News
Vital support for doctors to improve patient safety Doctors and dentists who have physical or mental health problems or addiction concerns will be able to access a specialist GP ser vice in total confidence as part of a new scheme being launched in the autumn. The Practitioner Health Programme (PHP) will operate as a prompt, first contact service run by GPs who are experts in mental health and dealing with addictions as well as experienced in treating health professionals. It will offer a wide range of services including out patient and rehabilitation. The programme will help healthcare professionals with concerns relating to mental or physical health concerns or addiction, in particular where their condition may be affecting their ability to work. Access to behavioural therapy or the services of occupational health physicians and expert addiction nurses will form part of the support package where necessary, as will confidential appointments with independent advisers able to provide information on appropriate changes to working arrangements such as locum cover. The programme has been set up as a two-year pilot aimed at providing support for registered practitioners living or working within the London Strategic Health Authority area but it could be extended to other areas if the prototype is successful It will be led by RCGP Vice Chair Dr Clare Gerada and her Hurley Group practice, following a competitive tender process. Commissioned by the London Specialised Commissioning Group
(LSCG) in conjunction with the National Clinical Assessment Service (NCAS) it is being funded by the Department of Health and lessons learned from the process will be available for those wishing to set up similar services. While it is a component of the Health for Health Professionals work stream being led by NCAS in response to the White Paper Trust, Assurance and Safety: The Regulation of Health Professionals – the programme is not linked with revalidation or General Medical Council processes. Dr Gerada said: “The PHP has been set up to support doctors and dentists, not to expose their problems. Today’s doctors lead very stressful lives and are trying to juggle many competing demands – younger women doctors in particular are at increased risk of suicide compared with their age match. It’s not surprising that increasing numbers are experiencing health concerns, particularly relating to mental health and addiction. “Doctors can approach us in confidence and be guaranteed targeted, individual care, with tangible results. As well as nipping problems in the bud, we hope the PHP will help to remove the stigma of asking for help. Doctors are only human but it often takes a lot of courage to admit there’s something
❛beenThesetPHPup has to
RCGP Chairman Professor Steve Field was summoned before the House of Commons Health Select Committee to present the College perspective on Lord Darzi’s Next Stage Review. Professor Field was one of the witnesses from six health organisations invited to give evidence to the Committee’s inquiry into the NHS review. Other participants included the King’s Find, the Academy of Royal Colleges and the NHS Confederation – as well as Lord Darzi himself. Professor Field’s appearance lasted for nearly two hours, during which he answered questions led by Chairman Kevin Barron MP on the gatekeeping role of the GP; GP-led health centres; the importance of clinical leadership and the future of general practice. Asked how the College had responded to the announcement of the review, Professor Field replied:
“Given that there was a White Paper only very recently in 2006, our first feelings were, ‘Why are we doing another review?’ but once we had considered the proposals, we thought this was a timely stock take of the Health Service as a whole. “We have been pushing for many years for high quality patient-centred care, moving care out into primary heath care teams and shifting the focus to health promotion and prevention.” The Committee also heard how Lord Darzi’s recommendations had developed over time, moving away from a one size fits all polyclinic approach to a model of care aligned to the RCGP federated model, with practices working together to share ex-
■ A full transcript of the Health Select Committee Inquiry is available at www.publications.parliament.uk/pa/cm200708/cmselect/ cmhealth/uc937-ii/uc93702.htm
NEWS Countdown to the RCGP event of the year! 2
INTERVIEW Dr Maureen Baker announces the end of ten years as Honorary Secretary
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GP TRAINING New e-learning resource
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CLINICAL UPDATE New guideline on Familial Hypercholesterolaemia Asthma diagnosis and management
Dr Clare Gerada
pertise and resources in order to deliver a wider range of services to patients in the local community. Professor Field said the College welcomed the new investment in services resulting from Lord Darzi’s review – but advised sensitivity to local need and urged that local GPs and patients be involved in decision making. “The big issue is about how you implement the ideas locally. There has been a lack of investment in premises in some of our inner city areas, while in others there has been quite a lot. Why not say this money needs to be invested, based on need? The argument is not with Lord Darzi, it is the local implementation of policy that we have concerns about.”
Inside...
RCGP support for patients on smoking cessation
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RCGP Chairman in Parliamentary spotlight on Darzi Review
SEPTEMBER 2008
MENTAL HEALTH
support doctors and dentists, not to expose their problems... This programme will protect patient safety by improving the health of practitioners
wrong. We’re optimistic about achieving excellent outcomes – 80% of doctors currently treated for addiction are abstinent after five years and by providing such targeted support, we’re hoping to raise this even higher.” Professor Alastair Scotland, Director of NCAS, said: “It is vital that
THE NEWSPAPER OF THE ROYAL COLLEGE OF GENERAL PRACTITIONERS
practitioners, like everyone else, feel able and are able to access highly professional and confidential care. This programme will help practitioners who have health concerns do this quickly, confidentially and effectively.” ■ More information about the PHP is available at www.php.nhs.uk
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CARERS Are you an award-winning practice?
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Martin takes the Ethics chair Martin Marshall has been elected as new Chair of the RCGP Ethics Committee. Professor Marshall (right) is Clinical Director at the Health Foundation, an independent charity which aims to improve the quality of healthcare across the UK. He joined the Foundation in November 2007 from his previous role in the Department of Health as Deputy Chief Medical Officer and Director General with responsibility for clinical quality and safety and medical education. Prior to this he was Head of the Division of Primary Care and Professor of General Practice at the National Primary Care Research and Development Centre, University of Manchester. He has worked as a principal in general practice for nearly 20 years, in a semi-urban practice in Devon and inner-city practices in Manchester and London. He has written over 130 publications in the field of policy-related quality of care and is past-President of the European Society for Quality Improvement in Family Practice. He was awarded a CBE in the Queen’s Birthday Honours list for Services to Health Care in 2005. Professor Marshall’s appointment is the first to be overseen by the new RCGP Nominations Committee chaired by Dr Phillip Evans. He succeeds Dr Clare Gerada who is stepping down from the role due to her commitments as Vice Chair of RCGP Council.
CONFERENCE
Counting down to the conference of the year Only a couple of weeks left to book your place for the second RCGP Annual National Primar y Care Conference, Dynamic Practice: Creating Solutions for the Future, at Bournemouth International Centre from 2-4 October. BBC Medical Correspondent Fergus Walsh will be in the chair for what promises to be a national showcase of latest developments in general practice and primary care – as well as comprehensive updates on what’s happening at the RCGP itself. Over 1,000 GPs and primary care healthcare professionals are expected to attend, following the success of the 2007 inaugural event in Edinburgh. The conference is now the must attend event in the primary care calendar, providing GPs and their practice team colleagues with an annual update and a one-stop shop for all their learning needs. Health Minister Lord Ara Darzi will deliver the conference address on his review of the NHS in England and Professor Allyson Pollock, Head of the Centre for International Public Health Policy, University of Edinburgh, will be sharing her insight into the commercialisation of general practice and the implications for patients. Other highlights include Sir Donald Berwick – President and CEO of the Institute for Healthcare Improvement, Cambridge, USA – adding an international perspective to the John Hunt Lecture and there will be a lively ‘Question Time’ session with the UK’s Chief Medical Officers, back by popular demand from last year.
Concurrent Streams GP education and Continuing Professional Development will be a major focus including ‘Essential General Practice Updates’ from Professor Ruth Chambers and Nigel Sparrow, Chair of the RCGP Professional Development Board. Dr Ben Riley – RCGP Curriculum Development and CPD Resources Fellow – will be highlighting the extensive work being carried out by and on behalf of GP trainees, including tailored e-learning packages. Policy stream sessions include James Reason on how develop-
ments in psychology can translate into innovative general practice and David Pendleton on leadership and effective team working. You will also have the opportunity to shape the conference agenda by submitting your questions to speakers in advance, submitting papers or suggesting topics for roundtable discussions.
New Members and GP Trainees New members and AiTs can save over £170 on their full conference registration and participate in a varied programme specifically tailored to their needs – as well as a dedicated social event on Thursday 2 October. A careers forum and AiT workshop on Saturday 4 October will cover overviews of the nMRCGP assessment, ePortfolio, accountancy and interview skills.
Why not bring the Practice Team? A number of sessions have been devised specifically for practice development, giving all members of the primary healthcare team the opportunity to participate and benefit from a range of discussions and workshops. Understanding emerging models of alternative providers of general practice, risk management, business skills and staffing issues are just some of the sessions on offer. Practice teams can purchase a group ticket for just £855 (one GP and two others), making a saving of £190 each.
Exhibition A lively and varied exhibition will accompany the conference, offering delegates the opportunity to meet representatives of over 60 diverse organisations and learn about new and existing products and services. Make sure you visit the ‘RCGP Village’in the main exhibition hall where you can familiarise yourself with current RCGP projects, products and services. GP Newspaper is the official media partner at the event and will be publishing a special conference edition every day, featuring news highlights, interviews and important announcements.
Social Programme The highlight of the social programme is the Annual Conference Dinner and Dance at the newly refurbished Bournemouth Opera House on Fri-
Annual National Primary Care Conference 2008 2- 4 October Bournemouth International Centre
Over 600 delegates have already registered to attend the largest professional primary care conference in the UK. Chaired by Fergus Walsh, BBC Medical Correspondent, highlights will include: Question Time Debate featuring: Don Berwick, President and CEO, Institute for Healthcare Improvement, Cambridge, USA Sir Bruce Keogh, NHS Medical Director, England Dr Tony Jewell, Chief Medical Officer, Wales Professor Allyson Pollock, Head of the Centre for International Public Health Policy, University Dr Michael McBride, Chief Medical Officer, of Edinburgh Northern Ireland Sir Ian Carruthers, Chief Executive, SW Strategic Update on the Darzi Review from Professor Health Authority the Lord Darzi of Denham, Parliamentary Under Secretary of State for Health Dr Richard Vautrey, Vice-Chair, GPC, BMA In addition, over 60 specialist sessions will be held covering all aspects of primary care.
Don’t miss the opportunity to attend! For further information or to register please visit: www.rcgpannualconference.org.uk or contact the conference organisers on 020 8832 7311 or email rcgp@profileproductions.co.uk Principal Sponsor
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Silver Sponsors
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day 3 October. For just £50, enjoy excellent food, drink and company to the sounds of a big swing band. A GP jammin’ session has been arranged for Thursday 2 October, where delegates can show off their musical talents. Wine tasting is also on offer for those less musically minded.
Why not bring the family? Bournemouth International Conference Centre is just minutes away from numerous attractions and activities to suit visitors of all ages. The town centre is home to relaxing courtyards and enclaves, beautiful gardens and an excellent range of shops and restaurants. Attractions include seven miles of sandy beach, with the Oceanarium on the seafront and new Bournemouth Eye offering panoramic views from 500ft high. A crèche will operate throughout the entire conference. Places are available at a cost of £15 per child, per day, if booked in advance. ■ Full details and Conference registration can be found online at: www.rcgpannualconference.org.uk or call Profile Productions on 020 8832 7311
It’s your Conference: you will have the opportunity to shape the agenda
NEWS
Surveys show GP training to be in the best of health By Daniel Smith Head of Surveys, PMETB The recently launched reports of two PMETB (Postgraduate Medical Education and Training Board) surveys have yet again shown that GP trainees and GP trainers are more satisfied than their equivalents in other specialties. This is the first year PMETB has conducted a trainers’ survey and the second year of the national trainees’ survey, which is in conjunction with the Conference of Postgraduate Medical Deans in the UK (COPMeD). The reports offer a summary analysis of the responses to the questions asked and examine some of the differences found in responses from different cohorts of trainees. Over 33,000 trainee doctors and over 10,000 trainers responded to this year’s surveys. The National Survey of Trainees showed that GP trainees (those identified as the Higher group on the reporting tool) are very happy with the training they receive, with 86 per cent (N=1,620) describing the quality of the training they receive as excellent or good and 95 per cent (N=1,620) rating their experience of their training post as excellent or good. These satisfaction levels are notably higher than other specialties and may well indicate a correlation between the amount of training given to GP trainers and the time specifically set aside for them to train. In the National Survey of Trainers, only 18 per cent (N=2,166) of GP trainers as against 62 per cent (N=6,994) of consultants confirmed that service demands meant trainees do not always have the opportunity to take advantage of learning opportunities. When asked whether their workload allowed them to provide appropriate clinical supervision for their trainee/s, 31 per cent (N=2,161) of GP trainers disagreed, as against 39 per cent (N=6,932) of consultants. Significantly, 90 per cent (N=2,180) of GP trainers as against 56 per cent (N=7,067) of consultants reported having received training for workplace based assessments in the last three years. GP trainers also widely outperformed consultants in having training in supporting trainees’ learning, with 81 per cent (N=2,180) having had training for this in the last three years as against 38 per cent (N=7,067) of consultants. While GPs outperformed other specialties in almost all areas, the surveys did pick up on some universal areas of concern, including the availability of flexible training. The further development of flexible training is a topical issue, raised by many across the postgraduate medical education sector as an important area to address. Most recently, the Chief Medical Officer’s 2007 Annual Report (pub-
lished in July 2008) highlighted the need for more flexible training opportunities. With an increasingly female medical workforce, there is clearly demand for more flexible training posts. Indeed, nearly 22 per cent of female trainees across all specialties report wanting to train flexibly but are not doing so, compared with just over seven per cent of male trainees. Seen in this light, although 11 per cent (N= 1,795) of female GP trainees are currently undertaking flexible training (which is among the higher proportions of flexible training in all specialties), a further 17 per cent would like to train flexibly but are not currently doing so, showing that there is still some work to be done on this issue. It is worth noting at this juncture that training flexibly does not appear to impact on trainees’ perceptions of the quality of their training as measured by the survey indicators. Given the changing demographics of junior doctors and the suggestion of unmet need amongst the growing female cohort, those responsible for planning the delivery of training should consider this information with interest. The two surveys show the training of future GPs to be in good health. Moreover, the fact that GP trainers choose to train and, unlike consultants, are given time and remuneration to do so, would seem both to be reflected in the results of this year’s surveys and potentially act as a beacon for the rest of the medical profession. The surveys came about thanks to considerable input and hard work from deaneries and colleges across the UK and were steered by working groups with input on GP issues from Dr Bill Reith, Chair of the RCGP Postgraduate Training Board, and Dr Mark Rickenbach. The online reporting tool, allowing access to reports of GP trainers by deanery, GP trainees in acute settings and trainees in GP posts is available at: http://reports.pmetb.org.uk Commenting on the surveys, Dr Has Joshi, RCGP Vice Chairman said: “The PMETB surveys work is proving an increasingly important source of information for those involved in training and this year’s results once more illustrate very high levels of satisfaction amongst GPs. The fact that our trainers uniquely choose to carry out training may well indicate what will become a trend for others to follow in time.” ■ Summary analysis reports for both surveys can be downloaded from: www.pmetb.org.uk/ index.php?id=2007surveys
➧ On page 4: e-GP, the RCGP’s new e-learning resource to support GP Specialty Trainees with the GP curriculum
RCGP News • September 2008
INTERVIEW
Dr Maureen Baker steps down as RCGP Honorary Secretary in November 2009. She looks back at the achievements of her ten year tenure and forward to the issues the College should now be addressing
The end of an era I
T WILL BE the end of an era when Dr Maureen Baker steps down as RCGP Honorary Secretary in November 2009 after ten years. After one of the longest tenures in the role, she feels the time is right to welcome someone new with a fresh outlook. Her lengthy ‘notice period’ means that she can oversee the appointment of her successor and ensure a smooth and successful handover. Maureen can look back on an impressive record of personal achievement, helping to make the College a driving force in areas such as child protection, patient safety and emergency planning for events like pandemic flu. Her involvement with the College goes right back to her days as a young researcher at Nottingham University. “I was moaning about something to one of the Professors of General Practice when he pointed out that being a member of the College was a way to shape and change things. That got me thinking and I made it my responsibility to get involved.” Maureen soon made a name for herself at the Vale of Trent Faculty, becoming a key member of the faculty board. She was elected to UK Council in 1994. “From the outset I really relished being on Council. Being involved with heated debates on varied and important issues made me feel right at the heart of the profession. I wanted the opportunity to have an impact on both the College and general practice and being on Council has allowed me to do that.” For Maureen, the College has an important role in building professional networks. “Right from the start, and especially during
my early days on Council, I really appreciated the opportunity to meet and engage with the great and the good in general practice, people that I had looked up to throughout my training,” she said. When the role of Honorary Secretary came up, she decided to put herself forward. “The role was perfect for me, it allowed me to immerse myself right at the centre of College business and I knew that I could use the networks and contacts the role provided to really fly the flag for general practice.” She still feels passionately about the vital support that the RCGP provides. “It does so much to develop and improve general practitioners in the UK and plays a vital role in providing GPs with up to date information and resources. Our work to develop the curriculum has been hugely significant for the profession, and as we embark on revalidation, I am delighted that the College’s role in GP education, CPD and training looks set to gather pace.” Maureen is only the second female Honorary Secretary – following in the steps of Molly McBride in 1987 – but gender has never been an issue for her. “The proportion of women who are involved with the various RCGP task groups, committees and Council is starting to reflect the wider trend in our profession and, on some groups, we now outnumber the men!” During her time in office, Maureen has managed to perform an impressive juggling act in both her professional and private life. She keeps a busy home life in Lincoln with her husband and two children and retains a clinical commitment.
❛ As GPs, we are ideally placed to ensure that older people
are looked after in the proper way. I feel that the College should offer support and guidance for GPs on how best to ensure the best possible care for our more senior patients ❜
RCGP News • September 2008
❛ What’s great about the College is that it has managed
to become a professional representative body for the entire profession without losing any of the collegiality ❜
In addition to her work as Honorary Secretary and her place on Council and numerous College committees, she has completed a doctorate and was recently appointed as the Patient Safety Lead for NHS Connecting for Health. While the College has always been fairly egalitarian, she does admit that the hours of business, including evenings, weekends and holidays can be a challenge for College Officers and is the first to admit that it hasn’t always been easy to keep all the plates spinning. “I’m no superwoman; I think one of my biggest achievements is that I’m still married and my children still talk to me! I know this kind of lifestyle isn’t for everyone but I thrive on new challenges. It’s like they say: if you want something doing ask a busy person.” Her biggest disappointment has been the lack of financial commitment to the GP Returner scheme to help those doctors who have taken time out from the profession due to family commitments, professional development or spending time abroad. “The Returner scheme could have been one of the great leaps forward for GP careers. Despite continued hard work and lobbying by the College to ease the process, the shift of funding to the Strategic Health Authorities has been a lost opportunity. “Local funding means that many returning GPs are still facing difficulties. What can be quite a simple process for GPs in some parts of the country continues to be an exasperating exercise for others.” Maureen has seen the College – and general practice – change remarkably during the past ten years, with a huge increase in patient involvement and much more emphasis on the importance of the broader primary care team.
She feels the RCGP has become a much more professional organisation and looks forward to it playing an even greater role in general practice. ‘What’s great about the College is that it has managed to become a professional representative body for the entire profession without losing any of the collegiality. It has maintained its role as a networking organisation while keeping its gravitas. Though the College has grown to represent over 35,000 members, it still offers a heart and voice for our profession.” While Maureen feels the time is right for a new Honorary Secretary, her involvement with the College will not stop here and she plans to continue her work with the many College groups and committees and her local faculty. She is particularly keen that the RCGP takes a stand in improving the experiences of older patients, and feels that this will be a key issue for both the College and the profession in the coming years. “Unfortunately the care of older people is not a glamorous subject, but there is no reason why any person, old or young, should not have dignity in ill health. “As GPs, we are ideally placed to ensure that older people get the best possible care, that they are not neglected or patronised, that everyone has access to decent food and hydration and that all our patients are cared for and looked after in the proper way. I feel that the College should offer support and guidance for GPs on how best to ensure the best possible care for our more senior patients.” Looking to the future, she is giving nothing away but hints that she has not ruled out standing for another RCGP role. Perhaps Chair of Council will be her next challenge?
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MENTAL HEALTH UPDATE
New statement on smoking and mental health The RCGP has joined forces with leading public health organisations to produce a position statement on smoking cessation for patients with mental health problems. Produced by the Faculty of Public Health,this statenent has the endorsement of the College along with the Royal Colleges of Psychiatry and Nursing, ASH, the Mental Health Network of the NHS Confederation, Chartered Insititute of Environmental Health and UKPHA. The statement Mental Health and Smoking is available on the RCGP website: www.rcgp.org.uk Here, RCGP Clinical Champion for Mental Health, Dr Carolyn Chew-Graham, outlines the main issues and the benefits smoking cessationt could bring about for patients with mental health problems. Smoking has a significant impact on the health of people with mental health problems, with higher levels of smoking responsible for a large proportion of the excess mortality of people with mental illness (1). Life expectancy is 20% less for those with schizophrenia compared to the general population and higher rates of smoking are likely to be linked to a ten-fold increase in risk of death from respiratory disease in people with schizophrenia compared with the general population (10). People who have mental health problems smoke significantly more, have increased levels of nicotine dependency and are therefore at greater risk of smoke-related harm (2). Smoking, however, also increases the risk of developing a mental health problem (3), is associated with an increased prevalence of all mental illness (4) and with higher suicide rates (5). Smoking cessation strategies aimed at people with mental health problems can significantly reduce health inequalities for this vulnerable group of people. Much chronic disease – particularly respiratory and cardiovascu-
lar disease – is preventable with the appropriate smoking cessation support. Smoking cessation medication and other non-pharmacological support, such as support and advice from individuals or groups, healthcare professionals or via the telephone/internet, can increase abstinence rates in those with mental health problems to as high as those in the general population (7,8). Although weight can increase after cessation, there is little evidence of worsening of psychiatric symptoms and no major effect on behaviour or aggression (6). Smoking increases the metabolism of a number of drugs, including anti-depressants and anti-psychotics, meaning that larger doses may be required. However, significant reductions in the medication dose may be needed following cessation (8). This is particularly important with clozapine and olanzapine, and is something that GPs, practice nurses and secondary care practitioners need to be aware of. The position statement makes the recommendations outlined on the right:
What needs to happen? Smoking cessation in people with mental health problems should be made a priority: ● Smoke-free policies adapted to fit the local context (6): guidance exists to support mental health trusts implement smokefree policies, working with staff and patients to overcome their concerns. This guidance advises that smoking cessation treatment for both staff and patients is critical for successful implementation of smokefree policy (11). ● Training: all staff in mental health settings should receive training on brief interventions for smoking cessation, with medical and nursing staff receiving more extensive training in smoking cessation. This should also include training staff in primary care settings, in particular GPs and primary care nurses. Such training would advise on best practice for assisting those with mental health problems to successfully give up smoking. ● Specialist cessation treatment provision: specialist cessation services for those with mental illness appear to achieve the best results (7,8). ● Creation of a wider health promoting culture: smokefree mental health units should be an integral part of a more health-promoting culture within mental health settings by providing alternative, meaningful activity during the day as well as other health promoting activities such as healthy eating and exercise.
References 1. Brown S, Barraclough B, Inskip H. 2000. Causes of the excess mortality of schizophrenia. British Journal of Psychiatry. 176: 109.
The Department of Health is currently holding a consultation on the future of tobacco control, with particular emphasis on ways to protect children and young people from tobacco. See: www.dh.gov.uk/en/Consultations/Liveconsultations/DH_085120. To send an e-postcard to the Government, or for help in giving a more detailed response, visit the Smokefree Action website at: www.smokefreeaction.org.uk
Recommendations for government and health services ● Tailored education campaigns aimed at service users, carers and health professionals (both specialist mental health and primary care) about the effects of smoking on mental heath, as well as on physical health. ● Effective coordination of smoking cessation ser vice provision between inpatient and outpatient settings; following discharge from hospital, ongoing smoking community cessation support should occur to prevent relapse. ● Sustained, long-term funding for specialist smoking cessation ser vices in mental health settings and continuity with community-based smoking cessation services following discharge. ● Smoking cessation targets to include settings with mental heath ser vice users to improve cessation rates in this group, comparable to those of the general population. ● Funding of research into smoking and cessation in those with mental health problems since there are relatively few studies in this area. ● Encouraging the extension of smoke-free policy to make mental health premises completely smoke-free, including provision of appropriate support mechanisms for clients and staff. 6. Campion J, Checinski K, Nurse J, McNeill A. 2008. Smoking by people with mental illness and benefits of smoke-free mental health services. Advances in Psychiatric Treatment. 14: 217-228.
2. Kumari V, Postma P. 2005. Nicotine use in schizophrenia: the selfmedication hypothesis. Neuroscience and Biobehavioural Reviews. 29: 1021-34.
7. Foulds JGK, Steinberg MB, Richardson D et al. 2006. Factors associated with quitting smoking at a tobacco dependence treatment clinic. American Journal of Health Behavior. 30: 400-412.
3. Cuijpers P, Smit F, ten Have M, de Graaf R. 2007. Smoking is associated with first-ever incidence of mental disorders: a prospective population-based study. Addiction. 102(8): 1303-9.
8. Campion J, Checinski K, Nurse J. 2008. Review of smoking cessation treatments for people with mental illness. Advances in Psychiatric Treatment. 14: 208-216.
4. Farrell M, Howes S, Bebbington P et al. 2001. Nicotine, alcohol and psychiatric morbidity. Results of a national household survey. British Journal Psychiatry. 179: 432-7. 5. Malone KM, Waternaux C, Haas GL et al. 2003. Cigarette smoking, suicidal behavior, and serotonin function in major psychiatric disorders. American Journal Psychiatry. 160(4): 773-9.
9. Jochelson J, Majrowski B. 2006. Clearing the air. Debating smoke-free policies in psychiatric units. London: King’s Fund. 10. Joukamaa M, Heliovaara M, Knekt P et al. 2001. Mental disorders and cause-specific mortality. British Journal Psychiatry. 179: 498-502. 11. McNeill A, Owen L. 2005. Guidance for smokefree hospital trusts. London: Health Development Agency.
EDUCATION UPDATE
e-GP: A new e-learning resource for GPs in training The RCGP and its partner e-Learning for Healthcare (Department of Health) are developing e-GP: e-Learning for General Practice. e-GP is a free e-learning resource to support GP Specialty Trainees learning the GP curriculum and preparing for the nMRCGP assessments.
Assists GP Training
What e-learning will e-GP provide? Over the next 18 months, the e-GP project will roll out a comprehensive programme of interactive modules and virtual patient consultations to cover the RCGP curriculum. As soon as new modules are available, they will be uploaded onto the e-GP system. Modules available over the next year will include:
Adolescent Health
Being a GP
Child Health
Equality and Diversity
Evidence-based Practice
Genetics in Primary Care
Learning Disability
Patient Safety
Rheumatology and Musculoskeletal
Rheumatology and Musculoskeletal
The GP Consultation
Women’s Health
Promotes Adult Learning
E-Gp
Supports the nMRCGP
Evidence for the ePortfolio
■ For further information, visit the e-GP website: www.e-lfh.org.uk/Projects/General-Practitioners.aspx or email: e-learning@rcgp.org.uk
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RCGP News • September 2008
CLINICAL REVIEW
New guideline on Familial Hypercholesterolaemia DR NORMA O’FLYNN Clinical Director, National Collaborating Centre for Primary Care
NICE published new guidance in August on Familial Hypercholesterolemia: the identification and management of adults and children with familial hypercholesterolemia.(1) This is the second NICE guideline relevant to lipid management developed for NICE this year by the National Collaborating Centre for Primary Care (NCCPC), which is based at the RCGP. The NCCPC developed the Lipid Modification guideline (2) and also developed the guideline on the Secondary Prevention for patients following a Myocardial Infarction which was published May 2007 (3). These three guidelines update the relevant sections of the National Service Framework for Coronary Heart Disease.(4) Familial hypercholesterolemia (FH) is an inherited genetic defect which causes raised cholesterol. Most people with FH have inherited a defective gene for FH from only one parent, and are therefore heterozygous. The prevalence of heterozygous familial hypercholesterolaemia in the UK population is estimated to be 1 in 500, which means that approximately 110,000 people are affected. The elevated serum cholesterol concentrations that characterise heterozygous FH lead to a greater than 50% risk of coronary heart disease by the age of 50 in men and at least 30% in women aged 60. Rarely, a person will inherit a defective gene from both parents. This group of people who are homozygous are at very high risk of early death. Homozygous FH has an incidence of approximately one case per million and usually presents in children. Early detection and treatment with statins is associated with reduced morbidity and mortality in people with heterozygous FH. Low density lipoprotein (LDL) apheresis and liver transplantation are treatment options for people with homozygous FH, with LDL apheresis being occasionally used for people with heterozygous FH who are refractory to conventional lipid-lowering therapy and optimal medical and surgical treatment. While the guideline recommends referral to a specialist for confirmation of diagnosis of FH, general practitioners need to be aware of FH and how it is diagnosed as the condition is currently often not recognised. .
Diagnosis A diagnosis of homozygous FH should be considered in adults with a low-density lipoprotein cholesterol (LDL-C) concentration greater than 13mmol/l and in young people and children with an (LDL-C) concentration greater than 11 mmol/l and referral should be made to a specialist centre. The clinical diagnosis of FH is based on personal and family history, physical examination, and lipid concentrations. The guideline recommends the use of the Simon Broome criteria for diagnosis of FH. These include a combination of family history, clinical signs (specifically tendon xanthomata), lipid profile and DNA testing. FH is diagnosed as ‘definite’ or ‘possible’ as follows: Diagnose a person with definite familial hypercholesterolaemia (FH) if they have: ● cholesterol concentrations as defined in table 1 and tendon xanthomas, or evidence of these signs in first- or second-degree relative; or ● DNA-based evidence of an LDL-receptor mutation, familial defective apo B-100, or a PCSK9 mutation. Diagnose a person with possible FH if they have cholesterol concentrations as defined in Table 1 and at least one of the following. ● Family history of myocardial infarction: aged younger than 50 years in seconddegree relative or aged younger than 60 years in first-degree relative. ● Family history of raised total cholesterol: greater than 7.5 mmol/l in adult first- or second-degree relative or greater than 6.7 mmol/l in child, brother or sister aged younger than 16 years. Health care professionals are advised that when considering a diagnosis of FH they should RCGP News • September 2008
repeat the blood test because of biological and analytical variability, rule out secondary causes of hypercholesterolaemia and establish whether there is a family history of premature coronary artery disease. The guideline recommends that where possible the diagnosis is confirmed by use of a DNA test. This allows certainty of diagnosis and is helpful when screening relatives. DNA testing is not 100% sensitive and so not finding a mutation does not mean the patient does not have FH. The guideline recommends cascade screening for FH in relatives of patients with known FH (the index individual). First, second and if possible third degree relatives should be referred for testing. If a specific mutation has been found when testing the index individual then relatives can be tested for presence of that specific mutation. Otherwise relatives can be assessed using LDL cholesterol levels but interpretation of these values is age and gender dependent and tables are available to guide this interpretation.
Management Lifestyle interventions should not be forgotten in people with FH – cessation of smoking, appropriate diet and physical activity are all important and patients may benefit from review by a dietician. People with FH need treatment with statins and this treatment should be life-long. The aim of treatment is to achieve a greater than 50% reduction in LDL-cholesterol. This will commonly require use of high intensity statins, i.e. statins which produce greater cholesterol lowering than simvastatin 40mg. Ezetimibe either as mono-therapy or in combination with statin is also recommended. Patients not achieving the desired level of cholesterol on these drugs or
who are intolerant of these drugs should be seen by a specialist. A decision to use fibrates, nicotinic acid or bile acid sequestrants either alone or in combination with a statin should be taken by a specialist. Referral should also be considered for people with FH who already have coronary heart disease or who have two or more additional risk factors such as male gender or smoking. Asymptomatic patients with heterozygous FH do not generally need referral for assessment of their coronary arteries. Referral for evaluation of coronary arteries should be considered for patients with homozygous disease, patients with family history of coronary artery disease in young adulthood or patients with added risk factors such as diabetes. Young women with FH have specific needs relating to contraception and pregnancy. There are potential teratogenic effects from lipid-modifying therapy and these should be explained when lipid-modifying drugs are first prescribed and the topic revisited regularly. If a woman becomes pregnant while taking lipid- modifying therapy she should stop treatment immediately and consideration given to foetal assessment. There is a potential small increased risk of cardiovascular events with the use of combined oral contraceptives (COC’s) and other forms of contraception should be considered but COC’s are not contraindicated for women treated with lipid modifying drug therapy.
Children and young people The investigation and management of children suspected as having FH should be carried out by specialists with appropriate expertise in this area. Clinical signs – xanthelasma, tendinous
Table 1 Cholesterol levels to be used as diagnostic criteria for the index individual 1
Child/young person Adult 1
Total cholesterol
LDL-C
> 6.7 mmol/l > 7.5 mmol/l
> 4.0 mmol/l > 4.9 mmol/l
Levels either pre-treatment or highest on treatment
LDL-C, low-density lipoprotein cholesterol
xanthomata and corneal arcus – are rarely present in affected children. Total and LDL cholesterol concentrations increase with age and affected children can have concentrations below those expected in adults with FH. DNA diagnosis therefore is extremely helpful in children aged under 16 years. In children at risk of FH because of one affected parent either a DNA test or LDL-C (if family mutation is not known) should be carried out by the age of ten years or at the earliest opportunity thereafter. LDL-C levels should be repeated after puberty before FH can be excluded because LDL-C concentration changes with puberty. Children with homozygous FH often have total cholesterol concentrations greater than 11mmol/l. They can present with cutaneous xanthomata that may be misdiagnosed as warts and may also have tendinous xanthomata and corneal arcus. It is important to screen both the maternal and paternal sides of the family. In children at risk of homozygous FH because of family history or clinical signs LDL-C concentration should be measured before the age of five years. The guideline also provides guidance on specialist areas such as LDL apheresis and liver transplantation and the recommendations for these areas as well as all the background evidence can be accessed on the NICE website www.NICE.org.uk/CG71
References (1) Familial Hypercholesterolemia: the identification and management of adults and children with familial hypercholesterolemia www.NICE.org.uk/CG71 (2) Lipid modification: assessment of cardio-vascular risk and the modification of blood lipids for primary and secondary prevention of cardiovascular disease www.NICE.org.uk/CG67 (3) MI: secondary prevention in primary and secondary care for patients following a myocardial infarction ww.NICE.org.uk/CG48 (4) www.dh.gov.uk/en/Healthcare/National ServiceFramework/coronaryarterydisease/
Gout: management tips DR CHULANIE DE SILVA Locum Consultant Rheumatologist St George’s Hospital Gout is one of the most painful forms of inflammatory arthritis. Monosodium urate (uric acid) crystals are deposited in joints, tendons and surrounding tissues leading to a marked inflammatory response. It is mainly a condition that affects adult men. Risk factors for gout include obesity, diabetes, hypertension, renal impairment, malignancy, chemotherapy and alcohol excess. Gout usually involves the first metatarsophalangeal joint of the foot – ‘Podagra’ (50-75% of first attacks), although it can affect many other joints such as ankles, knees, wrists and finger joints. In an acute attack of gout, the affected joint/s rapidly become very painful, hot and swollen. There may be a mild fever but usually the patient is systemically well. The attack settles within a few days with or without treatment. In older patients a more chronic form of arthritis can develop. Deposits of uric acid, called tophi, can appear as lumps under the skin, around the joints and at the rim of the ear. In addition, uric acid crystals can collect in the kidneys and cause kidney stones.
Hyperuricamia and gout Hyperuricaemia is common in gout, but is not an obligatory feature. Many patients with hyperuricaemia do not develop gout, whilst some patients with repeated attacks of gout have normal or even low uric acid levels. Serum uric acid levels can be normal during an acute attack of gout in up to 30% of cases. There is also a diurnal variation of serum uric acid concentrations – they are highest in the morning. Uric acid is the end product of purine nucleotide metabolism. Its formation is catalysed by the enzyme Xanthine Oxidase. Uric acid is not very soluble, but fortunately at physiologi-
cal pH, most of the uric acid in the blood stream is in its more soluble ionized form of urate. Particularly in men, urate levels in the blood can reach saturation point whilst still being within the normal range (body tissues and fluids become saturated with urate above 0.41mmol/L). Approximately 30% of the uric acid produced every day is excreted via the gastrointestinal tract. The rest is excreted via the kidneys.
British Society of Rheumatology (BSR) Guidelines for the management of Acute Gout Treatment goals include terminating acute gout attacks, rapid and safe relief of pain and inflammation, preventing future attacks, and avoiding complications such as formation of tophi, kidney stones, and joint destruction.
q Rest the affected joint(s), and prescribe an analgesic, anti-inflammatory drug. Continue therapy for 1–2 weeks. Applying ice to the affected joint can be helpful; for example, ice wrapped in a towel or a bag of frozen peas. The patient should try to drink plenty of water to keep as hydrated as possible. They should definitely avoid alcohol during an acute attack.
w Fast-acting oral NSAIDs at maximum doses are the drugs of choice when there are no contraindications. Indomethacin (150 – 200mg per day for three days followed by 100mg daily) is traditionally the drug of choice, but other NSAIDs have been shown to be equally effective. It is necessary to use maximal doses to get the inflammation under control and treatment should be continued for 48 hours after the inflammation has completely settled. COX-2 inhibitors could be used in patients with dyspepsia.
e Colchicine can be an effective alternative but is slower to work than NSAIDs.
In order to diminish the risks of adverse effects (especially diarrhoea) it should be used in doses of 500µg bd–qds. Colchicine may be used in patients with renal impairment. It can be taken in large amounts over a short period (1mg followed by 500mcg every 2-3 hours to a maximum of 6mg), but is not well tolerated due to the common side effect of severe diarrhoea. Taking smaller doses such as 500mcg up to four times a day is better tolerated but the effects are slower.
r Opiate analgesics can be used as adjuncts to NSAIDs or colchicine.
t Intra-articular corticosteroids are highly effective in acute gouty monoarthritis and intra-articular, oral, intra-muscular or intra-venous corticosteroids can be effective in patients unable to tolerate NSAIDs, and in patients refractory to other treatments. (When using oral steroids, high doses (prednisolone 40 – 60mg once a day) may be required for the first few days followed by lower doses until the attack has resolved).
y Allopurinol should not be commenced during an acute attack but in patients already established on treatment, allopurinol should be continued and the acute attack should be treated conventionally.
u If a patient is already taking allopurinol, but still gets an attack of gout, wait for two weeks after the attack has settled before considering a dose increase.
i If diuretic drugs are being used to treat hypertension, an alternative antihypertensive agent should be considered. However, in patients with heart failure, diuretic therapy should not be discontinued. ➧ Continued on page 7
5
CLINICAL REVIEW
Diagnosis and primary care management of asthma preferred approach, with investigations reserved for situations where the diagnosis is less clear.
DR HILARY PINNOCK MB, ChB, MRCGP, MD
‘I think my patient probably has asthma’
Senior Clinical Research Fellow, Allergy and Respiratory Research Group, Division of Community Health Sciences: GP Section, University of Edinburgh, Principal in General Practice, Whitstable Medical Practice, Whitstable, Kent
● The hallmark of asthma is a history of variable symptoms of coughing and wheezing which are worse at night and triggered by viral infections, exercise or allergy. ● We may know that our patient has rhinitis or eczema, or we may be treating other members of the family with atopic conditions, increasing the possibility of asthma.
British Thoracic Society-Scottish Intercollegiate Guideline Network (BTS-SIGN) British Guideline on the Management of Asthma. 2008
● If the patient is symptomatic, we may hear widespread wheeze on examination or there may be a record of a previous consultation in which wheezing was heard.
What is new in the 2008 guideline? Since the first BTS-SIGN asthma guideline was launched in 2003, annual updates have been published on the websites of the BTS and SIGN (www.brit-thoracic.org.uk and www.sign.ac.uk). The 2008 update is also published as a supplement to Thorax.[1] Key changes are: ● A new approach to diagnosis based on a clinical assessment of ‘high’, intermediate or ‘low’ probability of asthma and a ‘trial of treatment’.
● Comparison of the peak flow at consultation with historical readings may be helpful: a difference of more than 20% further increases the probability of asthma. ● Serial peak flow readings may provide corroborative evidence, though there are important caveats. Peak flows are effort dependent and wide variations in the absence of symptoms may be due to poor technique. Compliance with long-term peak flow charting is (understandably) poor, though a patient may be willing to complete a diary for a week or two to explore the cause of their symptoms. ● Peak flows can be misleading if they are not interpreted in the context of the clinical situation. For example, whilst peak flow variation which consistently correlates with symptoms supports a diagnosis of asthma, a series of normal readings in an asymptomatic patient does not exclude the diagnosis. Peak flow charting is of particular value in establishing a link with occupational exposure.[2]
● A new emphasis on ‘guided selfmanagement’, backed up by regular professional review. ● A reminder that, in patients with poorly controlled asthma, it is important to review the diagnosis, check inhaler technique, discuss concordance and identify triggers before stepping up treatment.
Diagnosis of asthma As primary care clinicians we will understand the ‘probability’ approach to diagnosis advocated in the 2008 guideline. As soon as the patient walks into our surgery and starts to tell their story, we begin to think about the probable diagnosis. Careful questioning, findings on examination, knowledge of the patients’ past and family history will increase, or decrease the probability of asthma. A trial of treatment is the
● Spirometry enables obstructive and restrictive causes of a low peak flow to be distinguished. An obstructive spirogram which reverses to normal with treatment supports the diagnosis of asthma, though because asthma is a variable condition, a normal spirogram in an asymptomatic patient does not exclude the diagnosis. The recommended approach is to commence a trial of treatment with a moderate dose of
‘I think my patient probably has an alternative diagnosis’ The clinical situation may suggest alternative diagnoses. For example: symptoms of lightheadedness and tingling may suggest hyperventilation, a significant smoking history increases the possibility of chronic obstructive pulmonary disease (COPD), and nocturnal breathlessness in a patient with angina may point to heart failure. Investigate and treat for the more probable diagnosis, reconsidering asthma in those who do not respond. ‘The diagnosis is not clear: my patient may, or may not, have asthma’ Further investigations will be needed if asthma is only one of a number of possible diagnoses, or if the response to asthma treatment is poor. Spirometry is the pivotal test as the differential diagnosis and approach to management depends on whether the patient has airflow obstruction (i.e. forced expiratory volume in one second/forced vital capacity ratio <70%). ● Airflow obstruction on the spirogram is usually due to asthma or COPD (or sometimes both), though the differential diagnosis includes causes such as inhaled foreign body, bronchiectasis, lung cancer. A practical approach is to repeat spirometry after a ‘trial of treatment’ for asthma, providing objective evidence of the response. ● Absence of airflow obstruction suggests diagnoses such as hyperventilation, heart failure, gastro-oesophageal reflux, or pulmonary fibrosis which will require further investigation.
● Normal spirometry in a patient who is asymptomatic at the time of the test does not exclude asthma. If asthma remains a clinical possibility referral for further investigations such as assessment of airway responsiveness and eosinophilic airway inflammation may help clarify.
Diagnosis in children The diagnosis of asthma in children follows a similar process of establishing probabilities and observing the response to a trial of treatment. There are, however, some specific caveats: ● It is important to clarify what parents mean by the word ‘wheeze’: patients use the term to describe a range of respiratory sounds.[3] ● The common clinical pattern in infants of viral associated wheeze will normally stop by school age.[4] Differentiation from asthma may only be clear in retrospect. ● There are other important diagnoses (such as cystic fibrosis, inhaled foreign bodies) to be considered especially in children with focal chest signs, symptoms from birth or who are failing to thrive. If there is an intermediate probability of asthma, and no features to support an alternative diagnosis the guideline outlines three strategies: watchful waiting (if symptoms are mild), a trial of treatment followed by withdrawal to rule out spontaneous improvement, or further investigations. Spirometry is often possible once children reach school age but other investigations may require referral.
Regular reviews and self-management Based on evidence of improved clinical outcomes[5], the guideline promotes ‘guided self-management’ in which education and the provision of personal asthma action plans are supported by regular reviews with a professional. Both components are important.
Self-management The guideline recognises the barriers to implementing self-management education, and offers some practical advice: ● Although personal asthma action plans should be introduced during a structured
Table 1: Key recommendations
Figure 1: Diagnosis of asthma in adults Presentation with suspected asthma in adults
inhaled steroids and monitor response, both symptomatically and with repeated measures of lung function. A good response confirms a diagnosis of asthma. A poor response, if inhaler technique and compliance are good, should lead to reconsideration of the diagnostic possibilities. Key to the safe implementation of this strategy is to explicitly describe the treatment as a ‘trial’ so that the diagnosis is not acquired by default and treatment continued inappropriately. Practical hint: use the 1J70 ‘suspected asthma’ read code in patients with a high probability of asthma until the diagnosis is confirmed.
GRADE
RECOMMENDATION
Presentation with suspected asthma
Diagnosis of asthma in adults and children The diagnosis of asthma is based on the recognition of a characteristic pattern of symptoms and signs and the absence of an alternative explanation for them. The key is to take a careful clinical history.
Clinical assessment including spirometry (or PEF if spirometry not available)
HIGH PROBABILITY Diagnosis of asthma likely
INTERMEDIATE PROBABILITY Diagnosis uncertain
LOW PROBABILITY Other diagnosis likely
D
Spirometry is the preferred initial test to assess the presence and severity of airflow obstruction in adults
B
Focus the initial assessment in children suspected of having asthma on: ● Presence of key features in history and examination ● Careful consideration of alternative diagnoses
Regular review and self-management FEV1/FVC <0.7
Trial of treatment
Response? Yes
Continue treatment
6
No
Assess compliance and inhaler technique. Consider further investigation and/or referral
Every asthma consultation is an opportunity to review, reinforce and extend both knowledge and skills.
FEV1/FVC >0.7
Investigate/ treat other condition
Response? No
Further investigation. Consider referral
Yes
Continue treatment
A B ✓ A
In primary care, people with asthma should be reviewed regularly by a nurse or doctor with appropriate training in asthma management. The review should incorporate a written action plan.
B
Initiatives which encourage regular, structured review explicitly incorporating self management education should be used to increase ownership of personalised action plans
Consider carrying out routine reviews by telephone for people with asthma Before initiating a new drug therapy practitioners should check compliance with existing therapies, inhaler technique and eliminate trigger factors. Patients with asthma should be offered self-management education that focuses on individual needs, and be reinforced by a written personalised action plan.
RCGP News • September 2008
CLINICAL REVIEW Gout: management tips educational discussion, it is also important that every asthma consultation is seen as an opportunity to review, reinforce and extend knowledge and skills. ● Regular structured asthma reviews can facilitate the provision of asthma action plans. ● The guideline includes a new table, based on the results of a systematic review which summarises the components of an personal asthma action plan with practical suggestions for implementation (See Table 2).[14]
Regular reviews To meet individual need, there can be flexibility in who undertakes the review (practice nurse, or GP provided that they have appropriate asthma training), and how the review is delivered (face-to-face or by telephone provided that arrangements are tailored to asthma severity and the need to deal with inhalerrelated problems). The aim of asthma management is to control asthma, such that the patient has no (or very occasional) symptoms. Although, there is evidence that this is achievable in the majority of
patients in the context of clinical trials, [6] in reality patients will wish to balance the perceived disadvantages of taking regular treatment with the potential benefit of maintaining perfect control. Studies suggest that most people underestimate the degree of control that is possible.[7] The updated therapeutic steps are similar to previous versions and continue to emphasise the need to start at the appropriate step, and stepping up or down according to control. There is a new emphasis on safety with inhaled steroids, including advice that children maintained on doses above 800mcg daily of beclomethasone or equivalent should be referred to a respiratory paediatrician. Smoking reduces the effect of inhaled steroids and higher doses may be needed. [8]
● Explore triggers, specifically checking for rhinitis which is a common association and should be treated with nasal steroids.[12] Allergen avoidance, though popular with patients, is of limited value because of the practical difficulty of sufficiently reducing the allergen load.[13]
ADDRESS FOR CORRESPONDENCE
Before stepping up treatment in patients whose control is poor, it is important to:
Dr Hilary Pinnock Division of Community Health Sciences: GP Section, University of Edinburgh 20 West Richmond Street Edinburgh EH8 9DX
● Review the diagnosis, to confirm that the increasing symptoms are caused by asthma. ● Check inhaler technique, as few patients have adequate inhaler technique, especially with metered dose inhalers.[9] ● Discuss compliance, as only a minority
References 1. British Thoracic Society – Scottish Intercollegiate Guideline Network. British Guideline on the Management of Asthma. Thorax 2008;63 (Suppl IV): iv1-iv121. 2. British Occupational Health Research Foundation. Guidelines for the Identification, Management and Prevention of Occupational Asthma. www.bohrf.org.uk/content/asthma.htm. 3. Cane RS, Ranganathan SC, McKenzie SA. What do parents of wheezy children understand by “wheeze”? Arch Dis Child 2000; 82:327-32. 4. Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med 1995; 332:133-8. 5. Gibson PG, Powell H, Coughlan J, Wilson AJ, Abramson M, Haywood P, et al. Self-management education and regular practitioner review for adults with asthma. The Cochrane Database of Systematic
of patients comply with regular preventer treatment.[10] Achieving concordance about treatment goals is likely to improve compliance. Combination inhalers have the advantage of reducing the risk of monotherapy with long-acting betaagonists by ensuring compliance with inhaled steroids.[11]
6.
7.
8.
9.
10.
Reviews 2002, Issue 3. Art. No: CD001117. DOI: 10.1002/14651858. CD001117 Bateman ED, Boushey HA, Bousquet J, Busse WW, Clark TJ, Pauwels RA, et al. Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study. Am J Respir Crit Care Med 2004;170:836-44. Haughney J, Barnes G, Partridge M, Cleland J. The Living & Breathing study: a study of patients’ views of asthma and its treatment. Prim Care Respir J 2004; 13:28-35. Chalmers GW, MacLeod KJ, Little SA, Thomson LJ, McSharry CP, Thomson NC. Influence of cigarette smoking on inhaled corticosteroid treatment in mild asthma. Thorax. 2002; 57:226-30 Brocklebank D, Ram F, Wright J, Barry P, Cates C, Davies L et al. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess 2001; 5:1-149 van Staa TP, Cooper C, Leufkens HGM,
Tel: 0131 650 8102 Fax: 0131 650 9119 E-mail: hilary.pinnock@ed.ac.uk
11.
12.
13.
14.
Lammers JW, Suissa S. The use of inhaled corticosteroids in the United Kingdom and the Netherlands. Respir Med 2003; 97:578-585 Nelson HS, Weiss ST, Bleecker ER, Yancey SW, Dorinsky PM, and the SMART study group. The salmeterol multicenter asthma research trial. A comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest 2006; 129:15-26 Scadding GK, Durham SR, Mirakian R, Jones NS, Leech SC, Farooque S et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2007; 38:19–42 Gøtzsche PC, Johansen HK. House dust mite control measures for asthma. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD001187. DOI: 10.1002/14651858. CD001187. pub3. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2004;59:94-9.
Table 2: Summary of the key components of a personalised action plan (adapted from Gibson et al) [15] COMPONENT OF AN ACTION PLAN Format of action points: Symptom vs peak flow triggered Standard written instructions Traffic light configuration
Number of action points 2-3 action points 4 action points
Peak expiratory flow (PEF) levels Based on percentage personal best PEF Based on percentage predicted PEF
Treatment instructions Individualised using inhaled and oral steroids Individualised using oral steroids only Individualised using inhaled steroids
RCGP News • September 2008
RESULT Similar effect Consistently beneficial Not clearly better than standard instructions
Consistently beneficial Not clearly better than 2-3 points
Consistently beneficial Not consistently better than usual care
Consistently beneficial Insufficient data to evaluate Insufficient data to evaluate
PRACTICAL CONSIDERATIONS Asthma UK action plans include both symptom triggers and peak flow levels at which action should be taken. Usual action points are: PF <80% best: increase inhaled steroids PF <60% best: commence oral steroids PF <40% best: seek urgent medical advice Personal best should be assessed once treatment has been optimised and peak flows are stable. Best peak flow should be updated every few years in adults, and more frequently in growing children. Patients may safely hold an emergency supply of prednisolone tablets for use if their symptoms continue to deteriorate and/or if their peak flow falls to 60% of their best. Increasing inhaled steroids is ineffective if patients are already taking moderate or high doses (≥400mcg daily) and these patients should be advised to move straight to the oral steroid step. Those on low doses (e.g. 200mcg) of inhaled steroids may be advised to increase the dose substantially (e.g. to 1,200mcg daily) at the onset of a deterioration. Any patients who have stopped medication should be reminded to recommence their inhaled steroids.
continued
Lifestyle Modifications Overweight patients are advised to modify diet and exercise, but crash dieting and high-protein/low carbohydrate diets such as the Atkins’ diet should be avoided. Alcohol consumption should be restricted to <21 units per week for men and 14 units/week for women. Beer, stout, port and fortified wines should be avoided. The patient should be advised to have three alcohol free days per week. Foods containing high levels of purines should be restricted. Avoid liver, kidneys, shellfish and yeast products. Vegetable sources of protein in the diet should be encouraged, eg lentils. There are some foods that may be beneficial for patients with gout. For example, foods high in complex carbohydrates (fibre-rich whole grains, breads, cereals, pasta, rice), fruits and vegetables. No more than 30% of calories should be from fat (with only 10% from animal fat).
Prophylactic treatment of gout Initiation of prophylactic treatment should be delayed until two weeks after the acute attack has settled. For patients already on allopurinol, the dose should not be increased for two weeks after the acute attack. Allopurinol is the first line drug used to prevent further attacks of gout. The decision to use this drug depends on several factors, such as the frequency and severity of attacks. Any evidence of erosions on x-ray would also be a strong indicator to initiate it. As a general rule it should be considered if a patient has two or more attacks of gout within the same year. The target plasma urate level is < 0.3 mmol/L (300µmol/L). Allopurinol is a xanthine oxidase inhibitor and reduces the production of uric acid. It takes several weeks to start working and starting treatment can precipitate attacks of gout for several months. The effects of allopurinol stop once the drug is ceased. Therefore it is important for the patients to take it regularly. It is started at a dose of 50 – 100mg/day and gradually increased every few weeks until the target uric acid range is reached. Renal function should be monitored and doses may need to be adjusted accordingly. The maximum dose is 900mg per day. Uricosuric drugs may be used in patients who are intolerant of Allopurinol and in under secretors who are resistant to Allopurinol. These drugs can increase the risk of renal stones. If the patient has normal renal function, sulphinpyrazone (200 – 800 mg/day) could be used. Probenecid is another uricosuric drug but is not very popular due to the need for multiple daily dosing. Also, it is contraindicated in renal impairment, there are multiple drug interactions and it may not lead to the desired reduction in serum urate level. Low dose colchicine (500mcg od or bd) or NSAIDs are co-prescribed when treatment is started with Allopurinol or uricosuric drugs and continued for up to six months in order to reduce the chance of an acute attack. The angiotensin II receptor antagonist Losartan is not specifically a gout medication but has a modest uricosuric effect and can reduce plasma urate levels by 7 – 15 %. Fenofibrate can also reduce uric acid levels by up to 40%. This drug is not effective if renal function is impaired.
Newer drugs IL-1 is a pro-inflammatory cytokine that plays an important role in acute gout attacks. The anti IL1 drug Anakinra, which is a new biologic agent, given in the form of daily subcutaneous injections (100mg once a day x3), has been shown to rapidly control gout attacks within 24 – 48 hours. Puricase is a polyethylene-glycolated recombinant version of the porcine enzyme, uricase. All mammals except humans and primates produce the uricase enzyme which breaks down uric acid, leaving very low levels in the blood circulation. Uricase converts uric acid to the more water-soluble metabolite allantoin that can be readily excreted. Febuxostat is a non-purine inhibitor of xanthine oxidase. It is effective in renal impairment. Abnormal liver function tests have been reported and may be a problem.
Reference Jordan K. M, Cameron J. S, Snaith M, Zhang W, et al. British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Gout. Rheumatology 2007
7
NEWS
Does your surgery offer outstanding support to carers? The Princess Royal Trust for Carers is looking for the UK’s top GP surgeries providing excellent support to unpaid carers. The RCGP has been working with the Trust for over two years to support GPs and practice teams in offering practical support to the estimated six million people – an estimated 200 patients per practice – who are providing unpaid care for relatives and friends and who become increasingly reliant on GP practices as their own health suffers. The Awards, run in conjunction with wellbeing group Simplyhealth, have been running for five years. The closing date for applications is 10 October 2008 and the winners will be announced at a conference hosted by the Trust on 3 November. Carole Cochrane, Acting Chief Executive at The Princess Royal Trust for Carers, said: “Many GP surgeries are doing fantastic jobs supporting carers in their communities throughout the UK. We are looking for surgeries that have really pushed the boundaries: from implementing excellent continual carer and identification programme to putting flexible appointment systems into place. These can all make a big difference to carers’ lives.” There are three prizes: Gold (£2,000), Silver (£1,000) and Bronze (£750). The Princess Royal Trust for Carers asks that 50%
RCGP welcomes new Director of Policy and Communications Mark Flannagan has been appointed as Director of Policy and Communications at the RCGP. He takes over from Jane Austin who has retired after 18 years’ service. Mark has successfully managed communications teams in a number of organisations including the RCN, Diabetes UK, the BBC and the homelessness charity Crisis. For the last three years, he has been Managing Director of his own communications consultancy providing specialist advice to not-for-profit and private sector clients, including the British Heart Foundation and EDF Energy. Mark started his career working for Action on Smoking and Health, lobbying for a ban on tobacco advertising and a ban on smoking in public places. He published one of the earliest handbooks on smoking control in workplaces and has written a guide on how to blog. Carers: your support could be doubly rewarding of the prize money be used to continue or improve the support the surgery gives to unpaid carers. There will one winner chosen from each nation and judges will be looking for the following:
GP wanted for charity Board
● GP surgeries that go way beyond the call of duty
Life saving charity MedicAlert is looking for a GP to join its Board of Trustees and advise on governance issues and the longterm development of the organisation. The role requires attendance at four meetings (approximately three hours long) per year and held at the charity’s headquarters in King’s Cross, London. The successful applicant will also need to advise occasionally on issues relating to legislation and charity activities but this is flexible and can be worked around other commitments such as surgery hours. The post is voluntary but travel costs and reasonable expenses will be paid by the charity. MedicAlert is the only non – profit organisation providing a life-saving identification system for people with hidden medical conditions and allergies.
● GP surgeries that have excellent carer support systems in place ● GP surgeries that are developing good systems and have some innovative ideas ■ Log on to www.carers.org to fill out an application form
Dilip raises £15,000 for cancer research Dilip Manek, RCGP Director of Operations, has raised a staggering £15,000 for cancer research during his presidency of his local Lions Club. Eminent consultant Professor Karol Sikora and BBC television and radio presenter Anita Anand were among the 300 guests who joined Dilip (pictured right) to celebrate the culmination of his presidential year at a fundraising evening held at the Sheraton Skyline Hotel in Heathrow. Professor Sikora, Professor of Cancer Medicine and Consultant Oncologist at Imperial College School of Medicine, Hammersmith Hospital, spoke about how the money would be used to fund personalised chemotherapy treatments. The evening also featured an auction, with prizes including cricket bats donated by Indian cricket legend Farookh Engineer and signed by cricketing stars including Brian Lara and Andrew Flintoff, alongside
■ If you would like further information or an application pack, please contact: Anna Coelho on 020 7923 6470 or recruitment@medicalert.org.uk
the signatures of legendary Bollywood actors Sharukh Khan and Preity Zinta. Dilip – a longstanding member of Loudwater and Rickmansworth’s branch of the Lions Club – decided to dedicate his fundraising efforts to cancer research following the sad loss of his sister Usha at the age of 47. He received an International Melvin Jones Fellow award and the President’s Excellence Award in honour and appreciation of distinguished and unselfish service to the Lions Club, which was founded 90 years ago and now comprises over 1.3 million men and women in 202 countries who participate in a variety of projects to support their local communities. Dilip said: “My family lost an irreplaceable part of our lives but we need to help those fighting against cancer in the hope of bringing happier endings to the stories of others.”
The RCGP Discovery Prize Entries are invited for the RCGP Discovery Prize, awarded every three years for outstanding research in general practice. The Discovery Prize recognises contemporary achievement that has helped transform healthcare and the well-being of patients in the UK or abroad. Nominees may reside anywhere in the world and need not be Members of the College. Application is by nomination, including self nomination. The winner of the inaugural Discovery Prize was Dr Julian Tudor Hart whose inverse care law has as much relevance to primary care today as in 1971 when he first demonstrated how patients in the greatest need tend to receive the poorest healthcare. The closing date for entries is 27 February 2009. ■ Details from: www.rcgp.org.uk/prizesandawards
DIARY DATES SEPTEMBER 15/16
nMRCGP Preparation Course Clinical Skills Assessment Module Venue: RCGP Assessment Centre, No 1 Croydon Fees: Members £330 Non-members £450
23/24
nMRCGP Preparation Course Clinical Skills Assessment Module Venue: RCGP Assessment Centre, No 1 Croydon Fees: Members £330 Non-members £450
24/25 26
Minor Surger y Course Venue: RCGP, Princes Gate, London Fees: Members £400 Non-members £450 RCGP Masterclass: Consulting Skills Dr Roger Neighbour Venue: RCGP, Princes Gate, London Fees: Members £175 Non-members £220
OCTOBER 2-4
22/23
8
RCGP Annual National Conference Venue: Bournemouth International Centre Fees: Members £175 Non-members £220 Organised by Profile Productions. Contact: 020 8832 7311 or email: rcgp@profileproductions.co.uk www.rcgpannualconference.org.uk Helping GP partnerships thrive Special two-day workshop in association with RCGP and the BMA Venue: RCGP, Princes Gate, London Fees: Members £175 per day Non-members £220 per day
24
RCGP Masterclass: Disease Mongering Dr Iona Heath Venue: RCGP, Princes Gate, London Fees: Members £175 Non-members £220
NOVEMBER 3/4
Minor Surger y Course Venue: RCGP, Princes Gate, London Fees: Members £400 Non-members £450
12
RCGP Masterclass: NLP in Consultation Venue: RCGP, Princes Gate, London Fees: Members £175 Non-members £220
19
MRCGP Preparation Course The Oral Module (Half day) Venue: RCGP Assessment Centre, No.1 Croydon Fees: £150
20
MRCGP Preparation Course The Oral Module (Half day) Venue: RCGP Assessment Centre, No.1 Croydon Fees: £150
Dr Roger Neighbour gives two forthcoming RCGP Masterclasses: Consulting Skills on 26 September and The Inner Physician on 26 November
21
nMRCGP for Trainers Helping your Registrar through the exams Venue: RCGP Assessment Centre, No. 1 Croydon Fees: Members £150 Non-members £150
26
RCGP Masterclass: The Inner Physician Dr Roger Neighbour Venue: RCGP, Princes Gate, London Fees: Members £175 Non-members £220
DECEMBER 17/18
nMRCGP Preparation Course Clinical Skills Assessment Module Venue: RCGP Assessment Centre, No 1 Croydon Fees: Members £330 Non-members £450
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: rsgp news@rcgp.org.uk
ISSN 1755-7720 © Royal College of General Practitioners. All rights reserved. Published monthly by the Royal College of General Practitioners 14 Princes Gate, Hyde Park, London SW7 1PU email: rsgp news@rcgp.org.uk website: www.rcgp.org.uk
RCGP News • September 2008