Dr David Archer cautions that compliance with the NSF on CHD must not stop GPs treating patients as individuals
The timetable imposed by the National Service Framework (NSF) for Coronary Heart Disease (CHD) means that many practices will have been frantically searching for patients to include in their CHD register for April 2001.
Much has been written in previous issues of Guidelines in Practice (e.g. October 2000, Vol. 3, pp. 16 & 33-39) to help facilitate this process. However, I do not wish to dwell on the process necessary for the compilation of registers. Rather, I am far more concerned about the outcome of all this painstaking work.
Sadly, I feel that all the information collected by practices may not lead to improved care in this area, and that GPs are in danger of losing their holistic approach to their patients, because of the rigorous number crunching that is unfolding.
The disease register set up in the practice in which I work includes diagnosis, date of birth, and date of diagnosis.
We have screened our patients annually and have reasonably good figures for patients who have had blood pressure, cholesterol, and body mass index measured, as well as those in whom we have enquired regarding exercise and smoking status.
We have also documented those patients who are taking aspirin (on FP10 from the NHS or purchased privately), beta-blockers and statins.
All the patients who are on this particular disease register have had their blood pressure measured in the past calendar year. However, only 65% of them are normotensive.
Despite treating 92% of patients with statins, only 54% have a cholesterol level below 5.0mmol/litre.
Surprisingly, we have been successful in our promotion of aspirin prophylaxis.
Fifteen per cent of patients continue to smoke, despite exhortation, counselling and bupropion.
Some of these smokers are patients with diabetic complications. As GPs, we have the duty of care to inform and educate. We do not have the duty to instruct, scold and alienate. Those patients with diabetes who smoke may seek their pleasure in nicotine. Should we deny them that, in pursuit of ever more impressive statistics and percentages with which to impress our peers, PCGs/PCTs and ultimately the Government?
Every practice has its recalcitrant patients. They are often rewarding management challenges, as GPs balance different treatment options, often agreeing with the patient the 'least worst scenario'.
Some patients may take only one hypotensive agent instead of the two needed for optimal control, in order to avoid the side-effects of the two drugs.
Enquiring into the known side-effects of drugs is revealing, as many patients either suffer in silence, or hoard the medication, dutifully picking up prescriptions that they have no intention of getting dispensed.
The holistic approach is to ask about side-effects, discuss treatment options, and tailor treatment to each individual patient separately.
My concern regarding the NSF approach is that unless we are careful, we will be reduced to treating each patient as a succession of tick boxes, further lose morale, and – worse for the patient – reduce the standard of care by failing to think expressly for that individual.