“Primary care is making a huge impact on secondary prevention across the country,” said Dr Roger Boyle, National Clinical Director for CHD, speaking at the Guidelines in Practice conference, in London on 12 May.
To demonstrate how effective good systematic primary care can be, Dr Boyle presented standardised mortality rate (SMR) data for CHD for three PCTs in the Wirral, two in deprived areas, Birkenhead and Wallasey, and one in an affluent, middle-class area, Bebington & West Wirral.
Initially the SMRs for CHD were substantially higher in the two deprived areas than in the more affluent area. Where systematic primary and secondary prevention measures were set up there was a decline in SMR for CHD in all three communities but the rate of decline was fastest in the most deprived areas, narrowing the gap.
More than 90% of practices now have CHD registers, the introduction of practitioners with special interests has been very successful and the new GMS contract will be a major spur to improving secondary prevention, said Dr Boyle.
“The target to reduce death rates from all circulatory disease in England by 40% by 2010, from the 1996 baseline, looks as if it will be achieved three or four years ahead of schedule,” said Dr Boyle.
There has been a reduction by almost a quarter already. “Age-standardised mortality rates for CHD in the under-65s are falling at a steady and dramatic rate,” he added.
|Dr Roger Boyle, National Clinical Director for Coronary Heart Disease:“Primary care is making a huge impact on secondary prevention across the country.”|
“The changes seen in Birkenhead and Wallasey are the sort of changes that we are going to see on a widespread basis as a result of the introduction of the quality and outcomes framework of the new GMS contract,” commented Dr John Chisholm, Chairman of the BMA General Practitioners Committee. “The contribution that primary care can make to good quality structured disease management is enormous,” added Dr Chisholm.
There will be major changes to the new GMS contract in 2006. “By then we will have negotiated the overall financial settlement for primary care for the next three years,” said Dr Chisholm.
“The Carr-Hill formula will have been reviewed and will evolve to become more sensitive in reflecting the relative differences between practices with respect to workload, population need and labour costs,” he explained.
“The quality and outcomes framework will be revised to take account of changes in the evidence and the potential inclusion of new areas,” he added.
|Dr John Chisholm, Chairman of the BMA General Practitioners Committee: “The contribution that primary care can make to good quality structured disease management is enormous.”|
Montrose GP Dr Alan Begg recommends a patient-centred approach when tackling the clinical indicators of the new GMS contract. He advocates the use of an integrated register for patient-centred CHD care where the patient can be looked at as a whole and all risk factors addressed.
“The quality and outcomes framework is very much disease centred but when we are faced with a patient in general practice we are not looking at a disease entity but often a patient with comorbidity. There is a huge overlap in disease entities in individual patients,” said Dr Begg, a member of the SIGN review group.
There is also some overlap in the clinical indicators. For example, there are indicators for blood pressure monitoring in the CHD, stroke, hypertension and diabetes sections. Stopping smoking is an indicator in the areas of CHD, stroke, hypertension, diabetes, COPD and asthma and flu vaccination is an indicator in all these areas apart from hypertension.
Last year Dr Geoff Rawes and his team won first prize in the Guidelines in Practice Awards for their patient-centred service. Dr Rawes is a single-handed GP in Blyth, a town in Northumberland with high deprivation, morbidity and mortality. In 1997, he left a large practice to set up on his own with just a nurse practitioner, practice manager and trainee receptionist. The new practice invited patients to enter into a partnership of care with the team.
“We felt that if we could empower patients and provide appropriate support to allow them to take more responsibility for their own health they would be motivated to make appropriate lifestyle changes,” Dr Rawes explained.
“Many of our patients suffered from more than one chronic disease so we set up one-stop clinics for all screening tests for CHD, hypertension, and diabetes,” he said.
This approach has helped them tackle the NSF for CHD and led to dramatic improvements in chronic disease management.
“One measure of our success is that in 2001 only 25% of patients aged under 70 years with CHD had a cholesterol level of <5mmol/l, this figure rose to 82% in 2003 and is now 85%.”
“The NSF for Diabetes puts patient empowerment at the centre of care delivery,” said Nuneaton GP Dr Roger Gadsby.
IT will have an important role to play in the delivery of the Diabetes NSF. “The future is going to be a web-based personal record with diabetes included. Scotland already has DARTS which is superb,” commented Dr Gadsby, who is also a senior lecturer at Warwick University. DARTS is a web-based diabetes record that can be updated by GPs, hospital doctors and other healthcare professionals.
IT will also be pivotal in achieving the clinical indicators for diabetes in the new GMS contract.
Suffolk GP Dr Matthew Lockyer stressed the importance of entering accurate information onto the computer system. “Remember, if you put rubbish in you will get rubbish out and if you enter the wrong Read code you will have no record,” said Dr Lockyer who is a hospital practitioner in diabetes medicine at West Suffolk Hospital.
He pointed out the benefits of matching staff to tasks. More than half of the points available for the diabetes indicators are for the management of glycaemia, blood pressure and lipids and this is best carried out by the GP and practice nurse, he said. Their time can be freed up, he suggested, by employing other staff such as healthcare assistants to help with history taking and, with appropriate training, foot examination.
Dr Lockyer also acknowledged the importance of patient empowerment. “Patients are often keen to be involved in their own management and recognise the benefits,” he said. “The new GMS contract provides an opportunity to provide an integrated approach to address the complex medical, social and psychological needs of those with severe mental illness,” said Lanark GP Dr Jill Murie.
Patients with severe mental illness frequently suffer from anxiety and depression as well as having higher rates of physical illness.
A meta-analysis of studies covering 36 000 people with schizophrenia found that the SMR for all causes was 156 for men and 141 for women.
The SMR for respiratory disease and for cardiovascular disease was 250 and for infectious disease 500.
“The clinical indicators for mental health have been described as the least attractive because they appear to be a lot of work for few points but this is an opportunity to improve the physical and mental well being of the most vulnerable,” said Dr Murie, a member of the Scottish new GMS Quality Working Group.
“A collaborative approach with effective communication, and adequately resourced community services within our PCTs are also essential,” she added.
The innovative Swindon primary care psychology counselling service which has an open access, no wait policy was set up nearly 10 years ago, predating the NSF for Mental Health, which was published in 1999.
“Although not planned as such our service fits with the guiding principles and standards of the NSF,” said consultant psychologist Dr Liz Howells who heads the service.
“We aim to pre-empt secondary referrals. The emphasis of our service is on catching problems early and preventing more distress. We offer skills to deal with life’s problems, teach stress management, promote healthy lifestyles and exercise, and teach cognitive behavioural skills,” Dr Howells explained.
In 2003, the service won the mental health category of the Guidelines in Practice Awards. “The work we do with users and carers has been boosted by the prize money,” said Dr Howells.
The Guidelines in Practice conference “Implementing the new GMS contract and NSFs for CHD, diabetes and mental health” was held at the RSM, London on 12 May.