GP commissioning in England.

The NHS, yet again, is in transition with an emphasis on groups of general practitioners (GPs) (clinical commissioning groups) making decisions on which specialist services should be chosen for patients requiring referral from primary care. It is an area of new terminology with a new language and further change for all working in the NHS and the all-important interface between primary and secondary care, and its impact on teamwork. There are many drivers including choice, efficiency, franchising of services, coordination and leadership in an enormous organisation, but not least reducing costs and keeping to a budget. There are many logistical issues and ethical anxieties, and only time will inform patients, practitioners, stakeholders and politicians as to its success.

Can GPs working in secure environments in England re-license using the Royal College of General Practitioners revalidation proposals?

BACKGROUND: Revalidation for UK doctors is expected to be introduced from late 2012. For general practitioners (GPs), this entails collecting supporting information to be submitted and assessed in a revalidation portfolio every five years. The aim of this study was to explore the feasibility of GPs working in secure environments to collect supporting information for the Royal College of General Practitioners' (RCGP) proposed revalidation portfolio. METHODS: We invited GPs working in secure environments in England to submit items of supporting information collected during the previous 12 months using criteria and standards required for the proposed RCGP revalidation portfolio and complete a GP issues log. Initial focus groups and initial and follow-up semi-structured face-to-face and telephone interviews were held to explore GPs' views of this process. Quantitative and qualitative data were analysed using descriptive statistics and identifying themes respectively. RESULTS: Of the 50 GPs who consented to participate in the study, 20 submitted a portfolio. Thirty-eight GPs participated in an initial interview, nine took part in a follow-up interview and 17 completed a GP issues log. GPs reported difficulty in collecting supporting information for valid patient feedback, full-cycle clinical audits and evidence for their extended practice role(s) as sessional practitioners in the high population turnover custodial environment. Peripatetic practitioners experienced more difficulty than their institution based counterparts collating this evidence. CONCLUSIONS: GPs working in secure environments may experience difficulties in collecting the newer types of supporting information for the proposed RCGP revalidation portfolio primarily due to their employment status within a non-medical environment and characteristics of the detainee population. Increased support from secure environment service commissioners and employers will be a prerequisite for these practitioners to enable them to re-license using the RCGP revalidation proposals.

Revalidation for relicensing - reflections on the proposed British model.

BACKGROUND: In the United Kingdom, the General Medical Council aims to introduce revalidation for all medical doctors from 2012, in response to public and government pressure. Doctors will submit evidence to support their fitness to practise medicine every 5 years in relation to the four domains and 12 attributes of good medical practice. OBJECTIVE: This article reviews the argument for revalidation, the proposed process and some of the findings of a pilot carried out with general practitioners. DISCUSSION: A revalidation process is being piloted in several parts of the United Kingdom with a view to implementation in 2012. However, there is a lack of evidence internationally that revalidation or relicensure identifies doctors who are performing poorly. The medical profession in Australia needs to reflect on whether this model is one it wishes to consider.

Palliative Care and End-of-Life Issues in Elderly Cancer Patients With Head and Neck Cancer.

The number of elderly patients with incurable head and neck cancer will increase. They are in need of geriatric palliative care, that takes into account oncology, palliative care and geriatric medicine. In this review of the most recent and relevant literature and includes the expert opinion of the authors, several physical problems (e.g. pain, fatigue, malnutrition, and loco-regional problems) encountered by the elderly head and neck cancer patients are addressed. In addition end-of life issues in this patient population are discussed.

Re-licensing of general practitioners using the current UK revalidation proposals: a cross sectional study.

Objective To explore the views of general practitioners (GPs) on the feasibility of collecting supporting information for the Royal College of General Practitioners (RCGP) revalidation portfolio and mapping of this evidence to the General Medical Practice framework for proposed UK medical re-licensing. Design Cross sectional study with a questionnaire. Setting One inner city and one mixed urban/rural primary care organisation in the West Midlands, England and one rural primary care organisation in Wales. Participants 51/69 GPs who submitted a revalidation portfolio from November 2009 to February 2010. Results The majority of GPs considered the majority of work based supporting information was feasible to collect within a 5 year revalidation cycle; most concerns were expressed about providing evidence for extended practice, learning credits, and patient satisfaction and colleague feedback surveys (59%, 63%, 72%, and 77%, respectively, of GPs considered it feasible to collect this evidence) due to workload time constraints and lack of automatic access to evidence from others, which differed by GP work role. Two-thirds of participants (65%) stated that the submission of a portfolio of evidence was a feasible component of GP revalidation, reporting reservations on the appropriateness of patient and colleague feedback surveys and extended practice (55%, 57%, and 59% respectively) to provide objective evidence. GPs requested further clarity on the evidence mapping process. Conclusion Overall, GPs reported a positive response to the RCGP revalidation proposals. Concerns were focused on collecting the newer types of supporting information and the ability of GPs non-principals to collect this evidence. GP revalidation training and preparation is required.

General practice.

There have been considerable changes in the NHS, medical science and practice in the last 25 years. This article describes the developments in general practice over this period. The increase in the primary healthcare team members and the improved premises from which they now practise has revolutionised primary care. Issues of considerable influence have been the movement of care once provided in hospitals into primary care, the use of computers, new technologies, enhanced training, changes in the demographics of the workforce, the hours general practitioners work and commissioning.

Practice-based commissioning: implications for secondary care.

General practitioner (GP) practice-based commissioning (PBC) is a much debated politically driven NHS innovation at a time of ongoing change. Unlike GP fundholding it is envisaged that PBC will involve all GP practices by 2008. A possible outcome is that some current secondary care services may be commissioned in primary care in the form of local enhanced services or intermediate clinics and run by GPs with special interests. Examples where this has occurred are diabetes and anticoagulation. Similarly, private providers may be commissioned. Inevitably there will be an impact on hospital services through a possible reduction in funding and consultants being subcontracted to provide services in primary care. Issues such as clinical governance and cost-effectiveness, however, require evaluation to determine the potential effect on the working relationships and so the interface between generalists and specialists.

Polymyalgia rheumatica and its links with giant cell arteritis.

Polymyalgia rheumatica (PMR) was defined in 1957 and is linked with giant cell arteritis (GCA) in approximately 25% of cases. The peak incidence is between 60 and 75 years old and is increasing with the ageing population. Polymyalgia rheumatica is a clinical diagnosis without a 'gold standard' serological or histological test and there are other conditions that may mimic PMR. Treatment with a dose of 10-20 mg daily of prednisolone is suggested or 40-60 mg daily if GCA is also suspected. There are no absolute guidelines to the dose or its duration. The rate of reduction should be adjusted depending on the individual's response. Where temporal arteritis is suspected, this manifestation of GCA is a treatable medical emergency to prevent possible blindness, and steroids should be commenced immediately. There remain many unknowns in the cause, diagnosis and treatment of PMR and its overlap with GCA, and it is an ongoing challenge requiring further research.

A UK perspective on worldwide inadequacies in palliative care training: a short postgraduate course is proposed.

A chronological literature review illustrates how undergraduate and postgraduate education and training in the care of the dying and bereaved is inadequate worldwide. This is despite the foundation of the modern hospice movement in the United Kingdom in 1967 and its wider dissemination as a specialty in 1985. This situation has implications for those doctors working in both primary and secondary care, and this paper describes a 3-day course which has been successfully run in the West Midlands, UK, since 1997 for family physicians in training. A pre-course survey of 250, with a response rate of 54%, in 2003 revealed that 100% of respondents felt that they needed further training, and 51.5% said that they had had no previous training in palliative care.

Guarding against dispassion for doctors in the NHS.

Compassion has always been a vital component of healthcare anywhere in the world. With numerous definitions in a variety of contexts, it cannot simply be prescribed, measured or given in a bottle. When our patients are ill, great attention is paid to the verbal and non-verbal communication presented by a doctor and the manner in which they are delivered. However, with an ever-growing demand on the NHS workforce, numerous patient surveys across the UK have accused doctors for lacking compassion in their practice, amid the strains of their modern-day commitments. The concept of being caring to our patients is highlighted from the first walks of medical school or indeed any healthcare professional's training programme, meaning that patients will always be our prime audience for compassion. Yet, so often in medical training, it is emphasised how important it is to demonstrate a personal detachment between oneself and the patient and not to get too emotionally involved. So despite numerous challenges, how do we find the correct balance to optimise our day-to-day service and stay sensitive to the needs of our patients? This article reflects upon compassion from multiple perspectives in the NHS pertinent to doctors of all settings and experience levels, exploring the barriers, internal conflicts and facilitators of its delivery. We examine the objective evidence of measures that have been put in place to overcome these challenges and summarise key considerations to optimise the enablement of a workforce to deliver compassion at universally higher standards in future practice.

Implications of the new GP contract.

A new contract for general practitioners (GPs) was introduced in the UK on 1 April 2004 which has implications for secondary care. In particular, the contract means that GPs can opt out of out-of-hours care, and accident & emergency services have voiced their concern that their workload may increase as a result. The new contract provides the potential for a rise in GPs' salaries by two means: through the provision of the Quality and Outcomes Framework which includes the management of 10 common chronic diseases; and through 'Enhanced Services', which are a series of optional 'extra' more specialised services with national specified standards that can be commissioned by primary care organisations (PCOs).

Audit tools for palliative care services: identification of neglected aspects of care.

The purpose of this study was to investigate the extent to which audit of palliative care service occurs nationally in Britain and Ireland. The following items were measured: (1) audit tools employed, (2) aspects of services undergoing audit, (3) changes in practice as a result of audit, and (4) obstacles to conducting some aspects of the audit. Audit practices were surveyed by means of a postal questionnaire distributed to managers of all hospice and palliative care services in the United Kingdom and Republic of Ireland. A 10 percent sample of managers (n = 40) who responded were subsequently interviewed to confirm and elaborate on questionnaire responses. The response rate was 60 percent and was highest for hospices at 68 percent. Of the respondents, 73 percent audit their services. Of those who audit their services, 79 percent changed their service as a result. Although physical aspects of care were audited frequently (61 percent), other core aspects of palliative care that rarely were audited included bereavement care (17 percent), training (13 percent), and psychological and spiritual care (12 percent). Managers indicated that some aspects of care were rarely audited because they considered clinical and organizational aspects of palliative care to be more important. They also stated that they did not have enough time, expertise, or adequate measurement tools. Until the neglected features of palliative care are audited, the full effectiveness of the services remains unknown.