N ews Federations are the
future for primary care A significant contribution to preserving high quality services for patients and a natural progression for primary care – that is the view on GP federations following wide-ranging consultation by the RCGP
Politicians, Medical Royal Colleges at home and abroad, healthcare organisations, SHAs, PCTs and patient groups were all invited to comment on the proposals put forward by the RCGP in its document Primary Care Federations: putting patients first, launched in June as a follow-up to the RCGP Roadmap on the future of general practice and prior to the publication of Lord Darzi’s report on the future of the NHS. The document attracted widespread interest and over 40 responses to the consultation were received. Respondents included: ●
●
● ● ●
The BMA, Royal College of Physicians, Royal College of Surgeons and Royal Pharmaceutical Society of Great Britain SHAs, healthcare organisations and charities including the Family Doctor Association, Dispensing Doctor Association, Society for Academic Primary Care and the Royal National Institute for the Blind (RNIB) Patients and Patient groups A Conservative Member of Parliament RCGP Scotland, Faculties, the Rural Practice Standing Group and a wide range of College members
There was overwhelming support for the model from respondents and wide acknowledgement of the College’s contribution to preserving high quality services for patients. The BMA said the federated model was an ‘effective alternative to singlesite polyclinics’ that might not be able
to offer the same continuity of care and a ‘logical development in light of the gradual changes that some practices have already started to make’. Among the benefits that the model highlighted were: ● Increased local flexibility in service provision ● Increased patient choice ● Economies of scale lead to greater access to services ● Support for better access to diagnostics ● The opportunity for patient and carer groups to be linked into the model Some respondents sought reassurance that the federated model would not lead to the demise of the smaller practice. The College has been urged to recognise that it is likely there are areas where practices are of sufficient size and local services are such that there is no need for a practice federation, and that such practices should not be compelled to adopt a federated model. Local needs and local situations should always be taken into account. The BMA also suggested that measures should be put in place to ensure that practice federations do not add ‘complex, cumbersome and unnecessary bureaucracy to the management of practices and provision of primary care services’. The need to integrate the model with secondary care was highlighted, especially if screening and other services, which have traditionally taken place in secondary care, take place in a primary care setting. Sharing expertise by maintaining
Dr Maureen Baker: We still need more feedback from GPs on the federated route links with secondary care providers would be essential – as would the need to maintain effective systems of governance and high quality care – and it was suggested that more evidence such as case studies be provided. Some respondents warned that there may be some overlapping function with the PCT, especially with regards to commissioning and that the success of the federation was dependent on its ability to commission services. However, it was suggested by another respondent that unless the College acts now, less effective models of care will be pushed through by NHS management. The RCGP Rural Practice Standing Group claimed that the ‘concept may allow traditional General Practice to survive in an age when private corporate enterprise is looking to get a hold on Primary Care’. Initial findings from the consultation were presented at a workshop
Looking back at Bournemouth... Dr Don Berwick’s reminiscences on growing up as the son of a GP and the unique role played by GPs in reaching “the dark and tender places of people’s lives” brought delegates at the second RCGP National Primar y Care to their feet in a five minute standing ovation – and tears to many eyes. Dr Ber wick – President and Chief Executive of the Institute for Healthcare Improvement – travelled to Bournemouth from the US solely to deliver the prestigious John Hunt lecture on the first morning of the conference. His inspiring obser vations became the watchword for the entire three days.
The Bournemouth event followed the success of the inaugural conference in Edinburgh last year, attracting nearly 900 delegates and speakers including Ben Page from Ipsos MORI on GP satisfaction rates; Professor Alyson Pollock on privatisation of the health ser vice; and National Clinical Director for Primar y Care Dr David Colin-Thomé, standing in for Lord Darzi who had to remain in London for the Cabinet reshuffle. The event was chaired by BBC Medical Correspondent Fergus Walsh. The conference kicked off with a lively New Members’ Ceremony attended by over a hundred GPs
and their families. The conference dinner was held at Bournemouth’s impressive Opera House. RCGP staf f from around the UK showcased the College’s work at the ‘RCGP Village’ and, led by main sponsors Barclays, the event attracted record sponsorship from a wide range of external organisations. Journalists from GP newspaper also toiled long and hard to produce a daily conference edition, making sure that delegates were kept up to date with what was happening. Turn to page 3 for our picture report on the conference ➧ in pictures
seminar at the RCGP Annual National Primary Care Conference in Bournemouth by RCGP Honorary Secretary Maureen Baker and the report is now available on the College website: www.rcgp.org.uk After more analysis, the RCGP will draw up actions to further develop, promote and support the model of Primary Care Federations. This will include working with particular College groups, including the Ethics Committee and Health Inequalities Standing Group, to understand how the model can most effectively operate in particular community settings. Ways of promoting the model to stakeholders at all levels will also be explored. As part of College’s activity to influence the Darzi Review a senior College representative has been identified for each SHA in England to lobby, promote the College’s views – including the Primary Care Federations model – and raise relevant concerns. Each Faculty has been asked to nominate a representative to support this work. The Group will coordinate its work through monthly teleconferences. RCGP Honorary Secretary Dr Maureen Baker said: ‘We are really pleased with the level of response and the level of debate that the consultation has produced. We will continue to encourage further feedback on Primary Care Federations and hope that GPs and their practice teams will provide case studies, examples of developing Primary Care Federations and operation in local settings to allow the College to build up a range of evidence on what the barriers and factors for success are.’
THE NEWSPAPER OF THE ROYAL COLLEGE OF GENERAL PRACTITIONERS
NOVEMBER 2008
Inside... CPD for GPs Piloting the credit system
2
PATIENT SAFETY New SEA guidance
SUPPORTING CARERS An action guide for GPs
4
4
HEALTHTALK Celebrities line up for the launch
5
CLINICAL UPDATE Paget’s disease of bone
6
POSTNATAL DEPRESSION The GP’s role in detection
7
DIABETES The Year of Care programme
8
A voyage round my father: Don Berwick had the whole conference in his hands...
YOU AND RCGP
Your chance to contribute to GPs’ e-learning The RCGP is offering an exciting opportunity for two enthusiastic GPs to join the e-GP project team as Clinical Managing Editors. The e-GP project is designed to deliver a UK-wide online e-learning programme to all NHS GPs. There are two Clinical Managing Editor positions – one specialising in Professional Skills, the other in Clinical Skills. Each will lead a team of authors to develop e-learning materials on core knowledge and skills. The posts will run until December 2009 and will require a commitment of two to four half-day sessions per week. Applications from both experienced and less experienced GPs are welcome. Applicants should have: ● Good leadership, management, communication and team-working skills ● Sound IT skills ● An interest in online education ● Some previous experience of writing or editing.
NEWS
Impact and challenge in CPD credits Dr Chris J Price RCGP CPD Fellow In September the RCGP launched a pilot of a credit-based system for GP continuing professional development (CPD). The pilot is designed to assess the feasibility and acceptability of CPD credits based on the ‘impact and challenge’ model. The pilot is running in ten geographical areas of the UK (see panel on right) and it is hoped to include a representative cohort of doctors working in general practice, full or part time, sessional, salaried and partners, College members and non-members. The pilot aims to seek the opinions of as many GPs as possible in these regions in order to refine the system.
The RCGP is set to publish a short book – The General Practice Book of Golden Rules and Reflective Learning – comprising learning points that have evolved from discussions with Registrars over the years. The College is now seeking suitable reflective learning pieces (up to 1,000 words) for the first edition. Entries should be submitted by 30 November and include a short sentence at the end of the piece encapsulating the learning point or ‘Golden Rule’. All contributors will be acknowledged in the text.
The RCGP wishes to recruit a Deputy Editor to occupy a senior position on the editorial board of InnovAiT, the monthly academic journal for those undergoing GP specialty training, published in association with Oxford Journals. Launched in early 2008, InnovAiT is now the RCGP’s leading resource for Associates in Training. The Deputy Editor, reporting to the Executive Editor, will be required to provide a regular and consistent level of support to the Executive Editor and editorial staff in the commissioning and reviewing of content, and will work alongside other board members to ensure the future development of the journal. This post commands an annual honorarium in recognition of the level of responsibility that this post entails. To register your interest, and to receive a detailed job description and terms of reference, please email RCGP Publications Manager Helen Farrelly at sjemmott@rcgp.org.uk, no later than 7 November. Closing date for completed applications is 14 November.
2
JUL-SEP ‘08
SEP-NOV ‘08
‘A credit is a unit of professional development which is a product of the impact of a developmental activity and to a lesser extent the challenge involved in its completion’
●
Impact on patients – e.g. a change in practice, initiating a new drug – this has obvious overlaps with personal development
●
Impact on the individual – personal development
●
Impact on ser vice – e.g. becoming a training practice, teaching others, implementing a clinic system Context related – e.g. more challenging to become a new training practice than a trainer in an established training practice
●
Related to circumstances – e.g. a sessional GP undertaking audit is often faced with problems around the data and follow-up
●
Related to personal ability – e.g. personal disability, prior skills, prior experience etc
●
Related to effort expended – e.g. attending an ophthalmology clinic for a whole day to gain experience
How will this work? Self assessed credits The individual GP on the pilot will assess their CPD activity against impact and challenge criteria documents (produced for the pilot and likely to be refined as an outcome of the pilot), which suggest the degree of impact and challenge associated with the activity (on a five point scale from low to high). The doctor then plots them on a ‘scoring’ table (See Credits Table below). This plot will give an estimate of the number of credits. The GP then decides if this estimate is in keeping with their perception of the activity and records the number of credits claimed against the activity.
To APR/MAY ‘09
JUN-JUL ‘09
Analysis Report
Examples of FAQs
Q A
Q A
year was not focused to aim at a target of 50 credits. If this system is introduced you will have sufficient notice to tailor your development if that is required.
I use the table to estimate the credits allocated to an activity and I find that the number of credits suggested is well below my estimation. What should I do? In this situation the first thing you should consider is the impact of your activity. If you feel the impact is worthy of higher credit then rate the activity to the level you feel you can justify. In this situation you should list your reasons in your form 3. If you feel the challenge was higher than the definitions given then you may feel that the justification in form 3 will cover this difference. You should however remember that impact is weighted more highly than challenge. What if my credit total is less than 50? This is a pilot and it has no bearing on you. Your development over the pilot
Q A Q A
What if my credit total is more than 50? Many doctors will be able to demonstrate more than 50 credits of development – just as many doctors bring excellent work to appraisal. What if the appraiser disagrees with my estimation of credits? This is one of the things that the pilot is set up to measure – it is unlikely there will be universal agreement and, although this will have no punitive effect, it is vital that such disagreements are recorded in the surveys.
The next steps The data collected from the pilot will be examined and used to suggest improvements to the system. The supporting documentation and in particular the real life examples of credit claims will be refined and published. Depending on the degree of feasibility and acceptance a further period of testing of the system may be required. The ultimate aim is to produce a system of accreditation of CPD that is fit for purpose, is acceptable to GPs with different working arrangements, that is relevant to practice and collects much of its evidence in the workplace.
Example 1: I have been involved in examining prescribing in two areas on behalf of the practice. We share the workload on this issue and I have reflected my role in my appraisal record. I looked at the pros and cons of two drug switches (on purely cost grounds); the short documents I produced are available in my record. In both cases the savings a switch would have produced are more than outweighed by the impact on the patients and the practice. I reflect in my form three that perhaps this activity has ‘run its day’. Claim 1 Credit Example 2: Used the Essential General Practice online module on Chronic fatigue syndrome/ myalgic encephalomyelitis (or encephalopathy) – this was focused on the NICE guidance – firstly this has helped me in understanding at least four of my personal patients problems much better. I have had a very productive consultation with one of them and realised (along with the patient) that fluoxetine is not helping and we have agreed withdrawal. I used the suggested exercise to ‘check out what I did in my own practice’ and found that the four cases I could identify all had significant periods of misdiagnosis (usually depression) and probably inappropriate treatment before the penny dropped. I have further evidence in my appraisal documentation to show the significance of the change at a personal level and the reduction in prescribing of anti-depressants in this group. Claim 8 Credits
IMPACT
CREDITS TABLE
CHALLENGE
KSS Mersey Northern Ireland Scotland Wessex
Pilot runs
Challenge in this context may be: ●
East Midlands London Northern North Western Wales
Pilot launch
‘Credits are self assessed and verified at appraisal’ Impact in this context may include:
Areas of the UK participating in the pilot
Recruitment of pilot sites; recruitment of appraisers and GPs
The RCGP as a constituent member of the Academy of Royal Colleges endorses the consensus view that doctors should normally achieve 50 credits of CPD a year leading to a total of 250 credits in a five-year cycle. The proposed model undergoing the pilot is based on two statements:
For further information, or to submit an entry, please contact the RCGP Publications Manager Helen Farrelly at hfarrelly@rcgp.org.uk
Deputy Editor required for trainees journal
The collated credit claim for the year is discussed at appraisal and the appraiser validates the number of credits they feel that the GP has presented. One of the outcomes of the pilot will be to examine the concordance or otherwise of the appraiser and the GP. The pilot is designed to allow for disagreement between the appraiser and apraisee, as this potential difference will be used to inform developments in the system.
Impact and challenge model
Further information about the post and the application process is available from e-GP@rcgp.org.uk. Closing date for applications is 14 November.
Share your learning points – in print
Validation at appraisal
LOW
MINOR
MODERATE
SIGNIFICANT
HIGH
LOW
1-2 Credits Example 1
2-4 Credits
3-5 Credits
4-8 Credits
5-10+ Credits
RCGP Impact Report 2008
MINOR
1-3 Credits
2-4 Credits
3-7 Credits
5-10 Credits
6-12+ Credits
The College’s Impact Report, giving details of RCGP activities over the past year, is now available for members to view and download through the RCGP website: www.rcgp.org.uk/ PDF/corp_Impact_report2008.pdf. Printed copies, priced £5 each, can be purchased through the RCGP Bookstore.
MODERATE
2-4 Credits
3-6 Credits
4-8 Credits
6-12 Credits Example 2
8-15+ Credits
SIGNIFICANT
3-5 Credits
4-7 Credits
5-11 Credits
7-15+ Credits
10-20+ Credits
HIGH
4-6 Credits
5-10 Credits
6-14+ Credits
10-20+ Credits
20+ Credits RCGP News • November 2008
CONFERENCE
Reflecting on a highly successful conference in the RCGP Village
Standing in for Lord Darzi: Dr David Colin-Thomé
‘I thought Blue Band was a margarine until I came to Bournemouth...’ Conference chair Fergus Walsh
THE DYNAMICS OF BOURNEMOUTH Dr Kay Mohanna gets the attention of RCGP chair Professor Steve Field
No tunnel vision among delegates at this event
Double vision: Professor David Haslam opens the conference
Getting together before dinner at the Bournemouth Opera House
Important contributions to the conference came from the floor as well as the podium
‘Time for bed,’ says a young delegate RCGP News • November 2008
3
NEWS
HPA introduces online Practices get new guide migrant health resource to help support carers Jamie Gottschalk Migrant Health Information Officer Dr Ruth Gilbert Migrant Health Scientist Dr Jane Jones Consultant Epidemiologist, Head of Travel and Migrant Health Section, Health Protection Agency Migration affects nearly every country world wide and global migration is steadily increasing. In 2001, 7.53% (4,301,280) of the people living in the British Isles were non-UK born1 and in 2006, an estimated 591,000 people migrated to England and Wales for a period of 12 months or longer2. Migrants are diverse in terms of their reasons for migration and their countries of origin. Although most are young and healthy some may have a range of health needs that differ from those people born in the UK. Their health needs may be affected by three key determinants: their individual characteristics (e.g. age, sex, ethnicity), their country of origin and the circumstances of migration, and the socioeconomic conditions in the host country. For some migrants, health needs may include those associated with infectious disease. In 2006, the Health Protection Agency (HPA) produced a report on infectious diseases in the non-UK born population that showed the major burden of a range of diseases in England, Wales and Northern Ireland falls upon particular groups who were not born in the UK. For example, approximately 70% of TB cases and HIV cases reported in England, Wales and Northern Ireland and 70% of malaria cases reported in the UK in 2004 had been born outside the UK. The increased burden of infection in some non-UK born populations is in large part related to the higher prevalence of specific infections in the countries from which they originate, and many infections are likely to have been acquired prior to arrival. However, the report also shows that some first and second generation migrants may be at ongoing risk of infectious disease in the UK, or as a result of travel back to their country of origin to visit friends and relatives. One of the key recommendations that arose from this report was that health services for the migrant population should reflect the needs and risks of this diverse group, and that health care professionals should be supported adequately to meet those needs. With these recommendations in mind, the HPA is investing in the development of a web-based migrant health resource. It will be tailored primarily for primary care practitioners who are at the forefront of providing healthcare to their communities.
Health in Pregnancy Grant next year All pregnant women will be entitled to a new Health in Pregnancy Grant (HiPG) from April 2009. The HiPG is a universal one-off payment available to expectant mothers from the 25th week of pregnancy. It will be a payment of £190 paid directly to the expectant woman to provide financial help, to support their general health and well-being in the later stage of pregnancy and to meet the wider costs in the run up to the birth. To receive the payment, the claim form will need to be signed by a registered doctor or midwife who has provided health advice during the pregnancy. Information regarding the availability of the forms will follow later this year. A toolkit of resources will also be available for healthcare professionals later this year, providing full information regarding all aspects of the HiPG, such as how it can be claimed and how to respond to questions that pregnant women might ask about the grant. The HiPG will be administered by HM Revenue and Customs. It will not be taxable or means-tested and will not affect the claimants’ entitlement to other benefits. Updates on the healthcare professional resources including a website with claim forms and full details of the launch will follow over the next few months.
4
This resource will be free to use and will be organised on a country of origin basis. It will bring together information and guidelines that primary healthcare workers will find useful in assessing and managing their migrant patient’s health needs. It will include information on infectious diseases and immunisations, which are a main focus of the HPA, as well information on a wider range of health needs that are experienced by migrants and dealt with in primary care, such as chronic disease and sexual health. Keeping in mind the time constraints of primary care, this website will aim to be a succinct, holistic and user friendly ‘one stop shop’ that will bring together a wide range of information and resources in an easy to use format. The HPA intends that this resource will contribute to protecting both individual and public health by providing necessary information and guidelines to healthcare practitioners. To ensure that this website offers maximum value for practitioners, the proposed content and design have been discussed with a number of stakeholders in primary and secondary care to determine exactly what format and information will be most useful. The Royal College of Nursing and the Royal College of General Practitioners both fully endorse this project. The HPA is also very conscious of the sensitivities that may exist around such a resource for some migrant communities and is actively engaging with community organisations to ensure that any sensitive issues are dealt with in an acceptable way. The HPA would like to arrange a number of focus groups with GPs around the UK to gather further input on the content and design of this website from potential users. A group of primary care practitioners will also be used to pilot the project in Spring 2009 before its official launch in July next year. Anyone interested in taking part in a focus group or helping to pilot this resource is asked to send an email to the Travel and Migrant Health Section at tmhs@hpa.org.uk or call 020 8327 7482. Any other enquires regarding this resource are also welcomed. For a hard copy of the Migrant Health Report please email tmhs@hpa.org.uk, or visit the HPA website for an online copy (www.hpa.org.uk, see the ‘Migrant Health’ section under Topics A-Z).
A new guide to help GPs support carers has been launched by the RCGP and the Princess Royal Trust for Carers. The guide, Supporting Carers: An action guide for general practitioners and their teams, has been designed for use by the entire primary care team. It should become an invaluable resource to help GPs and their colleagues consider the services and care they offer to carers and encourage practical improvements – without creating extra work or bureaucracy for the practice. Developed by a partnership between the RCGP and the Princess Royal Trust for Carers, the action guide was piloted in more than 20 GP practices and evaluated by Sheffield University. It includes a self-assessment checklist; suggested action and discussion points; Powerpoint resources and an online feedback facility, as well as practical case studies showing how GP practices have worked to support carers. The guide will: ● Raise awareness within your team and help you develop an action plan ● Encourage sharing your team’s knowledge and skills to build on your existing good practice ● Help to put systems in place for identifying carers at the earliest possible stage ● Facilitate linkage to other agencies that can help you support carers ● Help support employees who are carers ● Provide examples of good practice The guide is the latest useful resource to result from the partnership between the RCGP and the Princess Royal Trust for Carers, now entering its third year. Led by Professor Nigel Sparrow, the initiative was established to help GPs provide emotional and practical support for carers and make them aware of their own health needs. An estimated 10% of patients in every practice population now have caring responsibilities,
with many more ‘hidden’ carers who, for one reason or another, are not getting the services and support they need. Professor Sparrow said: “GPs and their teams are uniquely placed to recognise that someone is, or is about to become, a carer and we are already the gateway to a huge range of support. “We hope the action guide will lead to tangible results and new ways of working within the primary healthcare team. It will also support the continuing education of GPs so that doctors can more easily identify patient carers and be aware of their needs.” ■ The action guide is available free of charge from the RCGP website www.rcgp.org.uk and the Princess Royal Trust for Carers’ website www.carers.org
References 1 Health Protection Agency. Migrant Health: Infectious diseases in non-UK born populations in England, Wales and Northern Ireland. A baseline report – 2006. London: Health Protection Agency Centre for Infections. 2006. 2 Office for National Statistics. International migration, 2006. Newport: HMSO, 2008. www.statistics.gov.uk/downloads/theme_population/ MN33.pdf
Seven stages to improve patient safety New guidance enabling general practice teams to learn from patient safety incidents and ‘near misses’ has been launched by the National Patient Safety Agency (NPSA). The Significant Event Audit (SEA) guidance has been produced by the NPSA in collaboration with Professor Mike Pringle, University of Nottingham, and NHS Education for Scotland, with support from the RCGP and Quality Improvement Scotland. Significant Event Audit (SEA) was established in the mid-1990s as an effective quality assurance method in general practice with the aim of improving patients’ experience, care and outcomes and to identify changes that might improve future care. These episodes could include a wrongly administered MMR vaccination or wrongly prescribed medication. SEA was incorporated into the Quality and Outcomes Framework in 2004, as part of the new General Medical Services contract re-
Standing up for patient safety: Joanna Parker of NPSA; Professor Mike Pringle, University of Nottingham; Chair of RCGP Patient Partnership Group Ailsa Donnelly; RCGP Honorary Secretary Maureen Baker; Dr Ken Lawton, Chair of RCGP Scotland; Paul Bowie, NHS Education for Scotland; Professor James Reason and Christine Johnson of NPSA at the launch of the SEA guidance quirements. An initial scoping exercise by the NPSA found that the quality of SEAs conducted was variable and could be improved. The new guidance aims to raise awareness of how to conduct an SEA in seven simple stages so that general practice teams can learn and improve the quality of patient care.
Stage 1: Awareness and prioritisation of a significant event Information gathering The facilitated team-based meeting Analysis of the significant event Agree, implement and monitor change Stage 6: Write it up Stage 7: Report, share and review
Stage 2: Stage 3: Stage 4: Stage 5:
Speaking about the guidance, Professor Mike Pringle, University of Nottingham, said: “SEA is an established and effective quality assurance method in general practice. It helps to improve patients’ experience, care and outcomes by facilitating learning from experience and will be part of GP revalidation. This guidance will help encourage and inform existing and new users of SEA.’ RCGP Honorary Secretary Dr Maureen Baker, said: ‘SEA is a learning technique that GPs and practice teams are already familiar with. The guidance will help practices improve their use of SEA and lead to greater incident reporting in general practice.’ ■ The full guidance on SEA can be downloaded from www.npsa.nhs.uk/nrls/gp RCGP News • November 2008
NEWS
Connecting with GPs Peter Short of NHS Connecting for Health (below) explains the National Programme for IT and his role as a GP National Clinical Lead
Talking heads: (l-r) Sir Jonathan Miller, Jon Snow, Dr Ann McPherson, Sir Muir Gray, Chief Knowledge Officer of the NHS, Health Minister Ann Keen and Philip Pullman
Celebrity launch for new health talk site Sir Jonathan Miller, broadcaster Jon Snow, children’s author Philip Pullman and Health Minister Ann Keen joined RCGP Fellow Dr Ann McPherson for the launch of healthtalkonline.org, the UK’s largest online collection of real life health stories and shared personal experiences of health and illness. Dr McPherson – who works extensively with the College particularly on adolescent health issues and is co-author of the bestselling Diary of a Teenage Health Freak – is Medical Director of the DIPEx charity (Database of Individual Patient Experience). The launch of healthtalkonline.org – and its sister site youthhealthtalk.org – follows extensive redevelopment of the dipex.org site. While the former site as well used and won awards, it was felt that the name did not properly describe the resources on offer. The new sites have greatly improved accessibility, enhanced navigation and comprehensive search facilities to support individuals who feel isolated as a result of a particular medical condition. Both sites feature real people talking – in video, audio clips and transcripts – about their own health experiences. Each topic features 30-50 people from different backgrounds and locations all over the UK sharing their personal experience. Thousands of carefully selected interview clips offer insights into how health concerns can affect
be frightening ❛andIt can bewildering to be diagnosed with an illness. Listening to the experiences of others can help you to understand and cope with what you’re going through
❜ Jon Snow
everyone and portray stories on all aspects of life: how people make choices and decisions, their experiences of treatments, telling the family and managing work, dealing with the health services and many other widespread concerns. Site users can also join an online forum. Around 50 illnesses and general health topics are now covered, including cancer, heart disease, chronic pain, bereavement, diabetes, epilepsy and women’s health. Three new health topics, one on Parkinson’s disease and two on autism also feature. All content on the healthtalkonline.org site is based on detailed academic research led by the University of Oxford, from interviews with almost 2,000 people. As well as patients and carers, health professionals and medical students across the UK are using healthtalkonline.org resources to help them better understand people’s perspectives on disease and to support improved patient doctor communication. Healthtalkonline.org also links to hundreds of other health groups and organisations, including NHS, Macmillan Cancer Support, Cancer Research UK, British Heart Foundation and the Wellcome Trust. Speaking at the launch, DIPEx patron Jon Snow said: “It can be frightening and bewildering to be diagnosed with an illness. Improving your knowledge of the condition, and listening to the experiences of others can help you to understand and cope with what you’re going through. Healthtalkonline provides a medically endorsed forum for this kind of support.” Sir Jonathan Miller recalled his days as a medical student in the 1950s when the priorities were “keeping the wards clean and taking down the narrative of patient histories because there was little else we could do for patients. “Today, there have been great advances in technology but doctors are less attentive to the narrative of what it’s like to suffer, or what it’s like to be the relative or carer of somebody who is suffering. We don’t pay enough detail to the narrative and we miss out as a result,” he said. ■ To access the site, or to share your own personal health experience, go to: www.healthtalkonline.org
Time to put your best foot forward The RCGP is joining forces with Cancer Research UK to host the GPs’ Great Three Legged Race at the 2009 national conference in Harrogate next October – but hurry if you want to take part, as places are limited.Cancer Research UK – the world’s leading charity dedicated to cancer research – is hoping to raise sufficient funding to ensure that by 2020, two-thirds of all cancer cases will be diagnosed at a stage when the cancer can be successfully treated. ■ Register your interest by e-mailing your name and contact details to: threelegged@cancer.org.uk RCGP News • November 2008
For clinicians, the primary goal that sums up the aims of the National Programme for IT (NPfIT) is ‘better, safer care’. Our core business is to sustain and improve the health of our nation on an individual and population basis. We aspire to measure improvements to healthcare in objective, subjective and financial ways. Having two working GPs at the heart of NHS CFH is recognised as a significant asset for the organisation. We are employed through the Prescription Pricing Authority (PPA) to give clinical advice from a GP perspective, and not to promote the benefits of the National Programme as ‘salesmen’. This difference is the key to credibility for the role, and to our interactions with professional colleagues. We are placed in a position of influence, to be critical and objective about the translation of broad IM&T objectives into clinical reality, and as an ‘early warning system’ with regard to possible implications for Primary and Community care. We place the patient at the heart of everything the NHS does, and this includes the IT strategy. The information held, its use, security, and accuracy must all primarily be focused around the needs of an individual, to be accessible to them, and to enable the partnership of care between an individual and their NHS clinicians. Choose & Book, and HealthSpace developments, and the intensive discussions and consultation around consent models and implementation, are clear examples of where the National Programme is enacting this strategy. The patient partnership further reinforces the need to provide access to reliable health information for patients, to enable them to have fully informed partnerships with their clinicians and make positive choices. Pioneering GP work, to allow records access, provides a solid foundation to build on success, and the NHS Choices website has had rapid development to become a powerful, positive and accredited information source. We should welcome the aspirations, knowledge, experience and enthusiasm of the current NHS workforce to lead, direct and ‘own’ IT developments. All areas of IM&T, including planning, development, testing, implementation and review, need significantly greater front-line clinician input from all disciplines. Adoption of this principle under the NPfIT Local Ownership Programme (NLOP) is patchy around the country, particularly with the financial and service delivery challenges competing for the resource of clinician time. Failing to invest in significant clinical engagement with the IM&T agenda carries significant risk for health communities. NHS CFH is facilitating work streams to offer wider clinical engagement and influence of the National Programme. The Clinical Content Programme, Common User Interface on data and usability/ safety issues and the Clinical Leaders Network are good examples. There is an increasing recognition of pragmatic alternatives to single system solutions, with the ability of being able to build on the success of currently available systems while having clear standards to facilitate interoperability. Challenges remain with some technical issues such as the records structure, architecture and code alignment, but these are likely to prove less of an obstacle than records governance and the need for co-operation between professional groups. Shared Professional Records Guidance for healthcare staff being led by the RCGP will, I hope, provide a pivotal reference point. There is now a long overdue acknowledgement that strong and informed clinical leadership is essential to deliver improvements in healthcare. Understanding the core element of reliable, accessible and secure integrated electronic records will be essential for current and new leaders. Raising the profile of health informatics in the medical education curriculum, at all stages, is a long-term priority and the support of the RCGP and other colleges in championing this element will be vital. Closer communication and links between NHS CFH and the RCGP are entirely appropriate, to benefit from the detailed specialist knowledge resource and to be a ‘quality assurance’ marker for professional engagement. The high profile and priority for Information Technology within future NHS plans is recognised at the
NHS Connecting for Health (NHS CFH) has two designated National Clinical Leads (NCLs) for GPs. Dr Peter Short and Dr Manpreet Pujara advise on system implementation and they also have an open dialogue with many GP representative groups, speak at Primary Care events and conferences and take part in NHS CFH advisory committees. Peter Short practises at the Stewart Medical Centre, Buxton, Derbyshire. He describes himself as carrying out the ‘traditional GP role’, with additional work in community hospitals as a clinical assistant in elderly medicine, covering GP beds and a minor injury unit. He is proud to be a ‘generalist’ and increasingly to use electronic information resources to monitor and improve levels of care. Manpreet is a GP in Rochester, Kent. He became an EMIS user in 1990 and was elected to the National User Group (NUG) committee in 1994 and was NUG chair between 2001 and 2007. highest level within RCGP, who will be key partners in enabling ambitious plans for ‘world-class’ service delivery. Historical variation and inconsistencies in communication continue to be a challenge and become evident with disappointing reports of ‘lack of engagement’ from grassroots GPs. Improving the clarity of priority and purpose for GP system development will provide a co-ordinated channel for functional development requests, and balance clinical need with contractual requirements. The complex strategy for IT deployment around the NHS will inevitably lead to variation in the success achieved, areas of unexpected success, apparent relative failure and surprising spin-off benefit. Learning from such processes, disseminating and applying such lessons effectively is another key aim of the NHS IT strategy. The NHS IT strategy will continue to develop, challenge and change, supported and informed by greater clinical involvement and leadership and by the lessons learned, but must remain true to the aim of enabling ‘better, safer care’ for all.
TOP INFORMATION LINKS FOR GPS ● ● ● ● ●
Choose and Book Electronic Prescription Service (EPS) GP2GP GP Systems of Choice (GPSoC) Support materials for the NHS
We want to hear from you How ready is your organisation to implement these technologies locally and get maximum benefit from them for your patients and staff? What barriers are in your way and how can we help you overcome them? ■ We welcome your views and opinions. Contact the GP National Clinical Lead team at gplead@nhs.net
5
CLINICAL REVIEW
Management tips for Paget’s disease of bone JOHN D PAULING
Elevated ALP
ASHOK BHALLA
Royal National Hospital for Rheumatic Diseases, Bath
Repeat ALP after one week
Persistently elevated ALP
Key message Paget’s disease of the bone is a common condition of late life that carries significant morbidity. There are treatments available that can improve symptom control and possibly delay the progression of disease.
Background James Paget originally described the condition that bears his name as a form of chronic inflammation of bones (osteitis deformans).1 We now understand Paget’s disease of bone (PDB) as a chronic disorder in which there is accelerated bone turnover initiated by aggressive osteoclast-mediated bone resorption and subsequent imperfect osteoblast-mediated new bone formation at one or more sites within the adult skeleton.2
Epidemiology The cause of Paget’s disease remains uncertain but is multi-factorial with recognised important genetic and environmental influences.3 Paget’s disease is marginally more common in men than women. The onset is insidious and usually presents after the fifth decade. The prevalence of Paget’s disease is highest in populations of Northern European ancestry such as the UK, North America, Australia, New Zealand and Western Europe and is uncommon in non-caucasian races.4 A radiological survey in the 1970s estimated the prevalence of Paget’s in the UK to be approximately 5.4% in those over 55 years with increasing prevalence with advancing age.5 The incidence and severity of Paget’s disease appears to be falling and more recent studies estimate prevalence within the UK in the order of 0.3% of people over the age of 55 years rising to approximately 6.5% of those over 85 years.6 Reasons for the apparent decline in prevalence remain uncertain. Onset below the age of 40 years is extremely rare and often represents a rare autosomal recessive, juvenile-onset, condition of similarly disorganised, albeit more generalized, bone remodeling.2 Paget’s disease of bone causes significant morbidity as the resulting structurally inferior remodeled bone can cause pain, deformity, loss of function and fracture. Mortality was previously thought be higher in patients with Paget’s disease but complications such as neoplastic transformation appear to have declined along with the decreasing prevalence of the condition and a recent study has not identified a reduction in survival in an unselected community population.6,7
Presentation Paget’s disease has the highest propensity for the pelvis, axial skeleton, skull and long bones, e.g. femur. Established PDB typically affects more than one site within the adult skeleton (polyostotic, 72%) but can remain limited to a single focus (monostotic, 28%).7 It is commonly accepted that the majority of patients with PDB are asymptomatic, although estimates of the proportion of patients experiencing symptoms vary considerably depending on study design. Recent published work identified symptoms related to PDB as being present in as many as 58% of patients at diagnosis.7 Diagnosis of PDB is often made following further investigation of an unexpected elevation in serum alkaline phosphatase (ALP) or as an incidental finding on X-ray and many of these patients remain asymptomatic. Symptoms of Paget’s disease are the result of local expansion of hypervascularised bone, altered structural integrity of affected bone, systemic manifestations or rarely malignant transformation and are listed in Table 1 below. Hypervascularity of affected bone can cause palpable local warmth and is thought to be the cause of the deep seated aching in the affected bone which patients often describe, particularly when loaded, e.g. during weight bearing with femoral Paget’s.2 Localised bone expansion can lead to visible deformity such as altered size and appearance of head and ‘bowing’ of long bones. Bone expansion and deformity affecting articular surfaces, or
Table 1: Complications of Paget’s disease of bone ●
Local effects of bone expansion ● ● ● ●
●
Altered structural integrity of affected bone ● ●
●
●
6
Compound fractures Fissure fractures
Systemic complications ●
●
Bone pain Osteoarthritis of adjacent joints Bone deformity, e.g. ‘bowing’ of long bones Neural damage, e.g. cranial nerve palsies, spinal stenosis and myelo-radiculopathy
Hypercalcaemia following immobilization High-output cardiac failure secondary to hypervascularisation of pagetic bone
Malignant transformation to osteosarcoma
Full history and examination
Check Alanine transaminase (ALT) and Gamma-glutamyl transpeptidase (GGT) Abnormal HEPATIC DERIVED? Drugs e.g. augmentin, NSAIDS etc Cholestasis Extra-hepatic e.g. gallstones Intrahepatic e.g. PBC, PSC Hepatitis Fatty liver Alcohol excess Primary or secondary liver neoplasms
Normal BONE DERIVED?
Serum calcium?
LOW Osteomalacia (check PO4 and 25-OH Vit D) Renal dysfunction
NORMAL Paget’s disease of bone
HIGH Hyperparathyroidism Metastatic disease Paget’s disease (following immobility)
Figure 1. Interpretation and further investigation of an elevated alkaline phosphatase (ALP) result leading to altered biomechanics, can result in early development of osteoarthritis (OA) in adjacent joints. Expansion of bone can lead to local impingement of neural structures, most notably the cranial nerves as they leave the cranial foramina, e.g. deafness from cranial nerve VIII entrapment, and within the spine causing symptoms of spinal stenosis or myelo-radiculopathy.2 Pagetic bone is weaker than healthy bone and susceptible to the development of fissure fractures along the surface of long bones or compound fractures which cause acute severe pain and can be complicated by malunion, particularly when involving the proximal femur.2 Hypervascularisation of extensive polyostotic cases (over 40% of skeleton affected) is rarely associated with high-output cardiac failure. Sarcomatous change of pagetic bone is rare, affecting fewer than 1% of patients, but should be considered in any patient who develops a new mass or rapid expansion of a previously affected site, often in the presence of constant or worsening bone pain. Biopsy should be considered in these patients to exclude malignant transformation.2
Investigations Biochemical The diagnosis of Paget’s disease is primarily a radiological one but is usually made upon further investigation of an elevated serum ALP (a marker of bone formation), which may be 3 to 15 times higher than normal range. ALP levels can be only marginally elevated or even within normal range in untreated Paget’s disease when the disease process is limited to small foci and this should not deter clinicians from treating painful lesions. There are many other causes of an elevated ALP and additional investigations might help to distinguish between bone and hepatic derived enzyme and help guide further investigation and management (Figure 1 above). Patients should be thoroughly assessed for features of Paget’s disease and to ensure there is not an alternative explanation for bone-derived ALP such as metastatic disease. Patients should be referred for rheumatology assessment ● if they are young, e.g. under 65 years ● symptomatic ● or if the ALP is three times the upper limit of normal
Figure 2. Typical radiograph appearance of Paget’s disease with bone expansion, cortical thickening and coarse trabeculae leading to bowing of the tibia fected at diagnosis accurately establish the extent of disease as it is uncommon for new sites to become affected at a later stage following initial diagnosis.
Histological Biopsy of affected bone reveals typical histopathological appearances but can cause fracture and is unnecessary unless there is concern regarding possible neoplastic transformation, or uncertainty as to whether the affected sites represent an alternative diagnosis, e.g. metastatic disease.8
Management Patients should be assessed and managed by physicians with experience in treatment of Paget’s disease of the bone.
Supportive care Asymptomatic Paget’s does not necessarily require treatment but all patients should be educated about Paget’s disease and advised to seek medical attention should they develop any new symptoms. Patients should be guided to useful sources such as www.paget.org.uk and www.arc.org.uk for further information. Pain is the commonest symptom experienced by patients with PDB and all patients should be carefully assessed to establish the exact cause of their pain and guide appropriate treatment.8 Complications of Paget’s such as OA and altered gait patterns secondary to bowing of long bones often responds to aids and appliances such as heel raises, walking aids, physiotherapy etc. Simple analgesics are helpful for osteoarthritic pain but tend to be less effective for true pagetic bone pain. Use of intra-articular
Patients with asymptomatic Paget’s associated with only modest elevation of their serum ALP should have their ALP monitored on an annual basis and advised to seek advice if they develop any new symptoms. Bone specific ALP may be required to monitor disease activity in patients with pre-existing liver disease in whom total serum ALP is unreliable.8 Other markers of bone turnover, e.g. serum CTX and P1NP, are usually elevated but are not required to formulate the diagnosis or monitor treatment.
Radiological Characteristic changes are found on plain radiographs of affected sites with bone expansion, cortical thickening and coarse trabeculae with areas of osteosclerosis interspersed with areas of relative osteopenia (Figure 2, top right) and at least one skeletal site should be X-rayed to confirm the diagnosis.8 A full skeletal survey is not warranted but all painful sites should be further examined with plain radiographs.8 Isotope bone scanning using 99mTc-labeled bisphosphonate tracer (Figure 3, right) is more sensitive (although less specific) than plain radiography in identifying pagetic lesions and is recommended as part of investigation of all patients with suspected Paget’s disease to assess disease extent and severity.8 The sites af-
Figure 3. Isotope bone scan demonstrating increased uptake in a patient with pagetic involvement of the skull and left hemi-pelvis RCGP News • November 2008
CLINICAL REVIEW Table 2: Recommendations for the use of anti-resorptive medication in PDB ●
Good evidence from clinical trials to support the use of bisphosphonates to achieve: ● ●
●
Bisphosphonates are recommended, despite insufficient clinical trial data, for: ● ● ●
●
●
Improvement in bone pain secondary to PDB Reduction of serum ALP
The GP’s role in the detection and management of postnatal depression
Prevention of facial deformity secondary to PDB Hypercalcaemia secondary to PDB Prevention of neural damage in PDB of the skull base and axial skeleton Management of pain where the cause remains unclear, e.g. OA of pagetic joints
There is insufficient evidence to support the use of bisphosphonates solely for: ●
● ● ● ● ●
The prevention of bone deformity at sites other than the facial bones Treatment of osteolytic lesions Prevention of excessive peri-operative bleeding To improve quality of life Prevention of the development of osteosarcoma Prevention of fractures
steroids can transiently improve pain from osteoarthritic joints to allow more effective physiotherapy. Weight loss in overweight patients can reduce bone pain and slow the rate of progression of OA of weight bearing joints.2 Patients should have their falls risk assessed and modified to reduce fracture risk. Surgical intervention is sometimes required for secondary complications such as joint arthroplasty in OA, osteotomy for deformity, and fractures.8
Antiresorptive therapy Primary treatment of Paget’s disease involves the use of bisphosphonates that inhibit osteoclast function and reduce bone turnover. Bisphosphonates effectively suppress serum ALP and there is firm evidence supporting their use in pagetic bone pain.8 Bisphosphonates are effective in the management of hypercalcaemia and should be considered in patients with hypercalcaemia as a result of PDB. Recommendations regarding the use of bisphosphonates in Paget’s disease of bone are listed in table 2.8 The two most commonly used agents are oral Risedronate (30mg orally daily for two months) and intravenous Zoledronate (5mg IV as single infusion). The latter appears to be more effective than the oral preparations in maintaining suppression of the alkaline phosphatase. It is important to ensure patients have adequate oral intake of calcium and vitamin D before using bisphosphonates to avoid symptomatic hypocalcaemia and secondary hyperparathyroidism. Calcitonin was previously the mainstay of treatment of PDB but because of its side effect profile, weaker activity and shorter duration of action, its use has been largely superseded by the newer bisphosphonates. It still has a role in cases where bisphosphonates are contraindicated or poorly tolerated.8
Monitoring disease and repeat treatment Many clinicians aim to normalize the alkaline phosphatase level but data is lacking to support this strategy which may be misleading in limited disease. It is generally accepted that repeat treatment can be considered in the absence of symptoms for pagetic lesions at critical sites if the alkaline phosphatase rises by 25% from its nadir but data is lacking to support use of treatment in this manner.8 Repeat treatment can be reconsidered six months post-treatment for recurrence of symptoms with evidence of continuing disease activity. Repeat isotope bone scanning is not generally recommended but may be useful for persistent pain despite improvement in biochemical markers.8
Conclusions Paget’s disease of bone is a common disease with significant morbidity and mortality. There are effective treatments available that can improve the impact of the disease and might alter the natural progression of Pagetic complications. Long-term randomized trials are needed to assess the efficacy of aggressive early pharmacological treatment in primary prevention against late Pagetic complications to help establish optimal treatment regimes.
References 1) Paget J. On a form of chronic inflammation of bones (osteitis deformans). Trans Med-Chir Soc 1877;60:37-63 2) Whyte MP. Paget’s disease of bone. N Engl J Med 2006;355:593-600 3) The Paget Foundation. Available at www.paget.org Accessed 29 May 2008 4) Cooper C, Harvey NC, Dennison EM, Van Staa TP. Update on the epidemiology of Paget’s disease of bone. J Bone Miner Res 2006;21(suppl 2): 3-8 5) Barker DJ, Clough PW, Guyer PB, Gardner MJ. Paget’s disease of bone in 14 British towns. Br Med J 1977;1:1181-1183 6) Van Staa TP, Selby P, Leufkens HGM, Lyles K, Sprafka JM, Cooper C. Incidence and natural history of Paget’s disease of bone in England and Wales. J Bone Miner Res 2002;17:465-471 7) Wermers RA, Tiegs RD, Atkinson EJ, Achenbach SJ, Melton LJ. Morbidity and mortality associated with Paget’s disease of bone: a population-based survey. J Bone Miner Res 2008;23:819-825 8) Selby PL, Davie MJW, Ralston SH, Stone MD. Guidelines on the management of Paget’s disease of bone. Bone 2002;31:366-373 RCGP News • November 2008
Table 2: Questions to ask of your primary care team
CAROLYN CHEW-GRAHAM RCGP Clinical Champion for Mental Health ●
What is postnatal depression? Postnatal depression affects 8-15% of women. It is defined as a non-psychotic depressive episode meeting standardised diagnostic criteria for a minor or major depressive disorder, beginning in or extending to the postnatal period1. Postnatal depression should not be confused with ‘baby blues’ which is the tearfulness that commonly occurs in the first few days after delivery. Postnatal depression can result in long-term adverse consequences for maternal mood and infant development2 and may erode already difficult marital relationships and reduce confidence in parenting. The recently published NICE guidelines3 for antenatal and postnatal mental health use the term ‘perinatal mental disorder’, recognising that symptoms may begin in the antenatal period, and outline the potential role of all healthcare professionals in the detection of depression. The guidelines suggest the establishment of specialist multidisciplinary perinatal services in each locality but that, until the commissioning of such services, health visitors and GPs should continue to have a major role in the detection and management of perinatal depression.
Making the diagnosis The role of the GP is to assess the woman in the same way as any patient in whom depression is suspected (Table 1). This may be during an appointment made by the woman when she volunteers feelings of sadness and low mood, but the GP also needs to explore depressive symptoms in appointments antenatally, at the postnatal check, in routine baby checks and appointments for the child (particularly if a woman presents her child frequently). The GP may, following an exploration of symptoms, use the Patient Health Questionnaire 9 (PHQ-9) to assess the severity of depression4. It has been suggested that health visitors should screen for postnatal depression using the Edinburgh Postnatal Depression Scale5. How widely the EPDS is used by health visitors is not known, but there may be confusion between health visitors and GPs about whose responsibility it is to make the diagnosis of and manage women with PND6.
Management of postnatal depression Most women with postnatal depression are currently managed within primary care, with only women with psychosis or suicidal intent being referred to secondary care. The NICE guidelines3 stress the need for a trusting relationship between clinician and mother and the provision of culturally sensitive information to women, including discussion of the impact of the disorder and its treatment on the health of the woman and baby. Management options include psychological interventions (‘talking treatments’) and/or antidepressants.
Table 1: Areas to cover in the primary care consultation ● ● ● ● ● ● ●
●
●
●
●
Explore depressive symptoms: Low mood Crying a lot Poor concentration Anxiety Guilt Lack of confidence in her ability as a mother Not enjoying motherhood Loss of appetite or overeating Extreme tiredness
● ● ●
●
●
●
Irritability Sleeping problems No interest in sex Being hostile or indifferent to husband or partner A sense of being overwhelmed and unable to cope Difficulty in making decisions Difficulty concentrating
Other relevant history ● ● ● ● ● ●
●
●
Duration of symptoms (at least two weeks) Severity of core features Impairment of function History of depression in past Co-morbidity e g. anxiety, substance misuse Previous treatment experience – successful and unsuccessful
Assess risk to self and harm to baby ● ●
● ● ●
Ideation/thoughts and plans Intent and means to commit harm (eg, store of tablets) Protective factors Social support Feelings towards baby
●
●
●
● ● ●
● ●
Is the EPDS used by HV and/or GP? If so, how/when? Does our postnatal check protocol include screening questions for depression? Do we know what services are available for women with postnatal depression in our area? Do we provide information to women on postnatal depression – including websites and voluntary sector provision? Have we got a system for updating this information? Do we prescribe anti-depressants appropriately? Do we arrange regular follow-up with one named clinician? Are there any training needs for our practice staff? Would an audit of postnatal care be helpful?
Talking treatments Evidence for the effectiveness of psychological interventions is limited but it is thought that women may prefer talking treatments to tablets7,8. It is recognised that the availability of psychological therapies may be limited and thus restrict what GPs can offer to women. GPs can, however, refer women to the many useful websites which offer support4, self-help groups run by the health visitor or the voluntary sector and GPs should familiarise themselves with what is available locally. Some Primary Care Mental Health teams will offer short-term interventions for women with mild to moderate PND and some Primary Care Trusts commission innovative services to support women postnatally, with a broader psychosocial approach and the offer of childcare facilities. Referral to Sure Start programmes, where available, may be appropriate, but evaluation of such programmes9 has been disappointing.
Antidepressants Antidepressants are effective in the management of postnatal depression10. Careful monitoring of symptoms, side-effects, suicide risk and risk to baby should be routinely undertaken, especially early in treatment. If an antidepressant is offered, an SSRI (selective serotonin reuptake inhibitor) rather than a TCA (tricyclic antidepressant) should be prescribed, because SSRIs are less toxic in overdose and less likely to be discontinued due to side-effects. If the woman is breastfeeding, fluoxetine is not recommended due to its long half-life and higher levels in breast milk, although harmful effects on breastfed babies have not been detected in case reports. There is most experience with sertraline and citalopram in breast feeding mothers and women can be reassured that no harmful effects have been described.
Implications for your practice Practices might want to consider postnatal depression as a topic for their in-house training, and Table 2 gives some suggestions of prompts that could be used to stimulate discussion and audit. Practices need to take ownership of the management of postnatal depression. If specialist multidisciplinary perinatal services are commissioned, as suggested by the NICE guidelines3, this may improve care through direct service provision, as well as the introduction of protocols and care pathways, educational initiatives and training for primary care teams. It could, however, lead to fragmentation of care11 and reduce the role of the GP in the management of women with postnatal depression.
References 1) Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psych 1993; 163: 27-31. 2) Hay D, Pawlby S, Sharp D, Asten P, Mills A, Kumar R. Intellectual problems shown by 11 year old children whose mothers had postnatal depression. Journal of Child Psychology and Psychiatry 2001; 42: 871-890. 3) Antenatal and postnatal mental health. NICE guideline 45. DoH 2007. 4) Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16, 606-13. 5) Murray L & Carothers AD. The validation of the Edinburgh postnatal depression scale on a community sample. Br J Psychiatry 1990; 157: 288-90. 6) Chew-Graham CA, Chamberlain E, Turner K, Folkes L, Caulfield L, Sharp D. General Practitioners’ and Health Visitors’ views on the diagnosis and management of postnatal depression: a qualitative study. BJGP 2008, 58:169-176. 7) Boath E, Bradley E, Henshaw C. Women’s views of antidepressants in the treatment of postnatal depression. Journal of Psychosom Obstet Gynecol, 2004; 25, 232-331. 8) Turner K, Sharp D, Folkes L, Chew-Graham CA. Women’s views and experiences of antidepressants as a treatment for postnatal depression: a qualitative study. Family Practice, in press. 9) Belsky J, Melhuish E, Barnes J, Leyland A, Romaniuk H. Effects of Sure Start local programmes on children and families: early findings from a quasi-experimental, cross-sectional study. BMJ 2006; 332: 1476. 10) Appleby L, Warner R, Whitton A, Faragher B. A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. 1997. BMJ, 314, 932-936. 11) Derrett C & Burke L. The future of primary care nurses and health visitors: Increasing fragmentation threatens the primary healthcare teams. 2006. BMJ Vol 333. 1185-6.
7
NEWS
Diabetes Year of Care: what GPs need to know Douglas Smallwood Chief Executive, Diabetes UK. In 2003 the National Science Foundation proclaimed: ‘The key to good outcomes is productive interactions between an engaged empowered patient and an organised proactive system’. The Year of Care project, a partnership between Diabetes UK, the Department of Health, The Health Foundation and the National Diabetes Support Team, is the embodiment of this and one of the first in a series of care-planning drives to put patient empowerment at the top of the health agenda. The project aims to use a planned approach to support people with long term conditions to manage their own condition with the aim of improving both their health status and their quality of life whilst at the same time making the most efficient use of healthcare resources. The model enables PCTs to systematically design, commission and deliver services to people with long term conditions, such as diabetes. The condition is one of the most complex long term conditions and so was an ambitious choice to ‘host’ a number of Year of Care pilots across the UK this year. In 2007, the Healthcare Commission published their review of almost 70,000 people with diabetes in England. They found that although 95% of people had diabetes checks at least once a year, less than half discussed their goals in managing their condition
GPs’ attention and time As important as diabetes care is, Diabetes UK recognises that there are a huge number of other issues and conditions that compete for GPs’ attention and time. Unfortunately, the
Year of Care puts patient empowerment at the top of the health agenda, says Douglas Smallwood Healthcare Commission’s findings above appear to be mirrored in research published by the Picker Institute in 2007. It showed that although people feel waiting times have been reduced, and trust in clinicians has remained high, they do not feel they are involved in decision making and are not given enough information about their medication. We frequently hear people tell us that this is nothing new, that they are doing this already. How do you know? Do your peers review your consultations? Do you ask your patients after each session? It is hard to do when the waiting room is full of people who need your care, but can you honestly say that you take the time to ensure that you get to the bottom of each person you see and understand all of their needs: not just their biomedical needs, but emotional, psychological and behavioural needs too? Three pilot sites are currently testing this approach to care for people with diabetes: Calderdale & Kirklees PCTs, NHS North of Tyne and Tower Hamlets PCT. The sites have just completed Phase I of the programme (‘set up’); Phase II (‘delivery’) will continue from now until autumn 2010.
RCGP Clinical Lead in Diabetes (Primary Care) Job description Purpose of the job Using their extensive experience as a leading clinician/healthcare professional, the chief medical adviser will take a leadership role in Diabetes UK’s work with health care professionals in diabetes. The Chief Medical Adviser will ensure that Government, professional representative bodies, senior figures within the professions, our 6,000-plus healthcare professional members and our future supporters will recognise Diabetes UK to be at the forefront of shaping the future of diabetes care and research.
The role Time commitment of approximately one day per week is envisaged. Location: flexible. Remuneration: negotiable and based on loss of earnings. The appointment will initially be for one year and subject to revision. No line management responsibilities but the post holder will attend Board of Trustees, Professional Advisory Council, and Executive Team meetings on an occasional basis in an advisory capacity. S/he will also occasionally represent the charity at conferences and in the media. Accountable to CEO, the postholder will work particularly closely with the Director of Research and the Director of Care, Information and Advocacy Services providing a wise counsel and acting as a sounding board for new initiatives. S/he will also support the Chair of the Professional Advisory Council in providing guidance to Diabetes UK. To advise and support the CEO and Directors with the delivery of their accountabilities for the following: ●
Liaison with the senior figures amongst healthcare professionals working in diabetes and their professional bodies.
●
Providing medical guidance to inform our policies often in conjunction with our Professional Advisory Council.
●
Ensuring that our work is valued by professionals, learned societies and policy makers, and in particular that our objectives are well communicated to them and result in them wanting to be members / supporters of Diabetes UK.
●
Communicating and influencing clinical leads across the UK in the prioritisation of diabetes services and how they are delivered as set out in our policy statements.
●
Our research strategy and priorities and the alignment between our research and care priorities.
●
Attracting and retaining clinical academic researchers to diabetes and Diabetes UK.
Motivations / Skills / Experience required Diabetes UK is committed to an Integrated Care approach to diabetes and this post holder will be motivated to help lead the work involved in making this a reality throughout the UK. The successful candidate will be a highly respected senior member of their profession. S/he will be strongly motivated to make a difference by providing leadership in shaping the future of high quality diabetes care and services delivered by professionals in partnership with patients. For further information, please e-mail Douglas.Smallwood@diabetes.org.uk
8
Since the publication of Lord Darzi’s report, High Quality Care for All, there has been considerable interest in the Year of Care. This not only reflects the NHS Next Stage Review’s target that everyone with one or more long term condition should be offered a care plan by 2010; it is also because Year of Care is all about quality of care, support to self-manage and developing effective clinical partnerships. In response to this increase in interest in the Year of Care, Getting to Grips with the Year of Care: A Practical Guide was launched at an event on 15 October in Westminster. This publication sets out the nuts and bolts of what is required to deliver a Year of Care approach, as well as sharing resources and sharing examples of work the pilot sites have undertaken.
A strong GP lead The Year of Care programme is being evaluated externally, and the report of Phase 1 of the Year of Care has recently been completed. The evaluators identified that clinical leadership was vital, and that having a strong GP lead was critical to the project’s success locally. As well as being able to respond to clinical concerns from their peers, and convince other healthcare professionals by testifying, for example, that having their patients prefer results being sent out in advance so they can interpret and work out what they want to get out of consultation, GP leads
were able to make full use of Practice Based Commissioning levers to have an impact on the redesign of local services. One of the main advantages of the Year of Care approach for clinicians was that it could be used as a way of arguing for more time to spend with each patient. Commissioners recognised that care planning, a true sharing of stories, needs additional time and so have taken measures to formalise this, for example through Local Enhanced Services. The Year of Care also puts GPs, practice staff and people with long term conditions at the heart of local commissioning. It provides a way of ensuring that services are not commissionedbased on what has been done historically, but on what local communities need and what actions improve outcomes. However, in spite of the potential benefits of the Year of Care, there needs to be some realism. The project can link clinical data to effective commissioning but the experiences of patients in our pilot sites highlight that this is not merely a project. Rather, it is an incredibly complex change programme which may need a redesigning of services and a strong commitment to work in new ways. It requires a great deal of enthusiasm and effort from all sides and needs to develop into a starting point for relationships between key local stakeholders.
Advantages for practices One of the pilot sites have published a comprehensive service directory which they have distributed to every GP in the area, letting them know every single service available locally for a range of interventions. Have you ever heard a patient say that they wanted to attend a service but there was never anywhere to park, or the classes finished too late and they were scared of walking home alone, or the bus was full of schoolkids? The Year of Care will provide a mechanism to flag barriers to access, or lack of appropriate services, directly to commissioners. We are looking into creating IT templates capable of recording all of the information that comes out of consultations – emotional, psychological, behavioural, health beliefs – that will reflect the wealth of non-biomedical work undertaken by GPs that goes unnoticed and uncaptured. The guide is available by emailing yearofcare@diabetes.org.uk or calling Diabetes UK on 020 7424 1113.
Dr Deryck Lambert MBE FRCGP Dr Der yck Lambert has died aged 83 after a remarkable lifetime of ser vice to the medical profession. Over the course of his career Dr Lambert was a teacher, mentor and inspiration for many young doctors. He was a pioneer of vocational training and held a variety of teaching positions throughout Yorkshire in the 1960s and ’70s. He served as course organiser, GP trainer and RCGP clinical tutor, and held teaching positions at the Universities of Bradford, Leeds and Liverpool. Dr Lambert was strongly influenced by his wartime experience serving in the RAF’s legendary Pathfinder Force. In 1944 his Lancaster bomber was shot down over Germany with just one other crew member surviving. He was forced to endure eight brutal months as a PoW before the war ended in 1945. After the war Dr Lambert studied at Edinburgh University and then served as a GP in Keighley, Yorkshire and Runcorn New Town. He was a long term member of the RCGP, gaining his Dr Lambert with his MBE MRCGP in 1971. which was followed by his FRCGP in 1977. During the 1970s he was an RCGP examiner and was also a member of the RCGP Fellowship Committee. In the 1980s, he worked on communicable diseases, health education and prevention at a national and international level. His lifetime of achievement was recognised in 1992 when he was awarded the MBE for Services to Medicine. Many of his former colleagues and students have paid tribute to his compassion, integrity, sense of humour and positive nature, describing him as ‘a courageous, honest and thoroughly worthy colleague who will be greatly missed but long remembered’. Dr Lambert leaves his second wife Jill, four children from his first marriage and six grandchildren.
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: rcgp news@rcgp.org.uk
ISSN 1755-7720 © Royal College of General Practitioners. All rights reserved. Published monthly by the Royal College of General Practitioners 14 Princes Gate, London SW7 1PU email: rcgp news@rcgp.org.uk website: www.rcgp.org.uk
RCGP News • November 2008