News In Brief 26 June 2009

News From NAPC

Dr Johnny Marshall, NAPC's Chairman attended a GP leader’s dinner this week.  Ian Dalton updated the meeting on the flu issues and informed attendees that a list of GPs who are available to be called on either as locums or out of retirement has been constructed.

NAPC Events

What You Need To Know About Integrated Care
 
1st July 2009 - Newcastle

Some places still available

for the full programme and how to book click on the following link

http://www.napc.co.uk/index.php/ico

NAPC Annual Conference

www.napcannual.co.uk

17-18 November 2009

Hilton Birmingham Metropole, Birmingham

National Association of Primary Care joins forces with Pulse and Practical Commissioning to launch the NAPC Annual Conference 2009 on 17-18 November in Birmingham.

For the full programme and how to book click on the following link

http://www.napc.co.uk/index.php/napc-conference

News

Genetic Cholesterol Test Warning 
 
Thousands of people in England and Wales are unaware they may have a high genetic risk of heart disease because testing is patchy, doctors warn.

When people are diagnosed with familial hypercholesterolaemia - an inherited condition causing high cholesterol - family members should also be screened.

But an audit by the Royal College of Physicians found genetic testing is not happening in many places.

One expert said up to 80% of those affected are not diagnosed.

Familial hypercholesterolaemia (FH) causes high levels of "bad" or LDL cholesterol.

If left untreated it can lead 50% risk of heart disease in men by the age of 50 years and at least 30% in women by the age of 60 years.

There are around 100,000 people going about their lives unaware they are at risk of this silent killer.

In 2008, the National Institute for Health and Clinical Excellence (NICE), estimated that one in 500 people have FH and siblings or children of a person with the condition have a 50% chance of having it themselves.

They recommended that everyone diagnosed with FH should be referred to a specialist for "cascade testing" where family members at risk are identified and offered screening.

The audit of 248 patients in 12 hospitals in England and Wales found that while care for those diagnosed was generally good, very few of their families were being systematically tested.

Trial Drug Leaves ‘Last Chance’ Prostate Patients Cancer Free

Two men with advanced and inoperable prostate cancer have recovered after being treated with an experimental antibody drug.

The patients, who are now free of cancer, were taking part in the trial of a drug called ipilimumab that boosts the immune system.  Before the treatment in the Mayo Clinic in Rochester in Minnesota, each of them had aggressive tumours that had grown into abdominal areas.  The patients receive traditional hormone therapy to remove testosterone, which fuels prostate cancer.  Researchers then introduced a single dose of ipilimumab.  Both patients saw their prostate specific antigen (PSA) levels drop to the point where they became eligible for surgery.

Johne Neate, Chief Executive of the Prostate Cancer Charity, said that if these early and small-scale results were replicated in larger trials, this represented a potentially very exciting development.

Doctors’ Leader Faces Revolt Over Torture Collusion

More than 700 doctors from 43 countries have written a letter of protest to their governing ethical body, the World Medical Association, alleging that its recently appointed Israeli president, Yoram Blachar, has turned a blind eye to the involvement of medicals staff in torture.

The letter, whose lead signatory is the paediatrician, Alan Meyers, from Boston University School of Medicine,  said Blanchar’s presidency made a mockery of the principles on which WMA was founded in 1947, which was a response to egregious abuses by German and Japanese doctors’ in the Second World War.

Meyers said Blanchar had in effect defended the participation of Israeli physicians in the torture of Palestinian prisoners in Israeli jails.

In a letter to the Lancet medical journal in 1997, Blanchar wrote: ‘The guidelines on interrogation recommend that only ‘moderate physical pressure (in accordance with international law, and not unknown in other democratic countries) be sanctioned.

What Difference Has QOF Made To Health Inequalities

Last week reported some of the contents of NPCRDC’s research on QOF.  This week we continue with its impact on health inequalities and aspects of care that have not been incentivised.

QOF appears to have reduced inequalities in the delivery of healthcare.  In the first year median achievement rates for practices in the most affluent areas of England were 4.4% higher than for practices in the most deprived areas.  However, by the third year, this gap had been narrowed to 0.8%.

Poorly performing practices in deprived areas looked as if they were just as able to respond to incentives in QOF as those in affluent areas.  Practices in depriver areas exception reported marginally more patients than those in more affluent areas, but exception reporting was not a major factor in the high achievement of practices in deprived areas.

Overall, NPCRDC’s view was that QOF had reduced inequalities in the delivery of care, but it was too early to say whether this would translate into improving the inequality in outcomes.

What effects has QOF had on aspects of care that weren’t incentivised?

Any incentive has the potential to produce unintended consequences, including care becoming worse in areas that are not incentivised.

It was widely reported, for example, that the introduction of advanced access to meet the 48 hour appointment target resulted in patients finding it difficult to book ahead.  As a consequence, the indicator was changed to a more sophisticated on based on the responses to patient questionnaires.

In NPCRDC’s QUIP study, they asked patients about their experiences of care at four points in time using the GPAQ questionnaire.  They found no significant change in the ease with which patients reported getting an appointment within 48 hours or more generally in interpersonal aspect of care.  However, there was a significant step decline in reported continuity of care in 2003 which continued at a new lower level following 2005.  This corresponded to a 6% decline in patients’ reported ability to see their usual doctor.

NPCRDC also had more evidence of a negative impact of QOF on unincentivised clinical aspects of care.  This came from comparisons of incentivised and non-incentivised indicators in the QUIP study, which suggested that recording of care for indicators which were not incentivised in QOF may have declined since the introduction of the scheme.

What effects has QOF had on practice organisation and professional attitudes?

General practices responded to the introduction of QOF by increasing staffing levels, with nurses initially absorbing a higher proportion of the clinical workload than doctors.  GPs’ income initially rose and their hours of daytime work decreased.  However, practice income was constrained by government in subsequent years and there may have been a further re-balancing of work across practice teams.

Alongside its quantitative studies, NPCRDC carried out a series of qualitative research projects examining the impact of recent contract and related reforms in general practice. Issues identified include:
o Clinical tasks being increasingly devolved to nurses and healthcare assistant, and a growing number of salaried doctors relative to GP partners.

o Increasing use of computerised templates to guide clinicians and to assist in collecting data during consultations;

o A combination of QOF and Practice Based Commissioning has led to the emergence of a new strata or elite, with groups of doctors involved in both the surveillance of others and action to improve compliance in individuals and practices seen to be deficient.

o There is a wide range of attitudes towards the contract among GPS and practice staff.  Many are positive, although discontent is higher in practices which employ a more intensive ‘surveillance’ regime.

o Increasing acceptance of the legitimacy of external scrutiny of clinical practice, suggests the development of new professional norms.  However,  policies which convey to GPs that they are not trusted (eg greater restrictions on exception reporting) are likely to threaten this willingness to engage in surveillance ob the of themselves and others;

o NPCRDC found some evidence that this acceptance of new professional norms  and the new reliance of computerised forms of data collection may be at the expense of more traditional  norms about the importance of holistic or patient centred care.

Houses That Help Elderly To Remain Independent

Researchers are working on a ‘health hours; so sophisticated that it will not only track everyday habits but also check weight and blood pressure and predict whether a person is at risk of a serious fall.

Britain is one of the largest inventors in ‘telemedicine’ – using medical technology to help chronically ill and older people to be treated for longer at home rather than in hospitals or care homes.

The system developed by GE Healthcre and Intel, uses sensors that track behaviour and send alerts when unexpected disruptions or data are picked up.  Similar networks are already being used by about 3,000 people in care home settings, but researchers now hope to introduce a much more sophisticated model for use in private  homes.

Doctors Challenge Suicide Clinic Over Patients Who Could Have Lived For Decades

Senior figures within the medical community have expressed concerns about people with non-fatal illnesses using the euthanasia service provided by Dignitas, after the Guardian obtained a list of British patients.

Thirty six of the 114 unnamed Britons had various forms of cancer, 27 had motor neurone disease and 17 had multiple sclerosis.  However, the rest of the list comprised people with less serious conditions: two had Crohn’s disease, an inflammatory bowel disease; two were tetraplegics; three had kidney disease, one had rheumatoid arthritis – all conditions which doctors say are not terminal.

Dr Tony Calland, chairman of the ethics committee at the British Medical Association, said that the list raised considerable concern.  There were some conditions such as Crohn’s disease and rheumatoid arthritis that, whilst extremely unpleasant, were eminently treatable and many of the symptoms could be relieved.  To go off and commit suicide on the basis of theses conditions would be premature and unreasonable.

Smokers Too Stressed To Quit

Smokers are delaying giving up smoking because they are stressed by the recession, according to a poll by Ipsos MORI.

With British people worrying about their job security, paying their bills and putting food on the table, almost a quarter of smokers (23 per cent) said they were delaying plans to kick the habit, and 28 per cent of them believed that they had been too stressed to make a successful attempt to give up smoking in the past six months.  They were more likely to cut spending on clothes (42 per cent) and at the supermarket (21per cent) than to stop buying cigarettes (15 per cent).

£300 DNA Test Could Save Smokers’ Lives

Thousands of smokers could be saved by a £300 DNA test launched this week which rates their chances of getting lung cancer.

A patient’s saliva is collected with a mouth swab, which is tested in the laboratory to establish the likelihood of the person developing the disease. Some genes make a smoker ten times more likely to contract the disease.

The Respiragene test combines DNA analysis with other risk factors to come up with a score.  Researchers Dr Robert Young, of the University of Auckland, said that all smokers faced an increased risk of developing lung cancer, along with other health problems.  However, for some the risk was much greater than for others.  With this test, doctors would be able to identify those at greatest risk while there was still time to help.