News
Revalidation for GPs: What you need to know The Guide to the Revalidation of General Practitioners sets out for the first time the RCGP’s current proposals for the evidence that will be required in order for GPs to be revalidated. While it has been agreed with a wide range of stakeholders, it will be regularly updated in light of continuing consultation and future policy decisions made by the GMC, Departments of Health, the Academy of Medical Royal Colleges and others before becoming the definitive source of advice for general practitioners preparing their evidence for revalidation, appraisers and their advisors, and assessors. The eventual details of revalidation for GPs will need to be signed off by the General Medical Council. However it is expected that the proposals in this Guide will be the kernel of the approved system for revalidation. The result of wide consultation with GPs and stakeholders such as the General Practitioners Committee of the BMA, it reflects the needs of GPs across the UK taking into account where they practise, different types of practice and individual employment circumstances. It also demonstrates the RCGP’s determination that revalidation will be driven by the profession and be supportive of GPs. The Guide brings together in one document all the work that the College has produced so far to support GPs in preparing for revalidation and maps to the General Medical Council’s Revalidation Framework. Revalidation will be officially introduced from 1 April 2010. GPs will not be expected to provide a five-year programme for evidence straight away – these requirements will be gradually phased in on a year-by-year basis – but they can start putting together a portfolio of evidence from 1 April this year. The Guide is divided into four sections explaining what is required of GPs and how it will affect doctors with different professional experience.
What GPs will need to provide The required evidence will include: ● A statement of professional roles held (whether paid or not) ● Evidence of active and effective participation in annual appraisals ● A personal development plan for each year, and review of the previous year’s development plan ● Multi-source feedback from colleagues ● Feedback from patient surveys; the RCGP has commissioned a review of patient surveys and will recommend which ones are appropriate for use in revalidation ● At least five significant event audits, with reflection, discussion and change as a result ● Statements of probity, health and appropriate use of healthcare, including registration with an independent GP
● At least two full-cycle clinical audits ● Any additional evidence of extra roles, such as out of hours work, teaching or research Although paper portfolios will be allowed, the clear preference will be for all GPs to complete an electronic portfolio for each appraisal that will build into an e-Portfolio covering the whole of the revalidation period.
How the process works The College recognises that there is still uncertainty around the roles and responsibilities of Responsible Officers and appraisers; the concept of Assessors and the local groups; the RCGP National Adjudication Panel; and the quality assurance of revalidation decisions. This section describes the RCGP’s current proposal, but it is dependent on future policy development. The RCGP proposes that, once a portfolio is submitted, it will be assessed by a ‘Responsible Officer’, a senior doctor within the Primary Care Trust or Health Board responsible for evaluating the performance and conduct of doctors. We also propose that an RCGP assessor and a lay assessor will be asked to check that both the quantity and quality of evidence is appropriate for revalidation. Further discussions will be held with the General Medical Council and the Departments of Health in England, Scotland, Wales and Northern Ireland about how these ideas might operate in practice. Piloting on the ground with thorough evaluation and economic analysis will help to shape the final agreed system.
RCGP’s commitment to delivering a professionally led system that is supportive, sensible and not overly bureaucratic. “I appreciate that many GPs are feeling nervous and daunted by the prospect but revalidation will improve the quality of care we provide for our patients and we must show strong professional leadership in taking it forward. “It’s far better for revalidation to be driven by the profession than to have something forced on us by an external agency with no understanding of who we are or what we do.” Professor Field is the main RCGP lead on revalidation and has appointed Professor Mike Pringle as RCGP Medical Director for Revalidation, responsible for the development, testing and delivery of the proposed system, as well as liaison with external stakeholders on revalidation issues. Professor Pringle is Professor of General Practice at the University of Nottingham and was Chairman of RCGP Council from 1998-2001. ■ The Guide will be available at www.rcgp.org.uk from 1 April
APRIL 2009
Inside this issue... Provider accreditation
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RCGP pilot hailed a success
In the chair Dr Clare Taylor on the important role of AiTs
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e-learning for everyone Latest developments in RCGP e-packages for all GPs
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The Ageing challenge RCGP Clinical Champion Louise Robinson on care for older people
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Debt and mental health A four-step programme to helping patients through the credit crunch
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Twice the Quality Top RCGP appointments to new Quality Board
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BRISTOL EVENING POST
A landmark document detailing everything that GPs will need to know and do in order to prepare for revalidation is unveiled by the RCGP this week
THE NEWSPAPER OF THE ROYAL COLLEGE OF GENERAL PRACTITIONERS
Flexibility for different roles The guide contains provisions for those who might find the standard portfolio impractical – such as those who have had career breaks, or who are not currently working as clinical GPs but who are working in NHS management, education, academic, defence or political roles. The RCGP will be recommending to the GMC that there is some choice available to GPs who are eligible for revalidation, but who can justify a claim that the collection of a standard portfolio would be unreasonably onerous. However, there will be no alternative to participation in appraisals and clinical governance. A key issue is to ensure that revalidation doesn’t discourage GPs from taking on leadership roles in primary care; the RCGP is working with the BMA, the GMC and others to find ways of achieving this. For those who are on the GMC register but cannot meet the evidence criteria, there will be re-entry programmes involving approved knowledge and clinical skills assessment.
Top of the league: Rickie Lambert presents the RCGP Quality Practice Award to Dr Schroeder and the staff at the Stokes Medical Centre in Bristol
Rickie of the Rovers rewards Bristol GPs
Driven by the Profession
Bristol Rovers striker Rickie Lambert took time out from training to present GPs and staff at Stokes Medical Centre with the prestigious RCGP Quality Practice Award (QPA).
The College will undertake pilots during 2009 in preparation for the anticipated introduction of revalidation. The evidence from those pilots will help to shape the revalidation process and inform further revisions of the Guide. RCGP Chairman Professor Steve Field said: “The Guide for the Revalidation of General Practitioners is our most explicit signal to date of the
The ten doctor practice in Little Stoke looks after 12,441 patients and took 18 months to achieve the award, which will now be displayed in the surgery for the next five years to demonstrate to patients that they are receiving high standards of care. GP Dr Knut Schroeder said: “Achieving the award has involved all members of the practice
team, who have all worked very hard to achieve the stringent award criteria. It was a great morale boost to get official recognition of our commitment to providing high quality patient care. “We feel proud that the assessors recognised our particular strengths and skills which include the quality of our clinical care, teamworking and practice organisation.” The Quality Practice Award (QPA) has been running since 1995 and is open to all practices. Participating practice teams are required to meet set criteria on clinical care, patient safety issues and team working. The criteria are regularly modified and developed to reflect ongoing changes in general practice.
COLLEGE NEWS
Positive response to RCGP provider accreditation pilot The results of the RCGP pilot on provider accreditation have revealed strong support for a professionally-led, voluntary and developmental scheme to recognise quality in non-clinical aspects of the care The pilot was conducted over 15 weeks but it is envisaged that the full programme will take place over a two or three year period when properly rolled out. Despite the short time, 30 per cent of participating GP practices passed 100 per cent of the core criteria and half of all practices scored 90 per cent or above. Key findings included: ● RCGP leadership was ‘critical’ to motivating practices to sign up to the pilot and ensuring the successful implementation of the scheme ● GPs generally made the initial decision to be involved and then led the scheme, supported by practice managers who co-ordinated the day to day workload ● PMCPA demonstrated excellence to patients and led to improvements in patient safety ● It is valuable, achievable and relevant to primary care and creates a sense of ‘professional pride’ among practices ● It works best where there is teamwork with designated responsibilities; shared goals and GP leadership within the team ● Practice size does not affect achievement ● Financial incentives were not a motivator for taking part ● Workload was higher than expected but almost all practices emphasised that this was due to the 15-week duration of the pilot; the timing (over the summer) and the fact that it coincided with practices being busy with concurrent demands including the IMT DES ● PMCPA could be rolled out as a two or three year programme (with new Care Quality Commission standards seen either as eligibility criteria or as part of the first year’s work) The Primary Medical Care Provider Accreditation (PMCPA) pilot was led by the RCGP in partnership with Professor Helen Lester and her team from the National Primary Care Research and Development Centre at the University of Manchester. It was funded by the Department of Health but the standards were developed by a team which included the General Practitioners Committee of the BMA, patient representatives, the General Medical Council, Healthcare Commission, Royal College of Nursing, NHS Confederation, National Patient Safety Agency and others. RCGP Chairman Professor Steve Field said: “The pilot has been a huge success. It demonstrates that accreditation is feasible – and that it is acceptable to the profession. “I am particularly pleased that the pilot attracted such a positive and enthusiastic response from individual practices who were prepared to invest their time and effort. “I am indebted to Helen Lester and her colleagues Stephen Campbell and Umesh Chauhan at Manchester who have achieved a project that meets the highest standards of academic rigour yet still managed to be realistic and add value to busy practice teams going about their daily work with patients. “Professionally-led accreditation is the way forward to further improving the quality of care provided by practices and it has the potential to satisfy the regulatory needs of the Care Quality Commission once additional work has been done to incorporate their new requirements which will be announced shortly.” Helen Lester, Professor of Primary Care at the National Primary Care Research and Development Centre said: “We were delighted by the positive responses from GPs, practice managers and practice nurses to PMCPA, particularly that the criteria were sensible and fitted with their views of what quality practice should be like. We were also really pleased that there was evidence, even in the short pilot timeframe, of real benefits for patients.”
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We were delighted by the ❛positive responses from GPs, practice managers and practice nurses to PMCPA, particularly that the criteria were sensible and fitted with their views of what quality practice should be like
Love your tender: Market yourself by showcasing the success of your practice, delegates are told
Not so tough: The way ❜ to a successful tender
Helen Lester
The RCGP is now in the process of setting up a group to implement the full programme and has had in-depth meetings with the GPC, Department of Health and the CQC. The RCGP is awaiting publication of the Department of Health standards which, after consultation, will be adopted by Care Quality Commission and will become part of the final programme so that regulatory requirements are satisfied. Lessons learned from the programme will lead to a reduction in the number of criteria to avoid duplication and feedback from assesssors will also help inform future work.
Piloting the PCMPA The PCMPA scheme was developed using the methodology of the RCGP Quality Team Development (QTD) scheme supplemented with international primary care accreditation schemes and other recent related policy. The pilot took place over a 15 week period and involved 36 practices in four Primary Care Trust areas – ten in Haringey; eight in Nottinghamshire; nine in Oldham; and nine in Warwickshire. The sample of practices was nationally representative in terms of QOF scores, and practice sizes were almost identical to national values but tended to be in slightly more deprived areas than the national norm. Of these, 32 practices fully completed the pilot and 30 practices (with over 200,000 patients) completed the entire scheme including an assessment visit by a PCT-appointed threeperson team (clinical, practice manager and lay assessor). Two of the initial 36 decided to withdraw early on in the pilot scheme due to unexpected staff changes. Two others uploaded some data during the pilot but withdrew during the 15 weeks. PMCPA has six domains: 1) Health Inequalities and Health Promotion 2) Provider Management 3) Premises, Records, Equipment and Medicines Management 4) Provider Teams 5) Learning Organisation 6) Patient Experience/Involvement The PMCPA pilot scheme included five key stages: q A pre-entry qualification stage: Providers were asked to demonstrate compliance with contractual criteria and to sign a confidentiality agreement w A set of 30 core or summative criteria: Providers were asked to self-assess and provide written documentation against all these criteria e A set of 82 developmental or formative criteria divided into six domains: Providers were asked to self-assess against chosen criteria within their randomly allocated developmental domain r Data on QOF organisational indicators was collected from the 31 March 2008 Quality Management and Analysis System for each of the participating providers t Practices also had an independent assessment visit from PMCPA trained assessors and were given a Quality Improvement Plan
GPs must gain the confidence to become more involved in tendering for projects if they are not to lose out to private companies This was the strong message from the RCGP seminar How to be successful in a competitive tender, aimed at demystifying the tendering process and encouraging GPs to take greater control. Organised by Dr Janet Hall and the Sheffield Faculty, the event brought together around forty people, including GPs involved in tendering (both successfully and unsuccessfully), alongside NHS staff responsible for allocating contracts.
Common mistakes to avoid RCGP Vice-Chair Dr Clare Gerada led a workshop highlighting some of the most common mistakes made by applicants, such as not including enough information in bids. Delegates were urged to showcase the success of their practices with statistics, pictures, diagrams and QOF results wherever possible. Good tenders included case studies and explained how similar health services were provided in the local area, said Dr Gerada. As one delegate suggested: “You need to sit down with your team and have a big brainstorm together on all the things your practice provides and does well. If you’re doing it by yourself, it’s very easy to forget and overlook things. We often take for granted all the good things we do in general practice!” False modesty is no advantage either. Delegates were urged to market themselves and blow their own trumpet – something many GPs admitted they are not always good at. “Don’t worry about overselling yourself,” urged Dr Gerada. “That’s what private companies do all the time. Make the most of what your practice or consortium offers!” Local knowledge is critical when bidding for services outside a local area, when applicants will be expected to provide analysis of the local health needs and Google was highlighted as a helpful tool for researching local health issues, key stakeholders and providers already in the area. Local councils were also an excellent source of information, through their public health documents. Other advice included: ● Answer all the questions asked directly! ● Use plain and simple direct language. ● Seek help where you need it from other GPs who have been through the process. ● Find out what weighting is given to various parts of the application Dr Gerada warned delegates not to underestimate the time involved in preparing a proper application. “It can take up to six months, so start early! And take into account the cost of doing this.”
How the decision is made Presenting a view from ‘the other side of the fence’ was Caroline Mabbott, Associate Director of Healthcare Procurement at NHS Sheffield. She reassured delegates that there is little difference in quality between tenders from big companies and GP-led enterprises, many of whom have made excellent submissions. “We put a lot of priority on local integration – on how providers will integrate into the local health economy. And we assess value for money, not the lowest cost.” Delegates were told that all tenders were read by a team of specialists (up to 22 people at Sheffield) who assess different parts of the tender. After a contract is awarded there is a tenday standstill where unsuccessful bidders are given feedback, and the final decision can be challenged at any time. “By its very nature it is a process and the big guys will always be good at that, because that’s what they do,” said Ms Mabbott. “But it’s not just filling out forms – you must have the clinical skills to deliver.”
Keeping a balance Sandy Gower is a Managing Partner at Bennetts End Surgery and the first practice manager to be awarded fellowship of the RCGP. Her workshop looked at the experience of managing a bid, and working in partnership with other practices. Winning a bid can often just be the start of the hard work, she explained. Particular challenges arise from working with organisations with different cultures, such as care centres and after-hours clinics. Sandy stressed the need for work-life balance in these projects: “Make sure you have ‘not-todo’ list, as well as a ‘to-do’ one.”
Demystifying the process Many conference delegates who had previously admitted to being intimidated at the process of bidding emerged with new confidence. According to Dr Gerada, the process of tendering is nowhere near as daunting as many GPs fear. “If it’s so simple, why doesn’t everyone do it? Because they think it’s too hard!” Dr Ericson Laudato is a GP Registrar from Boston, Lincolnshire who came away enthused. “It has been very interesting and useful – before today I’ve had no experience of commissioning. “In my local practice we are very keen to start providing more services. We have a large elderly population and we want to get more involved with chronic disease management. Today has really encouraged us.” Organiser Dr Janet Hall concluded: “Tendering is one of the main challenges for general practice today – as was demonstrated by the excellent turn-out. “It was a really good opportunity to share advice, useful information and, perhaps most importantly, real-life experiences that we can all learn from.” RCGP NEWS • APRIL 2009
PERSPECTIVE
In safe hands: the next generation of General Practice Dr Clare Taylor - Chair of the RCGP Associates in Training Committee - talks about the increasingly important role played by AiTs within the College
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AM PRIVILEGED to be Chair of the Associates in Training (AiT) Committee this year. The committee was established in 2007 following the introduction of the new Membership of the Royal College of General Practitioners (nMRCGP) examination. There are now nearly 9,000 associate members comprising nearly one quarter of the total College membership. The committee has a regional representative from each deanery in the UK elected through an electronic ballot. We also have college officers and administrative staff on the committee. Last year, I was deputy chair and our first year was spent establishing our role within the College and addressing key issues such as examination costs and the functionality of the eportfolio. We were keen to find answers to the questions often asked by trainees such as ‘Why is the CSA so expensive?’ or ‘Where can I find out more about what is required for the e-portfolio?’. These issues were addressed in three interviews conducted with College officers including the Honorary Treasurer Dr Colin Hunter and can be found on the New Professionals part of the RCGP website. This year we have a very dynamic, enthusiastic and hard working committee and we are keen to ensure the views of trainees continue to be heard at the highest level within the RCGP. We have recently been given a seat on the College Executive Committee, an important body which meets a few weeks before Council to discuss key issues for the College to put before Council for decision. As a Committee we have daily contact via the AiT Committee ‘Google Group’ and we meet three times a year.
the ❛RCGPWehasfeela that key role in supporting newly qualified GPs through those crucial first five years up to the first point of revalidation as well as for the rest of their careers. We are currently developing a document to suggest ways that the RCGP may support new GPs
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THERE ARE several issues which we are currently addressing. The Tooke report into Modernising Medical Careers recommended that GP training should be increased from three to five years. The case for increasing length of training is strong and gives a real opportunity to develop highly skilled specialist generalists and for the profession as a whole to be seen as equivalent in competence and training to other medical specialities. We are conscious, however, that the additional years should include practical, valueadded experience and training rather than ‘more of the same’ and we are having a key role in ensuring the ideas and concerns of trainees are considered at each stage of this consultation.
CLARE TAYLOR Clare graduated from Cambridge in 2002 and did a six-month GP house job in a rural practice near Huntingdon. She spent six months as an A+E SHO, then went on to complete a medical rotation at Addenbrookes in Cambridge and gained membership of the Royal College of Physicians. Realising her destiny was in General Practice, she did a year of Paediatrics in Kent then moved up to Birmingham where she now works as an Academic GP Registrar. She is the Chair of the Associates in Training Committee and the AiT representative on College Council. RCGP NEWS • APRIL 2009
We are working closely with the Postgraduate Training Board (PTB) and its subcommittees to ensure the examinations and e-portfolio are constantly improving in response to trainee feedback. In particular problems with uniformity in workplace-based assessment and ongoing improvements to the e-porfolio are being discussed at present. We are keen to promote both local and international involvement of AiTs. We are encouraging each AiT representative on the national committee to interact with their local faculties to address AiT issues at a more local level and also host events and be the familiar face of RCGP within their region. We are also planning to work more closely with the Vasco da Gama movement of WONCA (the European organisation of family doctors) which aims to promote communication and collaboration between young GPs (both in training and in their first few years after qualifying) across Europe. The AiT Committee also recognises that the moment a trainee stops being an AiT they find themselves in the increasingly uncertain world of the newly qualified GP. The trainer is no longer present in the next room as a source of advice and guidance. There is no regular time to meet up with colleagues, so the peer support enjoyed at VTS may be lost. The job market is
uncertain and newly qualified GPs often find themselves locuming in unfamiliar practices. We feel that the RCGP has a key role in supporting newly qualified GPs through those crucial first five years up to the first point of revalidation as well as for the rest of their careers. We are currently developing a document to suggest ways RCGP may support new GPs. WE ARE ALSO developing an exciting AiT programme for the RCGP conference Excellence in Practice in Glasgow in November. There will be five sessions for AiTs which will range from exam preparation, how to make the most of your ST3 year, career opportunities and a Question Time-style discussion to address any trainee issues delegates wish to raise – and much more! Members of the committee will be on hand throughout the event and we will be hosting an AiT night out on the Thursday to give trainees from across the UK an opportunity to meet informally. We would encourage all AiTs to come along for what should be an interesting, educational and, above all, very enjoyable three days! General Practice is the cornerstone of the NHS and, as the next generation of specialist generalists, we are an important and increasingly recognised voice within the RCGP. If you have any views or comments please contact us at ait@rcgp.org.uk.
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DIARY DATES Here’s a taster of upcoming RCGP courses, events and conferences. A full listing can be found on the RCGP Courses and Events web page: www.rcgp.org.uk/news_and_events/ courses__events.aspx
APRIL 29
Clinicians, Quality and Data: Analysis and sharing information to drive health care improvement The third annual partnership conference of The King’s Fund, RCGP and RCP. The King’s Fund, London W1G 0AN 09:30 – 16:45 Members: £125 Non-Members: £175
MAY 7
Working with Drug and Alcohol Users in Primary Care The 14th National Conference of the RCGP Sex, Drugs and HIV Task Group. ACC, Liverpool
11-12
Consulting Skills for GP Registrars Specifically tailored for GP registrars. Enhance your consulting skills under the guidance of consulting skills expert, Dr Roger Neighbour. RCGP, 14 Princes Gate, London SW7 1PU 09:30 – 16:00 Members: £275 Non-Members: £350
JUNE 15
Sex in 10 Minutes A guide for busy GPs by the Institute of Psychosexual Medicine This day will cover sexual problems commonly presented in General Practice. The focus will be on what you can do within the 10 minute consultation including the basic skills and attitudes required. RCGP, 14 Princes Gate, London SW7 1PU 09:00 – 16:30 Members: £175 Non-Members: £220
NOVEMBER 5-7
Excellence in Practice Winning Ways for Primary Care RCGP Annual National Primary Care Conference The third Annual National Primary Care Conference of the RCGP. Update yourself on the latest primary care developments and meet, network and exchange ideas with over 1,000 primary care professionals. SECC, Glasgow Details: www.rcgpannualconference.org.uk
Take your partners for the Great Three Legged Race Put your best foot forward and sign up now for the Cancer Research UK Great Three Legged Race at the RCGP National Conference in Glasgow on Friday 6 November 2009. Full details and a fundraising pack can be found on the RCGP website www.rcgp.org.uk So join a friend/colleague and do something good for charity.
GUIDELINE UPDATE
Meeting the challenges of Antisocial Personality Disorder Almost two years ago I was invited to be the GP representative on the NICE Antisocial Personality Disorder Guideline Development Group. The idea of sitting on the group both interested and intrigued me. I was not sure how much I knew about this condition but was told that because I had many years experience working with prisoners, drug users and homeless people that I would have more than enough experience to contribute to the group. Like many GPs seeking to develop strong trusting relationships with patients, there has also been a part of me that has been uncomfortable with the term ‘personality disorder’. It seems such a severe diagnosis to give someone. Sitting on the group and meeting a patient who had received a diagnosis of personality disorder was most enlightening, however. It reminded me of our primary vocation as doctors – to seek to meet individuals’ health need irrespective of their behaviours, orientation or cultural background. Perhaps nowhere is this more a challenge to GPs than those with personality disorder. The guidelines remind us that whilst assessing risk of violence is not routine in primary care on occasions we will need to assess risk. If such an occasion arises we are encouraged to consider: ● Current or previous violence, including severity, circumstances, precipitants and victims ● The presence of comorbid mental disorders and/or substance misuse ● Current life stressors, relationships and life events ● Additional information from written records or families and carers (subject to the person’s consent and right to confidentiality), because the person with antisocial personality disorder might not always be a reliable source of information ● Contact with and/or referral to secondary or forensic services where there is current violence or threats that suggest significant risk and/or a history of serious violence, including predatory offending or targeting of children or other vulnerable people.
those who have such previous risk factors for antisocial behaviours. Such professionals do not seek to ‘play the martyr’ and put themselves or their staff at risk. Rather they have developed the skills and experience necessary to deliver health care to those who are often considered a marginalised, excluded group of individuals. It is worth bearing in mind that even where an individual has been assessed as presenting with an antisocial personality disorder, this does not mean he or she constitutes a grave, constant or immediate danger to others, and our anxiety that this might be the case should not detract from our ability to provide services to that person. Working with such individuals inevitably entails communication with specialist mental health services so what can our patients expect to receive from such programmes. The guidelines highlight the ineffectiveness of medication such as sedatives as treatment and suggest that they should not routinely be used. Rather the evidence base supports group-based cognitive and behavioural interventions, in order to address problems such as impulsivity, interpersonal difficulties and antisocial behaviour. Historically ‘personality disorder’ has been a diagnosis of exclusion from primary and secondary care services. However, in addition to the evidence base supporting effective treatment, many individuals have a ‘dual diagnosis’ of either another mental health problem, or for drug and alcohol dependence. There is now an effective evidence base for treating such conditions in primary care. What is unlikely to change is that unless the individual is residing in prison, the most appropriate place to treat and support those with antisocial personality disorder is in the community. The guidelines remind us that inpatient admission is a lengthy process and the individual should be under the care of forensic/specialist personality disorder services and not usually be under a hospital order under a section of the Mental Act. Therefore this guideline is of relevance to all GPs, and particularly those working in deprived or prison communities. Many GPs have already acquired the training, knowledge, skills and experience to work creatively with this patient group without putting themselves at risk and it is my hope that this guideline will further encourage others working in primary care to more proactively engage with such individuals.
In essence a person’s previous history can help illuminate the current risk. It has been encouraging how in recent years an increasing number of GPs have sought to work positively with
■ The guideline on Antisocial Personality Disorder can be downloaded from the NICE website: www.nice.org.uk/CG77
Nat Wright GP at HMP Leeds On behalf of the Antisocial Personality Disorder guideline development group
NHS Evidence: a new resource for GPs The National Institute of Clinical Excellence is establishing a new comprehensive evidence base to support GPs and others working in health and social care in making decisions about treatments or the use of resources. NHS Evidence will inform patient care, commissioning and service management by providing a single free access portal to information and evidence. The NHS Evidence portal goes live on 30 April. As well as providing access to a wide range of information, NHS Evidence will establish an accreditation scheme for producers of information and evidence so that users of the resource can have confidence in the information available. The accreditation scheme will be for sources of information
and not for the information itself. Information that is available from an accredited source will be easily identifiable on the portal and will be prioritised in the search results. The portal will help GPs to browse evidence, from international information to local experience, using topic trees such as commissioning, drug treatment, social care and research. Later in the year as functionality is enhanced and developed, you will be able to personalise your webpage so that the information you seek is categorised under headings that make it easier for you to access. You will be able to access the NHS Evidence portal from either your practice or from home – if you have access to the internet, you have access to NHS Evidence. ■ Please e-mail NHSevidenceqeries@nice.org.uk for further information or visit the portal after the 30 April at www.evidence.nhs.uk
e-GP e-learning is now open to each GP The e-GP.org website is now available to all NHS general practitioners across the UK as a valuable resource that will aid both postgraduate training and lifelong learning e-GP is an innovative joint project between the RCGP and e-Learning for Healthcare which has produced a comprehensive, free-toaccess programme of e-learning sessions, written for general practitioners and structured around the GP curriculum. In January, general practice trainees were the first group to be
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given access to e-GP, and it is now available to all NHS general practitioners. Access to e-GP can be obtained by registering on the www.e-GP.org website. Soon after registering you will receive an email informing you of your username and password and providing information to help you use e-GP. The learning within e-GP is delivered through interactive elearning sessions and ‘virtual consultations’. There is an e-learning module for each of the curriculum statements, and each module will typically contain two to four hours of e-learning, divided into a variable number of independent sessions. More information is available on www.e-gp.org.
The e-learning content is being rolled out gradually over the next year and so not all modules or sessions are currently live. Current modules available include: Being a GP, The GP Consultation, Equality and Diversity, Patient Safety, Sexual Health, Women’s health, Adolescent Health and Supporting Self Care. New content just added includes models of the consultation, pelvic pain, Hormone Replacement Therapy, prescribing in pregnancy and use of the contraceptive injection. New e-learning on Safeguarding Children will also be available later in the year to help GPs develop their knowledge and skills in this area, in the wake of the Lord Laming report into the death of Baby P. RCGP NEWS • APRIL 2009
NEWS
Tobacco industry attacks Ageing: a major challenge for 21st public health plans century primary care
The Health Bill 2009 contains bold new measures to prevent children from taking up smoking. However, the tobacco industry is up to old tricks: spreading scare stories and distorting the data to undermine the case for legislation. Hazel Cheeseman of ASH outlines the latest evidence and explains how GPs can support the advocacy battle to put tobacco out of sight.
Dr Louise Robinson RCGP Clinical Champion for Ageing and Older People’s Health and Wellbeing
q Improved professional awareness, and more timely diagnosis, of dementia The introduction of the Quality and Outcomes Framework has led to a considerable improvement in chronic disease management. There is clear evidence, however, that the standard of some aspects of primary care received by older people is in urgent need of improvement. The National Audit Office Report on Dementia (2008) identified several areas of clinical care of relevance to general practice that could be improved: namely diagnosis and disclosure, early intervention, carer support and end-of-life care. The recently published National Dementia Strategy has defined 17 objectives which, if implemented, aim to do just this. A number of educational initiatives will be developed and introduced directed at GPs and medical students.
w Advance Care Planning (ACP) – how to approach ACP in primary care The process of advance care planning is currently recommended as good practice for people with long term conditions, so that they may document their wishes about their future care and any specific treatments they do not wish to receive. The Royal College of Physicians has just published a good practice consensus document on ACP but our aim is to produce educational resources on how to practically carry out such discussions.
e Safeguarding adults: preventing adult abuse The College will – through joint working with key stakeholder groups, CEOs, Medical Directors and Directors of Primary Care in PCOs– aim to improve awareness, and earlier recognition, of adult abuse by general practitioners via the development of e-learning resources.
r Management of multi-morbidity in the primary care of older people. There will be an ongoing research agenda in the area of how GPs can best manage the increasing multi- morbidity seen in primary care in ageing populations. I will be working together with RCGP NEWS • APRIL 2009
Population increase in 80+ age group (UK) 6
Number of people aged 80+ years (millions)
Four key themes have been identified:
Robinson: Ageing population presents enormous challenges for health and social care provision
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The evidence 3 2 1 0
2009
2010
2015
2020
2025
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Dementia prevalence (UK) 1,800
Number of sufferers (thousands)
Life expectancy is increasing by two years every decade. Currently older people represent the fastest-growing sector of our population, with those over 60 years of age comprising one-fifth of the population. The largest population increase will be seen in the oldest old, ie people over 80 years. In the United Kingdom, improving the health and social care of our ageing population is one of the government’s priority areas as highlighted in the National Health Service Strategic Review, Ageing and age-associated disease and disability and the National Service Framework for Older People. These social demographic changes will present enormous challenges for health and social care provision in the United Kingdom. As one of the key priorities for future healthcare delivery to older people will be to ensure that it is delivered as close to their homes as possible, there will be particular implications for general practitioners and primary care as a whole. Although there is evidence that the number of disability-free years is increasing for older people, an ageing population will undoubtedly result in an increased incidence of age-related illness such as osteoarthritis, dementia and the neuro-degenerative diseases. The RCGP aims to identify and address the key challenges ageing presents for general practice in order to improve the quality of primary care received by older people.
Tobacco is a unique product, the only one legally available which kills half of its users when used as directed by the manufacturer. In the UK more than 100,000 people a year are killed from smoking and many more live with the painful consequences of emphysema, bronchitis, cancer and heart disease. The Government has responded over the years to the threat tobacco poses to public health with various pieces of legislation and the latest measures are designed to help prevent young people from taking up smoking and support those who have made the choice to quit. One measure is to restrict the availability of tobacco through vending machines; the second is to remove the display of tobacco in shops. These measures are also currently being considered by the Scottish Parliament and the Northern Ireland Assembly. The tobacco industry has fought every public health intervention on tobacco since the 1950s and has been at it again, attempting to undermine the case for change and frightening small shops into believing this will put them out of business. The industry claims are misleading and intended to preserve their platform for recruiting new, young smokers. The public health community must act together to ensure this legislation is not thwarted by these familiar tactics.
1,600 1,400 1,200 1,000 800 600 400 200 0
2009
2020
2050
my fellow Clinical Champions for Mental Health and End of Life Care respectively on this and other projects as they arise. ■ For further information about RCGP Clinical Priorities and the work of the Clinical Champions, please contact circ@rcgp.org.uk or call 0203 170 8245 ■ CIRC is looking to recruit GPs with an expertise in all clinical, educational and research areas to act as an Expert Resource within the College. To register, please visit www.rcgp.org.uk/clinical_and_research/ circ/expert_resource.aspx or email rwebb@rcgp.org.uk for further information ● Graph statistics sourced from the Government Actuary’s Department (GAD) www.gad.gov.uk and Alzheimer’s Society www.alzheimers.org.uk
Most advertising for tobacco, even in countries where media advertising is legal, is what is called ‘below the line’ advertising, such as pointof-sale displays rather than the more familiar billboard, press and broadcast media ‘above the line’ advertising. When advertising tobacco was banned in 2003 it was the ‘above the line’ media advertising that was removed. But this was just the tip of the iceberg,with activities such as point-of-sale promotion and brand imagery on the pack more prevalent and more persuasive. Since the ban, point-of-sale displays of tobacco – which were already an important promotional tool – have become even more prominent. They are larger with a more sophisticated use of lighting and colour, and the number of different brands they display has increased significantly. Brands within a single brand family have increased by a third since 2003, giving a single logo or brand name much more shelf space to advertise the product. A recent UK study demonstrated the impact of the industry’s advertising activity. Since the ban on tobacco advertising, the number of young people who are aware of new brands has increased from 11 per cent to 18 per cent. This is despite a ban on tobacco advertising on billboard adverts, in commercials, through sponsorship and in newspapers. Point-of-sale displays are clearly a significant source of information with 46 per cent of teenagers aware of tobacco marketing at the point of sale. Brand awareness is also closely linked to smoking initiation. The research found that every additional brand that a 15-year-old could recall increased their interest in trying smoking by 35 per cent. Plainly point-of-sale displays are adverts and they are effective in recruiting young people to smoking.
Tobacco industry misinformation The tobacco industry has argued that this marketing has no impact on children and that its soul purpose is to allow adult smokers to choose between brands. However, the evidence shows that only six per cent of adult smokers use displays to make a choice about what they will purchase, while 94 per cent know what they will buy before they walk in the shop. They have also been scaring local shops that these measures will financially cripple them, claiming the cost will be in its thousands. In re-
Point-of-sale: Raising awareness of new brands ality for a typical UK display the cost would be in the region of £200. The tobacco industry has also made a concerted attempt to undermine the international evidence. In Iceland the restrictions have been in place since 2001. The tobacco industry has persistently used data to claim the ban had no effect on youth smoking. While their claim to be using government data is accurate, what they fail to mention is they have been told in writing by the Icelandic government that they are using the wrong data, figures that do not accurately indicate youth smoking prevalence because the sample size is too small. Instead the data used by the Icelandic government to measure youth smoking shows that smoking prevalence fell from 18.6 per cent two years before the ban to 13.6 per cent two years after, which is double the previous rate of decline.
Vending machines Restricting the sale of tobacco to children from vending machines is also clearly a sensible measure. Currently 17 per cent of 11-15 year olds regularly buy tobacco from vending machines and test purchasing shows that children are often not challenged when buying tobacco from a vending machine. We believe that the Government should follow the lead of the 22 other European countries who have already banned the sale of tobacco from vending machines.
Write to your MP GPs can make a real difference on this issue. Politicians have been receiving communications from local shops frightened by the tobacco industry into claiming the legislation will damage their business. Local GPs can fight the corner for the public health community explaining why it is so important that young people do not start smoking. The younger people start to smoke the more likely they are to become heavily addicted and never manage to quit. More information can be found on the website of the Smokefree Action Coalition: www.smokefreeaction.org.uk. You can find contact details for your MP at www.writetothem. co.uk. If you have any questions please email hazel.cheeseman@ash.org.uk Your letter will make a difference, helping MPs to get a balanced perspective about what is good for their local community and countering the false claims of the tobacco industry. ■ The RCGP is one of 30 public health organisations signed up to the ASH budget submission for 2009 calling on the Government to raise taxes on tobacco and set new HM Revenue and Customs and UK Border Agency targets for reducing the market share of illicit cigarettes and hand-rolled tobacco.
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CLINICAL UPDATE
Inhaled anticholinergics and adverse CV events PETER BURRILL Specialist Pharmaceutical Adviser for Public Health Derbyshire County PCT A recently published meta-analysis of randomised controlled trials in JAMA1 suggests that inhaled anticholinergic drugs increase the risk of cardiovascular (CV) events in people with chronic obstructive pulmonary disease (COPD) compared with placebo or active comparators (inhaled corticosteroids and/or beta-agonists). This paper has been widely reported in the media but must not be looked at in isolation. Instead all the available evidence needs to be considered. The Saltpeter meta-analysis2 found that anticholinergics reduced severe exacerbations and respiratory deaths, whereas LABAs did not reduce severe exacerbations and may have worsened disease control, as there was a two-fold increase in respiratory deaths. The authors concluded that anticholinergics should be the bronchodilator of choice in COPD. A Cochrane review of tiotropium3 concluded that tiotropium reduced COPD exacerbations and related hospitalisations compared to placebo and ipratropium and improved health-related quality-of-life scores, and may have slowed decline in FEV1. A Cochrane review comparing ipratropium with LABAs for COPD4 found no significant differences in quality-of-life, exacerbations, or symptoms. A more recent systematic review (May 2008) of bronchodilators in COPD5 did not find an increase in respiratory deaths for LABAs but the changes in lung function and quality-of-life for LABAs were ‘of uncertain clinical significance’ according to the authors. However, LABA treatment was associated with significantly more severe COPD exacerbations and a lesser increase in FEV1 from baseline compared with tiotropium. The authors concluded that ‘our analysis suggests the superiority of tiotropium over LABAs’. The accompanying editorial6 concludes that ‘tiotropium is currently positioned as the most appropriate firstline therapy’. What about the JAMA article itself? As the authors say, none of the trials were specifically designed to monitor the risk of CV events, which were not adjudicated (a problem with all these types of studies). They did not seem make any adjustment for baseline CV risk, smoking status, statin use etc, which may have been different and affected the results. They quote a one-year NNH for MI of 174 (CI 75-1835) and 40 (18-185) for CV death. Interestingly, there was no difference in all-cause mortality so you are no more likely to die overall. This could be because it was not powered for all-cause mortality (possible) or because CV mortality is offset by a reduction in respiratory mortality (also possible). The Newcastle Regional Drug and Therapeutics Centre appraisal report7 of this meta-analysis concludes: ‘The small in-
crease in cardiovascular risk needs to be balanced against the potential benefits of inhaled anticholinergics. More prospective, robust studies are needed to establish whether inhaled anticholinergics are associated with an increase in cardiovascular risk in patients with COPD. Until such time, a change in prescribing practice is not recommended’. The UPLIFT study8 has now been published and does not support an increase in cardiovascular risk with tiotropium. UPLIFT tested whether tiotropium would reduce the rate of decline in FEV1 and evaluated the long-term effects on health-related quality of life, exacerbations, related hospitalisations and mortality. UPLIFT was a four-year, randomised, double-blind, placebo-controlled, parallel-group trial involving patients with moderate-tovery-severe COPD. ● During treatment, fatal adverse events occurred in 12.8 per cent of the tiotropium group, compared with 13.7 per cent in the placebo group: hazard ratio 0.84 (95 per cent CI 0.73 to 0.97), ie reduction in risk. ● Myocardial infarction developed in 67 patients in the tiotropium group and 85 patients in the placebo group: RR 0.73 (0.53 to 1.00) ● Stroke developed in 82 patients in the tiotropium group and 80 patients in the placebo group: RR 0.95 (0.70 to 1.29) ● In the tiotropium lung function was significantly better than in the placebo group throughout the trial and there were improvements in health-related quality of life and rate of exacerbations. UPLIFT did not show an increased risk of MI or stroke with tiotropium. This provides some reassurance on the CV safety of tiotropium. There was no increase in mortality and may even have been a decrease with fatal adverse events occurring less often in the tiotropium group (NNT=111). All drugs come with risks. The question is does the benefit outweigh the risk for the individual? Is the risk/benefit ratio for tiotropium better than that for LABAs? Based on all the evidence, then on a population level (which are all studies can tell us) it would seem so. The clinician has to decide on the individual patient level. Should tiotropium be placed as the first-line long-acting bronchodilator in the management of COPD? The results from UPLIFT, taken together with the other evidence for tiotropium, strongly suggest that this is so.
References 1) 2) 3) 4) 5) 6) 7) 8)
JAMA 2008; 300: 1439-50 J Gen Intern Med 2006; 21: 1011-19 Cochrane Database of Systematic Reviews 2005, Issue 2 Cochrane Database of Systematic Reviews 2006, Issue 3 Chest 2008; 133:1079-87 Chest 2008; 133:1057-58 http://www.nyrdtc.nhs.uk/docs/rda/FinalRDTC.pdf N Engl J Med 2008; 359:1543-54.
Appointment of RCGP Clinical Champions 2010–12 The Council of the Royal College of General Practitioners has recently approved four new clinical priority areas to be taken forward for three years from January 2010. In order to support the development of innovative programmes of work the College is inviting applications for the role of Clinical Champion in each of these areas. Appointment as a Clinical Champion offers an exciting opportunity to influence and shape the development and delivery of a clinical programme of work within the College as well as to spearhead collaborative and partnership working with key stakeholders. The RCGP Clinical Champions are supported by CIRC to play a key role in providing leadership for the College in the respective clinical areas as well as in pressing for changes in clinical areas where the College has identified a need for improvement.
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Application Process The closing date for applications for the 2010 – 2012 Clinical Champions is Friday 15 May 2009. To apply, please submit: ● Your short CV (maximum 8 pages with a specific focus on your relevant recent activities) ● A covering letter highlighting your suitability for the role, an outline of your proposed programme of work and an explanation of its relevance to the advertised remit (maximum 1000 words) ● Appropriate letters of support from primary care organisations or other societies or associations as appropriate Please submit applications via email to circ@rcgp.org.uk All applications will be acknowledged on receipt.
The position of Clinical Champion is unsalaried (with set expenses) with a suggested time commitment of two sessions per month.
Shortlisting and interviews Following the closing date, a shortlisting process will take place. Interviews will be held during the weeks beginning Monday 15 and Monday 22 June 2009 (dates to be confirmed) and appointments made thereafter.
THE CLINICAL PRIORITIES FOR 2010 – 2012 ■ Allergy ■ Child Health ■ Learning Disabilities ■ Minor Surgery
Further information about the role of the Clinical Champion To view the relevant clinical priority remits and for further information about the role of the Clinical Champion, please visit www.rcgp.org.uk/circ
Debt and mental health Dr Sian Williams Problem debt has always been important and in the current economic climate, there is financial pressure on most socioeconomic groups and across many different job sectors. Nine out of ten people with a mental health problem are managed in General Practice. One in four people with a mental health problem is also in debt. It is important to ask people presenting with anxiety, depression or a relapse in their pre-existing mental illness about any financial difficulties. People may find it too awkward or embarrassing to mention debt as a contributory factor themselves. Some may be in denial. Debt can also result from overspending associated with mania, and due to delusional ideas in people with schizophrenia. Addictive behaviours can be very costly. Mental or physical ill-health can lead to job loss and consequent loss of income. GPs are not expected to be debt experts, but there are things we can say and do in ten minutes that can make a significant difference to our patients. The Final Demand (2nd edition) booklet is distributed this month with the British Journal of General Practice. It outlines some simple steps that all frontline practitioners in health and social care can take to continue providing good whole person care when people have money worries or problems with debt. GPs and practice nurses could use this acronym to guide them in helping their patients through their financial difficulties:
CONSIDER debt as a root cause of stress-related ill health, both physical and mental.
ASK some relevant questions (See Final Demand booklet). R EFER to a money advice expert either online, by telephone helpline or face to face.
ENGAGE with debt advisers(See DMHE Form) Final Demand (2nd edition) is based on debt and mental health research undertaken by the Royal College of Psychiatrists. Important contributions have been made by people with firsthand experience of debt and mental ill-health, also from a multidisciplinary team including General Practitioners, social workers, psychologists, representatives of Rethink and Mind and financial advisers.
Early intervention is key People should be encouraged to address any debt problems as early as possible before a crisis such as disconnection of utilities or loss of a home occurs. Ignoring bills because there are no means to pay them will only lead to increased stress and a deteriorating mental state. Bank debts are often sold onto unregulated credit agencies which sometimes use unscrupulous methods to intimidate their clients. Signposting to one of the many online debt advice sites may be all that is needed. Otherwise, both Rethink and Mind have telephone helplines. For those people who need face to face advice, it would be helpful if the practice has contact details to hand for the local money advice service. Some practices have successfully established formal links with the Citizens Advice Bureau working on the practice premises. Patients should be advised to gather any relevant papers regarding income and expenditure, bank statements, credit cards, loans etc to take with them for the debt advice. A trusted friend or relative might help in this task. (See budget calculator below).
Further resources and tools ● Forum for Mental Health in Primary Care is a new collaboration between the RCGP and RCPsych. Go to www.primarymentalwellbeing.org.uk for further information and to view Final Demand 2nd edition. Primary Care Guidance on Debt and Mental Health – a new factsheet, will also be available to support GPs via the same website. ● www.mhdebt.info includes the Final Demand booklet, tools, guidelines, links and research. It also includes the Debt and Mental Health Evidence Form (DMHEF). This is a standardized clinical information form comprising eight simple questions. With the patient’s consent, debt advisors may ask the health or social care workers to complete one in order for them to better negotiate with the creditors on the client’s behalf. ● www.moneymadeclear.fsa.gov.uk/tools/ budget_calculator.html for a useful budget calculator. ● www.adviceguide.org.uk Citizen’s advice rights guide. ● www.mind.org.uk/money MIND’s money resources for people with experience of mental distress and debt. ● www.rethink.org Go to ‘living with mental illness’. From the dropdown menu select ‘money debt and mental health problems’. Dr Sian Williams is a part time GP in South London. She has been a trustee of a work related mental health charity called First Step Trust since 1997. RCGP NEWS • APRIL 2009
NEWS
Everything you need to know about the Essential Knowledge Challenge Alternatively, you can click on Practising as a GP on the left-hand side of the current RCGP home page and then click on the subtitle Essential General Practice.
Dr Chris Elfes Essential Knowledge Challenge Lead Essential General Practice (EGP) has been renamed to avoid confusion with a similarly titled e-learning package (see story on page 4). From 1 April, it will be known as Essential Knowledge Updates (EKU), with the linked Knowledge Challenge becoming Essential Knowledge Challenge (EKC). Read on if you want to test your knowledge of emerging evidence in general practice.
How much does it cost? It’s FREE to all RCGP members, as part of membership benefits provided by the College. Associates in Training who have a reference number are counted as RCGP members. GPs who are non members will be able to pay an annual fee (£79.00 in 2009/10) which will enable them to access the year’s cycle of two EKUs and two EKCs. Look out for sample questions in forthcoming issues of the RCGP News.We intend to put occasional sample questions with links to the evidence in future publications.
What is the Essential Knowledge Challenge (EKC)? This is currently a web-based 50 item applied knowledge test – a format which has evolved from multiple choice-type MRCGP papers of old. The EKC has been produced by collaboration between the RCGP Essential Knowledge Update Steering Group and an experienced number of RCGP Examiners involved in the triangulated assessments which comprise the PMETB approved nMRCGP Licensing exam. Questions are based on internationally accepted formats1 and written by experienced question writers. Formats include: ● Single best answer – often based on a clinical scenario with a choice of five options for diagnosis, management or investigation ● Photo interpretation ● Graph interpretation ● Extended matching – where a range of management options are listed and then two or three different clinical scenarios are given. The best management option needs to be chosen for each scenario. ● Algorithm completion – such as flowchart-type questions with missing gaps to complete. For more detail about question types, please refer to the RCGP exam information page 2. The Knowledge Challenge is easy to take once you have logged your details on the EKU website. The required details are little different for those which are held by the College for an existing member already; they are then used to verify who you are and to ensure we can offer you feedback over consecutive Knowledge Challenges. Each question is answered by clicking a box by the available option you find the most appropriate. After completing all 50 questions, if you achieve a standard of 70 per cent correct answers or more, you can print off a certificate of completion. The certificate records the number of times you have taken to complete the test. Feedback is sent to you at the completion of the EKC but is not specific to every individual question. We want to preserve the validity and lifespan of questions which take a not inconsiderable amount of time (and RCGP funds) to produce to a high standard. Towards the end of the life of an individual EKC we will highlight the areas and some specific questions which proved hard for everyone. For example in the Pilot, many doctors found that the most up to date management of LV failure was different from their current practice and underlined a need to look again at the indications for the use of Spironolactone. Other areas of changing management which proved difficult also included the recommended length of time to treat a child with an uncomplicated UTI, as well as the management of an acutely unwell person who has been on longterm steroids. We aim to also provide individual feedback regarding common areas of strengths and weaknesses highlighted by an individual doctor taking successive knowledge challenges over consecutive years. The format for this feedback is under review but will hopefully include your own score on a graph showing where you lie on RCGP NEWS • APRIL 2009
a distribution curve of other similar doctors to you, eg other doctors aged 40-50 or other nonprincipals. Our hope is that this will link into your long professional development and help you in the process of providing evidence for recertification.
What areas does the EKC assess and how does the EKC fit in with Essential Knowledge Update (EKU)? The EKC questions are based on the EKU web modules, linked guidance and referenced peer reviewed articles. This means the subject matter is derived directly from the associated major EKU modules and minor listed web briefings. The questions are therefore sometimes limited in their scope but can stray ‘outside of direct attributable evidence’ in order to test related areas. For example, one question in the Pilot had a photo of scabies even though the module was about atopic eczema in children. This was felt to be a reasonable approach, otherwise the module content too easily cues an answer for most doctors! The EKU modules are based on areas of new or important changing evidence as well as topical updates in general practice. The Editorial Board has a formal process to ensure topic selection is wide ranging, varied from previous modules and potentially relevant to working GPs. Many questions in the pilot were found difficult for doctors to answer without looking at the referenced guidance.
Reminder of purpose of the current EKU Programme ● Enable practising GPs to be aware of, and learn about, new and changing information relevant to the GP specialty. (That is, important newly published best practice or national guidance or research/consensus of key relevance to GPs); providing general updating and encouraging effective application of that knowledge. ● Enable GPs to meet previously identified and unrealised learning needs in relation to new and changing knowledge and information ● Encourage practising GPs to apply the learning of EKU ● Be a key element of a GP’s annual CPD folder if EKU suits their learning style ● Contribute as part of the managed CPD scheme, to facilitate practising GPs in their provision of evidence of their learning and application in their personal portfolio
How do I find the EKC? You should find the direct link on the RCGP home page or try www.rcgp.org.uk/practising_as_a_gp/essential_general_practice.aspx
Why take the EKC? Doctors in the pilot appeared to fall into two main groups – either those who preferred to test their current knowledge and take the Challenge without looking at the EKU modules or those who wished to read modules of interest/identified need first and then test their understanding of the subject using the challenge second. Based on our objectives, medico-political discussions and the feedback of those doctors who piloted the first project which was known as Essential General Practice, any or all of the following might apply: ● ● ● ● ● ● ● ● ● ● ●
Academic interest Appraisal evidence Benchmarking exercise Efficient use of time to delegate the research of topics to others Identify learning needs Keeping up to date in General Practice One way of proving that already up to date Peer referencing Personal Development Plan creation Preparation for AKT Revalidation (see next paragraph)
How does the EKC fit in with Revalidation now? The EKC is currently a voluntary applied knowledge test which can be used as one tool contributing towards your annual CPD and Revalidation portfolio evidence. The EKC can be incorporated into the RCGP CPD Credits system of Impact and Challenge in the same way as any other educational activities undertaken. In addition to including your certificate as a piece of portfolio evidence you will be able to reflect on how the knowledge gained through the ECU and EKC packages helped you to improve your practice, through self development or implementing changes beneficial to your patients or the practice team, and demonstrate this in a variety of ways – for example through audit in your practice. You will then self assess your credits depending on the difference it has made and the effort expended in bringing about change. The RCGP will provide guidance about self accrediting and you will be able to discuss your self assessment with your Appraiser at your annual appraisal.
Future Plans The Essential Knowledge package will be fully launched in April 2009. As a new programme it will continue to evolve as we receive feedback. We would be interested in your comments.
References 1) www.nbme.org/publications/ item-writing-manual.html 2) www.rcgp-curriculum.org.uk/nmrgcp/ akt/presentations.aspx Dr Elfes works as a part-time GP Partner in Swanage, Dorset as well as being a GP Trainer, ST3 Programme Director and nMRCGP Examiner. Contact via arosen@rcgp.org.uk
POSTBOX The end of an era Last month, as the Chair of Examinations for our College, I had both the sad task and privilege to administer the final examinations board for ‘old MRCGP’. As you are all aware, the examination celebrated its 40th anniversary last year and at the celebrations we witnessed the transition from the old to new MRCGP. The transition process took several years, and I wish to thank and pay tribute to all who have been involved in it. In particular, the vision of my predecessor Val Wass and her Convenor Pete Tate in recognising the need for change was inspiring. Pete’s role was taken up by his successor, Andrew Wilson, with his usual understated skill and intellect, so completing the task. They developed a key team who worked tirelessly to evolve and implement the necessary changes required in a relatively short period of time. Many were honoured by the College recognising the significant contribution they all made. The College is now the sole licensing body for all doctors entering our speciality, a major achievement and step forward. All of this would not have been possible were it not for the foresight of a group of College members and fellows, who recognised the absolute need to modernise General Practice, and to develop an assessment which reflected this process. The examination evolved rapidly, and was the first to take on new technology, initially in machine marking of papers, and the use of video in the consultation. More recently we have been the first to UK assessment to be delivered online, for our knowledge test. I found my time both as an examiner and as the College lead in assessment to have been the most stimulating part of my career. The new friends we make are often life long and go beyond the confines of the examination itself. The various administrators and college staff who have ably supported the examiners need special recognition. Without them all of our ideas would never have been implemented. They deserve our gratitude and respect. I would like to thank everyone who made a valuable contribution to the exam and can reassure you that the assessment which has replaced it is a progressive and world-leading one. Dr Mike Bewick
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NEWS
On the double: College experts join Quality Board RCGP President David Haslam and RCGP Fellow Sir John Oldham have been appointed as ‘Expert Members’ of the National Quality Board, set up by Lord Darzi to advise the NHS on priorities for improving quality in health and social care Chaired by NHS Chief Executive David Nicholson, the NQB will consider how quality is measured, oversee the development of indicators and advise the NHS on priorities for improving quality. The Board will deliver its first report on quality to the Secretary of State for Health in June
2009, one year on from Lord Darzi’s review. Professor David Haslam said: “Quality matters – it isn’t just an abstract concept. After all, everyone in the NHS should be offering the level of care they would want for their mum. After 30 years as a family doctor, I fully understand the realities of healthcare, and the positive difference that clinicians can make.” Sir John Oldham, a GP Principal and Managing Director of the organisation Quest4Quality said: “I have dedicated my career to finding ways of improving the quality of outcomes and experience for patients. It has been my passion and I am delighted to continue that work with the NQB. Working to eliminate errors and poor quality will be pivotally important in the challenges over the next few years.”
Involving patients is a virtue: (l-r) Sue Kinsey, P3 Chair; Paul Alexander, RCGP Scotland Policy and Committee Coordinator; Graham Box, CEO of NAPP; Dr Ken Lawton, Chair of RCGP Scotland
Making the connections: the importance of involving your patients RCGP Scotland patient group P3 held an interactive workshop to discuss the value of setting up a patient group at the historic Playfair Library in Edinburgh
Haslam: Quality isn’t just an abstract concept
Oldham: Eliminating errors is pivotal
Ministerial launch for RCGP Wales Welsh Health and Social Services Minister Edwina Hart will join members of RCGP Wales at the Senet in Cardiff for the launch of their landmark document on the future of healthcare. Next Steps: The Central Role of General Practice in the evolving Health Service in Wales sets out an ambitious vision for the future of the health service, calling for greater recognition of the role of GPs. It explains the unique relationship of trust GPs have with their patients, the importance of continuity of care and the challenges of treating patients with co-morbidities then demonstrates
how a strengthened general practice can provide the solutions to many health and social problems. The paper suggests three priorities for change which will help GPs better connect the community with the NHS: ● Better collaboration between doctors and patients, communities, primary and secondary care, management and policy makers ● Improved quality in standards and consistency of care through education and research, with increased investment in premises, IT and the workforce ● Methods for tackling health inequalities ■ The full report is at: ww.rcgp.org.uk/
councils__faculties/rcgp_wales.aspx
Around 60 delegates attended the day, hosted by P3 Chair Sue Kinsey who said that effective, patient and public involvement should be approached “with openness, honesty and genuine commitment on both sides, rather than being tolerated as political correctness”. Dr Ken Lawton, Chair of RCGP Scotland, joined the event to demonstrate RCGP Scotland’s commitment to patient involvement. Opening the workshop Dr Lawton argued that “true patient involvement is not just a tick box
New guide for newly-qualified GPs and Trainees The College has published Management for New GPs, a practical guide and reference tool for new GPs, offering an introduction to management and leadership in general practice in the widest sense. It covers management in primary care at the national level, looking at the history of general practice and the structure of the NHS and primary health care. Part of the RCGP Curriculum for General Practice Series, encompassing vital support for Curriculum statement 4.1, it also provides information on more specific practice-level management. The book is aimed at GP registrars or GPs who are newly qualified. It provides background reading to the nMRCGP curriculum and for those just becoming involved in management in primary care.
Your opinions, please The RCGP will soon be launching an online Membership sur vey so that you can tell us what you think of the College, our services, how you feel we represent you and how you think we could improve things. All members are invited to take part and there will be a prize of a one-year annual membership (2010-11). More details will be available shortly.
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exercise for QOF, patients have a lot to contribute to the development of a practice”. Keynote speaker Graham Box, CEO of the National Association for Patient Participation (NAPP), gave an interactive presentation on the ‘Value of Patient Groups in General Practice’ which offered delegates the opportunity to discuss both the functions and difficulties in setting up a patient group. The day also included further breakout sessions, facilitated by P3 members, for attendees to interact on key issues. Feedback from the day has been extremely positive and points discussed by delegates in the breakout sessions are currently being collated for display on the RCGP Scotland website. For further information on patient involvement and the PG Tips initiative set up by P3, visit the Patients section of the RCGP Scotland website.
■ The book, priced £24.95 (with a 10 per cent discount for members) is available from the RCGP Bookshop online: www.rcgp.org.uk/ bookshop or telephone 020 7344 3198
RCGP News invites your comments or letters... Please write to: The Editor, RCGP News Royal College of General Practitioners 14 Princes Gate, Hyde Park, London SW7 1PU email: rcgpnews@rcgp.org.uk ISSN 1755-7720 © Royal College of General Practitioners. All rights reserved. Published monthly by the Royal College of General Practitioners 14 Princes Gate, London SW7 1PU email: rcgpnews@rcgp.org.uk website: www.rcgp.org.uk
RCGP NEWS • APRIL 2009