News
RCGP outlines its plans for remediation of GPs The College is launching a paper outlining its proposals for meeting the challenges of remediation for General Practitioners
Based on the findings in the Department of Health’s Tackling Concerns Locally report (2009) and experience in Wales and the London Deanery, it aims to draw together good practice to address three key challenges: ● Clarity on the responsibilities of all the key stakeholders in remediation ● Consensus on the processes for tackling concerns and remediation, and the application of those processes consistently throughout the UK ● Achieving sufficient resources to deliver a system of remediation that is value for money and effective in maintaining services while ensuring patient safety Led by RCGP Vice Chair Dr Has Joshi, the College is proposing a four stage process as set out in Tackling Concerns Locally and which has already been implemented in Wales:
q w e r
Identifying issues Investigation Deciding on actions Remediation, re-skilling and rehabilitation For each of these stages, the College is pro-
Dr Has Joshi: Leading the RCGP proposals on remediation
posing a simple but effective model which reflects the best practice already evident in some sites throughout the UK. A funding model is also being proposed, with the main financial burden for remediation being shared by the primary care organisation and the deanery. The RCGP is aware that there is wide variation across the UK and that the model will need to be adapted to local circumstances and so the paper also argues the need for additional resources to guarantee the success of the project. The paper has the support of the General Practitioners Committee of the British Medical Association, the Postgraduate Deaneries, NES Scotland, the National Clinical Assessment Service, the Revalidation Support Team, the Independent Doctor’s Forum and the Patient Partnership Group of the RCGP At a meeting of these organisations held at the College in October, it was agreed that: ● Where remediation has been systematised and adequately resourced it works reasonably well ● Investment in remediation, especially in the early stages of deteriorating performance, can save money ● There is a need for a structured approach to facilitating GPs out of the profession when remediation has failed or where remediation is not appropriate ● There must be support for those involved with remediation to manage the risks involved, ranging from protecting patient safety to indemnity of those commissioning and providing the remediation. While the paper is based largely on the Department of Health’s report Tackling Concerns Locally (2009), it has been further informed by the Standard Operational Policy for the Primary Care Advisory Team in Public Health Wales provided by Professor Malcolm Lewis; and by evidence provided by Dr Alex Jamieson and Dr Julia Whiteman of the London Deanery. RCGP Chairman Professor Steve Field said: “With 53,000 doctors licensed to practise on the GMC Register, it is inevitable that a tiny number of GPs will perform poorly and this places patients at risk. “There are already systems for offering remediation in some parts of the country but the provision is inconsistent and geographically patchy. As local processes such as clinical governance and annual appraisals are developed in
Sign up for 2010 RCGP Pandemic Forum The swine flu pandemic will be the subject of an RCGP Forum in Leeds on 18 March 2010. The event will bring together keynote speakers to discuss the pandemic from a variety of perspectives, including primary care professionals working at the frontline. The Forum will provide an opportunity to analyse the pandemic strategy and how it worked in theory – and reality. It will also high-
light lessons learned during the pandemic and how these can be applied effectively in future planning. A discussion panel will look at how the swine flu story was reported in the media and the influence this had on public perception. Attendance fees are £99 for members and £149 for non members. ■ Full details about the event are available at: www.rcgp.org.uk/pandemicforum Or email: pandemicforum@rcgp.org.uk
preparation for revalidation, we need to ensure a more consistent approach so that doctors across the UK can have confidence in the system and know that they are being treated equitably and fairly. “Remediation is not revalidation – they are very different. Remediation is an issue for now, not just the future, and agreements need to be sorted urgently over the finance available for remediation. “We understand that a committee is being set up by the Department of Health to look at remediation and that this will reach its conclusions late in 2010. However, urgent attention is needed and it’s important that this is not confused with revalidation. “We are really encouraged that all the stakeholder organisations who are key to successful delivery have signed up and supported the paper which will inform all our current and future discussions around remediation. Nothing is cast in stone and we want to hear from jobbing GPs across the UK that our proposals are acceptable and workable and that we are heading in the right direction.”
THE NEWSPAPER OF THE ROYAL COLLEGE OF GENERAL PRACTITIONERS
JANUARY 2010
Inside this issue... Auditing cancer in primary care How GPs are improving access to treatments
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A different perspective Launch of landmark report on the future of medicine
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Culture change How self-care could save the NHS a fortune
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Charity begins at home A retired GP puts unused medicines to good use
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Managing the mystery Understanding unexplained symptoms
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Championing older people New models for care for the ageing population
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A bumper year Highlights of the RCGP Annual General Meeting
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Dr Walker-Love with Samar Sheik who nominated her for the award
Meet Scotland’s first GP of the Year Dr May Walker-Love from Cumbernauld Medical Practice in Glasgow has been named as RCGP Scotland’s very first GP of the Year – by her patients. RCGP Scotland has established two new annual awards – The GP of the Year and Practice of the Year – to recognise excellence in general practice and celebrate the outstanding contribution of GPs and practice teams across Scotland. Dr Walker-Love received her award at a gala event in Edinburgh that also raised over £2,000 for Depression Alliance Scotland. Patient Samar Sheik who nominated her for the award, said: “Dr Walker-Love has been a pillar of strength for us, because of her caring and empathetic manner. She went out of her way to help us organise everything from health visitors, nurses, hospice care and also contacted another family whose child had the same rare condition as my own. Without her help, coping would have been far more of a challenge. She did and continues to do whatever is humanly possible to ease our burden.” The title of Practice of the Year went to Linkwood Medical in Elgin. The gala event was attended by representatives from the Scottish Government, and healthcare organisations including key members of the Health and Sport Committee of the Scottish Parliament. Dr Ken Lawton, Chair of RCGP Scotland, said: “Quality of patient care is a priority for GPs in Scotland and it is important to recognise the success stories of general practice at its best. Creating the opportunity for patients to nominate their GP for an award gives us an important insight to the dedication of grassroots GPs who play an important role not only in treatment, but as a valuable member of the community.”
NEWS
National cancer audit in primary care highlights New posting for Dame Lesley the attributes of good general practice Imran Rafi Medical Director of RCGP Clinical Innovation and Research Centre Greg Rubin Professor of General Practice and Primary Care, Durham University and co-author of this audit work
Significant Event Audit (SEA) is a familiar and widely used technique for quality improvement in general practice. Invariably the findings of an SEA result in change at practice level in the way things are done. This article describes the systematic use of SEA to produce information that can inform service redesign at PCT level. As part of the National Awareness and Early Diagnosis Initiative (NAEDI) to promote timely diagnosis of cancer, a national audit of cancer diagnosis in primary care has been commissioned by the Department of Health. One part of this audit is an analysis of SEAs for lung and Teenager and Young Adult (TYA) cancer. The work has recently been completed and is already informing service redesign for lung cancer diagnostic services. What follows is a short summary of what came out of the study. The main aim of this study was to gain insights into the events that surround the diagnosis for these two cancers. General practices from the North-east of England were invited to participate, recruited by Local NHS cancer leads. The 92 practices involved were invited to record clinical details on the last patient diagnosed with lung cancer (132 SEA returned) and the last patient diagnosed with cancer as a teenager or young adult (TYA, aged 15-25 with 35 SEA included). Participating practices were provided with electronic templates to record their SEA based on a structure recommended by the National Patient Safety Agency. Box 1 below indicates the five sections covered by the template. A qualitative analysis of the data was undertaken.
Box 1: SEA template sections ● Document the process of the event ● Reflect on what and why the SEA happened ● Identify the learning needs ● Consider changes to be made or actions taken ● What was effective about the SEA?
Lung Cancer Audit
Box 3: Key Messages in the presentation and referral of cancers in TYA
The good news is that in many cases GPs examined their patients, noted their findings, prescribed and ordered chest x-rays appropriately when patients presented with respiratory symptoms. A third of all patients were referred more than one month after presentation. In nine of the 45 cases there were opportunities for earlier diagnosis which included recurrent consultations for respiratory symptoms, a patient with known asbestos exposure, patient with recurrent exacaberation of COPD and a patient known to the respiratory team. Some of the key factors in delayed referral were the complexity of presentation as a result of co-morbidity, patient delay or reluctance to accept health care, false negative chest x-rays and reasonably treating the initial presentation as benign.
● Unless there is a history of infection or trauma, refer all neck and axilla lumps under the two-week rule ● Ensure follow-up plans are in place; eg give appointments ● Beware of bone tumours and sarcomas, which may present with persistent muscular or joint pains, or non-resolving (alleged) sports injury ● The importance of patient-centeredness for young people ● Atypical presentations are not unusual ● Continuity of care with good record keeping ● Safety netting ● Good communication within primary care and between primary-secondary care is important ● Be aware of the two-week rule guidelines
Box 2 contains the key learning points that emerged:
Box 2: Learning points for lung cancer
● Differentiating new, potentially malignant symptoms in patients with known chest disease can be difficult. ● Lung cancer should be considered in the differential diagnosis of shoulder and neck pain, particularly in at-risk groups. ● There is scope for education of patients at particular risk of lung cancer, in order to encourage earlier presentation with ongoing and new chest symptoms. ● Co-existing disease may mask the symptoms of malignancy. There is a need for clearer guidance regarding the role of CXR in COPD assessment, and the role of CXR in long term condition reviews for known smokers. ● It is important to have appropriate safety-netting and to implement follow-up plans with patients, even if they are presenting with their first recent infective episode.
Good communication between members of the primary care team and the primary-secondary care interface, good practice organisation, safety netting, continuity of care with follow- up plans all contribute to early diagnosis.
Teenage and Young Adult cancers These are, of course, rare cancers. Many cases of exemplary practice are listed in the audit report. However some cases, unsurprisingly in view of the rarity of the cancers, presented diagnostic difficulties. Key messages are listed in Box 3:
One of the striking outcomes from these SEAs was the number of changes made after reflection; at the consultation level, at the practice level or at the cancer network level. For example, at the consultation level GPs said they would keep more detailed records and lower their threshold for chest x-ray. At a practice level practitioners were made more aware of guidelines. Practices planned to discuss all cancer diagnoses at practice meetings, encourage patients to see the same GP for ongoing problems and encourage locums to discuss their cases.
This is a comprehensive audit with a robust methodology that could easily be reproduced. Practices engaged well with the concept of secondary analysis of SEAs. Practitioner and system factors were identified that could be improved. At the same time, there were many examples of reflective practice with all the attributes of good general practice on show including patient centredness, continuity of care, safety-netting, good follow-up plans and excellent communication between health care professionals. Cancer in primary care: Analysis of significant event audits for the diagnosis of lung cancer and cancers in teenagers and young adults 20082009. Mitchell E, Macleod U, and Rubin G. www.dur.ac.uk/resources/school.health/ AnalysisofSEAforcancerdiagnosisUpdatedfinalreport.pdf Also available on the RCGP-Clinical Innovation and Research Centre (CIRC) website: www. rcgp.org.uk/clinical_and_research/circ.aspx
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RCGP Clinical Champion for End of Life Care Professor Keri Thomas will discuss Improving End of Life Care in Primary Care at the College on 19 January 2010. Professor Mike Richards, National Director for Cancer and End of Life Care, and former RCGP Chairman Professor Mayur Lakhani, Chair of the National Council for Palliative Care, are also among the guest speakers. The event is the latest in a series of ‘Supper Seminars’ hosted by the RCGP to provide updates on the work of its Clinical Champions. Several seminars on musculoskeletal disorders, chaired by local GPs, are also in the pipeline. They include:
Shoulder and elbow pain Hip pain and arthritis Carpal Tunnel Syndrome Red Flags
The Royal Veterinary College is the UK’s first and largest veterinary school and a constituent College of the University of London. It also provides support for veterinary and related professions through its three referral hospitals, diagnostic services and continuing professional development courses. The RVC Council has legal responsibility for strategic direction, governance and control of the College and the majority of its members are drawn from business and commerce, the veterinary profession, academia and the public sector. Professor Quintin McKellar, Principal of the RVC, said of the appointment: “Dame Lesley Southgate is an internationally-renowned medical educator who has devoted enormous energy to establishing innovative approaches to the teaching of clinical skills in the medical field. It is this expertise that will contribute to the RVC’s continued drive to deliver excellence in teaching and education.” Professor Dame Lesley Southgate said: “I am delighted to have been appointed to the RVC Council. The interrelationship of medical and veterinary sciences leads to much crossover in the education of the two disciplines. Having worked for many years developing and implementing assessment methods in the human medical field, applying this knowledge to the veterinary sector is a natural step.”
Summary
Have your say in Supper seminars with the Champions King’s Fund Inquiry The King’s Fund is running an 18-month Inquir y into the quality of general practice in England. As part of this work, the Fund is conducting an opinion survey on the extent to which general practice is currently providing high-quality patient care and the reaction of those working in general practice on current approaches to ‘quality improvement’. RCGP Chairman Professor Steve Field has been invited to join the Inquiry panel. He said: “This is an important opportunity for us to stand up for general practice and demonstrate the high quality care that we are all working hard to provide for our patients. I hope that as many RCGP Members and Fellows as possible will find the time to contribute.” ■ Please visit www.kingsfund.org.uk/yourviews to contribute.
Former RCGP President and RCGP Council Member Professor Dame Lesley Southgate, has been appointed for a four-year term to the Royal Veterinary College (RVC) Council to bolster expertise in the field of clinical education.
LONDON
BIRMINGHAM
6 January 3 February 3 March 14 April
13 January 11 February 11 March
The events are sponsored by BMI Healthcare, and places are available to members at the subsidised rate of £20 (non-members £45). ■ Visit www.rcgp.org.uk/courses to book your place.
Professor Jones: New editorial role
New GP at the helm of the BJGP Professor Roger Jones is the new Interim Editor of the British Journal of General Practice, succeeding Dr David Jewell who has stepped down after ten years. Professor Jones has played a leading role in the development of UK academic general practice over the last 20 years, during which time his main area of research interest has been the epidemiology and management of common gastrointestinal problems in the community and in primary care. He is currently leading a national programme of research to develop quality indicators for the care of gastrointestinal disorders in general practice and is also involved in research on abnormal liver function. He has been Wolfson Professor of General Practice at King’s College London School of Medicine since 1993 and previously edited Family Practice between 1990- 2004. He was also Editor-in-Chief of the prize-winning Oxford Textbook of Primary Medical Care. RCGP NEWS • JANUARY 2010
PERSPECTIVE
The changing face of general practice With women now accounting for 57 per cent of medical school entrants, a landmark report outlining proposed solutions to accommodate the changing face of the medical profession has been published – with vital contributions from key members of the RCGP Council. The report – Women Doctors: Making a Difference – was authored by Baroness Deech, Chair of the National Working Group on Women in Medicine, of which RCGP Chairman Professor Steve Field was a member. In the report, the National Working Group on Women in Medicine has proposed developmental solutions to issues that have and continue to become evident as the profession approaches gender parity. The report states that, despite women accounting for more than half of medical school entrants, gender disparity still remains in many senior medical positions. The report attributes this to the increased attrition rates of female doctors in senior positions, which in turn was attributed to the clash of career turning points and external, personal influences such as childbirth. The report identified five main ‘barriers to
success’, citing pregnancy and maternity leave, children, age and professional and psychological barriers as the main obstacles standing in the way of women’s progression in medical careers. RCGP Chairman Professor Steve Field noted that, in contrast, half of the RCGP’s senior officers were women. He said: “We are very proud that so many of our senior posts are held by women. The RCGP believes that women in medicine should be able to take advantage of any and all opportunities within their competency and expertise, and that these opportunities should not be placed out of reach because of the demands of family life.” RCGP Honorary Secretary Professor Amanda Howe described the challenge facing many doctors – both men and women – who find they need to take a career break at some point in their lives, and said that one issue was finding a way to maximise doctors’ input into the workforce over a working lifetime. She said: “You don’t want to train doctors and then lose them for bits of their career unless it’s inevitable, so one of the tricks is to plan for the potential need of any doctor to have career breaks.” In an open letter to Sir Liam Donaldson, Chief Medical Officer for England, Baroness Deech said that the Board had been confronted with the question of why there was still discontent among many women in the industry despite
several reports in recent years focusing on the progress of women in medicine. Baroness Deech said that an increasingly female workforce brought with it a series of challenges ‘not unique to medicine’, and stressed that lessons could be learned from other professions that had undergone similar demographic shifts. The conclusion was that previous reports had focused on ‘desired outcomes, rather than on the necessary levels of change needed to achieve them’. As a result, this new report has instead focused on the implementation of change, with recommendations targeting three primary areas: ● Improving existing structures so that there are different ways of working, as well as improved advancement to crucial career turning points ● Ensuring that new processes, such as revalidation, are flexible and have the capacity to accommodate doctors without usual working patterns ● Providing support for the practicalities of caring for a child or dependent relative Professor Howe described a recurring situation in which she has been approached by doctors who have struggled to return to work following a career break. She said: “What you actually hear is women saying ‘I would have
done more work, but I couldn’t get a job that had flexible hours’, or ‘I would have come back to general practice, but I couldn’t get funding for a returners’ scheme’. You get some men saying the same, but the big change is when a man says I want to work part time, everyone thinks ‘we’d better sort that out’. So we need more guys to say that this is an issue for them too. “A lot of my young colleagues already have families and are saying the same thing: ‘which specialties can I do where people plan for family commitments?’ They are trying to juggle their work commitments with having children, or of course, elderly parents.” The report set out a number of proposals to address these issues, from improving access to mentoring and advice to improving access to childcare. It recommended that women doctors should find themselves in a position where they feel able to advance in their careers, both professionally, through encouraging women in leadership and in applying for the Clinical Excellence Awards Scheme, and personally, by improving access to childcare and support for carers. In the report, Baroness Deech said: “If we do not make provisions to ensure that the workforce is able to meet patient expectations and professional and academic requirements, then the UK will face a dramatic shortage of working doctors in the future.”
CASE HISTORY: CLARE GERADA
CASE HISTORY: CLARE TAYLOR
Career Summary
Career Summary
RCGP Vice Chair Dr Clare Gerada has worked as a GP for almost 20 years, having initially trained as a psychiatrist. Based in south London, Dr Gerada specialises in substance abuse and mental health. She has held positions at the Department of Health and runs a service for sick doctors in London. A Fellow of the RCGP, she is a member of the Royal College of Psychiatrists, and was recently made a Fellow of the Royal College of Physicians.
Clare graduated from Cambridge with a distinction in Medicine in 2002 and did a four-month GP house job in a rural practice near Huntingdon. She was the Chair of the Associates in Training committee 2008/09 and has recently been appointed as the First5 CPD fellow at RCGP. She also works at an inner-city practice in Birmingham and is an NIHR in-practice fellow at the University of Birmingham doing cardiovascular research.
Obstacles and challenges
Obstacles and challenges
“General Practice has been the most fantastic career because it has allowed me the flexibility to pursue my interests and the unbelievable privilege of seeing patients from different domains across long periods of time. I found that what I really loved was the continuity of care and the variety of seeing patients with a whole range of conditions. “I believe that as a parent, more than as a woman, you have to be prepared to make a choice – do you miss the first school nativity play, or do you go knowing that you may have to give up a very important meeting that could get you on the next step of your career? You have to realise that the person missing out isn’t necessarily the child but you, and you have to accept that. Throughout my life my salary has been spent on providing excellent childcare for my children – and good holidays for us to spend time together.”
“My work as an academic GP registrar and role within the College have been an important part of my life over the past couple of years. I get a huge amount of fulfilment from doing a job I love, and I realise not everyone feels this way about their work, so I am very fortunate. However, having a healthy balance is essential and I always find time for the people who are important in my life. I also have an amazing group of friends that I’ve known since school who are all nonmedics which keeps me grounded and, above all, sane.”
Advice for women entering medicine “My maxim in life is to say yes and then think about it afterwards. My advice is to seize opportunities as they come, because in my experience they don’t usually present themselves again. The second piece of advice I’d offer is work hard – and don’t expect people to notice. “I do think that as a woman you’re much more torn with choices about home versus career. I think the anguish and persistent guilt if you choose to focus on your career is probably greater for a woman as we have a biological drive to be home makers and carers. In the end nobody though has it easy – and you have to make a choice if you want to get on with your career.”
Advice for women entering medicine “Medicine is a fantastic career. I didn’t go into medicine with any preconceived expectations but it has proven to be a hugely satisfying and rewarding career for me. I feel proud to call myself a doctor. As a man or woman, being a doctor can, however, be physically and emotionally demanding. There are many career paths available which can mean some difficult choices along the way. The measure of success can ultimately only be judged by you. Be it esteemed professor, GP retainee or GP with special interest, we all have our part to play in the team. As in any career, you need to surround yourself with people who respect you for who you are and what you do and who will celebrate your successes and support you when the job gets tough.”
CASE HISTORY: VAL WASS Career Summary
CASE HISTORY: HELEN LESTER Career Summary Helen graduated from Cardiff in 1985, before completing the Cardiff Vocational Training Scheme in 1989. After 18 months of work in psychiatry, she became a partner in an inner-city surgery in Birmingham where she worked for 14 years. In 1995 Helen began a taught masters in Research Methodology and an MD. Helen currently works for Manchester Primary Care Group.
Obstacles and challenges “In terms of barriers, I think back when I was looking for a partnership in 1990 the situation was very different for women doctors; it was a much more gendered world. I laugh about it now, but there were situations where I had applied for partnership – I’d get as far as an interview – they would discover that my husband was also a GP looking for a job and I would be politely turned away. “My support mainly comes from home: my husband is a full-time GP and is very busy – but right from the word go, he has been absolutely an even partner in bringing the kids up, doing the cooking, doing the shopping. Just as I have always known what I wanted from my career, we also knew that we wanted to have a family. It’s a completely even partnership. I had to juggle some things like any career woman – but having an equal partnership has made all the difference.”
Advice for women entering medicine “The best advice I can offer to women entering medicine is that you have to be strategic – it was smooth because I always knew what I had to do next. Don’t expect it to happen – you have to make it happen, and you can only make it happen by thinking ahead. Sometimes people say I’m too strategic, but you really do have to be organised, and that’s the basic message. “There are lots of potential knockbacks, but at some point things will go your way. Sometimes you don’t get your papers and you don’t get grants – in the end, if you want it enough, and you’re strategic enough and you’re good enough, you’ll get there.” RCGP NEWS • JANUARY 2010
Val Wass is the new Head of Keele University Medical School. Her path through medicine for the first ten years progressed from paediatrics to clinical research and then adult nephrology. Val then became a full time GP for 11 years before moving back into Academic Primary Care first at Guy’s, Kings and St Thomas’s and then Manchester medical schools. She secured a Masters and PhD in Maastricht and now trains others.
Obstacles and challenges “I was particularly lucky when I graduated that there weren’t the strict career paths that there are now. Back then, it really was a man’s world. If you were caught on the phone to John Lewis you were teased, but if you were phoning your bank manager it was fine. “When my children were young I had the benefit of help from my mother and the crêche at Great Ormond Street. I had a great support network of working women who would help each other out. “I believe you’ve got to move yourself. If you take opportunities when they present themselves you don’t have to be assertive or obnoxious. I don’t think there’s any point in sitting back and complaining when you’re faced with an obstacle – building a career can be, and often is difficult, but with any obstacle, if you can’t get over it, you can always move around it.”
Advice for women entering medicine “I’m a big advocate of mentoring, and think that it’s really important to have a mentor throughout your career. I’ve always one, and I’ve particularly had a male one because I wanted to try and work out how men’s minds work! “There’s so much flexibility for women in primary care. But one of the most important things is that you really work at building your own CV – it’s very competitive out there, and you won’t be able to compete if you don’t keep your training and skills up. It’s so important to look after your own personal development. It can feel like a bit of a trade-off if you want to take time out of your career. If you do, you have to accept that you will have to strive to resume pace with your peers. The trick is not to look at it so much as a compromise, but an active choice. If you take time out, particularly in primary care, you can always come back to it, but you can’t expect to cut corners.”
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NEWS
Blackthorn pushes the boundaries in disability care The RCGP Disability Care Award is an annual award sponsored by Leonard Cheshire Disability to recognise innovative or significant developments in the delivery of care to disabled people in general practice.
Making a point: RCGP Chair Professor Steve Field debates the self care question with King’s Fund director Anna Dixon, Shadow Health Minister Mark Simmonds and Dr Laurence Buckman, Chair of the General Practitioner Committee
The argument for self care How to change the public’s mindset on minor ailments was the theme of a conference on self care supported by the RCGP. The conference – organised by the Proprietary Association of Great Britain (PAGB) with free entry for RCGP Members – was attended by Shadow Health Minister Mark Simmonds MP, GPs, policymakers, health managers, pharmacists and patients. College speakers included RCGP Chairman Professor Steve Field, Dr Maureen Baker and Professor Mike Pringle. With the NHS likely to experience a shortfall of around £3billion over the next three years, delegates looked at ways of encouraging a change in attitude towards the treatment of minor illnesses. Many felt a ‘self help’ culture amongst primary care providers and patients for minor, oneoff ailments, such as headaches and indigestion, would alleviate some of the pressure on the profession. Professor Field cited the strong doctor-patient relationship as one solution. “We are the navigators of the NHS and many of our patients come to us with information from various sources. It’s our duty to point them in the right direction to access creditable, evidence-based information and help them to manage it in partnership with us.” King’s Fund Director of Policy Dr Anna Dixon provided the figures: “We conducted quite a large scale study and our evidence suggests that 57 million consultations with GPs each year are for minor ailments, the majority of which end in prescription. These prescriptions cost the NHS around £371million a year and largely centre on ten ailments including back pain, heartburn, indigestion and headaches. Promoting self care for these ten ailments could save around £2 billion per year for the NHS.”
Dr Laurence Buckman, Chair of the General Practitioner Committee, said GP leaders were keen to drive this forward. “It will be a huge challenge and will take a long time but I believe it can be done. Doctors need to lose some of their ‘saintliness’ and start saying ‘look you don’t need this from me, you need another type of care’. We also need others to change and stop saying ‘of course, you must go and see your GP’.” A number of speakers mentioned the swine flu helpline – a new approach which GP Dr Simon Fradd said has been “absolutely fascinating”. “The public have taken to the telephone support line and the website in a massive way and are quite happy to deal with lay people. The message is now quite clear – let us give the public the facilities they need to make their own decisions. We are a resource for them and we need to let patients make decisions about their own lives.” The conference also included a ‘mock trial’, with the NHS standing ‘accused of perpetuating a culture of dependency’. Feedback from delegates said they felt it had been an excellent event, promoting new ideas and ways of working. Some felt there needed to be more emphasis on how commissioners can drive change and meet that challenge. The general feeling was that public campaigns were the wrong approach – a change in mindset was necessary and people needed to start taking responsibility locally. The event concluded with delegates signing the London Declaration for Self Care, drafted by PAGB and calling for training packages for GPs on conducting self care-aware consultations; a strategy to raise awareness and improve self care among the public; and comprehensive self care training in schools. ■ For further information: www.pagb.org.uk/selfcare/PDFs/ conferencereport17Nov.pdf
Holding court: Professor Mike Pringle during the mock trial at the conference on self care
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This year’s Award went to the Blackthorn Medical Centre in Kent. It works to rehabilitate patients with long-term conditions using Anthroposophy – only one of five NHS practices in the UK to use such methods. Anthroposophy – ‘knowledge of the human being’ – encourages patients to overcome their illness using physical, psychological and spiritual methods. The experience aims to put patients in greater charge of their lives, which in turn benefits their general wellbeing. Each year the Pain Management Clinic takes on around 30 patients who have failed to be helped either in secondary care or specialist pain clinic. Referrals come from all surrounding practices in Maidstone. Dr David McGavin, a partner at the practice, said: “The patient needs to be desperate enough to feel ready to try something else; when just a strong hope for a cure for their pain persists, patients are less likely to engage.” Blackthorn is investigating the work of Rudolf Steiner who pioneered anthroposophic methods in education, architecture, biodynamic farming and medicine in the 1920s. Therapies include painting, modelling, sculpture, coloured glass, counselling, eurythmy and rhythmical massage. Therapies are decided on a case-by-case basis by the team who maintain a thorough knowledge of their progress with regular meetings, changing treatments as and when they feel it is necessary or when the patient feels they are ready to move on. Dr McGavin continues to manage prescriptions of opiates, tranquillisers and anti-depressants where necessary. He also prescribes anthroposophic remedies based on homeopathic and herbal constituents. The team at Blackthorn continuously evaluate its methods. Dr McGavin has recently finished working on a paper with Professor Gene Feder, Professor of Primary Care Research in Bristol, who works at another anthroposophic practice. The research, Chronic Pain as an Instrument for Change; Anthroposophic Management for Long Term Conditions, has found that of 37 patients treated with anthroposophic medicine and therapies 24 per cent demonstrated significant physical improvements and mental health improvements were found in 70 per cent. “One has to distinguish between what a patient might want and what he or she needs. The therapies are an attractive one-to-one activity but
they require work and homework. They have the capacity to introduce friction by increasing the difficulty of the task. Once a patient gets into a comfort zone, it is evident that progress slows, so the challenge needs to be increased. One has to be fair about this according to the patient’s capacities but these can usually be stretched and there are many options, including the prospect of leaving if keenness to keep trying for progress recedes. Blackthorn extends the opportunities beyond therapy, offering sheltered training and employment. It aims to empower patients with new skills and confidence to try to help their own self-worth. It runs a kitchen garden behind the medical centre, a Workways careers office, a wood workshop, beehives, a function room, an arts and crafts room, two training kitchens, a shop and a vegetarian café. Co-workers make food and crafts to sell and have also produced items for the community such as benches for a local council park. The Blackthorn Charity Shop around the corner is run by volunteers. “Our work is about providing a supportive environment in which people can respond to challenges and rebuild their resilience, self-esteem and confidence, as well as learning new skills and developing their social networks,” explains Jan Prior, Chief Executive of the Blackthorn Trust, a registered charity which has worked closely with the Medical Centre for the past 25 years. “While much of the work we do is directed to helping people back into the workplace, this is not the whole picture. Some will achieve softer but no less significant outcomes of an increased sense of self and a greater connection to the community around them. The work is physical, psychological and spiritual, and you can watch people transforming before your eyes.” Patients work alongside volunteers and employed staff. To ensure equality, all workers in the garden and the surrounding buildings are known as co-workers. Employment Development Workers help set short and long term goals and provide advice on CVs, interview techniques and job searches, reviewing co-workers’ progress, and aiming to help them find regular employment be it voluntary, full time or part time. The hard work is paying off. Martin, one of the patients, is using sculpture as a therapy. He said: “I feel like I’m part of the stone. I take bits off, wash it and perfect it. I’m at one with it and it relaxes me. This makes me feel completely different – it’s amazing.” More can always be done and alongside the fundraising activities, the Trust is now developing its efforts in social enterprise as a means of sustainably supporting its work. ■ www.blackthorn.org.uk
Taking shape: Martin, a Blackthorn patient, finds major benefit from sculpture as therapy RCGP NEWS • JANUARY 2010
INTERNATIONAL FOCUS
GPs sans frontières: Delegates at this year’s WONCA conference
The work of the ‘Junior’ International Committee gathers pace Sending healthcare where it is needed: St Mary’s in Zambia is one of the units that benefits from Inter Care consignments
Demand and supply: How a charity puts vital unused medicines to work in Africa Dr Tony Jarvis Retired GP, Leicester and former team doctor for Leicester City Football Club
We are fortunate in the UK compared with most of the rest of the world in our National Health Service, with its facilities, abundance of medical staff and the vast range of available medicines. Unfortunately, the scene is different in rural Africa where a doctor is a rarity, nurses and hospitals are scarce and most medicines have to be bought by patients even if they happen to be available locally. The governments of most African countries will budget perhaps £5 a year per head to provide medicines and vaccines for their populations. This means that the rural poor, who may be struggling to find enough money just to feed their families, cannot afford to buy medicines when they fall ill. The global economy has seen a substantial growth over the past 50 years, but Africa has remained poor and its health care systems weak. We know that poverty is not conducive to health, but we also know that access to inexpensive drugs and medicines has proven to be efficacious and beneficial. Within this setting, the charity Inter Care provides essential medicines for some of the African people. In essence, Inter Care collects surplus medicines from doctors’ surgeries and pharmaceutical companies, sorts them appropriately under licence, then donates them to hospitals and other health care units in rural subSaharan Africa where the needs are the greatest. We also collect and send small medical and surgical equipment, dressings of all kinds, and provide an information service. Our aim is to support local African people in their efforts to improve their short- and long-term health care needs. The charity was founded in Leicester in 1974 by two British doctors, husband and wife Dr Patricia and Dr David Rosenberg, both now deceased. They began with the knowledge of two simple facts that large quantities of useful in-date medical and surgical supplies are discarded in the UK each year, and that rural clinics in Africa are desperately short of these supplies. Inter Care follows the WHO core principles of drug donations, which are: that they provide maximum benefit to the recipient; and respect the wishes and authority of the essential drug list. There are good communications with the recipients and Inter Care staff, and Trustees visit projects in Africa at regular intervals to maintain the personal relationship, and to gain updated information on their needs. We are fully authorised by holding a Home Office licence and also an Environment Agency licence to handle waste (returned medicines are classified as industrial waste). Our patrons are Bishop Malcolm McMahon, Bishop of Nottingham; professional boxer Amir Khan and Margaret Grieff MBE. Currently, we have three paid part-time staff and 31 volunteers, including four doctors, four pharmacists and three nurses who process the medicines and co-ordinate dispatch to the medical units we serve. At present we supply medicines to 106 rural units in six African countries – Cameroon, Ghana, Malawi, Sierra Leone, Tanzania and Zambia. Each unit receives a consignment at least twice a year. In the past 12 months we have sent £393,825 worth of medicines comprising 171 consignments made up of 774 parcels. RCGP NEWS • JANUARY 2010
Donations gratefully received: Dr Jarvis sorts recycled medicines Over the 35 years of our existence, we have sent nearly £9 million pounds worth of medicines to Africa. If these medicines had not been collected, they would have been destroyed by high temperature incineration or landfill. The parcels travel to their destinations by parcel post as we find that the safest and best method. More than 95 per cent of the parcels arrive intact, and collection by the units from their local post office involves a short journey only. This reliable method of transportation greatly diminishes the risk of pilfering and in-country diversion. With the epidemic of AIDS in Africa, we also play a small part by supplying extra palliative care medicines to our units, thus ensuring that HIV-positive patients are able to get medicines free of charge. We also provide them with information on how to apply for free or preferential priced antiretroviral drugs from international pharmaceutical companies. Haemoglobin testing strips for anaemia and urinary glucose test strips are also supplied. Despite being a small charity, we do have an impact on health care in Africa. The sick know that somebody cares and it is estimated that the combined areas supported by Inter Care contribute to the health care of around five million people. Our donations are regular, year in year out, and therefore have an impact; and the medical staff are provided with a means to heal, thus improving their morale. Inter Care is truly a humanitarian charity that is unique. Everyone who hears about us recognises its value. We may be small, but we are practical, focused and have all the right credentials. With continuing encouragement and help we hope to be able to bring in more medicines and finance, thereby increasing the number of medical units we support. There are so many more waiting for our help. ■ To progress the work of Inter Care, we encourage GP practices to collect and send medicines. A Doctor’s Information Pack is available on request. Other ways of helping are to contribute financially to our shipment and running costs. For detailed information, see our website www.intercare.org.uk, or speak to the office on 0116 269 5925.
Dr Jessica Watson ST1 Academic GP, Severn Deanery, University of Bristol
The newly formed RCGP Junior International Committee has been busy since its inaugural meeting only six months ago. Thanks to the generosity of RCGP Faculties and the hard work of some dedicated individuals over 30 GP trainee and newly qualified GPs had the opportunity to attend the 2009 WONCA Europe conference in Basel, Switzerland. We were united with trainee and newly qualified GPs from across Europe by the Vasco da Gama Movement (VdGM), which was set up in 2005 as the movement for young and future GPs within WONCA Europe. VdGM activities are encompassed within five theme groups, which have been mirrored in the UK Junior International Committee: ‘Education and Training’, ‘Recruitment’, ‘Research’, ‘Exchange‘ and ‘Image’. One of the VdGM activities is to organise an annual preconference workshop at WONCA. Those of us who were lucky enough to attend had a fascinating opportunity to meet and share ideas and experiences with colleagues from different cultures, healthcare systems and training schemes. Meanwhile others with a research interest enjoyed a valuable whistlestop tour of research methodologies at the preconference research course. This set us up perfectly for the research bonanza which was to follow, with over 300 oral presentations and 500 posters as well as 130 hours of workshops covering topics as diverse as climate change and general practitioners; humanities as an aid to lateral thinking in medicine decision making; behaviour in risk and stress situations – and even mountain climbing! Opportunities abounded and the Junior International Committee has been quick to get on board with Vasco da Gama projects which range from organising international exchanges through the Hippokrates program; distributing a Europe-wide survey to compare motivation and satisfaction with GP training; and organising an online forum for international research collaboration among trainee GPs. ■ We would like to encourage GP trainees and newly qualified GPs to get involved in this exciting new venture. To find out more look at www.vdgm.eu or join the RCGP Junior International Committee Google group at http://groups.google.com/group/ junior-rcgp-international-committee
Choose and Book update New guidance on the effective use of Choose and Book has been issued by the Department of Health. Responsibilities and operational requirements for the correct use of Choose and Book provides greater clarity on the responsibilities of the NHS and clinicians. It follows a BMA review of local experience around the programme. Dr Stephen Miller, National Medical Director for Choose and Book said: “We have worked closely with clinicians, Strategic Health Authorities and with the BMA who have all recognised that some of the local ways of working to support Choose and Book simply don’t work for patients and are often unpopular with professionals. We hope that local health communities will use this guidance to review how they currently use Choose and Book and consider alternative ways of working to help maximise positive patient and professional experiences.” ■ The guidance can be found at www.chooseandbook.nhs.uk/staff/ communications/fact/correctuse.pdf
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CLINICAL UPDATE
A very modern problem: NICE guidance on mental wellbeing at work
Managing medically unexplained symptoms: Moving beyond somatisation
Professor Cary Cooper CBE Professor of Organisational Psychology and Health Professor at the Lancaster University Management School
Neil Berry Consultant Clinical Psychologist Psychology representative on the Council of The British Pain Society
AT THE START of November, the National Institute for Health and Clinical Excellence (NICE) produced public health guidance on the promotion of mental wellbeing at work. The guidance aims to help reduce the estimated 13.7 million working days lost each year due to work-related mental health conditions including stress, depression and anxiety; and represents the fourth set of guidance NICE has produced aimed at workers (following smoking cessation, physical activity, and long-term sickness absence). The NICE guidance highlights how employers and employees can work in partnership to improve mental wellbeing in the workplace, by taking a positive organisation-wide approach that promotes mental wellbeing through changes in ways of working, such as improved line management and the provision of flexible working where appropriate. As well as being applicable to businesses of all sizes, the NICE guidance is also aimed at improving mental wellbeing amongst employees working in the NHS. The NHS currently loses 10.3m working days annually due to sickness absence alone, costing £1.7bn per year (Boorman Review, NHS Health and Wellbeing 2009). The guidance’s key recommendations are therefore just as important to the NHS as the wider business community.
Recommendation 1 Strategic and coordinated approach to managing people Recommendation 2 Managing risks to employees’ mental wellbeing and opportunities for improving it Recommendation 3 Flexible working Recommendation 4 The role of line managers Recommendation 5 Small and medium-sized businesses The NICE guidance also includes recommendations for professionals working in occupational health services, along with those involved in national initiatives and programmes from government and the Federation of Small Businesses. Relevant recommendations for these organizations and services include the need to collaborate with micro, small and medium-sized businesses and offer advice and a range of support and services. This could include access to occupational health services (including counselling support and stress management training). The NICE guidance builds on the work carried out in the EU over the last ten years; and it is consistent with, and reinforces, the evidence-based findings of the major government Foresight project on Mental Capital and Wellbeing (Cooper et al, Mental Capital and Wellbeing, Oxford: Wiley-Blackwell, 2009). This NICE guidance is an innovative, far-reaching and significant piece of work that will help to minimise workplace stress and promote mental wellbeing at work. If we are to action the oftenheard HR rhetoric in the NHS, that ‘the most valuable resource we have is our human resource’, than it is important to take these guidelines very seriously indeed.
Additional information To support implementation of the mental wellbeing at work guidance, NICE has produced the following implementation tools: ● A slide set – a set of slides that summarise the guidance and prompt discussion about implementation. The set can be used to support early awareness raising activity ● A business case – outlining the estimated current costs of mental ill-health to employers, and the potential benefits and savings of implementing steps to improve the management of mental wellbeing ● A guide to resources – to signpost workplaces to resources that will help them and case studies of how some organisations have implemented the recommendations. The guide will be published ten weeks after the guidance The RCGP – and GPs around the country – are already making huge progress in this area. With a £1million grant from the Department of Work and Pensions, the College started running the National Education Programme for Health and Work in General Practice in June 2009 and more than 1,000 GPs across England have enrolled so far. The interactive half-day workshops deliver the latest evidence about work and health – along with practical skills and strategies for managing difficult consultations. ■ Book online for 2010 at www.rcgp.org.uk/healthandwork
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TRAVELLING IN the world of healthcare without a diagnostic passport can be very challenging. Patients who suffer medically unexplained physical symptoms (MUPS) may wander extensively from one medical territory to another in search of a passport and the treatments and services that go with it. At each new border, checks are carried out that may be time-consuming and costly and each time that the patient fails to meet the criteria for a passport, frustration and distress can mount on both sides. Psychiatry has often been the medical specialty that has stepped in to offer these distressed patients a home; and diagnoses such as ‘hysteria’, ‘somatisation disorder’ and ‘functional somatic syndrome’ have been proposed. With these diagnoses has come the offer of psychotropic medications and psychological therapies but many patients have been reluctant to go down this road. Furthermore, appropriate psychological therapies for these patients have been hard to access as mental health services have had to concentrate their resources on patients with severe and enduring mental illnesses. The arrival of IAPT – Improving Access to Psychological Therapies – has the potential to significantly improve the psychological care that patients with medically unexplained physical symptoms (MUPS) receive. IAPT’s Medically Unexplained Symptoms Positive Practice Guide encourages clinicians and commissioners to create pathways for these patients that enable them to access IAPT therapies. The guide reflects the widely-held view, rarely shared by patients, that anxiety and depression disorders underlie most MUPS. While somatisation explanations for MUPS have continued to be commonly used and accepted in medicine, they have become much less trusted within pain services. There is now a considerable body of research indicating that chronic pain states are the result of complex sensitisation processes within the sensory nervous system, both peripherally and centrally. This means that pain conditions that have traditionally been placed under the MUPS heading no longer belong there. This includes non-specific low back pains, other musculoskeletal pains, post-whiplash syndromes, chronic abdominal and pelvic pains, atypical facial pains, non-cardiac chest pains and fibromyalgia. Many clinicians working in pain services are members of the British Pain Society and it was a senior member of the Society who, in the spring of last year, contacted the Society’s president with concerns about IAPT’s MUPS guide. The guide’s recommendations, if implemented, would mean that many patients with chronic pain risk being made more psychologically distressed. These patients would also be less likely to access specialist pain services (contrary to the views expressed in the recent report from the Chief Medical Officer) and less likely to receive the interdisciplinary care that many of them need. Pain clinics and pain management teams treat patients who would previously have been considered to be suffering from MUPS alongside patients with pains that are better understood. These patients normally follow the same interdisciplinary pathways and access the same treatments and services. Psychological therapy is often offered as part of this biopsychosocial package of care and, in this context, it is often accepted. The Society initiated a dialogue with IAPT early in the summer which has been both amicable and productive. The British Pain Society is the UK chapter of IASP, the International Association for the Study of Pain. The official journal of IASP is Pain and, as if to coincide with the ongoing discussions, it published two very relevant papers on somatisation in the September 2009 issue. Geert Crombez et al’s ‘Systematic review of the concept of somatisation in empirical studies of pain’ concluded that: “...The construct of somatisation as applied in pain research is scientifically flawed. Persevering in its misuse will lead only to a poorer understanding of patients with pain, places an inappropriate focus on presumed patient psychopathology and risks misdiagnosis and rupture in physician-patient alliance.” The journal’s editorial, by Harold Merskey, Emeritus Professor of Psychiatry, entitled: ‘Somatization or another God that failed’ concludes: “Thus notions of somatization (and also of the DSM-IV idea of a pain disorder) increasingly lack validity and it is to be hoped that both Somatization Disorder and Pain Disorder will be dropped in the forthcoming revision of DSM-V.” This conclusion is the more noteworthy because Merskey had served on the committee that had put these diagnoses there in the first place. This challenge to the concept of somatisation does not deny that psychological factors may play a causal or maintaining role in chronic pain conditions. It is accepted, for example, that there are important neurochemical and neuranatomical connections between pain and affective states. Emotional factors, both historical and current, undoubtedly contribute to these neuroplastic pain mechanisms, at least in some of the patients some of the time. Psychological factors may even make the largest contribution in some patients. It is worth noting, however, that even though many pain services routinely assess and treat patients for depression and anxiety disorders, and offer patients interdisciplinary Pain Management Programmes, their pain normally persists. Patients often report
● Pain research fails to support the concept of somatisation ● Chronic pain conditions reflect complex neuroplastic changes within the sensory nervous system ● It is no longer appropriate or useful to put chronic pain conditions under the MUPS umbrella ● Pain diagnoses based on somatisation may be dropped from DSM V(R) ● Patients with ‘MUPS’ often require interdisciplinary support ● Psychological therapies are more likely to be accepted in an interdisciplinary context ● Patients with ‘MUPS’ face many of the same challenges as other patients with recognised long-term conditions ● Long-term condition pathways may require few changes to accommodate ‘MUPS’ patients a reduction in pain or say that the pain has become more manageable but they rarely report that the pain has gone. Patients with medically unexplained pain who attend pain services are often advised that their pain probably reflects dysfunctional changes within the complex mechanisms of the pain system itself. An analogy that is commonly employed is that of ‘the faulty burglar alarm’. In this context, pain is no longer viewed as secondary, as a symptom, but as the primary condition to be treated and managed. Pain itself is the diagnostic passport. IAPT has happily provided a second guide that allows the controversy relating to the MUPS guide to be put to one side. IAPT’s Long-Term Conditions Positive Practice Guide includes chronic pain as a long-term condition that may be accompanied by anxiety and depression. Pain conditions that have persisted long enough to be described as chronic – by convention it is three to six months – are themselves long-term conditions. Patients with chronic pain conditions therefore face the same self-management challenges as other patients with long-term conditions: q Understanding, accepting and managing the condition (as far as possible); and w Maintaining and improving their health, physical function, psychological wellbeing and quality of life. This also applies to other patients with symptoms – such as chronic fatigue – that have traditionally been placed in the MUPS category. To designate a condition a long-term condition does not necessarily mean, of course, that it is destined to persist indefinitely. In the pain field, it is recognised that appropriate early interventions – medical, physical and psychological – may be very important in determining whether a pain state becomes chronic and there are powerful voices promoting the view that the neuroplastic changes that maintain a chronic pain condition may be far more reversible than has so far been demonstrated. Whatever the condition, it makes good sense to promote self-management strategies as early as possible. A consensus is emerging that MUPS are best understood and managed as long-term conditions where patients need to be offered psychological therapy, if required, alongside other medical, physical and social forms of support. For any particular long-term condition, the challenge of understanding, accepting and managing the condition may require the support of a specialist service. However, as the focus shifts away from the condition itself onto wider health, psychological, functional and social issues, it is appropriate that patients should access primary care services, closer to home. From the earliest opportunity, positive self-management messages should be part of the management package. It may be possible and appropriate to bring patients with disparate long-term conditions together and this can include patients with conditions that have eluded appropriate diagnostic efforts. We may envisage community based, interdisciplinary teams of health professionals pooling resources and working across medical specialisms and across diagnoses. Thinking along similar lines, John Hague, who chairs the IAPT Special Interest Group for Long-term Conditions and Medically Unexplained Symptoms has recently proposed the creation of primary care ‘Symptom Management Teams’ for patients with IBS and he points out that this idea can be extended to many other conditions. In the world of long-term conditions, services are being developed which do not primarily depend on the patient’s medical citizenship or on the diagnostic passport that is carried. Through the support of services like these, patients with medically unexplained or poorly explained physical symptoms may at last feel understood and receive the guidance and encouragement that they need.
References Tracey I and Bushnell MC (2009). How neuroimaging studies have challenged us to rethink: Is chronic pain a disease? The Journal of Pain. 10(11). 1113-1120. Siddall PJ and Cousins MJ (2004). Persistent pain as a disease entity: implications for clinical management. Anesthesia and Analgesia. 99. 510-520. Merskey H(2009). Somatization: or another god that failed. Pain. 145(1).4. Crombez G, Beirens K, Van Damme S, Eccleston C, Fontaine J (2009) The unbearable lightness of somatisation: A systematic review of the concept of somatisation in empirical studies of pain. Pain. 145(1). 31-35. RCGP NEWS • JANUARY 2010
CLINICAL UPDATE
Interface Geriatrics: New models of care for frail older people Professor Louise Robinson Clinical Champion for Ageing & Older People Royal College of General Practitioners Dr Simon Conroy Honorary Secretary British Geriatrics Society Mr Jay Banerjee Emergency Physician University Hospital, Leicester OUR AGEING POPULATIONS will naturally lead to an increase in age-related illnesses and greater numbers of frail, older people to be cared for in the community. Soon people over 65 years of age will outnumber those under 16 and the ‘oldest old’, the over-85s, are the fastest growing sector of our population. With the continuing emphasis on care for those with long-term illnesses to be as close to their homes as possible, such responsibility will rest initially with primary and community care teams, although help will undoubtedly be required from our specialist secondary care colleagues in geriatrics and old age psychiatry. However as the nature of primary care has changed dramatically over the last 10 to 15 years, so too has the acute care of frail older people. Previously, much of the acute care and rehabilitation of older people was delivered in acute hospital settings. Now, acute care is delivered predominantly in acute medical units (AMUs), often over very short time periods, with ongoing rehabilitation provided in a variety of community settings, including intermediate
care schemes (home based or residential) and community hospitals. Some older patients with complex needs, who would previously have been managed in hospitals by geriatricians, may not receive the specialist geriatric component of comprehensive geriatric assessment (CGA), even though they may still access other aspects of care (physiotherapy, occupational therapy etc). The consequence of this change in health care delivery is unclear, but in some centres the outcomes for frail older people attending AMUs and being discharged back into the community setting are worrying – up to 55 per cent are readmitted and 26 per cent die in the following 12 months 1. While there is welcome and long overdue renewed interest in community geriatrics, it may be difficult to persuade both hospitals and primary care trusts to invest in such services. Why would an acute hospital want to fund a scheme which ultimately might lead to a reduction in ‘business’? And why would a PCT want to invest in a post when the postholder will be spending half their time working in a hospital? One solution would be to develop services which are jointly funded by the PCT and the acute hospital trust and which can benefit both parties. Such is the rationale behind interface geriatrics: geriatricians working at the front door (either the emergency department or the acute medical unit or both), identifying who needs to be admitted and for how long and who would be better served by a community-based multidisciplinary team. These same geriatricians should be part of this team to ensure an integrated approach. An Australian trial has shown that a ‘Comprehensive Geriatric Assessment’ (CGA) approach spanning primary and secondary care can reduce readmissions by around 25 per cent 2; similar UK studies are underway.
The community role of the geriatrician, working within a multidisciplinary team, can not only be linked into early expedited discharge support from hospital. More importantly, they may be able to decrease the need for access to acute care settings and unnecessary admissions, as has been shown by several of our colleagues in recent years 3. Of course, avoiding admissions or readmissions is fine, but the real aim is to improve the quality of care for frail older people. Appropriate resource utilisation and allocation is more important than reducing resource use. These arguments are the currency of the day and may be helpful to colleagues trying to develop services in this challenging economic climate. So maybe a fusion of community and acute geriatric medicine, the ‘interface geriatrician’, is one way by which care for older people can be improved, whilst keeping both commissioners and providers happy. A conference specifically focused on Interface Geriatrics is being organised by the British Geriatrics Society, and supported by the Royal College of General Practitioners and the College of Emergency Medicine. The Interface Geriatrics Conference will be held on Friday 5 March 2010. It will be of great interest and relevance to all healthcare professionals involved in the care of older people in the community and will include contributions by representatives from both primary and secondary care. We look forward to seeing you there. ■ For more information about Interface Geriatrics and to book places at the conference, please visit: www.bgs.org.uk/Notices/interface_geriatrics.html
References 1) Woodard J, Gladman J, Conroy S. Frail Older People at the Interface. JNHA 2009; 13 (suppl 1 S308) 2) Caplan GA, Williams AJ, Daly B et al. A Randomized, Controlled Trial of Comprehensive Geriatric Assessment and Multidisciplinary Intervention After Discharge of Elderly from the Emergency Department; The DEED II Study. Journal of the American Geriatrics Society 2004; 52(9):1417-1423 3) Donald IP, Gladman J, Conroy S, et al. Care home medicine in the UK – in from the cold. Age Ageing 2008: afn207
Putting responsiveness to patients into practice: College hosts free workshops
Why you should go NAPT if you provide psychological therapies in your practice
The RCGP is hosting free one-day events to support GPs and Practice Managers in making practices more responsive to the needs of patients.
Do you provide psychological therapies in your surgery? Do you have a therapist or counsellor attached to your practice? Then Auditing Psychological Therapies for Anxiety and Depression (NAPT) is of interest to you.
The interactive workshops will provide practical solutions to issues including: ●
Managing workload and demand
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Making technology work for you
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Marketing your practice
GPs and practice managers are encouraged to attend to: ● Find out about best practice in your area – so you don’t have to reinvent the wheel ● Find out how to make your life easier by working smarter, not harder ● Achieve five CPD credits (or ten if you can demonstrate change in your practice) Run in partnership with the General Practitioners Committee of the BMA and the Practice Management Network, ten regional events will be held during February 2010.
Forthcoming workshops 2 February 3 February 3 February 4 February 9 February 9 February 10 February 11 February 23 February 25 February
HUNTINGDON, East of England LONDON GOSFORTH PARK, North East READING, South Central BOLTON, North West LEEDS, Yorkshire & Humber LOUGHBOROUGH, East Midlands EXETER, South West CRAWLEY, South East WARWICK, West Midlands
■ To book places at these events, please visit www.rcgp.org.uk/gpaccess RCGP NEWS • JANUARY 2010
Nici Gideon National Audit of Psychological Therapies Imran Rafi Medical Director of RCGP-CIRC
NAPT is a national initiative that seeks participation from all services, teams and individual therapists who provide treatment for anxiety and depression in England and Wales, provided they are funded by the NHS. It includes both primary and secondary care, as well as voluntary sector services. NAPT has been funded by the Government through the Healthcare Quality Improvement Partnership and is managed by a team at the Royal College of Psychiatrist’s Centre for Quality Improvement in partnerships with a range of professional and voluntary organisations, including the Royal College of General Practitioners. It is particularly challenging to recruit counsellors and therapists attached to GP practices. If you are offering psychological services in your practice we would value the participation of those therapists and encourage you also to inform your colleagues about NAPT. The audit will begin in May 2010. Data will be collected on four important dimensions of quality. ● Access – who is offered therapy and how easy is it for people to take up the offer? Data will be collected on people’s demographic characteristics and on their waiting times. ● Appropriateness – what kind of therapy is provided and is this consistent with best practice? Data will be collected on the types of therapies being delivered and it will be assessed to what extent these therapies are in line with NICE guidance. ● Acceptability – is the type of therapy offered acceptable to the patient? The NAPT project team has developed a service user survey in collaboration with people who have experienced psychological interventions for anxiety and depression, which includes a measure of therapeutic alliance. ● Outcomes – do people feel better and are they better able to cope with their anxiety and depression as a result of therapy?
Data will be collected on outcome scores at the start and end of therapy, so that services will be able to assess the effectiveness of their therapy. The data will be used to provide individual services with specific feedback on their performance and on the views of service users. It will further highlight areas for quality improvement and promote best practice. Services will also be able to benchmark themselves against national performance. In order for the obtained results to be as meaningful as possible, it is crucial for as many services and therapists to participate in NAPT. Psychological services throughout England and Wales have been encouraged to sign up for the audit now by contacting the project team directly (napt@cru.rcpsych.ac.uk) or by downloading a registration form online (www.rcpsych.ac.uk/napt).
General Practice Foundation General Practice Nurses Managers Physician Assistants
The General Practice Foundaiton is a new RCGP initiative that offers practice managers, nurses and physician assistants working in general practice in the UK the opportunity to be a part of the Royal College of General Practitioners
www.rcgp-foundation.org.uk 7
RCGP AGM
A portrait of Professor David Haslam was unveiled at the RCGP Annual General Meeting to commemorate his three-year term as President of the College. The portrait is the work of Bing Jones – who is also a doctor in blood and bone marrow transplantation. Professor Haslam said: “I am delighted with how Bing’s portrait has turned out – and I’ve been told it is an uncanny likeness. It’s fantastic to have a lasting legacy in the college.” Bing Jones said: “This painting was a particular pleasure. Though it’s a traditional portrait, painted in oil and tempera from live sittings, the sitter was such good company that the time just slipped by. I paint sitters from all walks of life but feel a particular empathy for other doctors, which I hope is evident in this piece.” The painting will hang in the RCGP art collection of previous Presidents at the College’s headquarters in Princes Gate.
GPs of enterprise and excellence
JASON LANCY
JUSSTIN GRAINGE PHOTOGRAPHY
Portrait of a doctor – by a doctor
The GP Enterprise Awards are organised by the RCGP, GP Newspaper and sponsored by the Medical Defence Union to promote ideas from general practice that can be easily replicated around the UK. MDU chief executive Dr Christine Tomkins (left) and Professor David Haslam (right) are pictured with this year’s winners Dr Sanjay Pitalia and Dr Shikha Pitalia from the SSP Health at the Ashton Medical Centre, Wigan, who impressed the judges with their ‘text to cancel’ initiative for improving access to appointments. The AGM saw a number of Awards, Fellowships and Memberships presented. Dr Maureen Baker was presented with the Foundation Council Award for ‘special meritorious work in connection with the College’, while Scottish CMO Harry Burns, patient champion Ailsa Donnelly and Michael Farrar, CEO of NHS North West, received Honorary Fellowships of the RCGP. The Phoenix Surgery, in Cirencester, Gloucestershire, was awarded the inaugural RCGP Adolescent Health Care Award promoting higher standards of care for their teenage patients. It has been set up in memory of Dr Kathy Phipps, an enthusiastic member of the RCGP Adolescent Task Group who was killed in a motorcycle accident in March 2008.
JUSSTIN GRAINGE PHOTOGRAPHY
Passing the baton Dr Iona Heath is the new President of the RCGP. She is seen here being congratulated by the outgoing President.
Sustainable
Primar Care growing healthy partnerships
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The ‘Uber General Practitioner’ was the theme of the James Mackenzie lecture presented by RCGP immediate past Chairman Professor Mayur Lakhani. Professor Lakhani – pictured with daughters Sonam, Priyanka, son Rahul and wife May – said: “I wanted to explore and advocate a stronger role and a higher level of clinical medicine in general practice and emphasise the importance of diagnosis. Leadership from GP organisations has been key in this and our College has been at the forefront. Unity is important between GPs, working together and avoiding tribalism.”
If you’re a poet, why not show it? A new annual poetry competition with an award fund of £15,000 has been launched and is looking for applications from NHS professionals. The Hippocrates Prize, supported jointly by the Warwick Institute of Advanced Study and the UK national Fellowship of Postgraduate Medicine, is a new international poetry competition on the theme of poetry and medicine. Encouraging entrants to think of medicine in its broadest sense, the competition will be judged by poet and chest physician Dannie Abse, NHS Medical Director Professor Sir Bruce Keogh and broadcaster and journalist James Naughtie. The prize is awarded in two categories: the Open International Category, into which anyone may enter, and the NHS Category, which is open exclusively to UK National Health Service employees and medical students. The fee to enter is £6 per poem, and entrants may submit as many poems as they wish. All winning and commended poems will be published in a book of 46 poems, and the highest-ranked 300 entries will also be published electronically. The competition is open until 31 January 2010. ■ More information can be found at www.hippocrates-poetry.org 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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RCGP News invites your comments or letters... Please write to: The Editor, RCGP News Royal College of General Practitioners 14 Princes Gate, Hyde Park London SW7 1PU email: rcgpnews@rcgp.org.uk RCGP NEWS • JANUARY 2010