROPE 2008 opened with fire. We sat with over 4,000 international family medicine practitioners for the opening ceremony; an inspiring lecture from the WONCA president followed by the vigour and passion of the world record holding Fire of Anatolia dance group. This dynamism persisted over the following three days. We were among a group of nine trainees and newly qualified GPs who had the privilege of attending this exciting meeting. We were selected after submitting an application letter or essay on the importance of Europe in famRCGP News • October 2008

accepted clinical guidelines. Specifically, longacting -agonists with or without inhaled corticosteroids should not be used as first-line treatment and especially not for persons with mild asthma. In addition, the prudent course would be to use this treatment only when the physician is confident that the patient will adhere to close monitoring and instructions to seek care when asthma is out of control. ‘Ultimately, nearly all drugs have therapeutic windows within which physicians and patients must function. Like insulin and oral anticoagulation, long-acting -agonists have a particularly narrow therapeutic window. They deserve the same caution and meticulous attention to detail that physicians expect of themselves when they prescribe potentially harmful drugs.’

More evidence on the effect of salmeterol alone in asthma A Cochrane review of serious adverse events of regular treatment with salmeterol for chronic asthma has also recently been published.(5) 26 trials comparing salmeterol to placebo and eight trials comparing salmeterol to salbutamol were included. Studies in which salmeterol was randomised together with an inhaled steroid (in separate inhalers or a combined inhaler) were excluded from this review. Baseline use of inhaled corticosteroids ranged from 0 to 100% in the trials included. Overall, there were 62,630 participants with asthma (including 2,380 children). All-cause mortality was higher with regular salmeterol than placebo but the increase was not significant, Odds Ratio 1.33 [95% CI: 0.85 to 2.10]. Non-fatal serious adverse events were significantly increased when regular salmeterol was compared with placebo, Odds Ratio 1.14 [95% CI: 1.01 to 1.28]. One extra serious adverse event occurred over 28 weeks for every 188 people treated with regular salmeterol [95% CI: 95 to 2606]. There was insufficient evidence to assess whether the risk in children is higher or lower than in adults. No significant increase in fatal or non-fatal serious adverse events was found when regular salmeterol was compared with regular salbutamol. Individual patient data from two large surveillance studies were combined(6) (7). In patients not taking inhaled corticosteroids, there was a significant increase in the risk of asthma-related death with regular salmeterol compared to regular salbutamol or placebo, Odds Ratio 9.52 [95% CI: 1.24 to 73.09]. The confidence interval for patients taking inhaled corticosteroids is too wide to rule out an increase in asthma mortality in this group.

ily medicine in the UK and what we hoped to gain from the conference. The conference sessions ranged from keynote lectures and high quality plenaries to smaller workshops, oral and poster presentations. We had a unique opportunity to listen and discuss issues with a wide range of family doctors from across Europe and beyond in a friendly, open environment. All delegates could choose which sessions to attend throughout the conference. Our choices were as varied as us – ethics workshops, oral presentations on different approaches to postgraduate training, women’s health discussions and a patient safety plenary. As the first group of UK delegates supported by our deaneries we feel it is our duty is to bring back our renewed enthusiasm for such schemes in family medicine, with each of us providing individual reports to our faculty on our learning and ideas from this experience. The meeting area, with over 50 stands and 600 poster presentations, became the focal point for discussion and networking during breaks. We enjoyed the opportunity to represent the college at its stand; discussing how our new Speciality Training compares with other European schemes. We managed to fit in some time for socialising despite the busy conference schedule. The notable highlights were a party for all junior doctors that was hosted by the Dutch trainees and a sunset Bosphorus boat cruise hosted by the RCGP. Attending the conference was a fantastic opportunity that gave us all a broader perspective on our chosen career. We hope that other trainees will feel encouraged to find out more about WONCA and the VdG movement.

Authors’ conclusions ● In comparison with placebo, there was an increased risk of serious adverse events with regular salmeterol. ● There was also a clear increase in risk of asthma-related mortality in patients not using inhaled corticosteroids in the two large surveillance studies. ● Although the increase in asthma-related mortality was smaller in patients taking inhaled corticosteroids at baseline, the confidence interval was wide, so it cannot be concluded that inhaled corticosteroids definitely abolish the risks of regular salmeterol. ● The adverse effects of regular salmeterol in children remain uncertain due to the small number of children studied. The authors offer the following advice: ‘For patients whose asthma is not well-controlled on moderate doses of inhaled corticosteroids, additional salmeterol can give symptomatic benefit but this may be at the expense of an increased risk of serious adverse events and asthma related mortality; risks which are not clearly abolished by inhaled corticosteroids. Therefore, the risks as well as the benefits of regular salmeterol should be discussed with patients, the drug should be discontinued if no symptomatic benefit is achieved and the manufacturers’ advice not to increase the dose of salmeterol during exacerbations should be made clear.’ Are LABAs overused in asthma? The NPC states that most patients can be managed successfully at step 2 (regular ICS plus reliever inhaler when required), at least most of the time.(8) Weiss(4) notes that the number of patients receiving the combination of ICS + LABA exceeds the number of patients with moderate to severe asthma, making it likely that physicians

are prescribing it for patients who do not fit the guideline-recommended indication of moderate asthma (that is, asthma not controlled by antiinflammatory medications alone).

Recommendations ● It is important to follow current guidelines and emphasise the use of ICS as the firstline treatment for patients with mild to moderate asthma symptoms. ● LABAs should not be used as initial therapy for any asthmatic patient. ● Make sure individuals are receiving an adequate dose of ICS. Escalate the dose of ICS to the levels recommended in the British Asthma Guideline (800mcg/day beclometasone equivalent in adults and 400mcg/day in children aged 12 and under) before considering a LABA. Do not jump to step 3 too early. If satisfactory control is not obtained at these doses then a LABA should be added. ● Do not move to step 3 without assessing inhaler technique and compliance. Encourage the use of spacer devices. ● If on step 3, review regularly as recommended by the British Asthma Guideline, and consider stepping down back to step 2. ● It is important to carefully monitor patients on LABAs to identify those who do not respond or whose condition deteriorates in response to LABA therapy. Health professionals should be prepared to provide an alternative medication for patients in whom LABA therapy fails. ● Remember that the step 3 recommendation for children aged under 5 in the British Asthma Guideline is not a LABA.

References (1) Salpeter SR et al, Ann Intern Med 2006; 144:904-12 (2) Bateman E et al, Ann Intern Med 2008; 149: early online publication (3) www.npci.org.uk/blog/p=156 (4) Weiss KB, Ann Intern Med 2008; 149: early online publication (5) Cates CJ, Cates MJ. Regular treatment with salmeterol for chronic asthma: serious adverse events. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No: CD006363. (6) Castle W, Fuller R, Hall J. Serevent nationwide surveillance study: Comparison of salmeterol with salbutamol in asthmatic patients who require regular bronchodilator treatment. British Medical Journal 1993; 306:1034–7. (7) Nelson HS, Weiss ST, Bleecker ER, Yancey SW, Dorinsky PM, the SMART StudyGroup. The Salmeterol Multicenter Asthma Research Trial: A Comparison of Usual Pharmacotherapy for Asthma or Usual Pharmacotherapy Plus Salmeterol. Chest 2006;129(1):15–26 (8) www.npci.org.uk/blog/p=114

Dr Soleman Begg ST2 (Northern Deanery AiT5 Representative) Dr Moontarin Ansar ST3 (East of Scotland Deanery AiT Representative) We were privileged to be chosen to represent the UK at the Vasco de Gama pre conference meeting at the WONCA Europe meeting in Istanbul in September 2008. Following the introductory plenary session, the participants divided into small groups of twelve. Each group was facilitated by a EURACT facilitator and a Turkish Primary Care academic. The initial session focused upon establishing our main concerns related to General Practice. The main issues focused upon: training; initial years in General Practice; European Exchange Programmes and establishing why someone would want to be a GP. In Turkey the situation was rather an eye opener, there is considerable frustration among GP trainees and GPs for many reasons. Areas of concern included the practicalities of training needs and employment conditions. A key goal for Primary Care in Turkey is the implementation of a standardised curriculum. On the second day the workshop groups composed a presentation summarising the main points from the discussions, which were presented at the plenary session. It became evident that across Europe there is currently a large variation in GP training and the methodology to establish oneself as a GP. Training is more trainee centred in the economically prosperous

countries where GPs act as the ‘gatekeeper’. As the cost savings of GPs to the health economy have become more evident there is greater motive for governments to increase invest in primary care. In addition we presented our group findings at the WONCA meeting. One of the suggestions, which addressed the previous concerns, was that the EURACT agenda should be applied to educational programmes across Europe and this should be actively encouraged to extend appropriate clinical content to learning programmes. Other groups promoted the activity of GP research and why this was perceived by many trainees as not ‘sexy’. The issues of promoting healthcare in rural Turkey were also highlighted.

Conclusion Overall we felt this was a very productive and thought provoking meeting. The opportunity to share knowledge and experiences with colleagues from across Europe was invaluable. It was clearly evident that a lot of the frustrations and future aims of the other delegates in the workshops had already been addressed in the UK. The presence of the GP curriculum along with the assessment process has allowed our training programme to be one of the more advanced and arguably the best in Europe. In addition we learned valuable experiences encountered by other delegates. The take-home message was the UK training has many structures in place. However, there is still a lot of work to be done and we must not become complacent. It is important that trainees take an active role.

CLINICAL REVIEW

NEWS

Intensive blood glucose-lowering and diabetes PETER BURRILL Specialist Pharmaceutical Adviser for Public Health Derbyshire County PCT Two important studies investigating intensive blood glucose-lowering in type 2 diabetes, ACCORD(1) and ADVANCE(2), have recently been published.

ACCORD ACCORD was a randomised, controlled, nonblinded study. Eligible participants had type 2 diabetes and glycated haemoglobin (HbA1c) levels of 7.5% or more; they were either aged between 40 and 79 years and had cardiovascular diease, or were aged between 55 and 79 and had atherosclerosis, albuminuria, left ventricular hypertrophy, or at least two additional risk factors for cardiovascular disease. Target HbA1c level in the intensive control group was less than 6.0%, and in the standard control group was 7.0 to 7.5%. Medications came primarily from a study formulary – any other marketed anti-hyperglycaemic therapy could be prescribed if clinically indicated, but was not provided by the study investigators. All patients were provided with instructional materials and behavioural counselling related to their diabetes. The primary outcome was first occurrence of non-fatal myocardial infarction, non-fatal stroke, or death from cardiovascular causes. Secondary outcomes included death from any cause. Levels of HbA1c fell from a mean baseline of 8.1%; after one year, they were 6.4% in the intensive group and 7.5% in the standard group. These levels were maintained throughout the study. The primary outcome was numerically less frequent in the intensive group, starting to diverge from the standard group at three years, however when the study was stopped the difference was not statistically significant (6.9% vs. 7.2%; hazard ratio [HR] 0.90; 95% confidence interval [CI], 0.78 to 1.04; p=0.16). The rate of death from any cause was higher in the intensive therapy group; there was an excess of three deaths per 1,000 participants per year in the intensive group vs the standard group, over an average of four years of treatment. This difference was stable to various sensitivity analyses and death rates in the two groups started to diverge after the first year with the difference persisting throughout follow-up.

ADVANCE The ADVANCE trial was designed to assess the effects on major vascular outcomes of lowering the glycated haemoglobin value to a target of 6.5% or less in a broad cross-section of patients with type 2 diabetes. Eligibility criteria were a diagnosis of type 2 diabetes mellitus at 30 years of age or older, an age of at least 55 years at the time of study entry, and a history of major

macrovascular or microvascular disease or at least one other risk factor for vascular disease. Participants were randomised to undergo either a strategy of intensive blood glucose control (target glycated haemoglobin value <6.5%) or a strategy of standard glucose control (with target glycated haemoglobin levels defined on the basis of local guidelines). Those who were assigned to undergo intensive glucose control were given gliclazide (modified release, 30 to 120 mg daily) and were required to discontinue any other sulfonylurea. Although the timing, selection, and doses of all other treatments were at the discretion of the treating physician, a treatment protocol was suggested. On the basis of the glycated haemoglobin level at each visit, this protocol initially advised increasing the dose of gliclazide mr, with the sequential addition or increase in dose of metformin, thiazolidinediones, acarbose or insulin. Patients in the standardcontrol group who were using gliclazide mr when they entered the study were required to substitute this drug with another sulfonylurea, if continued therapy was required. The primary study outcomes were a composite of macrovascular events and a composite of microvascular events, considered both jointly and separately. Macrovascular events were defined as death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. Microvascular events were defined as new or worsening nephropathy (i.e. development of macroalbuminuria, defined as a urinary albumin:creatinine ratio of more than 300 g of albumin per milligram of creatinine, or doubling of the serum creatinine level to at least 200 mol per litre, the need for renal-replacement therapy, or death due to renal disease) or retinopathy (i.e. development of proliferative retinopathy, macular oedema or diabetes-related blindness or the use of retinal photocoagulation therapy). Prespecified secondary outcomes were numerous and included death from any cause, major coronary events, major cerebrovascular events, heart failure, nephropathy, retinopathy, neuropathy and development of microalbuminuria. Hypoglycaemia was defined as a blood glucose level of less than 2.8 mmol per litre in the presence of typical symptoms and signs of hypoglycaemia, without other apparent cause. Patients with transient dysfunction of the central nervous system who were unable to treat themselves (requiring help from another person) were considered to have severe hypoglycemia. The mean baseline glycated haemoglobin was 7.5%. At the end of follow-up (median 5 years), the mean values were 6.5% in the intensive-control group and 7.3% in the standard-control group. A total of 2,125 participants had a major macrovascular or microvascular event: 18.1% in the intensive-control group and 20.0% in the standard-control group (hazard ratio, 0.90; 95% confidence interval (CI), 0.82 to 0.98; p=0.01). Thus, it was estimated that such an event would be averted during a five-year period

in one of every 52 participants (95% CI, 30 to 213) undergoing intensive control, i.e. NNT=52. As compared with standard control, intensive control resulted in a significant reduction in the incidence of major microvascular events (hazard ratio, 0.86; 95% CI, 0.77 to 0.97; p=0.01; NNT = 63) but not in the incidence of major macrovascular events (hazard ratio, 0.94; 95% CI, 0.84 to 1.06; p=0.32). The reduction in microvascular events was primarily because of a reduction in the incidence of nephropathy (HR, 0.79; CI 0.66 to 0.93; p=0.006; NNT = 91). The component of new or worsening nephropathy most clearly reduced through intensive glucose control was the development of macroalbuminuria (2.9%, vs. 4.1% with standard control; hazard ratio, 0.70; 95% CI, 0.57 to 0.85; p<0.001; NNT = 83). There was no reduction in the need for renal-replacement therapy or death from renal causes (0.4% vs. 0.6%; hazard ratio, 0.64; 95% CI, 0.38 to 1.08; p=0.09) and no effect on the doubling of serum creatinine level (1.2% vs. 1.1%; hazard ratio, 1.15; 95% CI, 0.82 to 1.63; p=0.42). A total of 1,031 participants died: 8.9% in the intensive-control group and 9.6% in the standard control group (hazard ratio, 0.93; 95% CI, 0.83 to 1.06; p=0.28). There were no significant differences between the two groups for any of the other pre-specified secondary outcomes. More patients undergoing intensive control were hospitalised for any cause (44.9% vs 42.8% of those in the standard-control group; hazard ratio, 1.07; 95% CI, 1.01 to 1.13; p=0.03; NNH=48), with some of the excess of hospitalisations due to severe hypoglycemia (1.1% vs.0.7%; odds ratio, 1.52; 95% CI, 1.01 to 2.28; p=0.04). Severe hypoglycaemia occurred more frequently in the intensive-control group than in the standard-control group: 150 patients (2.7%) undergoing intensive control had at least one severe hypoglycaemic episode, as compared with 81 patients (1.5%) undergoing standard control (hazard ratio, 1.86; 95% CI, 1.42 to 2.40; p<0.001; NNH=83).

The most significant message from ACCORD and ADVANCE is that in high-risk type 2 diabetics, intensive therapy intended to produce near-normal blood sugar levels does not improve cardiovascular outcomes over the 3.5 to 5 year time frame, and may worsen them. Neither trial showed a significant improvement in macrovascular outcomes with intensive therapy, and the increased risk of all-cause death in ACCORD is of concern. In both studies, patients in the intensive treatment groups had higher incidences of hypoglycaemia – around twice that of the standard treatment group in ADVANCE, and three times in ACCORD. The National Prescribing Centre blog ‘Putting blood glucose control in type 2 diabetes into perspective’(3), suggests the following action: ‘Managing cardiovascular (CV) risk factors are the priority for patients with type 2 diabetes. Although interventions (e.g. metformin and diet/ lifestyle) will often be required to control the symptoms associated with having high blood glucose levels, clinicians should not become over-focussed on intensive strategies to achieve HbA1c targets. These are often unnecessary and can put patients at risk of adverse drug-related events. Clinicians should give priority to reducing the risk of macrovascular events with evidence-based interventions (e.g. smoking cessation, blood pressure control and the use of metformin/aspirin/simvastatin).’ The priorities for people with type 2 diabetes to reduce the risk of adverse outcomes are as follows:

q Control the symptoms of hyperglycaemia, with diet initially followed by metformin if a drug is needed (to improve quality of life) Stop smoking if a smoker

w e Control blood pressure as tightly as possible

r Take simvastatin 40mg, aspirin 75mg and metformin if not already on it

t Then and only when 1 - 4 are sorted, consider further blood glucose lowering, if the patient wants more drugs to cope with.

Conclusion The ADVANCE trial did not show a significant effect of intensive glucose control on the risk of major macrovascular events. Intensive glucose control resulted in a reduction by one-fifth in the development of new or worsening nephropathy, mainly due to a reduction in the development of macroalbuminuria. There was no reduction in the need for renal replacement therapy or death from renal causes. There was no reduction in new or worsening retinopathy, including retinal photocoagulation, or in neuropathy. Intensive glucose control was associated with an increased risk of hospitalisation and severe hypoglycaemia, as compared with standard control. Is an NNT over five years of 83 to prevent one person developing macroalbuminuria worth an NNH of 48 for hospitalisation or an NNH of 83 for severe hypoglycaemia?

ACCORD and ADVANCE suggest that the current QoF target of HbA1c <7.5 may be reasonable, but that chasing targets of <6.5 should not be advised and may cause harm.

Key points ● The ACCORD study recruited type 2 diabetes with CVD or who were at high risk of CVD. In ACCORD, the mortality rate in diabetics in the intensive treatment group was higher than in the standard group

References (1) N Engl J Med 2008; 358: 2545-59 (2) N Engl J Med 2008; 358:2560-72 (3) www.npci.org.uk/blog/?p=147

Spotlight on... the RCGP Informatics Group Dr Libby Morris and Dr Alan Hassey discuss how their work has an impact on every GP Who are we? The group is made up of GPs who are also experts in different facets of Health Informatics. There is currently a mix of Scottish and English members on the group and we are actively seeking members from Wales and Northern Ireland so that we will represent all four nations of the UK.77 The value of people who are both clinicians and expert in Informatics is again being recognised by Government agencies (such as Connecting for Health). Members of the Group are involved in a number of national projects, as detailed below, and the Group also includes one of the GP National Clinical Leads for England, the director of SCIMP (Scottish Clinical Information Management in Practice), and one of the ehealth clinical advisors for Scotland.

What do we do? Members of the group represent the college on many different projects involving electronic patient records, including their management, quality and development. We feedback to College Council via RCGP Vice Chair Dr Has Joshi. The group meets twice a year, including an open meeting and a workshop at the college conference. Much of our work can be summarised as integrating different aspects of sharing electronic records across different computer systems and different professional groups. Components of this are technical architecture, terminologies (e.g. Read and SNOMED CT), semantic issues about preservation of meaning, the impact on working practices and on clinical safety. The GP2GP project is being used in many practices across England: when patients register with a new practice it provides the new practice with the electronic records from the previous practice almost instantly. It illustrates all the components mentioned above and is an example of how informatics issues, that may previously have seemed somewhat esoteric, are now affecting mainstream practice. Discussions are underway

with Scotland to enable this to be extended to practices on both sides of the border. An impending change that the profession should be aware of is the introduction of SNOMED CT. At present GP clinical computer systems use Read codes (version 2) or its derivative ctv 3, while hospital systems use different coding languages. SNOMED CT has the advantage of applying to both primary and secondary care, thus facilitating the electronic exchange of information. It is a fundamentally different coding system (terminology) and the way that it is implemented will have a direct effect on how systems work and how searches and queries are run. The Informatics Group has learnt a lot about clinical safety, largely through our involvement in the GP2GP project. Maureen Baker, through her work with the National Patient Safety Agency, has been responsible for establishing a world-leading system that applies industry standard practices to clinical safety testing. The Informatics Group would like to see this technically excellent work further supported through a stronger clinical voice. We feel that the governance of clinical safety should be ‘owned’ by the profession and would

What comes next after ‘Smoking kills’

One of the few international league tables Britain can claim to be at the top of these days is the European tobacco control league table. This illustrates what a great public health success tobacco control policy has been: smoking prevalence is falling, people are exposed to less secondhand smoke and there is increasing evidence that this is having a positive impact on the nation’s health. This month Action on Smoking and Health (ASH) in collaboration with Cancer Research UK and the British Heart Foundation publish a report Beyond ‘Smoking Kills’: protecting children, reducing inequalities which sets tough new targets for a reduction in smoking prevalence. Over 80 organisations, including the RCGP, endorse the report, illustrating the strong support in the public health community for a strong new strategy for tobacco control. The Government will publish the outcome of its consultation on tobacco control in December and both a new strategy and legislation are expected early in 2009. Beyond ‘Smoking Kills’ will help to set the agenda and inform the development of policy. The report is wide ranging and makes 44 recommendations, some call for legislative change but most do not. The report discusses improving smoking cessation services, developing a more robust response to smuggled tobacco and the adoption of a harm reduction approach looking at new ways to use nicotine replacement therapies. It also supports greater public awareness regarding the need for smokefree homes, an issue raised last month in a position statement developed by the Faculty of Public Health with ASH and circulated to all GPs. Two of the legislative measures proposed have been seen as controversial: banning point of sale displays of tobacco and mandating plain packaging for tobacco products. These are only two measures in what must be a comprehensive strategy if we are to achieve a reduction in the inequalities caused by smoking.

Point of sale displays Most forms of tobacco advertising have been banned in the UK since 2003. A compelling case was made at the time that children and young people are influenced by advertising. Overnight the industry lost its key recruiting tool, but it didn’t take long for them to find a new one. As World Tobacco Trade Magazine said: ‘If your brand can no longer shout from billboards

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like there to be more awareness among grassroot clinicians about patient safety issues and of how to report them. We are also interested in Education and Training in informatics and work closely with the RCGP Ethics Committee.

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Our current activities ● ●

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Emergency Care Summary, including palliative care forms Docman Transfer Project: electronic transfer of documents along with a structure electronic summary of the GP record GP systems migration Information Governance Terminology Steering Group Clinical Support for IT facilitator network

England ● ●

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Scotland

GP2GP project (Board member and safety testing) Data migration (maintaining data quality when records are moved from RCGP News • October 2008

Pack branding is ❛powerful and

It is now ten years since the Government’s White Paper on tobacco control, Smoking Kills, and over a year since smoking in public places was banned. Hazel Cheeseman of ASH looks at what has been achieved and the challenges that remain to be overcome

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one clinical system to another, e.g. EMIS to SystmOne) Patient Demographics Service (handling patient registration data in a single system) Clinical Adviser to CFH Information Governance team Good Practice Guidelines (for paperless practice) Choose and Book UKTC NHS CFH content model PRIMIS Plus Clinical Safety Officer for Summary Care Record Summary Care Record Laboratory communications

International ● ●

Member of Wonca International Classification Committee IHTSDO

Shared Record Professional Guidance Over the past few years Connecting for Health (CfH) system suppliers have implemented Primary/Community IT systems with explicit sharing of a single record by clinicians from different teams and NHS bodies. RCGP News • October 2008

seductive. Changing pack imagery has been shown to add sales, and the industry describe the pack as a ‘promotional tool in its own right’ or cinema screens at least court smokers from the retailers’ shelves’. The tobacco industry has increased the number of varieties within a brand as it means that a greater number of packs appear on the shelf, maximising the opportunity to advertise the brand. ‘Power walls’ of tobacco product displays have sprung up with innovative use of colours and positioning, and the visuals of the pack are ever more sophisticated and appealing. Research commissioned by ASH as part of our report shows that the existing laws are not stopping the industry from finding new and increasingly clever ways to push their product: ‘More noticeable in 2008, however, is the use of colour and lighting on the overhead gantries and within the display area. In addition, blocks of product were widely reported as a means of gaining prominence for a brand’. Even the safeguards put in place to remind the public that smoking kills were compromised. In 19% of stores visited as part of the research health warnings were obscured. Point of sale displays are powerful means of communicating with the children and young people who regularly visit stores selling tobacco. But removing point of sale displays alone isn’t sufficient, the pack remains a powerful promotional device which can only be neutralised by getting rid of pack branding.

Plain packaging Plain packaging is the tobacco control measure the industry is most concerned about. The front cover of a recent trade journal read ‘Plain packaging can kill your business’. The tobacco industry argues that branding does not recruit new smokers and is only used to help existing ones differentiate between brands, something they will be denied the opportunity to do if branding is removed. However, there is a different story. A British American Tobacco employee said in 2002: ‘One in every two smokers is not able to distinguish in

This has led to rising levels of uncertainty from all sides about the governance, medicolegal and patient-safety consequences of shared electronic clinical records systems. Following a successful competitive tendering exercise, the RCGP Informatics Group has been awarded a contract to develop a professionallyled set of guidelines for the governance of shared electronic patient records in the primary care domain. The guidelines will carry the endorsement of the full range of relevant health professional representative bodies and be promoted by CfH to their clinical system suppliers and all system users.

Context The governance and guidance of Primary Care systems has historically rested with General Practice, which has assumed supervisory roles for the pragmatic purpose of allowing wider clinical teams access to an effective locally shared electronic record. The guidance produced is likely to have immediate implications to relieve uncertainty in Community settings, and to further encourage the roll-out and fuller use of much needed National Programme information systems in community settings. The key questions for this project to address are:

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blind tests. For most smokers, and the decisive group of new young smokers, the consumer’s choice is dictated more by psychological and image factors than minor differences in smoking characteristics’. Pack branding is powerful and seductive. Changing pack imagery has been shown to add sales, and the industry describe the pack as a ‘promotional tool in its own right’ and state that ‘in this struggle to win over smokers, the pack and its messages have become increasingly important weapons’. However, it is rarely used to win over existing smokers, the majority of whom are very brand loyal, so the question to ask is why does the industry continue to put so much emphasis on the ‘silent salesman’ if they are not trying to recruit the 200,000 new smokers they need in this country each year to replace those who die or quit. Brand imagery is not just used to recruit new young smokers, it also has a role in negating health warnings and misleading smokers into believing that one brand is less harmful than another. Since 2003 it has been illegal for the tobacco industry to suggest that some forms of tobacco are less harmful than others. Descriptors such as ‘low-tar’ and ‘light’ were banned. However, the industry has continued to use much of the same colour coding and imagery and young smokers, who would have been about ten when the ban came in, will tell you that ‘gold’ is less harmful than ‘red’, and white means it will be less addictive and less harsh. None of which is true. Branding is also damaging the saliency of health warnings. Young people shown branded packs with health warnings are less able to remember the health warnings than those shown them on plain packing. ■ The full report and executive summary are available at www.ash.org.uk/ beyondsmokingkills More information on the Faculty of Public Health and ASH position statement on protecting children from secondhand smoke is available at www.fphm.org.uk

q What are the purposes of shared clinical record systems?

w How can these requirements be delivered safely?

e What are the principles and practice that ensure clarity, safety and continuity and at what level does responsibility for clinical record system governance lie?

Approach This project is being supported and sponsored at the highest levels within the RCGP. The work itself will be undertaken by members of the RCGP Informatics Group, co-opted domain specialists and a small team from Dundee University led by Professor Jeremy Wyatt. This project is different from other projects undertaken by the RCGP Informatics Group in that our key aim is to develop guidance that is endorsed by all key stakeholder groups in the primary care setting.

Scope

Breakthrough Breast Cancer urges GPs to share crucial message with patients Breakthrough Breast Cancer is calling on GPs to support its latest campaign Talk TLC, encouraging women to check regularly for signs of cancer. The charity’s latest survey of 2,005 women shows that only 35% are regularly checking their breasts – but that they are much more likely to do so if their GP or practice nurse discusses breast awareness with them. Talk TLC – Touch, Look for changes, Check out anything unusual with your doctor – runs throughout October, national Breast Cancer Awareness Month. Breakthrough hopes that 46,000 people – the number of UK women now diagnosed with breast cancer every year – will visit www.touchlookcheck.org.uk during the next month.

Evidence Matters An online forum celebrating evidence-based medicine is being launched by the charity Sense About Science to coincide with this month’s 40th anniversary of the Medicines Act. Evidence Based Medicine Matters aims to show how EBM is widely supported from patients through to professionals. The project will include a visual ‘wall of support’ with advocates including Nobel Prize winners, senior scientists and clinicians, patients and Parliamentarians all talking about their experiences and why EBM is so important. ■ www.senseaboutscience.org

Genetics and patient care A one-day conference for GPs, educators and trainers to explore how knowledge of genetics can enhance patient care will be held Birmingham’s International Conference Centre on Wednesday 15 October. Connecting Evidence to Practice is organised by the National Genetics Education and Development Centre, with expert contributions from Professor John Burn, Medical Director of the Institute of Human Genetics, Newcastle University; Professor Philip Candy, Director of Education, Training and Development, NHS Connecting for Health; and Sir Muir Gray NHS Chief Knowledge Officer . Interactive sessions include: Where does genetics fit into clinical practice and how can I support it? and Using patient stories to enhance your teaching and learning of genetics. ■ For more information visit www.geneticseducation.nhs.uk/ events/registration.asp

● The implementation of patient decisions on consent to share electronic detailed care records ● Governance of clinical records relating to clinical staff that currently have the ability, or potential, to add records (including): ● General Practitioners ● Practice employed clinical staff ● Community Clinical staff ● Clerical staff ● Ownership, responsibility and governance of record elements, together with medicolegal record integrity and liability. ● All routine functions from the above groups that need to be recorded in the shared record should be considered. Record maintenance and the ability to filter, edit and amend records between different legal entities will also be included, as will ‘lapsed’ legitimate relationships, search and audit implications, and business issues such as QOF score.

This project will focus on:

Next Steps

● Local detailed care record in the form of current ESP (GPSoC) and LSP Primary Care IT systems.

The project is already underway with the aim of delivering its final report to the RCGP & CfH by the end of March 2009.

NEWS

Working for health – changes to Incapacity Benefit and the ‘sick note’ What do the changes mean for GPs?

Dr Nerys Williams Principal Occupational Physician at the Department for Work and Pensions From 27 October, Employment and Support Allowance will be introduced across the United Kingdom and will replace Incapacity Benefit and Income Support paid on incapacity grounds for new customers. The principle underpinning this change is that everyone should have the opportunity to work and that people with an illness or disability should be provided with the help and support necessary for them to move into suitable employment, if they are able and when they are ready to do so. Employment and Support Allowance builds on the success of the Pathways to Work programme, which was created to provide individuals with extra support in preparation for moving into work. This support includes groundbreaking condition management programmes specifically designed to help patients manage and cope with their illness or disability. Pathways to Work has helped more that 94,000 people into work since October 2003, and nearly 50,000 customers have been referred to condition management programmes. In Great Britain, over 2.6 million people depend on incapacity benefits, and yet nine out of ten new customers tell us that they want to return to work. With the introduction of the new allowance we are building the package of support to help people return to the workplace.

The patient experience Paul Wild benefited from the Pathways to Work programme in December 2007. “For many years I was laid up with my leg. I was in a rut. I couldn’t work because I wasn’t well enough, but then I had an operation which allowed me to be pain free. I realised that I could start to do things again.” After interview preparation with his personal adviser, and advice on how he would disclose his disability to prospective employers, Paul was offered a role at the Imperial War Museum in London. Paul said: “My colleagues wondered why I was so happy, and said I’d lose the smile once I’d been here for a month, but I’m still just as happy. I get up for a reason in the morning – I feel useful and wanted. I love the sense of camaraderie, and the great thing is that I’m getting paid too.”

The introduction of Employment and Support Allowance will not make significant changes to your interactions with patients, nor the paperwork you need to complete. The Department for Work and Pensions or the Northern Ireland Social Security Agency already asks you to provide information about your patients, but some of the forms you complete for this will be changing. You will still be asked to provide ‘statements of incapacity for work’ (usually on the Med 3 form) until the Work Capability Assessment is carried out. In addition, you may be asked to complete an ESA113 form for patients with severe disability, who may be entitled to Employment and Support Allowance without the need for a face-to-face assessment.

What do the changes mean for patients? Entitlement to Employment and Support Allowance will, for most customers, be assessed through the new Work Capability Assessment, which will focus on what an individual can do, in addition to what they cannot. The Work Capability Assessment includes the new work-focused health-related assessment, giving customers the opportunity to discuss their views about moving into work, and identifying any health related interventions that may support this. The customer will receive a copy of the report from their work-focussed health-related assessment and may share this with their GP. Customers who are assessed as having some capacity for work-related activity will join the ‘Work-Related Activity Group’ and take part in a series of work-focused interviews with a personal adviser. The personal adviser will be able to refer customers for personalised support, including condition management, training or employment support, to help them prepare for appropriate work. Those patients with a severe illness or disability, who are assessed as being unable to take part in work-related activity, will join the ‘Support Group’. These patients will therefore not be required to actively prepare for work, unless they want to volunteer for any appropriate support, and will receive additional financial help. Evidence shows that the right type of work can be therapeutic for people with both mental and physical health problems and can help promote recovery and even improve a patient’s condition. However, some patients may take a long time to be ready to consider working – Employment and Support Allowance has been designed to support patients, to ensure their needs are recognised and that they receive help to manage their condition, so that they can realise the benefits of being in work.

Forging better links between GPs and pain specialists Dr Clare Gerada, Vice President of the RCGP, has been co-opted as a member of the British Pain Society (BPS). The British Pain Society is the largest multidisciplinary professional organisation in the field of pain within the UK. Its membership comprises medical pain specialists (including GPs), nurses, physiotherapists, scientists, psychologists, occupational therapists and other healthcare professionals actively engaged in the diagnosis and treatment of pain and in pain research for the benefit of patients. Its multidisciplinary nature is pivotal in making the society a uniquely relevant representative body on all matters relating to pain. The BPS is aware of the key role which all general practitioners play in dealing with the majority of pain problem, as well as the newer developments that some GPs have instigated, including GPwSI, in dealing with this complex group of patients. Secondary care services only manage a small subset of the patients with pain. The number of patients presenting to primary care with pain may be tenfold greater, with most care being administered outside secondary care services. A recent annual scientific meeting of the BPS included an interactive workshop looking at the education needs of primary care services. GPs present said that there was still a lot of uncertainty around the management of pain for patients, particularly chronic pain. They also felt unsupported by local and national guidance and frustrated at the lack of available treatments. In turn, secondary care workers voiced their concerns at being remote from the community context in which primary care practice operates.

Given the huge cost of pain related disability both in terms of healthcare resource and social cost, many in the BPS were disappointed that good management of pain was not considered in its own right as part of the Quality and Outcomes framework (QoF). Despite this, it was felt that education could provide a powerful opportunity of improving patient care in the community.Against this backdrop, an education in primary care group has been now set up as part of a special interest group. Dr Joan Hester, President of the BPS, said she was excited at the prospect of increasing links between both groups. She said: “There are many new developments occurring across a whole range of sectors and professions who care with patients in pain. The BPS is both delighted to be invited to liaise with GPs and keen to learn from them. Pain patients are complex but it is clear that there are treatments that can improve their symptoms and the interaction they have with all members of the primary care team.” Dr Gerada, who has recently been involved in the BPS committee looking at competencies for GPs with a special interest in pain management, said she was “delighted to join one of the most truly multidisciplinary councils I have ever been a part of.” ■ Further information on the BPS, its publications and its activities can be accessed at www.britishpainsociety.org. A more detailed summary of the primary care pain education meeting will appear in the winter edition of Pain News, the BPS newsletter, which can also be downloaded from the website.

Changes to the ‘sick note’ The Department for Work and Pensions is currently carrying out a review of medical certification including form Med 3, more commonly known as the ‘sick note’. The aim is to ensure that certification is more simple to complete and supports GPs in providing the best quality fitness for work advice for their patients, without adding to their administrative burdens. The recently published independent report ‘Vocational Rehabilitation what works, for who and when?’* indicates that most common health conditions can be accommodated in the workplace. As such, our aim is to ensure that the form helps employers consider whether it is both possible and appropriate to facilitate an earlier return to work for employees. The Department has been working with a range of medical organisations, including the Royal College of General Practitioners, the Faculty of Occupational Medicine and the British Medical Association, as we consider possible changes to the certification system. This work has led to a broad consensus on how form Med 3 could be changed. To test whether these changes are appropriate and practical we have invited a range of GPs to complete the new forms and provide feedback on their views of the potential changes. We are currently considering the responses we have received and this will further inform any possible changes to the certificate. We are keen to ensure that GPs’ views are fully represented before the introduction of revised medical certification in 2009. Therefore the Department will be holding a formal consultation on our proposed changes later this autumn. Please note that separate arrangements about updates to form Med 3 may apply in Northern Ireland. In addition, the Department is currently running a pilot in a number of GP practices in Wales, to assess the use and effectiveness of electronically generated medical certificates, as an alternative to the current handwritten version. The pilot is running until December 2008 and will be evaluated independently. *

Source: Waddell, Burton, Nicholas ‘Vocational Rehabilitation what works, for who and when?’: 2008

■ For more information on Employment and Support Allowance visit www.dwp.gov.uk/esa In Northern Ireland visit www.dsdni.gov.uk/esa For more details on the evidence base that work is good for health, visit www.workingforhealth.gov.uk

Professor Carl Pearson Distinguished neuroscientist Professor Carl Pearson – who embarked on general practice training at the age of 50 – died only three months after achieving his MRCGP. Earlier this year, Professor Pearson’s wife Enid and young daughter Grace attended the RCGP New Members’ Ceremony at Kensington Town Hall, with Grace donning full ceremonial gown to accept College membership on her father’s behalf. The son of a GP, Professor Pearson made a significant contribution to the study of Alzheimer’s disease. He was a senior lecturer at St Mary’s Hospital Medical School before becoming Professor of Neuroscience at Sheffield Univeristy. Later appointed Chair of Neuroscience in Sheffield, he abandoned this prestigious role to embark on his radical career change. Professor Pearson’s family attend the He spent the last 18 months of his RCGP New Members’ ceremony working life as a GP in Sunderland, which he claimed was one of the happiest and most fulfilling periods of his entire career. After spending a year teaching undergraduates in Tanzania, he established a fund for sponsorship of medical education which to date has put six students through medical training. He continued to give tutorials in neuroanatomy to a young medical student during the final few weeks of his life. Professor Pearson’s widow, obstetrician and gynaecologist, Enid Michael, said he had been very proud to receive College membership status. “It was a very special experience to come and receive the award of MRCGP on his behalf.”

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RCGP News • October 2008