News
Revalidation e-portfolio: Pilots get underway for prototype A prototype of the electronic ‘e-portfolio’ for Revalidation will be piloted from this month The e-portfolio aims to provide a complete solution to support the Revalidation of all GPs – and to deliver a secure system that is able to integrate with other RCGP products. Here, Dr John C Howard, Vice Chair of the RCGP Professional Development Board, reports on progress so far and outlines how input from grassroots GPs is crucial to its future development. OVER THE SUMMER a small team has been developing a prototype revalidation e-portfolio which we hope will be available for members during 2010. The system will be piloted over the winter with around 100 GPs and 20 appraisers in a variety of locations in the UK testing the system. The pilots are in several countries of the UK in both urban and rural environments and we anticipate a similarly wide variety of GPs will be involved. Feedback from the pilots will be used to refine the final system which will be free to members as a benefit of membership. This should give plenty of time for members to use the e-portfolio before the first submissions to the GMC begin. The e-portfolio, unlike current appraisal systems, is based around the areas of revalidation set out in The RCGP Guide to Revalidation for General Practitioners. It is based around a simple log of learning activities and has an easyto-use system for entering data. Because it categorises information in the learning log, it allows a pictorial representation of a doctor’s progress on the road to revalidation both before appraisal and ultimately before the five-yearly revalidation submission is required. Capturing information by learning events should make the system suitable for GPs working in practices and those working in other contexts, whether self-employed or salaried. A further important benefit is that the e-portfolio provides a link to the College’s newly launched CPD credit scheme. Under the scheme an hour of educational activity, including reflection on that activity, is equivalent to one credit. If the learner can demonstrate that the educational activity has had significant impact on their practice, ultimately improving
patient care, then two credits can be claimed for each hour of activity. The e-portfolio includes a guide to the system and includes a tool to show credits claimed over all areas of the doctor’s learning. Attachments can be easily uploaded and the system includes the ability to search for items of learning in a variety of ways. The College is confident the system will be a useful way for GPs to collect the necessary information they require for revalidation. The e-portfolio will be available as part of the College’s online learning environment and it is planned that College continuing professional development activities, such as Essential Knowledge Update, will be entered directly into the portfolio. The doctor will then simply enter their reflection on the learning they have undertaken. College members’ details will be automatically entered into the personal details section of the e-portfolio. Similarly, it is planned that relevant information recorded in the trainee portfolio will be easily migrated into the revalidation e-portfolio. If the prototype is confirmed by the pilots as being a valuable tool, we anticipate that the functions of the e-portfolio for GPs will be as follows: ● A learning log which provides easy to use templates in which to record day-to-day learning from and about general practice in any context. Each item can be linked to appropriate areas in the GMC Framework and also to the RCGP’s GP curriculum, although this is not required for revalidation ● An easy to use cataloguing system for an individual’s learning allowing doctors to see at a glance the range and quantity of their activities with the detail easily available ● A ‘traffic light’ indicator of a GP’s progress to revalidation, along with an electronic system to submit the portfolio to the Responsible Officer for revalidation ● RCGP members’ personal data will automatically be populated in the portfolio ● Support for the RCGP Credits System
‘Leadership, leadership, leadership’: Professor Steve Field calls on GPs to become clinical leaders
Leading the way: RCGP Chair rallies Conference RCGP Chairman Professor Steve Field has called on GPs to assert themselves as clinical leaders, saying that leadership in primar y care is crucial to the future of the NHS. He also spoke out against the abolition of practice lists and practice boundaries, and paid tribute to the defence services in Iraq and Afghanistan. Conference round-up overleaf.
● Direct links to other RCGP e-learning products: for example, eGP – the e-learning resource for NHS GPs and doctors undertaking specialty training; PEP – RCGP Scotland’s online learning needs assessment tool; and Essential Knowledge Updates. These will all autocomplete relevant entries in the portfolio ● An over view of the information available for each appraisal, as well as for each revalidation ● The ability for GPs to record all their medical activities, both within and outside the NHS and in every context ● A secure environment which will maintain data for years to come The system will include appraisal and will also have functions for primary care organisations or Deaneries managing appraisal. However these functions will be developed in Phase 2 of the project; at present the priority is to test the usefulness of this exciting development in everyday practice in the pilot sites.
The NewsPAPeR Of The ROyAL COLLeGe Of GeNeRAL PRACTITIONeRs
DECEMBER 2009
Inside this issue... Glasgow 2009 Roundup from the RCGP annual national conference
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e-learning essentials Easier navigation and latest Knowledge Update goes live
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Question time Cancer ‘Tsar’ Mike Richards talks to the RCGP
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Dementia dilemmas Examining the ethics of care
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A breakthrough for Breakthrough? Focus on breast cancer
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In memory of Mac Sir Denis Pereira Gray on the importance of posthumous honours
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Tribute to a titan Yvonne Carter dies aged 50
E A R LY B I R D B O O K I N G D E A D L I N E 2 8 J U N E 2 0 1 0
Sustainable
Primar Care growing healthy partnerships
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CONFERENCE
CONFERENCE Conference chairman Niall Dickson takes a point from the floor
EXCELLENCE IN GLASGOW
Bill Gunnyeon promotes health, work and wellbeing
Harvard talks health: Gordon Moore Westminster view from Minister Mike O’Brien
We promised it would be bigger and better than ever – and it was! Over 1,200 GPs and primar y care professionals converged on the SECC in Glasgow for the third RCGP annual national primar y care conference Excellence in Practice – winning ways for primary care. Practice boundaries and clinical leadership were recurring themes of debate but the main theme was revalidation, and delegates pitched their questions and concerns to a toplevel panel of College Revalidation Leads RCGP Chairman Professor Steve Field and Professor Mike Pringle, alongside General Medical Council Chairman Professor Peter Rubin. A packed programme showcased all the latest clinical and policy developments across the UK and attracted an impressive range of national and international speakers including Har vard Professor Gordon Moore and an inspiring social marketing session involving Maori visitors. Delegates were able to find out about the latest e-learning developments in the RCGP Village, where the work of the RCGP in Scotland Wales, Northern Ireland and the RCGP Faculties was also on display. Specific streams for non-GP members of the practice team proved ver y popular and culminated in the launch of the new RCGP General Practice Foundation for practice managers, physician assistants and practice nurses. A record number of Associates in Training attended, including the winners of the Great Expectations bursaries and a Vasco de Gama delegation of international trainees. The social programme went down a storm – the GP Jammin’ session and AiT curr y and karaoke proved huge draws, but the Red Hot Chilli Pipers stole the show with an unforgettable performance at the conference dinner held at the stunning Kelvingrove Museum. RCGP Vice Chair and Conference Lead Dr Clare Gerada said: “We expected great things – but the conference exceeded our expectations on all fronts. The atmosphere was fantastic and we’ve received excellent feedback. Thanks to ever yone who took part – see you next year!”
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Kamlesh Khunti tackles the obesity epidemic
Hitting out at health inequalities: Harry Burns
Health Secretary Andy Burnham beams in by videolink
RCGP Research supremo Nigel Mathers
Revalidation Ready? ask Mike Pringle, GMC Chair Peter Rubin and Steve Field Hidden talents: the GP Jammin’ session
Clinical Champion David Kernick takes to the floor at the conference dinner
Clare Gerada: “The conference exceeded our expectations on all fronts”
The Red Hot Chilli Pipers blow up a storm at the Kelvingrove
Shona Robison MSP puts the Scotland perspective
Strong Foundations: (l-r) Maureen Baker launches the RCGP General Practice Foundation with nurse Sue Cross, practice managers Sandy Gower and Fiona Dalziel and physician assistant Neil Erickson RCGP NEWS • DECEMBER 2009
RCGP NEWS • DECEMBER 2009
Great Expectations: Bursary winners (l-r) Dr Ha-Neul Seo, Dr Greg Irving and Dr Rati Rue Roy with RCGP President David Haslam and Caroline Anderson, Chair of Adjudicator Panel
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NEWS
Log on for essential easing into e-learning Knowledge Updates 4 Dr Dirk Pilat EKU Development Fellow
The latest Essential Knowledge Updates (EKU 4) was released in time for the RCGP conference in Glasgow. Consisting of 28 guidelines, meta-analyses and seminal papers covering a broad spectrum of the curriculum, it is hoped that EKU 4 will appeal to our colleagues across the whole of primary care. Eight of the guidelines were chosen by the Essential Knowledge Updates Editorial Board as being very important for day-to-day practice and were edited into concise learning modules to facilitate the acquisition of the key facts by learners. In May ’09 the RCGP Information Scientist identified 130 potentially applicable sources published between October 2008 and May 2009 – but only 28 were selected for inclusion within the final update. The sources were particularly chosen because of their applicability to general practice and for their new and changing knowledge content. Since the release of EKU 4, the search for the best topics for the next update has already begun and the Essential Knowledge Updates Editorial Board is reviewing the latest knowledge sources identified in order to pass on the selected guidelines to our dedicated team of Update authors. Since its first post-pilot release in April 2009 our user base has steadily grown: the e-learn-
ing website (http://elearning.rcgp.org.uk) has now more than 7,500 registered users. This is still only a fifth of College members, but the recently received feedback at the RCGP Annual Conference was encouraging and only a small minority of members were not aware of the Updates. Additional planned future developments include the production of materials to enable EKU to be delivered through faculty based workshops and the possible development of a version of EKU relevant to nurses to support the GP Foundation initiative. We will soon be piloting half-day seminars in which the key topics will be presented in a more traditional way to accommodate the needs of members who prefer a this way of learning or who are unable to access the internet. Remember: this service is free and a core membership benefit for Fellows, Members, Associates and Associates in Training. The Updates have an associated Essential Knowledge Challenge (EKC), an applied online self-assessment knowledge test which is issued six months after the Update. By passing the Essential Knowledge Challenge you will be able to demonstrate your understanding of the subject and by implementing your new knowledge into your daily practice not only your patients will benefit, but also your revalidation requirements will be made significantly lighter. Now drop this splendid magazine, fire up your web browser, log on to http://elearning. rcgp.org.uk and have a go – it’s a win-win situation.
Essential Knowledge Updates • Provides GPs with a six-monthly focussed update on new and changing knowledge central to everyday practice. • Updates on key clinical areas of national significance (including newly published NICE / SIGN guidelines and Gold Standards, new relevant legislation). Take • T ake the subsequent Essential Knowledge Challenge to test your knowledge of the Update - scores in excess of 70% eligible for a certificate to use towards CPD and revalidation. • Stay updated - enhance your skills and improve the quality of patient care.
Free to RCGP Members / non-members can purchase an annual subscription for £79. rcgp.org.uk/eku 4
The e-GP and RCGP Online Learning Environment websites provide consistent, streamlined e-learning programmes for general practice. But, as newly-appointed Medical Director for e-learning Dr Ben Riley explains, this brings with it its own set of challenges.
Since his appointment in September, Dr Riley has been tasked with leading the developmental rollout of e-learning resources produced by the RCGP to support GP training and continued professional development (CPD). Two recently-launched learning initiatives – e-GP and the RCGP Online Learning Environment – have been set up to provide high-quality e-learning resources to GPs. Over the next two years, the e-GP project is rolling out a comprehensive programme of interactive e-learning sessions and virtual patient consultations to underpin the RCGP curriculum. The aim of the e-GP programme (www.egp.org) is to provide an e-learning resource – free to NHS GPs and trainees – that delivers the RCGP curriculum at a national, local and individual level through relevant, comprehensive and accessible learning content. The e-GP programme will also support GP Speciality Registrars hoping to achieve certification to practice independently, as well as support GPs through revalidation and CPD. The RCGP Online Learning Environment (www.elearning.rcgp.org.uk) provides members and associates with free access to a range of e-learning materials to support preparation for revalidation. These include the Essential Knowledge Updates and Challenges – the six-monthly updates of new and changing clinical knowledge, and online courses for GPs wishing to extend their skills, such as the Improving Access to Psychological Therapies course. Dr Riley, a practising GP in Oxfordshire, explained that one of the major challenges he and his team face is providing a consistent and coordinated approach to the development of online educational resources that makes life easier for the GPs that use them. Describing his new responsibilities, Dr Riley said: “My role is to co-ordinate everything we’re currently producing, in order to develop an elearning strategy which will shape the future development of our education programmes. The idea is basically to make it easier for people to make sense of the wealth of resources available to them.” To facilitate this, he and his team have developed four simple educational themes into which all currently-available resources and initiatives will fit: GP Training, for training GPs, GP trainers and educators; CPD and Revalidation, to support all GPs in their CPD, appraisal and
Ben Riley: Making it easier for GPs to find the online educational materials they need revalidation; Advanced Practice, for practitioners wishing to build on existing skills or develop special interest; and Teams and Quality, to support practice team development. Dr Riley said that dividing resources in this way will create a sense of cohesion and accessibility that is currently unavailable with existing e-learning resources. He said: “It’s really about making life easier – busy GPs should be able to find the educational materials they need online quickly and easy. And beyond this, we have to ensure that the materials they access are relevant, and of high quality. “The plan is to tie all of the available resources together, and make sure that all of these e-learning resources really work together – so that they inter-operate and integrate with other tools such as the ePortfolio. “People don’t want to have ten log-ins and complete each task three times, and at the moment this is the situation they find themselves in. It’s going to take a few years to move to the position where this is no longer a problem, and where everything is a bit easier to use, but that’s our ultimate goal.” With the wealth of resources now available online for GPs, the concern which Dr Riley is committed to meet head-on is the issue of quality. He explained that RCGP branded e-learning resources should be the final word on quality, usefulness and relevance. He said: “That’s the other aspect to this project: There is a quality agenda to make sure there is consistency in our approach. We want to ensure that people recognise college-branded e-learning, and in recognising it know that it is going to be good quality, relevant and, of course, engaging. If we can achieve that it will be a great achievement for the College.”
GPs invited to become NICe fellows and scholars The National Institute for Health and Clinical Excellence (NICE) has launched a new programme giving GPs and other frontline healthcare professionals the opportunity to get more involved in its work. The NICE Fellows and Scholars programme will award ten fellowships to senior health professionals who will act as ambassadors for the Institute within their local health and professional communities. They will also have the opportunity to become involved in a range of other activities such as clinical audit, education and policy development. Fellowships will run for fixed term periods of three years. Ten scholarships will also be given to health
professionals in their final or penultimate years of training. NICE Scholars will be required to undertake research-based projects, as agreed by their local postgraduate deaneries or training supervisors. Scholarships will last for fixed term periods of twelve months. The deadline for applications is 31 December 2009, with the first NICE Fellows and Scholars appointed in spring 2010. For further information on the programme and fellowships, please go to: www.nice.org.uk/getinvolved Professor Peter Littlejohns, Clinical and Public Health Director at NICE said: “Frontline staff make a huge contribution to developing NICE guidance. This new programme will not only be a mark of professional distinction, but it will also foster a growing network of dedicated and influential individuals across the NHS that will support the implementation of clinically and cost effective practice.” RCGP NEWS • DECEMBER 2009
PROFILE
Questions in the fight against cancer Professor Mike Richards CBE, the National Clinical Director for Cancer, addresses RCGP members’ concerns about diagnosis, treatment and care particularly BME groups. It would be useful if GPs asked if their patients in the appropriate age groups had accepted their invitations for breast and bowel screening in routine appointments. We need a multi-pronged approach to increase uptake in hard to reach groups. This involves working at community level, involving GPs and improving the accessibility of screening services. Where such an approach has been adopted, it has worked.
How do you envisage that better access to investigations by GPs will work? We are establishing a diagnostics clinical reference group, which I will chair, to consider the details. GPs, radiologists and others will be represented on this group, and we will identify which tests would be most helpful to GPs in order to prioritise them. The implementation of better access to tests will be phased over five years. Initially we expect to focus on the diagnostic tests associated with ovarian, lung and colorectal cancers. By the end of the five-year period, we want to see all patients knowing the results of diagnostic tests within one week. For people who are shown to have cancer, the earlier diagnosis will increase the chances of curative treatment.
One of the key psychological needs of people after initial treatment for cancer is learning how to deal with the fear of recurrence. However, we are very rarely provided with information about actual risk of recurrence for individual patients by secondary care colleagues and even less often provided with information regarding what has been shared with the patient regarding their risk of recurrence. How can communication between secondary care and primary care be improved to ensure that we are given the information we need to support our patients in this way?
Which cancers should be the top priority for GPs in terms of: a) prevention? b) detection? c) surveillance? In terms of prevention, smoking-related cancers (eg lung, head and neck and oesophagus) have to be top priorities for GPs. Smoking still accounts for around one third of cancer deaths. Early detection and diagnosis matters for all cancers – but in terms of numbers of deaths that could be avoided through earlier diagnosis breast, colorectal and lung cancer are the most important and so could be prioritised by GPs. Surveillance is important for all patients with cancers. It is impossible to prioritise one over another.
As part of the National Cancer Survivorship Initiative (NCSI) we are proposing that all patients with cancer should undergo a full assessment at the end of treatment and be offered a ‘Survivorship Care Plan’. This would be tailored to their needs and would cover anxiety and risk of recurrence, where appropriate. A copy of this Care Plan should be sent to the GP. An assessment and care-planning framework has been developed and will be piloted in 12 test communities; evaluation of this piloting work will be complete by September 2010.
In the current financial climate, where is the economic analysis on where best we can invest in service improvement for cancer? In terms of primary care service change, detailed economic analysis is currently under way. However, all the evidence points to the fact that late diagnosis is our greatest problem in this country. It is estimated that up to 10,000 deaths could be avoided each year if survival rates matched the best in Europe – and that promoting earlier diagnosis is the key to this. Preliminary work indicates that this is likely to be highly cost-effective. Regarding secondary care service change, there is huge potential to improve the quality and productivity of inpatient care for cancer and reduce unnecessary hospital use (as set out in the Cancer Reform Strategy). Inpatient services can be improved by minimising lengths of stay in hospital for medical and surgical admissions and preventing unnecessary emergency admissions. We believe that making the necessary changes would save about a million bed days a year – a fifth of current bed days – with great benefits to patient wellbeing.
Given that many of the symptoms of cancer are vague, how much scope do you believe there is in primary care to improve performance in this area? Can you envisage a scenario in which GPs assess cancer risk in the same way they do cardiovascular risk? What can primary care do to achieve earlier diagnosis for rare cancers? Despite the vagueness of cancer symptoms I believe there is significant scope to improve early diagnosis. I can see GPs in the future estimating cancer risk in the way that they already do for cardiovascular disease. Research done by Dr Willie Hamilton and colleagues into risk assessment for primary care is helping to make this a reality. RCGP NEWS • DECEMBER 2009
QOF has been an important lever for quality improvement in general practice, but cancer is poorly addressed within it. What steps are you taking to address this with the DH? I agree that cancer is poorly represented in QOF. The difficulty has been in designing appropriate measures. Any suggestions would be gratefully received!
diagnosis is our greatest problem in this country. ❛ Late It is estimated that up to 10,000 deaths could be avoided each year if survival rates matched the best in europe – and promoting earlier diagnosis is the key to this
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Under the diagnostics work stream of the National Awareness and Early Diagnosis Initiative we are looking at methodologies for the assessment of current risk/likelihood of individual patients having cancer (or other serious illness) and how these may be used to improve decision-making in primary care (and inform patients). This may include the consideration of clinical decision-support tools, which are a method of supporting rare cancer diagnosis.
As more and more of our patients are living with cancer, what resources should be directed into providing support for these patients in our practices? Should practices have ‘cancer nurses’ who would provide pastoral support; review progress and arrange for markers etc to be assessed? In some ways cancer needs to be considered
alongside other long term conditions. I am not sure that dedicated cancer nurses will be needed at practice level – but nurses managing patients with long term conditions may well extend their roles.
Is it worth investing time and effort in promoting the role of primary care in improving screening uptake particularly in hard to reach groups or should this effort be directed into centralised and very effective methods of recruitment and follow-up? I think there is a place for both. Primary Care has an important role in promoting the benefits of screening – for breast, cervix and bowel cancers. Our recent work on developing a report for the National Cancer Equality Initiative showed that the attitude of GPs to screening is very important in how some groups respond to screening invitations,
Will the proposal to reduce the two-week wait down to one divert valuable resources away from other non-cancer illnesses which are equally deserving? The Government has not proposed to change the two-week maximum for urgent referrals to hospital. The one-week proposal applies to direct access to diagnostics. Earlier diagnosis is likely to be highly cost-effective, and improving access to diagnostics for GPs will contribute to this. It is likely to save lives as well as reassuring many patients who will have normal test results. If GPs have better access to diagnostics I also believe that referrals to secondary care may well fall, saving resources elsewhere.
The NICE urgent cancer referral guidelines are now quite dated. When are they going to be updated and how could they be better implemented in primary care? No decisions have yet been made on updating the NICE cancer referral guidelines. I will be chairing an advisory group to take forward the commitment on diagnostics. We will consider updating referral guidelines alongside the need for any guidelines on the use of diagnostics. We will then discuss this with NICE who are responsible for prioritising guidance development.
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CLINICAL UPDATE
New horizons for mental health: The implications for general practice Richard Byng General Practitioner and GP with Special Interest, NHS Plymouth; Member of Joint Forum for Mental Health THIS YEAR HAS SEEN the Department of Health’s publication of New Horizons – towards a shared vision for mental health 1. This document, the result of several months of research and collaboration, provides a vision for mental health ser vices and the promotion of mental health for the next ten years. In many ways it is bold, promoting the concepts of early inter vention, prevention and integration of mental health ser vices with other sectors. This article first outlines the achievements of the National Ser vice Framework for mental health over the last ten years, explores the main themes of New Horizons and then details the RCGP response to the consultation.
Background Since its publication in 1999 the National Service Framework for Mental Health 2 has dominated mental health commissioners’ and mental health providers’ decisions in service delivery. Although primary care and prevention figured large in the original document, it was the performance of secondary mental health services which was closely monitored. Community based teams were restructured with Early Intervention (EI) services focussing on those with first episode psychosis; Assertive Outreach teams delivering care for those who are hardest to engage (mainly those with psychosis); and Home Treatment (or crisis) teams delivering home-based care as an alternative to hospital admission. The number of hospital beds has dropped as a result of these initiatives but investment has increased overall. Community mental health teams providing care for the remaining patients and the primary care liaison function have sometimes reduced in size and have not been subject to such strict criteria. As a result, their services – upon which we in general practice depend – have been relatively heterogenous in their development, in some areas providing good links to primary care and in others developing a culture of separateness with clear thresholds required for care to be considered. This has led to considerable unmet need for people with enduring common mental health problems such as treatment-resistant depression and also for those with psychiatric co-morbidity, including personality problems, substance misuse and often a history of physical or sexual trauma. Recently, the development of Improving Access to Psychological Therapies services has heralded a new investment in psychological therapy based on evidence based interventions for those with common mental health problems in primary care. Another recent development, only just coming in to play across the country, is the development of the dementia services based on diagnosis rather than age. This has led to considerable uncertainty about the future of services for older, often frail, adults with functional mental illness (eg schizophrenia and depression) rather than dementia. NEW HORIZONS PROVIDES a picture of care across the ages; it focuses significantly on young people and children as well as on older adults. Services are unlikely to remain bound by age cutoffs and will be developed more according to need. There is a strong emphasis on social inclusion – ensuring that people with mental health problems move wherever possible into gainful employment, have good accommodation, satisfying relationships and participate in leisure and sporting activities. As a part of the focus on ‘well-being’ there is the assumption that stigma will be addressed by preventing discrimination against those with mental health problems but, perhaps more importantly, offering services that do not force people to admit they are mentally ill in order to get help. Running alongside this, but not as clearly stated, is the theme of breaking down the ‘Descartian’ body-mind divide that has been a dominant determinant of service provision with separate mental health and physical health services. General practice is one of the few health services where there is an integrated approach to the assessment and management of mental health and physical health care. Public mental health and prevention is an important theme throughout New Horizons. Promoting mental health requires collaborative effort across all government departments, regional bodies, commissioning PCTs and local authorities as well as those delivering front-line services. This is a complex and major agenda. Public mental health promotion will mean working with: parents who have mental health problems to improve attachment and minimise intergenerational trauma; children and young people in schools to develop resilience; employers to support people in the work place dealing with stress; people with severe mental illness to gain access to physical health promotion and treatment. Related to prevention is the concept of early intervention and following the successful development of early intervention services for psychosis, early intervention in childhood and for depression and dementia will be critical to the success of New Horizons. For example, Multi-systemic Therapy for children with
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conduct disorder aims to prevent them falling into the cycle of the long-term institutionalisation of prisons and worklessness. A couple of themes to be found across government policy are also flagged up in New Horizons. Firstly is the issue of personalised care and choice. It is expected that individuals will have clear information about services available, be able to make informed choices about the type of treatment they receive and where and when they receive it. This will be joined up with social care extending the personalised budgets agenda for those with long-term mental health problems. Secondly, there is an emphasis on collaboration, seen across the health service although at times at odds with competition (contestability) promoted by current commissioning arrangements. For some people collaboration will mean a breaking down of old boundaries and in general practice this raises the potential to improve the links between community mental health teams and primary care. In some ways the new improving access to psychological therapies teams, sitting as they do between primary and secondary care, has the potential to fulfil this promise. These teams are roundly supported by the New Horizons vision; general practitioners will need to become involved in developing collaborative arrangements which are fit for purpose. Lastly, innovation and value for money are promoted. It is likely that wholesale transformation of services will occur with disinvestment from ways of working that are seen as inefficient and investment in new flexible systems and pathways which deliver real outcomes. This offers an opportunity to general practice which has a strong track record of delivering innovative, cost-effective care. Research and evaluation are also promoted as a part of the New Horizons programme, and robust techniques (and sometime novel alternatives to RCTs) will need to be employed to both develop the right kind of outcome measures and evaluate implementation.
What it means for general practice The RCGP has responded to the New Horizons document. The general emphasis and the themes outlined above are supported. However, it is clear that New Horizons will be leaving the service design and mechanisms for achieving its aims to local commissioners. There is little emphasis on general practice having a central place in the delivery of mental health care. The majority of general practitioners see mental health as a core component of the care they provide, so the College has set out its own vision for New Horizons which includes the development of the primary care mental health team around general practices. Specifically this will involve greater involvement, supported by specialised mental health workers in the care of older people at home with mental health problems; for those people with complex co-morbid conditions such as substance misuse, mental health problems and personality problems; for those with medically unexplained symptoms and mental health problems in conjunction with long-term physical conditions; and for the care of those with psychosis who are relatively stable and at lower risk. These functions will require education and training for all members of the primary health care team, better systems of record keeping across the interface, collaboration with specialist services and, perhaps most of all, the development of self care supported through general practice. The box on the right provides an outline of the 16 ideals which the joint RCGP/RCPsych Forum for Mental Health in Primary Care has agreed.
References 1) New Horizons – towards a shared vision for mental health. 2009. Department of Health. London 2) National Service Framework for Mental Health. 1999. Department of Health. London
16 ideals of primary care mental health Developing professionals and teams ● Education: Increase confidence in mental health issues for primary care team members. ● Intervention training: Increase use of low-intensity interventions by non mental health specialists in primary care. ● Specialist support for primary care: Develop more integrated and flexible use of mental health specialists including psychiatrists in primary care.
Organisation of services ● Co-location of services: Encourage co-location of services where possible to facilitate communication, seamlessness and timely responses and interventions. ● Referral pathways: Develop referral pathways from and within primary care for people with long-term mental health problems to services that promote recovery and inclusion in educational and vocational activities. ● Primary care based care managers (generic or specialist mental health workers) to co-ordinate care from general practices with the ability to navigate across boundaries for people with complex mental health problems. ● Encourage partnership between voluntary and primary care services along care pathways, including health and social care. ● Local commissioning: Enable commissioning of flexible mental health services based on local need by practices (practice-based commissioning) and on individuals (individual budgets). ● Common information systems between specialist and generalist services to support shared communication between teams caring for the patients. ● Clear shared pathways and protocols for early intervention and ongoing monitoring of physical health care of people with mental health problems. ● Integrated evaluation: Develop integrated (primary care/specialist) approaches to audit, evaluation and research.
Specific patient groups ● Older persons/persons with complex physical and mental health needs: Develop locality based multidisciplinary teams, utilizing general practice IT systems, for those (often older) people with mental and physical health problems who are often (semi-) home bound. ● Medically unexplained symptoms (MUS and personality disorders): Develop pathways, protocols and practitioners with enhanced skills. ● Dual diagnosis: Accessible co-ordinated primary care and interventions for people with co-morbid substance misuse and mental illness. ● Early intervention: Develop primary care based early intervention services for young people. ● Services for persons and families with complex and multiple needs: Ensure that the most needy and distressed, as identified by local needs assessment, are specifically targeted and receive opportunities for effective individual and family-based interventions, eg BME groups, asylum seekers, unemployed, offenders, people who are homeless and travellers.
■ During the next few months the Department of Health consultation will examine responses and agree work plans for particular areas. It is likely that the development of care for those with medically unexplained symptoms will be one of these work plans, and it is anticipated that the College and the Forum will be involved in advising on implementation. Anyone interested in contributing to this work through the Forum should contact Saqib Ahmad and/or Professor Carolyn Chew-Graham: saqib.ahmad@rcgp.org.uk www.rcgp.org.uk/get_involved/rcgp_standing_groups/ mental_health.aspx
The ethics of dementia care All those involved in the care of people with dementia should have access to education and support to help them deal with the ethical dilemmas they come across in their daily work, according to a major new report from the Nuffield Council on Bioethics. Co-authored by RCGP Fellow and Leicester GP Dr Rhona Knight, Dementia: Ethical Issues looks at areas such as the sharing of confidential information with families, how to weigh up the past and present wishes of a person with dementia and when to use restraint. Dr Knight said: “GPs see people with dementia all the time – but we may not know how best to handle the difficult situations that can arise. Ongoing professional education, courses and peer support in ethical decision making should be available to all those involved in frontline care of people with dementia. Guidelines alone are not enough.”
The report makes a number of policy recommendations aimed at improving the lives of people with dementia and their carers including: ● Improved access to good quality assessment and support from the time they, or their families, become concerned about symptoms of dementia. ● Removal of the distinction between ‘health’ and ‘social’ care when allocating resources ● The need for professionals to work with families as ‘partners in care’ ● More guidance on how to apply mental capacity legislation in practice. “Any one of us or a member of our family could develop dementia,” said Dr Knight. “We need to pull together as a society to help people with dementia and their carers live better, richer lives.” ■ For more information see: ww.nuffieldbioethics.org/dementia RCGP NEWS • DECEMBER 2009
CLINICAL UPDATE
will the new year bring a red letter day for breast cancer treatment?
any unusual changes in their breasts, skin or nipples to their GP as soon as possible. Breast awareness is an area in which GPs have an important role in disseminating information to patients and supporting them to monitor their own health and Breakthrough Breast Cancer has developed a clear breast awareness message to help encourage even more women check themselves for the signs and symptoms of cancer. The charity’s new Touch. Look. Check. campaign includes illustrations alongside questions that act as a prompt for women when checking their breasts.
Breast awareness is as simple as TLC Jeremy Hughes Chief Executive Breakthrough Breast Cancer FOR MANY WOMEN, waiting for an appointment with a breast specialist after a GP referral is like being left in the dark – an anxious time, even though, in most cases, these women don’t have breast cancer. But if the Government upholds its promise, the first day of the new year should be a red letter day for Breakthrough Breast Cancer and how GPs can play their part to ensure the disease is diagnosed at the earliest opportunity. As a GP you’ll probably see only a handful of patients with breast problems each month and follow National Institute of Health and Clinical Excellence (NICE) guidance on referrals. From 1 January the Government has promised that all women referred by their GP with breast problems should get an appointment with a specialist within two weeks. As a tier one vital sign in the NHS Operating Framework, this is a key NHS priority. Breakthrough Breast Cancer has been campaigning since 2003 through its Left in the Dark campaign to ensure a two-week wait for all is implemented. While this has been achieved for urgent referrals, many women given routine referrals can wait much longer for their appointment.
Urgent or routine – you decide? In 2005 NICE published updated guidance for GPs detailing when patients should be urgently or routinely referred to a specialist for the investigation of suspected cancer, including breast cancer. But a survey of 200 GPs undertaken by Breakthrough in 2007 showed that some confusion still exists around when to refer women with breast problems urgently or routinely.
10 per cent of GPs the charity asked would refer a woman who has previously had confirmed breast cancer routinely
NICE guidelines state they should be referred urgently
A third (34 per cent) of GPs would refer a female patient under 30 presenting with a lump and reasons for concern (eg family history) routinely
NICE guidelines state they should be referred urgently
Findings from a survey of 200 GPs, conducted by nfpSynergy on behalf of Breakthrough Breast Cancer in 2007
Breakthrough believes this confusion, coupled with the stress patients endure waiting to see a breast cancer specialist, demonstrates why a simple two-week wait for all is essential. Breakthrough was delighted then that our Left in the Dark campaign led to the Government’s 2007 re-commitment to implement this across England by 1 January 2010. To support healthcare professionals and the NHS, Breakthrough has worked with the National Cancer Action Team to produce a guide to support the implementation of a two-week wait for all: Going Further on Cancer Waits: The Symptomatic Breast Two Week Wait Standard. In addition there is currently very limited guidance on the investigation of women presenting with breast symptoms that spans all the medical disciplines involved in their care. Up-to-date, multidisciplinary guidelines are needed from the point where patients visit their GP to ensure all patients are receiving standard care. Breakthrough Breast Cancer is currently working with experts from the Cancer Reform Strategy Breast Cancer Working Group to develop such guidelines. These will help define, and bring together in one place, the key clinical and process standards for the multidisciplinary diagnostic team to promote both quality and efficiency, and help to facilitate the commissioning process.
Early detection is key Women have told Breakthrough that they trust their GP as the most reliable source of health information. As a GP then you can play a vital role in promoting appropriate information about breast cancer risk, breast awareness and screening to women. You are in a prime position to encourage all women to be breast aware and, for those who are eligible, to attend regular breast screening appointments. With nearly 46,000 women diagnosed with the disease each year, breast cancer is the most common cancer in the UK and accounts for nearly one in three of all female cancer cases. Although better screening, improved treatments and increased awareness have led to more UK women surviving breast cancer than ever before, survival rates in this country still lag behind many other European countries and the USA. One of the reasons for this is thought to be women having more advanced breast cancer at diagnosis and therefore starting treatment when their disease is at a comparably later stage. RCGP NEWS • DECEMBER 2009
The message has to be that the earlier breast cancer is diagnosed and treated the better the chances of surviving the disease. The Cancer Reform Strategy acknowledges that more needs to be done to ensure that cancer, including breast cancer, is diagnosed earlier, including raising public awareness of the signs and symptoms of the disease and encouraging people to seek help sooner. It also acknowledges the essential roles that primary care professionals have at all stages of the cancer care pathway – and one of the most important is in the diagnosis of cancer. As well as encouraging regular breast screening attendance for female patients aged 50 and over, you can also help by reminding women aged 70 and over – and who therefore no longer receive routine breast screening appointments – that they can still continue this free, life-saving service by requesting an appointment through the surgery or local breast screening unit.
Breast Awareness v Breast Self Examination A third of the GPs (33 per cent), surveyed in Breakthrough’s commissioned survey of 200 GPs in 2007, said that they do not feel they understood the difference between ‘breast awareness’ and ‘breast self examination’. There is now consensus in the UK, led by the Department of Health, that it is not necessary for women to practice Breast Self Examination – a complicated, taught procedure carried out at the same time each month. Many women find it difficult and it can provoke unnecessary anxiety. There is also scientific evidence that this technique does not have any impact on breast cancer mortality rates. Instead ‘Breast Awareness’ is promoted – which simply encourages women to know what’s normal for them and to report
Breakthrough’s message is now as simple as TLC...
TOUCH your breasts. Can you feel anything unusual? LOOK for changes. Is there any change in shape and texture? CHECK anything unusual with your doctor. Research by Breakthrough has shown that just over a third of UK women (35 per cent) check their breasts regularly. At the same time, over a third (37 per cent) of women who reported not checking their breasts regularly said it was because they didn’t know how to check or what to look out for.
Working together Although awareness of breast cancer is improving and survival rates in the UK continue to increase, it is clear that more needs to be done to encourage UK women to get into the essential habits of being breast aware and attending breast screening appointments if they are over 50. By working together, charities like Breakthrough and primary healthcare staff can help to ensure women are provided with the most up-to-date breast awareness information. ■ Breakthrough Breast Cancer’s new breast awareness materials – A4 and A5 posters, leaflets and mini-guides – are all free to order through breakthrough.org.uk or the charity’s information line 08080 100 200. You can find out more information about Breakthrough’s work at breakthrough.org.uk
Genetics and breast cancer: The implications for primary care Anaar Sajoo Principal Genetic Counsellor/Genetics Education Facilitator Guy’s Hospital, London Michelle Bishop Education Development Officer (Medicine) NHS National Genetics Education and Development Centre Rob Newton Education Development Specialist NHS National Genetics Education and Development Centre
RED FLAGS FOR BREAST/ OVARIAN CANCER REFERRAL* ● Female breast cancer** ● One first degree relative diagnosed before age 40 ● Two first degree relatives diagnosed before age 50 ● One first degree relative AND one second degree relative diagnosed before age 50 ● Three or more first or second degree relatives diagnosed at any age ● Paternal history of breast cancer (two or more relatives with breast cancer on father’s side of family) ● As well as a family history of breast cancer: ● Unusual cancer in the family ● Bilateral breast cancer ● Male breast cancer ● Ovarian cancer ● Sarcoma diagnosed before age 45 ● Glioma or childhood adrenal cortical carcinoma ● Eastern European and/or Jewish descent
IN OCTOBER THIS YEAR, Times Online reported ‘the discovery of one of the most important genetic links to breast cancer after finding a gene that is thought to play a role in more than half of all tumours’. Patients are constantly exposed to these headlines and often have high expectations about the genetic clinical service they can receive. While all these studies are scientifically sound and published in peer-reviewed journals, how this information can be used effectively in a clinical setting is for the most part the focus of future research. The problem for primary care providers is managing patient expectations with the current clinical reality. While all cancers have a genetic basis, only a small proportion are due to an inherited cancer syndrome, for example in the case of breast cancer BRCA1 and BRCA2. These patients come under the remit of regional genetic centres which are able to assess genetic risk and offer genetic testing if appropriate. The role of the GP is to identify the patients who may fit into this inherited cancer syndrome category. The most effective way to do this is to take a genetic family history and recognise the red flags for referral (see box on the right). Most regional genetics services will have specific guidelines for cancer referrals and a list of Regional Genetic Services is available from the British Society for Human Genetics website (www.bshg.org.uk). Regional genetics centres will take a detailed genetic family history including the confirmation of cancer diagnoses and, if appropriate, discuss the option of genetic testing. In addition, they will also discuss implications for other family members. Following the consultation a summary letter will be sent back to the referring doctor as well as the patient. Recognition of the appropriate referral triggers will ensure that your patients can access appropriate care and information in a timely manner. For example, consider the case of Mary:
cancer at the age of 48. Mary was convinced she would also develop cancer. Despite a normal breast examination, Mary was still concerned, as other members of her family had also had breast cancer. When the family history was updated, it found that her father’s sister was diagnosed with breast cancer when she was 58, and a paternal cousin was diagnosed with breast cancer at the age of 40. While both of Mary’s parents were well, and her sister’s diagnosis was not particularly early, the combination of the sister’s cancer with the paternal history increased the chance of a hereditary breast cancer syndrome. The GP phoned the regional genetics centre for guidance and was informed Mary could be referred to the genetics service for further information and advice.
Mary, aged 41, presented to her GP wanting a referral for mammography as her sister was recently diagnosed with breast
■ For further information about genetics, please visit www.geneticseducation.nhs.uk
** First degree relatives include mother, sister and daughter; second degree relatives include grandmother, aunt and niece. * Adapted from NICE Clinical Guideline 41 – Familial breast cancer
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NEWS
Tackling health inequalities – the trainee perspective PICTURE BY KIND PERMISSION OF HENRY EYNON-LEWIS
Angela Jones Chair RCGP Health Inequalities Standing Group
McConaghey memorial: (l-r) Dr Paddy McConaghey (Mac’s daughter); Mac (Mac’s grandson); Miss Irene Scawn MBE (First Business Manager of the College Journal); Professor David Haslam CBE, President of the College; Sir Denis Pereira Gray OBE (Chairman, RCGP Heritage Committee)
Memorial plaque to Mac is the first of many to come A memorial plaque to a pioneering South Western GP is the first of a series to honour distinguished GPs, explains Sir Denis Pereira Gray, RCGP Chairman of Council (1987-90) and Chairman of RCGP Heritage Committee. In June the President of the College, Professor David Haslam CBE, came to Devon to unveil a plaque in memory of Dr RMS McConaghey OBE, MD, FRCGP (1906-1975) of Dartmouth, Devon, who was always known as ‘Mac.’ Mac was the only general practitioner from the whole of the South Western region to be selected in 1953 to serve on the Foundation Council of the College, chosen for his MD and the letters and work he had done for general practice. He convened the first meeting of the Faculty in the South West in Bristol that year, and he later served as Chairman and Provost of what was then called the South West England Faculty of the College. His outstanding achievement was as the Honorary Editor of the private Research Newsletter of the College. In 1958 he converted this into a scientific journal which he called the Journal of the College of General Practitioners. He edited this from his home so skilfully that, only three years later, in 1961 the National Library of Medicine in Washington USA decided to include it in Index Medicus, the first scientific journal of general practice in the world to be so recognised. This big international step towards establishing general practice as an academic discipline in its own right occurred two years before there was a Professor of General Practice anywhere in the world. This remarkable achievement was done while Mac was a full-time general practitioner – and, as an amateur editor, he was never paid for this job. Indeed in the early years, members of the College Council paid their own expenses to travel to London. This commitment from the
early leaders of general practice marked one of the turning points in medicine in the 20th century and helped to bring general practice into the medical family as an equal partner. Many honours came Mac’s way: the Gale Memorial Lecture, the James Mackenzie Lecture, his appointment as OBE in 1965, and the College’s George Abercrombie Award for exceptional contributions to the literature of general practice. The unveiling ceremony took place in the Dartmouth Medical Practice in Victoria Street, Dartmouth where Mac had worked as a general practitioner and whose current partners generously hosted the event. Dr Andrew Eynon-Lewis FRCGP welcomed the President and other visitors. These included Mac’s daughter, Dr Paddy McConaghey; his grandson Pieter also known as Mac; Miss Irene Scawn MBE, who had worked with Mac as the first Business Manager for the Journal and was later Mayor of Dartmouth; myself, who succeeded Mac as the College’s second and last Honorary Editor in 1972; Lady Pereira Gray, who worked as Assistant Editor on the Journal when it was based in her home in Exeter; Dr Steve Watkins, Provost of the Tamar Faculty; Dr Philip Evans, Director of the local Primary Care Research Network; and Dr Alex Harding, Community Sub Dean of the Peninsula College for Medicine and Dentistry, Exeter. I explained why this Committee had started to organise the installation of memorial plaques for general practitioners who had made major achievements and that this was the first of its kind in the UK. The President said how pleased he was to be present for this occasion and how much the College owed to those who had served it in the past. He unveiled the plaque, situated in the waiting room of the Dartmouth Medical Practice. A report and photograph later appeared in the Dartmouth Chronicle. The Heritage Committee is now working to arrange the installation of other memorial plaques for distinguished general practitioners.
essential reading on endocrine A new book on Diabetes and Endocrine Disorders in Primary Care is now available as part of the RCGP Curriculum in General Practice Series. Written by Roger Gadsby, the book covers all the main clinical areas in diabetes and endocrinology including diagnosis of obesity; macrovascular and microvascular complications; glycaemic control and the ethnic and psycho-social aspects of care. Roger Gadsby is an Associate Clinical Professor at the University of Warwick where he
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has developed training programmes in diabetes aimed at GPs and practice nurses. A founder member of the Primary Care Diabetes Society, he is Clinical Lead for the diabetes specialist collection for NHS Evidence and has been a member of the guideline development groups for four NICE clinical diabetes guidelines and for the IDF’s global Type 2 diabetes guideline. Diabetes and Endocrine Disorders in Primary Care is available from the RCGP bookshop, priced £24.95. RCGP Members and Fellows are entitled to a 10 per cent discount. ■ www.rcgp.org.uk/bookshop
It’s an exciting time for all of us engaged in fighting health inequalities. In Spring 2010, Professor Sir Michael Marmot will be publishing his strategic review, with recommendations on ways in which health inequalities in England should be addressed. The College was given an opportunity to provide a paper to the Review and it was the responsibility of the Health Inequalities Standing Group (HISG) to do this – a fantastic, if somewhat daunting, opportunity. We know that health inequalities are largely socially determined. So what can we, as health professionals, do when up against these huge social forces? In the paper we reviewed the contribution that primary care in England already makes to reducing the impact of health inequalities. We also suggested various ways in which GPs could be enabled to do even more, such as giving us access to appropriate resources including onsite benefit, housing and employment advice and better in-reach to primary care from mental health and addiction services. GPs are in a fantastic position within their communities to act as enablers, for communitybased projects that tackle some of the causes of health inequality. A better understanding of the principles of community development and a closer working relationship with local voluntary and community groups could help GPs to empower their communities to find solutions to local issues and improve health and wellbeing.
What else do we do? This year, HISG held a very successful spring conference, with a special guest appearance from Dr Julian Tudor Hart, founder of the inverse care law. Another event in July explored issues around privatisation and primary care. We also ran fringe sessions at the last two National Primary Care Conferences. For 2010, our main theme is Health Inequalities in the Curriculum. We are planning a conference in Liverpool in April 2010 on teaching medical undergraduates about health inequalities for medical undergraduates. We would also like to do something about the postgraduate curriculum and this is where we need your help. We are seeking an Associate in Training to join HISG for one year, to help us embed the issue of addressing health inequalities into the training of all UK primary care physicians. The role will involve attendance at three quarterly meetings in London and one in Liverpool, plus various email-based work, responding to consultations, helping to develop the agenda around registrar training in this area and possibly including an event at the next RCGP annual conference in October 2010. Travel expenses for meetings will be covered. ■ If you would like to be considered, please send your CV along with a statement of 500 words maximum on why you would like to undertake this role and the expertise you would bring. Please send your statement to TempCorp @rcgp.org.uk by 21 December 2009. We look forward to hearing from you.
NCAs seeks GPs as Clinical Assessors The National Clinical Assessment Service wants to recruit six to eight GPs to be part of the NCAS assessor panel (up to 15 days pa). You will work as part of a small assessment team to conduct clinical assessments. You will currently be working in a predominantly NHS environment in a single-handed or small practice with less than three WTE partners, providing an out-of-hours service in an inner-city or urban environment – and intend to do so for the next two years. It is essential that you are in good standing with the GMC and RCGP and that you have significant experience as a general medical practitioner. ■ For an application pack and further information please visit www.ncas.npsa.nhs.uk/jobs Closing date is noon, Wednesday 20 January 2010.
Professor yvonne Carter Professor Yvonne Carter, Dean of Warwick Medical School and Pro-Vice Chancellor of Warwick University, died on 20 October aged 50. Tributes appeared in the Guardian, Daily Telegraph and The Times. Hundreds of friends, colleagues, students past and present – even people who had never met her but knew of her work – recorded their condolences online on the university website. Here RCGP Chairman Professor Steve Field pays his personal tribute: ‘I’ve known Yvonne for years: in practice, College and university. She was a determined woman with a wicked sense of humour. Yvonne was a role model for GPs and, in particular, for women doctors. She was a great teacher, brilliant researcher and highly active leader. She died aged 50 – far too young – having battled breast cancer for many years. She leaves her husband Michael, her son Christopher and her sister Alma. The funeral, held at the St Francis of Assisi church in Kenilworth was packed with her many friends and colleagues from across this country and further afield. She leaves a huge void in all our lives but also a powerful legacy.’ The family have requested that contributions in memory of Yvonne are made to Cancer Research or the Yvonne Carter Memorial Fund which is being established at Warwick University to benefit, support and recognise the work of Warwick Medical School students. Donations to the Yvonne Carter Memorial Fund can be made online: www2.warwick.ac.uk/ alumni/giving/donate/online/single. Cheques should be made payable to ‘The University of Warwick’ and sent to FREEPOST RSBC-JAAG-TEST, Development & Alumni Relations, University of Warwick, University House, Kirby Corner Road, Coventry CV4 8UW.
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 invites your comments or letters... Please write to: The Editor, RCGP News Royal College of General Practitioners 14 Princes Gate, Hyde Park London SW7 1PU email: rcgpnews@rcgp.org.uk RCGP NEWS • DECEMBER 2009