News
College steps up work on federated practices
We have been promoting the ❛ role of GP federations, and of GPs working collaboratively to provide a wider range of services in their communities, and I believe they will play an increasingly important role in the NHS under the new administration
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Professor Steve Field vide. Federations can also deliver many advantages and benefits for locum and sessional GPs and their patients. “I really believe that federations of practices working together will provide many solutions to providing more care out of hospitals and improving the quality of care we provide whilst not diminishing the identity of small practices.” The Chairman added that he had already spoken to new Secretary of State for Health Andrew Lansley, who had supported the RCGP’s call for GP leadership, federations and moving care closer to home. Professor Field said: “We have been promoting the role of GP federations, and of GPs working collaboratively to provide a wider range of services in their communities, and I believe they will play an increasingly important role in the NHS under the new administration. “Federations were supported by the last Government, and are supported by the new coalition Government. I believe there is now a sense of urgency and we’re doing everything we can to help. We now need widespread demonstration that federations can and do work and that they are beneficial for patients right across the UK.” It was important for GPs to quickly and decisively support the federated model, and use the new survey as an opportunity to make their voices heard, he said. ■ Take part in the survey at www. surveymonkey.com/s/RCGP_Federations
Harrogate calling – get in early for the best deals Book now for the fourth RCGP Annual National Conference – and get your Early Bird discount until 28 June This year’s event – at the Harrogate International Centre from 7 to 9 October – has a decidedly green theme. The theme is Sustainable Primary Care and it will be our first-ever low-carbon footprint event, demonstrating the RCGP’s ongoing commitment to the environmental agenda – and to sustaining the position of general practice at the very heart of healthcare delivery. The Conference will serve as a showcase of the latest clinical and policy developments
JUNE 2010
Also in this issue... Home economics The cost-effectiveness of talking therapies
across the UK, bringing together a range of national and international speakers and politicians. Confirmed speakers include Baroness Tanni Grey-Thompson DBE and Dr David Pencheon, Medical Director, NHS Sustainable Development Unit. This year for the first time the College will be promoting the use of eco materials, the introduction of a car-sharing scheme, and serving only locally-sourced food on site. RCGP Vice Chair and Conference Lead Dr Clare Gerada said: “There are some great deals with discounts available on a variety of different tickets so book now to make sure you don’t miss out.” ■ For more information, please visit www.rcgpannualconference.org.uk
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A NICE fellow Sir Mike Rawlins on guidance for GPs
Matters of mental health
The RCGP has commissioned The King’s Fund, The Nuffield Trust and Hempsons Solicitors to develop its toolkit to support practices that want to set up GP federations. The move comes in the wake of a call by RCGP Chairman Professor Steve Field for practices to start working in federations as a matter of ‘massive urgency’ in order to avoid restructuring being forced on them by Primary Care Organisations in the future. To ensure the toolkit meets the needs of GPs and their practice teams, the College has issued an online survey to the RCGP membership. The survey aims to find out how widespread federations are, what makes them successful and to learn about any obstacles that might confront GPs when developing them. The College will also be hosting a feerations workshop at Princes Gate on 5 July. It aims to seek the views and experiences of GPs and practices of all variations across the UK – urban, rural, singlehanded, small and large – to inform and influence the final version of the toolkit. Professor Field said that he hoped the workshop and survey would uncover many examples of good and innovative practice that already exists across the UK. He said: “We have already had hundreds of responses to our survey and are hoping this will convert into thousands by the deadline date. We know that there are some examples of excellent practice out there already: the federation in Croydon, led by Agnelo Fernandes, has made brilliant advances, while Lawrence Pike and his GP colleagues in Lincolnshire have revolutionised the services and care available to patients in their rural area.” Professor Field said that he understood the concerns of small practices that adopting the federated model would come at the expense of personalised care and practice identity. He said: “I want to make it clear that the College supports the continuation of small practices. All evidence points to the fact that patients like small practices, and we know that the quality of care can be excellent, and that patients like the continuity of personalised care that they pro-
THE NEWSPAPER Of THE ROyAL COLLEGE Of GENERAL PRACTITIONERS
Clinicians work to get it right
Leading by example Medical leadership for trainees
Opioid prescription in primary care A good practice guide
Relative values Diagnosing FH in primary care
3 4 5 6 7
One hundred not out RCGP quality award for Ross-on-Wye surgery
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NEWS
Countdown to carers’ deadline
e-GP is a critical success e-GP, e-Learning for General Practice, has been recommended as a key resource for teaching and learning critical appraisal skills in an independent review of critical appraisal resources to be published in Education for Primary Care.
There are only days left to submit your entries for the new RCGP Award recognising the excellent work of GP practices in identifying and supporting carers. Run in partnership with The Princess Royal Trust for Carers, the new award is patient nominated and will be presented to a GP practice in each UK country, as well as to an overall UKwide winner. It is estimated that one in ten patients in every practice is caring for a relative or friend who is sick, disabled, or frail – and it is usually only a matter of time before the carer becomes ill as a result of neglecting his or her own health needs. GPs play a vital role in encouraging carers to look after their own health, as well as providing support to help them in their caring role. The Award will take the form of a certificate signed by The Princess Royal and a commemorative plaque to display in your surgery. Information can be downloaded from www.rcgp.org.uk. The deadline for entries is 11 June. Nominated GPs and practice teams will then be asked to complete a ten question self-assess-
Caring community: The Northern Ireland team launches the RCGP Caring About Carers Award ment checklist to provide evidence of their work in some of the key areas of carer support. Deadline is 9 July. This is a shorter version of the checklist in the Supporting Carers: An action guide for general practitioners and their teams (2009) (www.carers.org/professionals). RCGP Northern Ireland launched the event with a press conference and lunch. Dr David Johnston, Chairman of Northern Ireland Council, said: “More needs to be done to raise GPs’ awareness about the need to identify and support carers, so we are delighted to
announce this prestigious, high-profile award for GPs and practice teams who provide an excellent service to carers.” Paul McCormack, Development Manager for The Princess Royal Trust for Carers, said: “GPs work in close partnership with carers and are key in assisting the 186,000 identified carers in Northern Ireland – and in helping support the thousands of carers who remain hidden. Carers can now nominate their GP or surgery for this special award by telling us how they support you in your caring role.”
The economics of psychological therapies Leading economist Professor Lord Richard Layard has said that financial pressures on the NHS should not be used as an excuse to prevent improved access to psychological therapies. Lord Layard, Programme Director for Wellbeing at the London School of Economics, made his comments in the latest of a series of breakfast policy discussions hosted by the RCGP. Prompted by the responses of RCGP members to a survey on access to psychological therapies in which respondent GPs said, in almost eighty percent of cases, they were rarely able to get access to psychological therapies for children within two months of requesting referral, the discussion aimed to decide upon methods of improving access to these therapies following the general election. The campaign asked that each political party include in its manifesto the simple commitment: that within five years the NHS will offer evidence-based psychological therapy to all children and adults who need it. RCGP Chairman Professor Steve Field highlighted the impact that the changing political landscape would have on pushing the issue of access to psychological therapies to the top of the medical agenda. “Even though the general election has now reached a conclusion, we will be unsure of how policy will be taken forward under the new coalition for many weeks, or months, to come. We were delighted by the manifesto commitments, and from these we must ensure that mental
Steve Field: We must ensure mental health isn’t squeezed as a result of the financial crisis
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Lord Layard: The cost of implementation of access to psychological therapies will be repaid by the contributions of people returning to work
The review, which found e-GP to be ‘a modern, attractive resource that covers the core areas of critical appraisal’, was commissioned by the MRCGP blueprinting group. The authors of the review state that critical appraisal, as an essential part of the GP curriculum, should receive adequate coverage in training and assessment and be taught in a way that demonstrates its relevance to everyday general practice e-GP has been developed by the RCGP in partnership with the Department of Health’s e-Learning for Healthcare. It is suitable for doctors in specialty training for general practice, general practitioners and other primary care professionals. Explicitly linked to the RCGP curriculum, e-GP offers a comprehensive programme of e-learning sessions covering a broad range of primary care topics. The Evidence-Based Practice module helps learners develop the knowledge and skills to find the best evidence available to support clinical and managerial decisions. Seven engaging e-learning sessions examine evidence-based practice in detail, from working with the patient as a partner to critically appraising a randomised control trial in a therapeutic intervention, diagnostic studies and a systematic review. Each session takes around 30 minutes, provides links to sources of information and features case studies and interactive exercises. Dr Ben Riley, Project Clinical Lead for e-GP said: “Today’s general practitioner is expected to apply the results of a large volume of research evidence within the doctor-patient partnership and meet the high expectations of both the public and the profession. Within our Evidence-Based Practice module we break each aspect down into manageable chunks of learning and provide simple tools to support GPs in incorporating critical appraisal into their daily practice.” ■ For further information and to try out a sample session from the Evidence-Based Practice module visit www.e-GP.org
Ethics in practice PHOTOGRAPHY: WILDE FRY
health isn’t squeezed as a result of the financial crisis,” he said. He added: “Even if there is a financial squeeze, the evidence is there that the country will save money in the short and long term.” RCGP member Dr Alan Cohen, Director of Improving Access to Psychological Therapies in Primary Care, said that GPs were best placed to commission access to psychological therapies for anxiety and depression, as they deal with these problems on a day-to-day basis. He said: “If we can demonstrate through the really good data that is coming out of IAPT services at the moment that healthcare resources are reduced in the acute sector; that length of stay is reduced; that outpatient attendance is reduced, we make a case to Primary Care Trusts to commission services themselves – not because it’s a moral argument, but because it’s an economic one. “I think that’s why commissioning is really important, because it’s the commissioners who make that change, and I suspect the most appropriate people to do the commissioning are the GPs. Bread and butter GPs know about anxiety and depression – it’s what we deal with all the time.” The discussion focused on the financial restrictions that would affect the NHS following the General Election. Lord Layard stressed that financial pressures should not be used as an excuse not to increase access to psychological therapies, on the basis that implementation was not overly costly, and that the subsequent financial benefits would outweigh any initial service costs. He said: “We absolutely should not accept the
argument that there is no money – we should just completely reject those arguments on the basis that people do know that there is a lot of slack in the NHS and there will be savings made in order to make these developments.” Lord Layard said that the cost of improved access to talking therapies, through staff training and service provision would ‘come back 100 per cent’ through national insurance and tax contributions from those who were able to return to work as a result of treatment. ■ Video coverage of the discussion can be found at www.pulsetoday.co.uk
Alan Cohen: The most appropriate people to commission access to therapies are GPs
Professor Martin Marshall Chair, RCGP Ethics Committee Most GPs probably don’t spend a lot of their working day thinking about the ethical dimensions of their work. We all try to be reflective practitioners but pragmatism reigns in the schedule of a busy clinician. And anyway, ethics is a bit intellectual isn’t it? For dons rather than doers? But if you talk to clinicians about the value judgements they make many times each day, about what’s good and what’s bad, what’s acceptable and what’s unacceptable, about the tensions and moral dilemmas inherent in everyday general practice, it is likely you’ll provoke a lively and thoughtful debate. The RCGP Ethics Committee wants to help bring the subject of value judgements alive for readers of RCGP News. The group meets four times each year and between meetings it responds to queries raised from within and outside the College. In addition, some ethics issues are so important and enduring that the Committee develops and publishes a position statement on behalf of the College. We would like to engage more people in this work. Over the coming months RCGP News will run a series of short articles on the kind of issues the Ethics Committee is asked to consider: the use of advertising and sponsorship within practices and by the College; electronic health records; consent for treatment; the impact of financial incentives on professionalism; and organ transplantation. We start next month with a provocative article on confidentiality. We hope you enjoy reading it and welcome feedback, debate and ideas for future articles. RCGP NEWS • JUNE 2010
INTERVIEW What do you feel GPs can bring specifically to the guideline development groups? GPs can make three unique contributions to guideline development groups and the preparation of our clinical guidelines. First, many GPs have skills that allow them to examine the evidence base with a critical eye: and to exercise their judgement about its interpretation and relevance. Second, GPs can challenge the ‘experts’ in a particular field better than anyone else. Experts, of course, play an essential role in the development of our clinical guidelines. But sometimes ‘experts’ need to be brought down to earth. And I know, from personal experience, how good GPs are at it. Thirdly, GPs are often able to act as an interface between ‘experts’ and patients. All NICE guideline development groups include patients (or ‘service users’ as they prefer to be called). Although NICE tries to ensure that the service users on guideline development groups are equipped to take on their role, it can be intimidating for them to be confronted – across the table – with some of the greatest names in the field. GPs are particularly good at interacting, and sharing decision-making, with patients and therefore provide additional support from them at meetings. These qualities, collectively, also mean that GPs make very good chairs of guideline development groups.
Mr NICE guy Sir Michael Rawlins has been chairman of the National Institute for Health and Clinical Excellence (NICE) since its formation in 1999. Here he answers the questions of RCGP members about the relationship between guidelines and general practice.
We have not found it easy to recruit GP members to any of our advisory bodies. We have, perhaps, failed to ‘market’ vacant appointments as well as we might; and I suspect that many GPs wonder how much of a contribution they could make in a room full of ‘super specialists’. We are currently looking – with the College – at better ways to engage with GPs so that we recruit from a wider pool than we have managed previously. Nevertheless over 60 GPs currently sit as members of our various advisory bodies. And many of our guideline development groups have been chaired by GPs.
GPs are independent contractors – how is participation in external committees compensated for the practice/ practitioner, not just in terms of finance but disruption to business?
Is guidance drawn up with the participation of ‘ordinary’ grassroots GPs? (not just GPs who have very specialist interests or are part of a campaign)
There is a lot of expertise on the ground in primary care which is currently underutilised. Could this be addressed by having remote working groups or communication by email rather than lots of meetings? Could GPs express an interest in being involved in certain topics? Our guideline development groups conduct much of their business by email and teleconferences. Our experience shows, though, that it is impossible to avoid face-toface meetings if the evidence of clinical and cost effectiveness is to be fully discussed and appropriate recommendations are to be drawn.
Are the workload implications for GPs taken into account when developing guidelines? Yes. They feature in the economic evaluation we undertake when examining the cost effectiveness of particular interventions or RCGP NEWS • JUNE 2010
How do you guarantee that guidelines are based on robust evidence of clinical effectiveness and efficiency? At the start of the development of all our clinical guidelines, the guideline development group decides on the ‘questions’ it needs to answer. Each ‘question’ is then the subject of a full systematic review of the relevant literature. A single full guideline may need 20 to 30 systematic reviews involving the retrieval and scrutiny of – literally – thousands of papers. These are then condensed into ‘evidence tables’, by the guideline development group’s technical staff. The tables, and other data, form a basis from which members of the guideline development group draw appropriate conclusions about the recommendations that should be included in the final guideline. Estimates of the cost effectiveness of individual elements of a guideline are undertaken by the guideline development group’s technical staff and presented to the group for review, revision and discussion. In drawing conclusions, guideline development groups obviously take full account of the relevant research findings. But they are also expected to use good common sense! For example, the guideline development group that developed the NICE guideline on dyspepsia recommended that a patient with a haematemesis should be sent immediately to hospital. There are no randomised controlled trials to support this advice but I doubt whether any GP would dispute it!
How can the RCGP assist NICE in identifying GPs with group skills and content knowledge to take part in or chair future GDGs?
We advertise, widely, for GPs to apply to join our advisory committees (Appraisal Committees, Public Health Advisory Committee, Interventional Procedures Advisory Committee, QOF Advisory Committee, NHS Evidence Accreditation Committee) and our clinical and public health guideline development groups. The response has not usually been overwhelming. Part of the problem may be in the way we publicise these opportunities and, as discussed in the answer to the previous question, the College have kindly agreed to help us. Some GPs have also said to me: ‘Why would you want someone like me? I’m not a statistician; I know nothing about health economics; and I’m just an ordinary GP’. That is exactly why we want ‘ordinary’ GPs – because what they may lack in technical knowledge they more than make up for with an abundance of good common sense. And that, at the end of the day, is more important than all of the techie stuff combined!
to other government budgets such as sickness benefits, unemployment benefits and so on. We could do so but our Statutory Instruments specifically restrict our approach. Taking a broad ‘economic perspective’ has its attractions: we could take account of the wider interests of UK plc. But, even if necessary changes were made to our legal instruments, we would need to avoid the ‘law of unintended consequences’: giving advantage to those who are economically active might, potentially, disadvantage the economically inactive and most especially the elderly.
We pay the cost of locum fees as well as travel expenses, but I accept that this does not necessarily meet the needs of longsuffering practice partners who cover for their absent colleagues.
❛ We are currently looking – with the College – at better ways to engage with GPs so that NICE recruits from a wider pool than we have managed previously ❜ pathways of care. We are, though, conscious that these economic assessments are sometimes only approximations; and we rely on the GP members of our advisory bodies, as well as on those who are consultees for the draft versions of our guidance, to tell us if we have underestimated the workload implications.
Do you feel the production of guidelines by disease affects the ability of a generalist to provide comprehensive coordinated care? Not at all! But I fully appreciate that a clinical guideline provides advice about the management of a single condition. And yet, in the real world, many patients – especially the elderly – suffer from several chronic conditions simultaneously. In such situations trying to implement, fully, all the relevant guidelines – in an individual patient – would be at best impractical and sometimes foolhardy. To develop a guideline that covers all the possible co-morbidities that might afflict an individual patient is impossible although in some instances our guidelines include advice on adjustments that should be considered in patients with common co-morbidities. For patients with co-morbidities, in general, I look to GPs to exercise their clinical judgement, in conjunction with individual patients, in deciding which aspects of care, for each condition, are most appropriate.
Could NICE present its guidance in a readily accessible format for GPs, perhaps adopting the SIGN leaflet style as an additional format? We do produce ‘quick reference guides’ with all our guidelines but I accept that these do not necessarily meet the needs of all GPs. Indeed, we are fully conscious of the fact that our guidelines are not as accessible to doctors as they might be. NHS Evidence goes some way to help and we are in discussion with the providers of GP computer software to see how we might do better. In addition, we are piloting the production of ‘NICE Pathways’ that we hope will help make all our guidance much more accessible. The first – ‘beta’ version – should be available in a couple of months.
The NICE guidelines are researched with the involvement of patients and carers, as well as professionals, but what questions are asked of the generalists and the patients: are they encouraged to think of the money as being potentially transferable to other services and out of the drug budget? Our guidelines are developed taking account of both clinical and cost effectiveness. Our ‘economic perspective’ is based on the overall costs (and savings) to the National Health Service and the Personal Social Services. We do not take account of costs and savings
Guidance from NICE appears to be increasingly used for cost saving and not primarily for patient outcome and wellbeing. Can NICE operate truly independently of politicians, moving away from balance sheets and returning to clinical practice? The only ‘political instructions’ NICE have ever been given are in our Statutory Instruments that established us in 1999. To paraphrase the legal language, it stated that the Institute was required to provide advice to the NHS taking account of both clinical and cost effectiveness. The guidance we publish is, itself, developed by the independent members of our advisory bodies who are drawn from the NHS and academia; and, even though our guidance has identified changes to practice that will both improve patient care and deliver millions of pounds worth of savings, overall NICE’s advice has increased expenditure by about £2 billion per year. Throughout its existence NICE has appreciated that there is only a finite amount of money, voted by parliament each year, for the NHS. It is – I strongly believe – the responsibility of doctors to ensure that the money is spent wisely. The idea that there is some infinite pot of money, to draw on as we wish, is just absurd. Moreover, it will not have escaped any reader that the country is in a dire financial situation. Although all political parties have made commitments to support the NHS, there is no doubt that cuts in expenditure are coming. Indeed, the DH is seeking ways to reduce NHS expenditure by £20 billion per year by 2014. For NICE to stop providing the NHS with cost-saving advice would be irresponsible. ■ The full text of this interview can be found on the RCGP website at: www.rcgp.org.uk
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Dr Roger Banks FRCPsych FRCGP (Hon) Co-chair Forum for Mental Health in Primary Care It is well established that people with learning disabilities have higher rates of morbidity and mortality than the general population. What has become increasingly apparent is that this is due in part to significant inequalities in the provision of appropriate and adequate assessment and treatment, often of the most common and remediable conditions. Over the past few years, I have been involved with the Getting it right campaign, which aims to improve the health of people with a learning disability. In June Getting it right will be the focus of Mencap’s annual Learning Disability Week, a campaign which is supported by a number of professional organisations, including the Royal College of General Practitioners. During the week of 21-27 June 2010, Getting it right will present a fundamental challenge to the NHS, and primary care in particular, to greatly improve the health care of patients with a learning disability. Royal Colleges and the public will come together in this campaign to raise awareness throughout health services and with planners, commissioners and health professionals of the particular needs of this population. To understand the context of the RCGP’s involvement, it is worth taking a look back at how this issue has been raised in the consciousness of the public and health professionals, and what general practice can do now to enable better access to health care and improve health outcomes for patients with learning disabilities. In 2007, Mencap published the report Death by Indifference, which detailed the shocking deaths of six people with a learning disability while in the care of the NHS and levelled a charge of institutional discrimination at the organisation. The cases reported in Death by Indifference highlighted a number of key issues with regard to assessment, treatment and communication that require not only significant shifts in understanding, attitudes and processes but also clear commitments to making the necessary adjustments that enable equality of care and avoid discrimination. Perhaps the two most fundamental problems to be addressed are those where assumptions are made both about capacity and quality of life. The Mental Capacity Act makes it clear that one should make a presumption of capacity until proved otherwise. It is frequently the case, however, that a person is judged to be unable to
make meaningful decisions about aspects of their treatment simply because they have a learning disability and before any detailed assessment of their decision making abilities has been attempted. Similarly, decisions are often made about the appropriateness or efficacy of treatment on the basis of uninformed assumptions about the ‘quality of life’ of people with learning disabilities. Death by Indifference had far reaching ramifications, prompting an inquiry by both the Department of Health (led by Sir Jonathan Michael) and a separate inquiry in the House of Lords. In his report Healthcare for All Sir Jonathan made ten key recommendations with regard to how both professionals and commissioners could improve health for people with a learning disability. After continued lobbying, some of these are now coming to fruition – including the establishment of a confidential inquiry into why people with a learning disability continue to die early. Following these events, a coalition (Royal Colleges of General Practitioners, Psychiatrists, Nursing, Paediatrics and Child Health, Speech and Language Therapists, the College of Occupational Therapists, Royal Society of Medicine and the Nursing and Midwifery Council) came
Aiming to get it right: Dr Roger Banks
MENCAP 2010
Why GPs should be getting it right for people with a learning disability
Navigating the maze of mental health services together with Mencap to develop a set of principles and guidance about how all healthcare professionals should make reasonable adjustments to their practice for patients with a learning disability. As gatekeepers in primary care, GPs have a key role to play in ensuring that this most marginalised group, as well as their support networks, are able to access the healthcare they deserve and the law requires. It is important to note, however, that equality does not mean giving the same treatment to all people. It is about ensuring that in the care we do give we are taking into account the needs of the particular individual and adjusting our interventions as necessary to address these. Four key areas are worth mentioning that can have a significant impact in improving health care of people with learning disabilities from a preventive and public health standpoint: q Perhaps the most important is the annual health check – and experience in Wales has shown that these can frequently pick up previously unidentified and treatable disorders as well as more chronic or serious conditions. However: ● Take-up of health checks is not high enough ● It is not just about patients asking for the annual health check, but their being offered proactively and sometimes with the facilitation of local learning disability teams ● Funding in England is due to end in 2011 w It is essential to inform and empower patients with a learning disability as well as their carers and support networks about what they can expect and have a right to ask for when they use health services. e GPs have a major role in identifying and tackling underlying health conditions and are in a key position to: ● Be aware of, and prevent, diagnostic overshadowing (the assumption that
Reorganising psychiatric classification David Kingdon Professor of Mental Health Care Delivery University of Southampton Royal South Hants Hospital, Southampton Psychiatric classification is under revision with consultation underway on proposals for both DSM-5 and ICD-11 – and not before time. The present system is unwieldy, irrational and very confusing for patients, carers, and GPs. Even psychiatrists don’t think much of it and the Royal College of Psychiatrists has now called for a major simplification and reorganisation using broad categories with clinically relevant specifiers1. As David Goldberg2 has recently said, there are too many chapters in the current systems which lead to the use of a relatively few ‘unspecified’ categories and dual diagnoses. The proposal being made is to use a simple hierarchical system (see diagram on the right)
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with categories which are broad but recognised in clinical practice, fitting with those which have emerged for guidelines (for example, those developed by NICE). Some clinically relevant specifiers might be helpful to make diagnosis more specific and to reduce the problem of dual diagnoses3. So rather than having cumbersome and stigmatising categories such as ‘schizophrenia and other psychoses’, we might use ‘non-affective’ complementing ‘affective psychosis’. This might then be qualified by being ‘childbirth related’ (ie puerperal psychosis) or ‘with co-existing drug misuse’ as both these groups are important to identify in clinical practice. ‘Personality disorder’ continues to perplex the classificatory agencies. Apart from being an unhelpful and stigmatising term, it is often misused and misunderstood. Multiaxial classifications were intended to help but are rarely used, so a more practical alternative might be to use personality as a specifier for relevant conditions.
Depression and anxiety co-exist so frequently that separation is rarely helpful but specification of common complicating personality attributes – for example, avoidance and perfectionism – might be much more meaningful. Emotionally unstable personality disorder – borderline type – is used to describe quite a common group who very frequently present to primary care with rapidly cycling distress. Placing them with the mood disorders makes sense as they often need to be differentiated from bipolar disorder, depression or PTSD. Complex PTSD is a term often suggested as a descriptor for this condition as the individuals affected have frequently experienced childhood trauma. The artificial distinction made between conduct disorder (in childhood) and antisocial personality disorder (in adults) is also tackled in the new proposals with the probable adoption of the much more descriptive term, conduct disorder – child or adult.
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presenting symptoms or changes in mood are as a result of having a learning disability and thus other diagnostic possibilities are ignored or discounted ● Investigating promptly and thoroughly as appropriate to the presenting condition ● Arranging to provide longer appointment times – and making time to hear the views and concerns of family and carers Communication – in the absence of the recording of communication preferences on the coming Electronic Patient Record, the GP’s knowledge is critical both in the primary setting and when referring on to other services
Although I work as a psychiatrist for people with learning disabilities, I am very much involved in global assessments and treatment of complex co-morbidities in this client group, and in collaboration with my colleagues in primary care. I know that on occasions it can be a difficult, time-consuming and bewildering job to try to get to the root of the presenting complaints and symptoms of a person with profound learning disabilities. However, time, patience, sensitivity and commitment of primary care staff, working alongside our specialist services have led, amongst many others, to the successful diagnosis and treatment of bowel cancer in an elderly lady previously assumed to be depressed; the discovery of primary hyperparathyroidism as being behind the behavioural challenges and deteriorating mental state of a middle-aged woman; and the dedication to preservation of the quality of life and excellence in palliative care given to a man with Down’s syndrome and Alzheimer’s disease that allowed him to die peacefully, in his own home, in the arms of his carer, and wearing his Liverpool football shirt. Getting it right has to be worth the extra effort, does it not?
Perhaps most important in bringing some clarity to the present confused situation is distinguishing between disorder and illness. Currently systems try to cover both in single definitions unsuccessfully. A disorder could be described as any condition that causes distress or disability (physical or mental). However whether someone presents, or rarely is presented, for help or requires reduction in their responsibilities, for example time off work, varies greatly from person to person and in relation to the cause of the disorder. Society has standards and mechanisms for deciding whether someone is ill or not – usually relying on the GP to make that decision. Depression is a disorder but need not be an illness. It can be very severe, for example after a bereavement, but the individual may request very limited support or intervention. Conversely relatively ‘mild’ depression may present and treatment may be appropriate in someone with limited coping abilities and little social support – it may be agreed that they are ill and psychological intervention, for example, be reasonable. Similarly for physical conditions, a haematoma might be described as a disorder but not an illness – though it could become one. ➧ RCGP NEWS • JUNE 2010
NEWS
Developing leadership for all Dr Veronica Wilkie FRCGP Medical Advisor to the Enhancing Engagement in Medical Leadership Project AoMRC/NHS Institute GP Droitwich Worcestershire Dr Suchita Shah GP and Associate in public health Former Leadership Fellow in General Practice, Oxford Dr Gareth Kelly ST3 GP Droitwich Worcestershire “The doctor's frequent role as head of the healthcare team and commander of considerable clinical resource requires that greater attention is paid to management and leadership skills regardless of specialism. An acknowledgement of the leadership role of medicine is increasingly evident. Role acknowledgement and aspiration to enhanced roles be they in subspecialty practice, management and leadership, education or research are likely to facilitate greater clinical engagement” Aspiring to Excellence Professor John Tooke 2008 The Medical Leadership Competency Framework (MLCF) formed the basis of the Medical Leadership Curriculum (MLC), which was scrutinised by PMETB in 2009 as the first shared curriculum for all doctors in training. The MLCF describes the competences in shared leadership (the leadership skills that should be available to all clinicians not just those in positions of leadership and responsibility), and is designed so that the competences are attainable throughout a doctor’s training, from first year medical school to five years post completion of a certificate of specialist training. At the time of writing, the main competence statements are being inserted into the headline curriculum statement Being a GP, and will be incorporated in greater detail into a curriculum statement on leadership and management over the next few months. The MLCF was developed in response to a request from the Academy of Medical Royal Colleges, and the project was developed in partnership with the Academy and the NHS Institute of Innovation and Improvement. The steering group included representatives from many of the medical royal colleges, the GMC, BMA, COPMeD, MSC, NHS Confederation and other key medical professional, education and service organisations. The project team was supported by three reference groups (undergraduate, postgraduate and continuing practice), each of which was made up of medical students, junior doctors, patients, tutors, programme directors, educational advisors, Deans, advisors from the BMA and the GMC. The MLCF was also informed by interviews with undergraduate and postgraduate Deans, research into the literature and a review of experience from abroad. The MLCF was also tested out in five sites across the UK for its relevance to training and development of doctors. Further consultation led to the development of the MLC Disorders need therefore to be defined simply and, separately. Whilst there may be a case for defining more clearly when distress and disability is sufficient for treatment, if available, or help with responsibilities, it does not help to confuse the two especially in classificatory systems. Can we simplify a system which has so many vested interests at play? There might be a case for a clinical classificatory system which is clinically useful, destigmatising and rational which is linked to a more detailed system for research (or insurance payments) which is more comprehensive. The current system is broken – a rational simplified alternative is possible. It will need further work but the new proposals provide a framework to improve understanding, and thus treatment, of mental illness. RCGP NEWS • JUNE 2010
Case Study 1: Dr Gareth Kelly I worked with my trainer at the Corbett Medical Practice in Droitwich, Worcestershire, in developing a service in weight control using a Local Enhanced Service (LES). Working with the nursing and medical staff, I looked at the training and resources needed, then worked with the practice-based
Case Study 2: Suchita Shah The Oxford Deanery Leadership Fellowship is a six-month Senior Registrar (ST4) post. Informed by the RCGP Leadership Programme and developed locally, it combines clinical general practice with broader service development or educational projects. Using the Medical Leadership Competency Framework (MLCF) and specific educational tools to enhance generic skills acquired through vocational training, the programme aims to nurture primary care leaders who will contribute to organisational change and improved patient care, both locally and nationally. My project during this Fellowship was on Black and Minority Ethnic (BME) health in Oxfordshire. Despite a significant and growing BME population, along with legislative and policy measures to address inequalities, evidence based on national data suggests that BME groups experience poorer health outcomes in certain disease areas. A key part of the project was to scope and define the problem locally, using a mixture of taught management tools and self-designed approaches, applied to different settings. Key themes emerged from this: the intangible and heterogeneous nature of ethnicity, language and communication issues, GP engagement and dialogue between disparate service providers. In order to create an impact, my areas of focus were twofold: firstly, partnership building with and amongst the many different groups that provide services to BME users. Secondly, the contribution of a ‘GP voice’ to PCT and local authority priorities. This happened at both strategic and grass roots levels. As a clinician afforded the luxury of time during this post, I was able to somewhat which served as the basis of the first shared curriculum for all doctors in training. The MLCF looks at leadership as shared – that is, within a team of individuals delivering clinical care to patients. Each team member will have times when they step forward to lead, but at other times will follow one of their colleagues (or indeed the patient and their family), or encourage one of their other colleagues to take the lead. What does this mean for trainees? It will give
■ Contact Professor Kingdon at dgk@soton.ac.uk
q Demonstrating Personal Qualities Doctors showing effective leadership need to draw upon their values, strengths and abilities to deliver high standards of care. Areas of competence include: Developing self-awareness Managing yourself Continuing personal development Acting with integrity
dietician to deliver training and look at the evidence base for all involved. My project involved working with the practice manager to ensure that the financial elements were in place, both in terms of resources needed to set up the service as well as the incoming payments, and the office manager to ensure that the relevant claims could be made. I developed the clinical processes with his trainer and the nurse manager to ensure that all the elements of governance were appropriate, and was able to present to the whole team at the conclusion of my project.
w Working with Others Doctors show leadership by working with others in teams and networks to deliver and improve services. Areas of competence include: Developing networks Building and maintaining relationships Encouraging contribution Working within teams
mitigate the palpable perception GPs are key players but too busy to engage with PCTs and local authorities. Yet, as someone relatively naïve to management speak and organisational silos, I felt it important to ‘keep things real’. Therefore, my outcomes ranged from contributing to a Joint Adult Social Care Equality Assessment and collaborating with PCT/ mental health commissioners, to disseminating an innovative web-based translation tool to local GPs, to teaching local community groups and VTS trainees. My colleagues worked on a range of similar projects, based on national priorities such as dementia, access to psychological services and end-of-life care. The six months culminated in a presentation to the Executive Board of the Strategic Health Authority. The Fellowship experience is highly recommended. From a personal point of view, it gave me the time and flexibility to design, plan and implement a project independently, within the supportive and stimulating environment of a regular learning set. Different leadership styles were explored and nurtured and there were opportunities for research, teaching, reflection and involvement with the RCGP. From a broader perspective, it is my hope that introducing GPs to leadership at an early stage will lead to a professional culture wherein our daily practices of innovation and problem-solving in the face of complexity and uncertainty can be channelled toward wider policy and public health issues. The challenge is to create systems that will support all GPs, and not necessarily those in formalised leadership or executive roles, to be able to do this. Leadership happens at many levels and can often work best from the grass roots upwards. It is therefore important for all GPs – including junior GPs – to feel valued within the NHS and empowered to engender change where necessary to improve patient care. Leadership programmes and the MCLF can further the understanding of this nexus between policy, practice and the patient.
e Managing services Doctors showing effective leadership are focused on the success of the organisation(s) in which they work. This requires doctors to demonstrate competence in: Planning Managing resources Managing people Managing performance
r Improving Services Doctors showing effective leadership make a real difference to people’s health by delivering improvements to services. This requires doctors to demonstrate competence in: Ensuring patient safety Critically evaluating Encouraging improvement and innovation Facilitating transformation
t Setting Direction Doctors showing effective leadership contribute to the strategy and aspirations of the organisation and act in a manner consistent with its values. This requires doctors to demonstrate competence in: Identifying the contexts for change Applying knowledge and evidence Making decisions Evaluating impact
all trainees a chance to see how they have developed these competences in their three years of training. It doesn’t mean more work as the MLCF is designed to be integrated into clinical work, to be developed within the context of each doctors’ individual practice. It will mean that many ST3s may put themselves forward to do a small project or an audit, to see how they manage introducing or reviewing how clinical services are developed for patients. For instance, many of the competences in the
References (1) Royal College of Psychiatrists. Submission to World Health Organisation on ICD11. London: Royal College of Psychiatrists; 2010. (2) Goldberg D. Should our major classifications of mental disorders be revised? Br J Psychiatry 2010; 196(4):255-256. (3) Kingdon D, Afghan S, Arnold R, Faruqui R, Friedman T, Jones I et al. A diagnostic system using broad categories with clinically relevant specifiers: lessons for ICD 11. International Journal of Social Psychiatry 2010; in press.
MEDICAL LEADERSHIP COMPETENCY FRAMEWORK
first two domains are already looked at and assessed by trainers and educational supervisors in the first years of clinical practice after leaving medical school. The competences in the last three domains can be developed through small practice based clinical projects or audits, through joint discussion with their trainer and observation of how the practice works in team and practice business meetings. The need for all clinicians to be able to evaluate the service they offer to patients and continue their professional development to keep up with changes in clinical as well as system developments has never been so great.
References NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges (2009) Medical Leadership Competency Framework, 2nd edition. Coventry: www.institute.nhs.uk/mlcf Project Homepage: www.institute.nhs.uk/medicalleadership
DIAGNOSTIC SYSTEM FOR ICD-11 ‘broad categories with clinically relevant specifiers’ Mental disorder or not Common mental disorders
Psychosis unspecified Neuro psychiatric
Non-affective psychoses
Affective psychoses
Mood disorders
Substance use disorders
Developmental disorders
Dementia Delirium etc
‘Schixoprenia and delusional disorder’
Bipolar disorder Depressive psychosis
Anxiety/depression ‘Emotionally unstable PD’ Phobias, OCD and PTSD Eating disorders Somatic presentations Specifiers: ● personality ● childbirth-related ● culture
Drugs Alcohol
Learning disability ADHD Conduct disorder
Specifiers: early/late onset ● childbirth-related ● coexisting drug misuse ●
●
Specifier: childbirth-related
●
Specifiers: personality
●
Specifiers: child/adult
(Possible implications of Royal College of Psychiatrists Summary Response to ICD-11 consultation, 2010; Kingdon et al, 2010)
5
CLINICAL UPDATE
Opioids for persistent pain: A good practice guide Dr Richard Potter MRCGP MFPMRCA Principal in General Practice Lawton House Surgery, Congleton Lead Clinician Central Cheshire Pain Management Service Honorary Research Fellow University of Manchester
INTRODUCTION The British Pain Society (BPS) with representation from Royal Colleges, including the RCGP, has revised the guidelines supporting the decision-making process in prescribing strong opioid analgesia especially for chronic non-cancer pain (CNCP). As the vast majority of care delivered to these patients is in primary care the information is highly relevant to our daily work as general practitioners. This article discusses some of the practical aspects without repeating the guidelines themselves.
GP skills The pioneering work of GP academics and trainers in developing medical education over the past 30 years has resulted in the present day high quality of primary care in the UK. Our discipline now enjoys professional confidence in our discrete clinical skills: these might be summarised as below:
Distinctive GP skills The solution of undifferentiated problems Preventive medicine skills Multidisciplinary team working . Resource management skills These skills allow us, more than any other medical professionals, to switch between acute and chronic models of care depending on the clinical scenario. The latter is relevant to CNCP management when the investigation process aimed at biomedical diagnosis and definitive cure is complete, and the agenda has changed to symptom control and active self-management.
Assessment of the CNCP Patient Before proceeding with the putative pathological diagnosis, investigation results and specialist opinions are reviewed and the new agenda is negotiated with the patient. It may be a relatively straightforward process, especially in older patients, to establish that the identified organic lesion (for example, vertebral collapse) requires analgesic progression up the WHO Ladder, weaker opioids having proved insufficient (although psychosocial factors should not be disregarded). In these cases baseline data on pain intensity and functional impairment – together with a previous knowledge of the patient – may be sufficient. In younger patients (30 to 60 years) the situa-
Assessment of patients with CNCP BASELINE MEASUREMENTS Pain Intensity 11 point (0-10) Numerical Rating Scale
The ‘Pandemic Summit’ was also an opportunity to launch a new RCGP publication – At the Frontline of Swine Flu – providing an overview of the role of GPs and primary health care workers in managing the pandemic. The booklet includes interviews from Dr Ian Dalton, National Director for flu resilience at the Department of Health; GPs across the UK, patients, medical students, practice managers, nurses, stakeholder organisations and the media. It can be downloaded from the College website: www.rcgp.org.uk/pandemic Several speakers, including Professor Angus Nicoll, Head of the Influenza Programme, European Centre for Diseases Prevention and Con-
6
CLINICIAN’S OBLIGATIONS Regularly review pain intensity and functional gains
Functional Impairment Ask for three specific activities lost due to pain
Adjust the dosage of medication (up or down) for optimal effect
Current pain medication Including ensuring full compliance with regular regime
Advise of any safety concerns Provide repeat prescriptions at appropriate intervals
FURTHER ASSESSMENT Words used to describe the quality of the pain Consideration of a neuropathic component to the pain Anxiety symptoms From the history, or HADS score Insomnia due to pain Score the number of hours of sleep before pain disturbs Mood History of symptoms, HADS or PHQ9 scores Social circumstances Including past history of substance abuse, presence of an abuser in the home Flare-up strategies Current responses to exacerbations of pain tion may well be much more complex, with a modest pathology (for example, non-specific degenerative changes in the spine) and confounding factors such as anxiety symptoms, distress, illness behaviours, sleep disturbance, family disharmony, problems at work and low mood. In these circumstances the impression is of a pain syndrome by which one means an association with a high level of arousal within the central nervous system itself. The table above summarises the assessment.
Initiating treatment It is vital the patient is involved in the decision to start ‘morphine-strength pain killers’ and to meet head-on concerns over addiction (a craving behaviour for more medication which is unlikely to occur in non-susceptible subjects) and dependence (adverse withdrawal effects on stopping medication which is relatively likely to develop). After the first consultation a period of reflection may be needed. (Detailed patient information can be found at www.britishpainsociety.org/ book_opioid_patient.pdf). The aims of prescribing opioids should be more than a reduction in
Lessons learned from swine flu GPs, practice managers and Government leads on pandemic planning convened at the RCGP to discuss lessons learned from the recent H1N1 pandemic.
Components of a Patient Agreement when prescribing opioid analgesia
trol, were also interviewed for a short webcast which can also be viewed at www.rcgp.org.uk/ pandemic. Dr Maureen Baker, RCGP Pandemic Lead, said: “One of the things that this pandemic has taught us is that planning really paid off. We are very keen that we capture these lessons and take them forward into ongoing work so that, next time there is a major public health event in the UK, GPs will be able to look to the RCGP for guidance and material and respond as effectively as they did this time around.” RCGP Chairman Professor Steve Field, who chaired the Pandemic Summit, said: “This was a really good event and I would urge everyone to use the booklet to help them to adapt their own pandemic plans. It was excellent how GPs and their teams led the way during the pandemic. I think we all – GPs, practice managers, nurses, medical organisations and the Government – worked very well together for the good of patients and the public across the whole of the UK, but we must not become complacent.”
Richard Potter: The GP should take command of the decision-making process reported pain intensity and should include functional gains with objectives articulated by the patient before treatment commences. As the efficacy of long-term opioids is not certain a failure of response at a given dose should raise the possibility of abandoning the trial, rather than continuing to push the dosage as might be appropriate with cancer pain. The more complex patients will need more intensive work-up, eg two to three consultations, and whilst a ‘Patient Contract’ is not generally thought useful with certain individuals clinicians may feel the need for a verbal or even written agreement such as in the table on the right.
Monitoring treatment GPs are very good at monitoring chronic conditions over time (years) and CNCP management is no exception. A single, named doctor at the practice should be responsible for the patient’s prescription for opioids – although a repeat prescription should be available for a stable dosage in his/her absence. Unlike the treatment of cancer pain, experience suggests that a pragmatic dosage ceiling in primary care may be advisable to protect against inadvertent inappropriate use. This would be at an arbitrary level, but might I suggest an indicative upper limit of morphine sulphate MR 60mg bd/ oxycodone 30mg bd/ fentanyl patch 25-50mcg/h/ buprenorphine patch 70mcg/h, beyond which referral to a specialist Chronic Pain Management Service is considered? Having stabilised dosage and managed any persisting side effects, medium-term objectives may be discussed, including functional gains, improvements in lifestyle, mental health and relationship issues and other members of the primary health care team may become involved. Longe-term requirements are for a robust repeat prescribing system, periodical review appointments (three to six monthly once stable, depending on complexity) and alertness for adverse events. In addition to the patient agreement considerations it is vital to develop and strengthen strategies both aimed at preventing (eg, planning and pacing activity) and treating flare-ups of pain. Acute up-titration of sustained release opioid or the addition of short acting opioid preparations should be avoided if at all possible: the pressure to do this in a busy surgery presented by a patient demanding immediate relief (which itself indicates a failure of chronic pain management strategy) can be difficult to resist. In advance of such an event – and in calmer times – alternative strategies should be agreed (see table on the right) and recorded in the clinical notes.
Consider alternative medication if necessary Refer for specialist or other additional treatment if appropriate Periodically reduce dosage to review continued effect PATIENT’S OBLIGATIONS To take the medication exactly as prescribed Keep the drugs in a secure place Attend for review as agreed with the doctor Consult the same doctor at the practice with regard to the prescription Work on strategies for flare-up pain management to avoid increasing dosage Make lifestyle changes as agreed Inform DVLA on commencing this medication CAUTIONS In the event of pregnancy the doctor should be informed Reducing dosage should be gradual to avoid withdrawal effects (dependence) Loss of effect after stabilisation is uncommon (tolerance) Craving more medication is uncommon: needs monitoring (repeat prescribing) Sexual function may become impaired Increased pain may develop due to the medication (hyperalgesia) The immune system might be suppressed – clinical importance is unknown
Examples of acute flare-up manoeuvres Rest (<24 hours) Reduce Activity plan (eg by 50 per cent) Gentle stretching exercises
Conclusion
Change posture/ position
In general practice we are well placed to assess patients with CNCP and discuss with them the option of strong opioid analgesia. This gives these sufferers who are to live with chronic pain the same option as terminal cancer patients, although the complexity of many CNCP patient crucially changes the rules of engagement. With attention this complexity, the prevention of unnecessary functional decline, the deployment of the primary healthcare team and the identification of the correct agenda and avoidance of repeated, wasteful and frustrating specialist referrals the GP should take command of the situation. The BPS guidelines are important in realising this potential.
Apply heat (eg wheat bag) Cold packs Massage Add weak opioid (eg tramadol) Acupen device/ acupuncture Relaxation techniques TENS Distraction RCGP NEWS • JUNE 2010
CLINICAL UPDATE
Headache care in general practice
IMPORTANT DIFFERENCES BETWEEN MIGRAINE AND CLUSTER HEADACHE MIGRAINE
CLUSTER HEADACHE
Prodrome or aura can occur
Prodrome or aura very rare
Pain can occur in any location
Pain is mainly periorbital
Pain is severe and throbbing. Patients want to lie down.
Pain is very severe and piercing. Patients pace the room.
Attack lasts 4 to 72 hours
This is the penultimate in the series of five factsheets supporting the diagnosis and management of headache in primary care by Dr David Kernick, RCGP Clinical Champion for Headache. The factsheets are also published by GP newspaper at www.healthcarerepublic.com/go/rcgp
FACT FILE 4: CLUSTER HEADACHE AND OTHER AUTONOMIC CEPHALOPATHIES BACKGROUND Cluster headache is arguably one of the most painful conditions a GP will ever see. It is invariably misdiagnosed and usually inadequately treated. Often sufferers will have been to eye departments with suspected glaucoma, ENT departments with suspected sinusitis and dental departments to have their wisdom teeth extracted. Cluster headache has been known by a number of terms, including cluster migraine, but it is ver y distinct from migraine and one of a group of headaches known as the trigeminal automatic cephalalgias, characterised by strictly unilateral pain and autonomic features. The pathophysiology is unknown.
EPIDEMIOLOGY ● 0.1- 0.2 per cent ● Male: female ratio is 5:1 ● It can begin at any age, though the
most common age of onset is the third or fourth decade. ● Ten per cent of patients have chronic cluster headache (CCH) where remissions last less than one month ● Cluster headache is a lifelong disease but attacks invariably get less frequent with age
MAKING THE DIAGNOSIS The cluster attack ● The attacks are strictly unilateral,
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● ● ●
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● ●
although the headache may alternate sides with attacks. The pain is excruciatingly severe and is invariably associated with restlessness or agitation. Located mainly around the orbital and temporal regions. Headache lasts from 15 minutes to three hours. It has an abrupt onset and cessation. The cluster attack frequency varies from one on alternate days to up to eight daily. The condition can have a striking circadian rhythmicity, with some patients reporting that the attacks occur at the same time each day. There are associated cranial autonomic symptoms on the side of the pain and lasting with it. For example, conjunctival injection, lacrimation, miosis, ptosis, eyelid oedema, rhinorrhoea, nasal blockage and forehead or facial sweating. Nausea, photophobia and phonophobia usually absent. Alcohol, exercise and elevated environmental temperature can precipitate an attack but not outside a cluster period. Allergies, food sensitivities, reproductive hormonal changes and stress do not appear to have any significant role in precipitating attacks.
The Cluster Period or Bout A cluster period is an episode during which there are frequent cluster attacks following which the individual is in remission. ● The average cluster period lasts between six and 12 weeks but there is considerable variation between patients. RCGP NEWS • JUNE 2010
● Most patients have one or two annual
cluster periods, each lasting between one and three months. Often, a striking circannual periodicity is seen with periods occurring in same month of the year, often spring or autumn.
Attack lasts 15-180 minutes and come in clusters Autonomic features around the eye on side of pain
No autonomic features Nausea, vomiting, photophobia or phonophobia
Rare
DIFFERENTIAL DIAGNOSIS OF CLUSTER HEADACHE – OTHER RARE AUTONOMIC CEPHALOPATHIES Diagnosis Cluster headache Paroxysmal hemicrania SUNCT*
Type of pain
Severity
Location
Duration
Frequency
Boring
High
Orbital
15-180 minutes
1-8 a day
Boring
High
Orbital
1-30 minutes
3-30 a day
Stabbing
Moderate
Orbital
15-240 seconds
1 a day to 30 an hour
*short acting unilateral neuralgia form headaches with conjunctival injection and tearing ● Methysergide is a potent agent but as
INVESTIGATION Approximately one per cent of cluster headache presentations will have an underlying pathology. Pituitary tumours are most common. All new cluster headache should be imaged. This can be relaxed if a patient presents with a history of many years of stable cluster.
TREATMENT Acute treatment ● Subcutaneous sumatriptan 6mgs is the
drug of choice. Unlike in migraine, it can be prescribed at a frequency of twice daily on a long-term basis without reduction in effectiveness, side effects or rebound. ● Oral triptans are ineffective, but there is evidence to support the nasal route. ● Oxygen. The mechanism of its action is unknown. ● 100% oxygen is required for a
therapeutic effect. Ordering physicians should specify: A delivery of at least 10-12 litres per minute, a non-breathable mask. Specify ‘100 per cent oxygen for cluster’ on the Home Oxygen Order Form (HOOF) ● A static cylinder will provide up to 200 minutes supply depending on the cylinder pressure supplied. ● For portable use, an ambulatory cylinder can be ordered providing up to 40 minutes. ● Oxygen should inhaled for 10 to 20 minutes depending on the clinical response. ● For other co-existing pulmonary conditions where 100 per cent oxygen may be harmful, advice should be taken from a respiratory physician. ● Patients should be made aware of the dangers of continuing to smoke in the presence of oxygen therapy. The majority of cluster patients are smokers at presentation and smoking cessation intervention should be given. Using oxygen in cluster headache. Based on the British Association for the Study of Headache guidelines for Oxygen in Cluster Headache (www.bash.org.uk)
Short term prevention ● Steroids give rapid relief and are useful
where there are only two or three attacks each year. Prednisolone 1mg/kg, to a maximum of 60mg once daily for five days and thereafter decrease over a three week period. Relapse can occur as the dose is tapered and in this case steroids are used as an initial therapy in conjunction with preventatives until the latter are effective.
prolonged treatment has been associated with fibrotic reactions these are best used under specialist supervision.
Long term prevention ● Verapamil is the preventative drug of
choice in both episodic and chronic cluster headache but higher doses than those used in cardiological indications are needed. After performing a baseline ECG, start on 80mgs three times daily and thereafter the total daily dose is increased in increments of 80mgs every 10 to 14 days until the cluster attacks are suppressed with an ECG performed prior to each increment up to a maximum of 960mgs daily.
● Lithium, topiramate, sodium valproate,
gabapentin are used but their impact is often marginal. Lithium is the most effective aiming for a serum level in the upper part of the therapeutic range. Occipital nerve injection can be helpful. ● Surgery is a last-resort measure, either destructive procedures or neuromodulatory procedures with implanted electrodes.
Useful patient support group ■ The Organisation for the Understanding of Cluster Headache www.clusterheadache.org
Relatively simple: Identifying familial hypercholesterolaemia Dr Mike Knapton FRCGP Associate Medical Director of the British Heart Foundation When Martin Keighley collapsed with a heart attack while out running aged just 33, he was surprised to discover that he had an underlying heart condition and even more surprised that his doctor knew little about it. Martin, now 46, has heterozygous familial hypercholesterolaemia (FH) – a genetic condition causing dangerously high levels of LDL cholesterol. It is estimated the condition affects about 120,000 people in the UK, the equivalent to one in every 500. It is relatively simple to diagnose through family history, examination and blood tests and it is also relatively easy to manage through diet, exercise and the use of potent statins. Yet despite the prevalence of FH and the relative ease and low cost of diagnosis and treatment, only about 15 to 20 per cent of cases have been identified. Mr Keighley said: “It was frustrating there was so little knowledge about it. My doctor did his best but acknowledged I was more of an expert than he was.” Cascade screening is recommended to help identify FH because half of first-degree relatives will be affected. This is something BHF is supporting and was acknowledged as best practice by NICE in 2008. Genetic testing of the primary case is important because in 70 to 80 per cent of cases of FH, the causative mutation can be identified and it is then relatively straightforward to screen firstdegree relatives for this same mutation at a greatly reduced cost. BHF is investing in an FH cascade screening programme across Wales, in partnership with
the Welsh Assembly Government. Progress has also been made in Northern Ireland and Scotland, though progress in England is variable. There needs to be a far greater awareness among GPs of the condition itself and of the need to screen relatives to ensure cases are identified and potentially life-saving treatment is administered. Mr Keighley contacted several members of his family to warn them about the condition, including distant relatives in New Zealand. Tests revealed that his daughter, his brother and a niece all had the condition. His other daughter has also been diagnosed with high cholesterol. He said: “I would always have had those conversations with my family but cascade screening acts as a safety net. It’s such an easy way to identify people.” GPs must be aware of FH, particularly if patients have a strong family history of premature cardiovascular disease. The occasional reports of GPs falsely reassuring young patients with FH that they are too young to take statins also need to stop. Commissioning new services will be extra challenging in the current financial climate. However, it is estimated that if the detection rate for FH was improved to 80 to 90 per cent, the potential saving to the NHS in terms of dealing with people who later die from heart and circulation problems would be about £20m. ■ The BHF Factfile on familial hypercholesterolaemia is available www.bhf.org.uk/research_health_profession als/health_professionals/factfiles.aspx Primary Care Commissioning groups and PCTs can use the recently published Commissioning Guide to develop services locally: www.pcc.nhs.uk
7
NEWS
Winning centuryon Quality Street Deadline extension for
National Training Surveys The closing date for the GMC’s National Training Surveys 2010 has been extended for another month until 30 June to enable trainers and trainee doctors more time to provide a national picture of their training posts. (The pilot in Northern Ireland has been extended until 31 May.) Trainers and trainees are encouraged to contribute their voice to the regulation of medical education and training to help ensure it meets the standards that the GMC requires and which our trainees, the health services and patients are entitled to expect. Key findings from the surveys will be published in the winter, although survey reports will be available on line for deaneries from August 2010. Associates in Training (AiTs) and newly qualAlton towers above the rest: Professor Steve Field (left) with members of the surgery staff during the presentation of the Quality Practice Award
■ More information: www.gmc-uk.org/ education/postgraduate/surveys.asp
EQuiPed for European union
The Alton Street Surgery in Ross-on-Wye is the 100th practice in England to achieve the RCGP Quality Practice Award. The Surgery – which can be traced back to the 1830s – has 10,200 patients on its list and a staff of ten doctors, three practice nurses, two health care assistants and around 20 full or part-time administration staff. They had to meet criteria in 22 different areas of work, submit a huge portfolio of evidence and participate in visits by assessors who interviewed the team and inspected the premises, medical records and systems. Partner Dr Philip Clayton said that the QPA had been a huge and difficult undertaking but that all the effort had been worthwhile and that
ified GPs (within the first five years) are also invited to take part in a five-minute online questionnaire comparing GP training across Europe. The results of this questionnaire will feed directly into the ongoing development of the UK GP curriculum as well as providing a unique opportunity to compare the UK model of training with those of other countries. The questionnaire has been developed by Vasco da Gama – the World Organisation of Family Doctors (WONCA) Europe movement for young and future GPs – and is distributed by the RCGP Junior International Committee. One participant will be awarded £100 to spend at the RCGP bookstore.
the entire staff, as well as patients, had benefited from the experience. RCGP Chairman Professor Steve Field presented the award to patient John Brookes who registered with the practice before the NHS was established in 1938. He said: “The scale of what you have achieved cannot be underestimated. This award demonstrates the high standards and quality of care you provide to your patients and you should be proud of the fact that you are in the top 100 practices in England.”
GPs needed for tribunal try-out The Judicial Appointments Commission is looking to appoint medical members to first tier tribunals (Social Entitlement Chamber) – and needs GP volunteers to take part in a ‘dry run’ of the Selection Exercise. Anyone with a medical history can apply – as long as you are not considering applying for the post proper. You must be willing to spend a full day in London and will be paid a fee of £80 plus reasonable travel expenses. ■ Further details at www.judicialappointments.gov.uk or from Alex Hulme on 020 3334 0092.
RCGP President Dr Iona Heath (centre front) recently hosted the 37th Assembly Meeting of the European Association for Quality in General Practice/Family Medicine (EQuiP) at the College in London. Representatives from 14 countries attended to discuss issues such as QoF, Practice Accreditation and the future of general practice. ■ Further information on this and other EQuiP meetings is available at www.equip.ch
Patients guide to practitioners
Pre-employment checks updated
A patients’ guide to doctors’ training, Do you know who is treating you?, informs patients about the doctors they are likely to meet in a general practice or hospital setting, with information about their titles and how they are trained. It was produced by the Postgraduate Medical Education and Training Board (PMETB) prior to its merger with the General Medical Council in April this year. ■ www.aomrc.org.uk/component/content/article/38-general-news/120-atdg-test-news.html.
NHS Employers has updated its annual state of readiness checklist covering the pre-employment and induction for new specialty trainees who will begin in August 2010. The checklist supports employers and their medical staffing departments through the process. Deaneries are notifying employers of the successful applicants. ■ The checklist is available from the specialty and GP training webpage: www.nhasemployers.org
Management in Practice Manchester Team Avery’s chain reaction in aid of Maggie’s Centre 8 June 2010 – The Bridgewater Hall Now in their fourth year, the national Management in Practice Events promise a rewarding day of training and presentations from key figures in the practice management sector. New for 2010, we are proud to announce our new partnership with the RCGP, with an entire stream dedicated to sessions that will benefit not only practice managers, but GPs and partners too. In these changing times it is important to build a solid foundation of communication when running your practice – that’s why we have introduced this new stream to broaden learning horizons, generate conversation, bridge gaps, and encourage a team approach to business. Recognising the complex training needs for practice managers and GPs with a professional interest in the way practices are managed, each one-day event will enable you to plan ahead for the future of your practice and equip you to meet personal training objectives in a range of subject areas. The events are held in Manchester, London and Birmingham each year. The Manchester event in June is the first to take place in 2010, to be followed by London on 1 September and Birmingham on 20 October. These events are a unique platform for topical practice management issues to be discussed, experiences of problemsolving shared and valuable training sessions delivered.
Do join us on the day to refresh your personal development and consolidate the quality of management operations in your practice. For more information, please call the team on 0207 214 0598 or visit managementinpractice.com/manchester Accredited by
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Professor Tony Avery – Professor of Primary Care at University of Nottingham Medical School – has returned from a challenging 142 mile coast-to-coast mountain bike ride to raise money for Maggie’s Centre in Nottingham. Tony, his son Rob, brothers Geoff and Rich and nephew Lewis were part of a 12-strong team who cycled from Workington to Sunderland over four days. Sponsorship is still coming in but he expects the total to be well over £4,000 and is keeping his webpage open until early August: www.justgiving.com/tonyavery Tony said: “This was a great challenge and it is fantastic that so many people have supported us and Maggie’s Centres so generously.”
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RCGP NEWS • JUNE 2010