RCGP Honorary Treasurer Dr Colin Hunter reports on the historic move and how it will bringabout a wider range of services and benefits for College members.

The College has exchanged contracts on newpremises. The building, which is anticipated tobe ready by summer 2012, is situated at the corner of Melton Street and Euston Road, rightnext to Euston station. This is an ideal location and is only five min-

utes walk or one Tube stop from King’s Crossand St Pancras stations and four stops fromPaddington. The building is in fact two buildings: a

Grade 2* listed building on Melton Street datingfrom 1906 and a newer linked building whichwas added in 1924. The building was previouslya social security office. The College has beenable to take advantage of the downturn in themarket to purchase a building that will be a goodlong-term investment for the charity. The build-ing is freehold.Our new building will provide an enhanced

facility for Members and patients. It will includea contemporary conference suite encompassinga 300-seat lecture theatre, break-out space anddining space. We will also relocate the ClinicalSkills Assessment Centre (currently in rentedspace in Croydon). There will be state rooms similar in dimen-

sions to those in Princes Gate, enhanced andbetter meeting space and open plan office spacefor our staff. Subject to planning permission, wealso hope to include 40 study bedrooms with en-suite facilities. It will provide in excess of100,000sq ft of space, more than four timeslarger than Princes Gate.We have appointed a top team to take for-

ward the refurbishment project, including KathyTilney of Tilney Shane as architect and designer. Kathy has been working with us for anumber of years and has a philosophy of mak-ing the building really work for the organisation,so our move will be coupled with new ways ofworking. We are, as part of the project, investing in a

state of the art IT infrastructure which will deliver our progressive digital strategy. In addi-tion, we will work to a modern sustainabilityagenda and encompass environmental enhance-ment wherever we can. The refurbishment pro-gramme is due to be completed in summer 2012.How will it be funded and will the subscrip-

tion rate be increased to pay for it? We havebeen fortunate to be able to tie the sale of ourcurrent building at Princes Gate to the acquisi-tion. We have exchanged contracts on PrincesGate and that building is likely to return to residential use. Currently our staff are spread across three

other sites in London in rented space which hasassociated costs. We are in a position to be ableto meet the interest costs from any loan fromour current budget by redirecting monies to payour loan rather than other landlords. There will

therefore be no need to increase the subscrip-tion rate to pay for the building. The College continues to grow in terms of

membership and activities. Membership incomeonly accounts for 40 per cent of our annual in-come and so the College is not entirely depend-ent on membership fees. The new building willalso afford us some greater commercial oppor-tunity, not least the leasing of our ultra-modernconference facility at the hub of the Londontransport system.Immediate Past President David Haslam, to-

gether with our current President Iona Heath,will be heading up a capital appeal to help raisefunds towards the venture. The Appeal will prob-ably be launched later this year and will look at di-verse ways of raising funds towards the project.The sale of Princes Gate will necessitate us

moving into temporary accommodation fromAugust. We have again been able to take advan-tage of the market conditions and we intendmoving into temporary office space near theTower of London. The space will provide modern office accom-

modation for all our staff in London (with the ex-ception of London faculties who will remain atLeman Street) and meeting space. There will,however, be no residential element. This willallow us to trial new ways of working with staffand look to how best to configure staff when wemove to the new building.Over the past few years, I have received let-

ters of concern from members with regard tothe accommodation review. These have had two main themes: firstly, the

loss of our building at Princes Gate; and sec-ondly, around whether a more geographicallydispersed College strategy would be more ap-propriate and cost-effective. There is no doubt that Princes Gate is a

lovely building. However, it is already too smalland the conditions in which staff work on the

NewsTHe NeWsPaPeR

Of THe ROyal COllege Of

geNeRal PRaCTITIONeRs

APRIL 2010

Also in this issue...Countdown to appraisal e-PortfolioProgress report on new RCGP online tool 2

How green is my family?GPs confront the sustainability challenge 3

Reaching outGPs the key to quality care for everyone 4

Work in progressRCGP support on health and work a great success 5

Close-up on cardioManaging hypertension and heart disease in general practice 7

RCGP on the move: College signs deal on our new HQThe search for a new building is over – and the RCGP will be relocating from Princes Gate after 48 years.

� The new building will, I hope, provide a verydifferent but equallyprestigious and valuedHQ for us. We will doour best to ensure thelook and feel of thebuilding are consistentwith modern generalpractice and a forward-looking Royal College�

Dr Colin Hunter

All change for Euston: The new RCGP building (above) is ideally situated close to national and international rail links and is more than four times the size of the current headquarters at Princes Gate with the potential for much improved facilities for our Members and staff.

and from experience of organisations workingacross many sites.The next two years will be an exciting and

challenging time. Through the medium ofRCGP News, I intend to keep you up to date onplans and to seek input from Fellows and Mem-bers. Meanwhile if you wish to contact meplease email me on treasurer@rcgp.org.uk

second and third floors, and particularly thebasement, are very poor. It does cater for re-ceptions, small dinners and the summer recep-tion very well but it does not fulfil any otherfunction effectively. The 11 letting bedrooms are mostly without

en-suites. The new building will, I hope, providea very different but equally prestigious and val-ued HQ for us. We will do our best to ensure thelook and feel of the building are consistent withmodern general practice and a forward-lookingRoyal College.With regard to a more geographically dis-

persed College, we did considerable work andstudy in relation to this in 2005. The conclusionwas that, if it could be achieved, the best optionfor us would be a single large building in Zones1 and 2 in London. Much of this is derived fromthe quality of the transport network to London(essential for examinations and conferences)

Dr Cath Jenson RCGP Revalidation ePortfolio Clinical Leadand Bromley PEC/Board

The temporary shutdown of the NHS appraisal toolkit in Februarybrought the issue of electronicrecording of appraisal to the front of many English GPs’ minds.

The RCGP is continuing apace to develop theCollege Revalidation ePortfolio and we can nowannounce that the appraisal function (phase 1)will be available UK-wide from autumn 2010. This will be provided to all College members

as a new membership benefit and therefore partof their subscription. Consideration is beinggiven as to how the ePortfolio can be made avail-able to non-members. We believe the RCGP ePortfolio format will

enhance the ability of PCOs and appraisers toensure appraisal maintains its educational andformative benefits. Furthermore, the system isstructured to create an appraisal file specificallytailored to the needs of GPs undergoing recer-tification and revalidation. We wish to ensure that the College Revalida-

tion ePortfolio works seamlessly for traineesmoving from their registrar ePortfolio into reval-idation. It is also essential that there are no barriers to PCOs adopting the RCGP tool fromthe autumn. The ePortfolio has been designedto enable the College’s role in the quality assur-ance of the revalidation process.

Coming in 2011: Phase 2 of the RCGP Revalidation ePortfolioFurther functions to support PCOs in managingappraisal and revalidation are currently beingbuilt into phase 2 of the ePortfolio. These are ledby a RCGP Steering Group which includes rep-resentatives of several UK-wide PCOs.

Phase 2 functions will map to the require-ments stated in ‘Assuring the Quality of MedicalAppraisal for Revalidation’ (Revalidation Sup-port Team, May 2009). The need for the Re-sponsible Officer (RO) to be provided with asuccinct summary of the achievements of eachGP has been given paramount importance, sincethe College is aware that Responsible Officerswill be reviewing multiple portfolios and it is inthe interest of all parties to facilitate efficiency!

The information within the ePortfolio willbe structured and summarised to facilitate efficient assessment by the RO. The proposed‘dashboard’ summary is shown in the panelabove. Each ‘area’ (row) turns from red to

amber then green as data is entered in accor-dance with the requirements for appraisal and(in future) revalidation. By late 2010 accreditedformats for MSF and PSQ data will be agreedand revalidation pilots will shape the require-ments for inputting data such as complaints andclinical governance. The option for ‘views’ of selected areas of the ePortfolio by PCO revali-dation panels are also being planned.

Also in Phase 2: Appraisermanagement functionsOf interest to PCO appraisal leads will be tem-plates for appraiser development currentlybeing planned for phase 2. These are proposedto include functions for logging of each appraiser’s training, CPD, feedback and com-plaints. This will allow appropriate PCO officers(which could include the appraisal lead) to seeat a glance how each appraiser is performing,and track this electronically.

Phase 3: Linking the RCGP Revalidation ePortfolio to bodies external to the CollegeThe final (Phase 3) development of the RCGPRevalidation ePortfolio in 2011 will focus on therequirements of national bodies such as theGMC to view selected areas of the ePortfolio.Most of these requirements are not yet finalised(many pilots are underway across the UK) – theCollege is poised to proceed as soon as they areannounced.

Phase 3 of the RCGP Revalidation ePortfoliowill also include developing electronic inter-operability both with existing RCGP electronicproducts (such as the trainee ePortfolio and on-line learning environment) and national inter-operability – the sharing of information betweendifferent electronic systems. Most medical and surgical specialty colleges

and faculties have formed groups to developePortfolios; the RCGP is part of the largest na-tional cohort and is working with this group todevelop the highest possible standards includ-ing for any necessary interoperability outside ofthe RCGP. Whilst committed to interoperability work,

we consider the particular strength of our ePort-folio design is that it is an ‘end to end’ revalida-tion solution for anyone working solely as a GP,which means all data can be entered onto oneportfolio, which minimises the risks and ineffi-ciencies of sharing data across electronic sitesand hosts.

Compliance with national security requirementsThe College is in close discussion with the De-partment of Health to ensure our ePortfolio willmeet all aspects of the revalidation specification,including security requirements. We are draw-ing on our expertise with the trainee ePortfolio

and using independent IT advisors to ensure ourePortfolio is at the cutting edge of technology.

GPs leading the way amongst the specialtiesWe are one of very few Colleges already at thepilot stage for phase 1 of our ePortfolio, withphases 2 and 3 also on schedule to complete dur-ing 2011. We will be using the pilot to ensure the ePort-

folio is user-friendly for grassroots GPs, and todevelop various sources of help getting startedwith it (to include online video demonstrations).The College is exploring options to allow othercolleges to use our ePortfolio format, which willbe of particular interest to GPs working in a sec-ond specialty (to avoid having to use two differ-ent revalidation formats). The commercial valueof sharing our ePortfolio will also help to ensurethe ePortfolio can continue to be free to Collegemembers for years to come.The process of Revalidation is taking shape

and by the end of this year will be finalisedthrough the pathfinder pilots. The RCGP Reval-idation ePortfolio has been designed to beadaptable to changing requirements as theRevalidation process evolves. We are deter-mined to ensure this ePortfolio will be truly sup-portive for GPs in their preparation forrevalidation.

2 RCGP NEWS • APRIL 2010

NEWS

RCgP appraisal ePortfolio set for autumn launch

A membership survey conducted by the College has revealed that, in almost eighty percent of cases,respondent GPs are rarely able to get access to psychological therapiesfor children within two months ofrequesting referral.

The survey was carried out as part of a newcampaign calling for better access to psycho-logical therapies, spearheaded by economistProfessor Lord Richard Layard and the mentalhealth charity Mind, with support from theRCGP and the Royal College of Psychiatrists. Launched at Westminster, the campaign

challenges all of the political parties to make aguarantee in their election manifestos to offer,within five years, evidence-based psychologicaltherapies to all who need them within 28 days ofrequesting referral.The survey received more than 1,100 re-

sponses. In it, members were asked with whatsuccess they were able to access specialist psy-chological therapies, for both adults and chil-dren, within two months of referral. The survey revealed that while GPs experi-

ence a slightly higher success rate when re-

questing referral for adults, more than 60 percent of respondents said they could rarely access psychological therapies. In contrast, less than 15 per cent of respon-

dents said they could usually access appropriatepsychological therapies for adults, with less than10 per cent saying the same for children. RCGP Chairman Professor Steve Field

emphasised patients’ rights to ‘nationally-approved treatments, drugs and programmes,recommended by NICE for use in the NHS’. He said: “We believe that there needs to be

better access to psychological therapies and wel-come the substantial investment that has beenmade over the last few years, and we supportfully the campaign to ensure that adequate fund-ing continues to go into training therapists,rolling out talking therapies across England andmaking provision for children. “Even if there is a financial squeeze, the evi-

dence is there that the country will save moneyin the short and long term.”Professor Lord Layard, Programme Director

for Wellbeing at the London School of Econom-ics, urged the importance of improved accessfor patients. He said: “Mental illness is perhaps the great-

est single cause of misery in our country. Forthose who experience it, the least we shouldoffer is the same standard of care we would au-

tomatically provide if they had a physical illness.Politicians who committed to this would receivea huge vote of thanks from millions of families inthis country.”

� For more information on the campaign,please visit www.mind.org.uk

Record your experience and be part of historyThe RCGP is calling for entries for itsannual diary project on GP training.

GP trainers, trainees, programme directors, ed-ucational and clinical supervisors in generalpractice and hospitals, and others whose livesare impacted by the GP curriculum are beingasked to submit diary entries describing oneday’s experience of GP training.To take part, choose a day between 29 March

and 25 April 2010 and e-mail your entry to diaryproject@rcgp.org.uk. Contributions areanonymous and the results will be published onthe RCGP website. The RCGP Diary Project isnow in its third year and aims to create a livinghistory by capturing snapshots of the RCGP GPtraining curriculum ‘on the ground’.Charlotte Tulinius, RCGP Medical Director

of Curriculum, said: “The diary entries provideus with useful feedback that we can incorporateinto the changes we make to the curriculum tokeep it fit for purpose. Your entries have given,and will give, key insights for the teams respon-sible for implementing and developing the cur-riculum. They will be a rich resource for futureresearchers to understand the experiences ofworking with the GP curriculum at this point inhistory.”

gPs call for better children’s services

Professor Layard: Urging the importance of improved access for patients

Dr Cath Jenson: Developments continue apace

Appraisal Preparation (since last appraisal)

AppraisalItem

Requirement Status

1Area 1: Description of roles

Area 2: Exceptional circumstances

Area 3: Appraisal Form 4s

Area 4: PDP

Area 5: PDP review

Area 6: CPD credits

Area 7: Colleague feedback (MSF)

Area 8: Patient feedback (PSQ)

Area 9: Complaints/cause for concern

Area 10: Significant event audit

Area 11: Clinical audits

Area 12: Declarations

Area 13: Additional evidence

0

0 0

5 1

1 1

1 1

50 5

0 0

0 0

0 0

2 0

1 0

3 0

0 2

Revalidation

Requirement Status

1 0

0 0

5 1

5 1

4 1

250 0

2 0

2 0

0 0

5 0

2 0

15 0

0 2

Dr Judith KeighleyFormer Partner, Broxburn, West Lothiannow Locum GPAs a family we have been selected as one of fiveUK finalists for the Environmental Award of Fu-ture Friendly Family 2010.

I know some doctors feel that doctors shouldkeep out of environmental issues. Sadly, it isclear that at some point soon, we will reach PeakOil. Once we have passed this our current rela-tively cheap fuel will become much more ex-pensive, having an impact on most aspects ofdaily life. It would seem that staying healthy andliving sustainably go hand in hand.To be healthy we are advised to eat at least

five portions of fruit and vegetables, limit ourmeat and alcohol intake and exercise at least 30minutes five times a week. Fruit and vegetablesper calorie need less farmland to be producedthan meat does. If we walk or cycle all our shortjourneys we are fitter and use less fuel. The al-cohol we drink has often travelled thousands ofmiles giving it a high embodied energy.So what did we do to get this far in the

Award? Mainly the simple things. We insulatedour house with additional loft insulation, doubleglazing, cavity wall insulation and a new boiler.This cut our space heating fuel usage to aboutone-sxth of its original level. To conserve electricity we have put in energy-

saving bulbs, we switch off appliances at thewall, don’t leave anything on standby and grad-ually replace old appliances with more energyefficient ones as needed. We recycle everythingwe can and once a year ‘audit’ our shopping andour waste to get an idea of where further im-provements can be made.

When we were a two-income family I used toenjoy a bit of retail therapy. My shoe collectionvied with that of Imelda Marcos. As many ofthese were rarely worn, I realised that the highof retail therapy is shortlived and addictive. Igradually stopped – wow! what a change to thebank balance. As the children started to growup we began to walk to nursery, school, shopsand for local visits. The car fuel bills droppedand kids’ shoe bills grew!Our diet has evolved from highly processed

and pre-cooked one to fresh, largely vegetable-based. This came about as the children arrivedand we prioritised time to cook for them – andus. We then worked in the garden with themgrowing bits and pieces of vegetables and fruit.Fresh raspberries just picked or peas out oftheir pods cannot be beaten. Are we perfect? Far from it – the TV still gets

left on standby or we occasionally leave a lighton in an empty room. We are, however, thinkingabout it and by definition that changes our be-haviour, making us reduce, reuse and recycle.It is hard though when short of time and tired tothink about anything. We have gradually made iteasier to recycle and try avoid bringing thingsinto the house which will end up in landfill.Added to sustainability and health going hand

in hand, I feel we could also add financial stabil-ity. It’s cheaper to walk, buy locally (you don’t fallfoul of all the offers) and just reducing what youbuy makes life cheaper. This is so important butdifficult for many people and patients trying tocope with the aftermath of the recession.

� Vote now for Judith and her family atwww.futurefriendly.co.uk. The competitioncloses on Wednesday (31 March 2010).

FOCUS

3

The statement by Margaret Chan of the WorldHealth Organisation that climate change is thebiggest threat to health in the 21st century wasreinforced by the report of the UCL/LancetCommission on climate change and health pub-lished in May last year, the summary of whichcan be found at www.thelancet.com/climate-change. There is now an overwhelming view from cli-

mate scientists that global warming is a realityand that mankind’s activities are significantlycontributing to this process. Health is likely tobe affected in many ways, most of them ad-versely. There are the obvious changes such aschanging prevalence of endemic diseases, in-creasing incidence of skin cancers etc, but the

really big problems with health are related tohuman conflict triggered by resource issues andthe health consequences of mass migration. Incommon with much that influences health, thepoor will fare the worst. This will be most noticeable in the third

world where many of the world’s biggest cities,already with massive deprivation, are at sea levelon estuaries. Unchecked, the projected rises insea level are set to flood these cities. The possi-ble human response to the effects of climatechange can crudely divided into the two broadareas of mitigation and adaptation. Mitigation involves action aimed at minimis-

ing the environmental consequences of humanactivities. The major greenhouse gas is CO2.

This is due to the sheer volume that is beingpumped into the atmosphere. Many activities, inour oil based economies, can be reflected as thenet CO2 that is produced as a consequence.Adaptation covers the strategies aimed at min-imising the anticipated adverse effects of cli-mate change.Many individual doctors have recognised

much of the above and have begun to changetheir personal behaviour in response (see ourstory on Dr Keighley below left). To date there hasbeen little in the way of a cohesive professionalstance. I suspect that many doctors believe thatthe moral value of their clinical activities in someway insulates them from the massive environ-mental challenge that faces us all. Medical professionalism has been defined as

‘a set of values, behaviours, and relationshipsthat underpins the trust the public has in doc-tors’. It would seem that the public have a rightto expect that we do our best to raise awarenessof the impact on health of climate change. Wealso need to develop strategies aimed at de-creasing the contribution of healthcare deliveryto the problem, as well as beginning to thinkabout how we can deliver effective healthcare tothose in most need in a lower carbon economy.It is estimated that the activity of the NHS is re-sponsible for the production of 20 million tonnesof CO2 per year.It was in response to all of this that the RCGP

began to act. I was appointed as ‘sustainabilitylead’ in October 2008. The strategic plan that weare working on has many facets. At its heart isthe aim of including ‘environmental probity’ inthe core understanding of what it is to be a GP.There are several work streams that we are de-veloping. The first is the inclusion of sustainability as

it relates to primary care in the curriculum andassessment blueprints. I hope that we will beable to look at the activities of individual facul-ties. The carbon reduction that can be achievedwith faculties is likely to be small in the great

scheme of things but will still be an importantarea to focus on. We have also developed an environmental

practice award scheme and this is currentlybeing piloted. It is a web-based carbon calculatorspecifically designed for general practice andwill enable practices to input their activities anddemonstrate to them where appropriate savingscould be made. There will then be a link to theCarbon Trust – which has confirmed that its in-terest free loans scheme will be available topractices. These can be accessed to fund the introduc-

tion of schemes and technologies that will reduce the carbon footprint of a practice. TheRCGP has also been working with other RoyalColleges to look at how this topic can be intro-duced into undergraduate and postgraduatetraining prior to formal inclusion in curricula.There are also plans for five sustainability ST3scholars at the Severn GP School. These schol-ars will have an extra month of study leave to en-able them to focus on environmental issuesrelating to primary care.GPs are ideally placed to bring about change

in the environmental impact of healthcare in theUK, both by modifying their own behavior aswell as using their influence in commissioningdecisions. We are held in high esteem by soci-ety, as shown by IPSOS MORI polls and NHSpatient surveys. Patients trust and believe theirdoctors. Following the Doll report in the early 1960s

doctors were at the vanguard of those stoppingsmoking and this was noticed by others, result-ing in wider smoking cessation. Doctors stop-ping smoking was obviously motivated by directself interest. The approach to personal and pro-fessional carbon use needs to be motivated notonly by altruism but also by an intergenerationalself interest – concern for our children andgrandchildren. Hopefully patients and others insociety will be positively influenced by the posi-tive actions of their family doctors.

RCGP NEWS • APRIL 2010

Making the case for sustainable general practice

3

E A R LY B I R D B O O K I N G D E A D L I N E 2 8 J U N E 2 0 1 0

growing healthy partnershipsPrimar Care

Sustainablegoing green: how one gP’s family is making a difference to the planet

This year’s RCGP Annual Conference in Harrogate will be our first-ever low-carbonfootprint event. The venue has been specifically chosen so delegates can easily walk between the hotels and the conference centre. There will also be locally sourced food, a policy to limit printing, and delegates will be encouraged to car-share and use public transport wherever possible. Here, RCGP Sustainability Lead Dr Tim Ballard explains why the sustainability agenda is so crucial to the future of the College and wider primary care.

How green isyour garden? Dr Keighley and family (and dog and hens)

Cabinet Office Minister Angela Smithand National Director for Primary Care Dr David Colin-Thome joinedRCGP Chairman Professor Steve Fieldfor the launch of a landmark report on how to improve healthcare andservices for socially disadvantagedand harder to reach groups.

Inclusion Health – a joint initiative between theCabinet Office and the Department of Health(England) – acknowledges the need for agreater primary care focus in addressing theneeds of the socially excluded. It proposes a framework for action, including

strong clinical leadership; responsive, flexibleand joined-up services; innovation in service de-sign and delivery and increased emphasis onhealth promotion and prevention.New analysis by the Social Exclusion Task-

force in the Cabinet Office and the Departmentof Health (England) shows that – despite theprogress made in healthcare over the past tenyears – the homeless, those with learning dis-abilities, people leaving prison and sex workersare still finding it difficult to access the servicesthey need, often with life limiting results.A new National Inclusion Health Board –

chaired by Professor Field – will now take forward a programme of work to providestronger advocacy for the most disadvantagedand support for the health professionals whowork with them. This will include the establish-ment of a dedicated Faculty of Inclusion Health.RCGP member Dr Sam Everington, whose

work in Bromley-by-Bow is showcased as an ex-ample of good practice in the report, said thatsimple changes were often the most effectiveway of engagement.

“Look at things like the design of your con-sulting room. We have curved desks so that GPsand patients are on the same level and we go outinto the waiting room to meet our patients – itmakes a difference.”Charles Fraser, Chief Executive of St

Mungo’s charity for homeless people, said:“There are degrees of social exclusion and thisis not just about accessing healthcare but usingit. I feel more optimistic that something is being

Professor Graham WattProfessor of General Practice, University of GlasgowCo-Chair of the GPs at the Deep End Steering Group

Health inequalities are a major concern in Scot-land. An event was held in Glasgow in the autumn entitled General Practitioners at theDeep End: what can general practices in deprivedareas do to improve their patients health? to lookat tackling the problem. Arranged by the RCGP Scotland Health

Inequalities Short Life Working Group, the pri-mary purpose of the event was to inform theRCGP Scotland report on Health Inequalities (akey remit of the Short Life Working Group). Invitations were despatched to the 115 practiceswhich serve the most deprived practice popula-tions in Scotland (both urban and rural) and par-ticipation at the meeting was open to allpractices, regardless of RCGP membership sta-tus. RCGP Scotland and the Scottish Govern-ment shared the funding.The meeting provided an unprecedented op-

portunity for engagement directly with the‘frontline’ GPs who operate at the heart of dep-rivation in Scotland and the day was carefullystructured to gather the views and methods ofpractice as well as soliciting suggestions for po-tential policy changes to create the beginningsof a GP-led support group that will have ‘onevoice’ for tackling Scotland’s growing concernof inequalities in health. Due to the success of the event and the over-

whelming sense of solidarity generated, a GPsat the Deep End Steering Group was conceived.Comprising GPs from the top 100 most deprivedpractices in Scotland, the initial perceived re-sponsibility of this group was to continue totackle the specific issues faced by general prac-titioners operating in these areas.

Initially funded by the Glasgow Centre forPopulation Health, the GPs at the Deep EndSteering Group has met several times over thepast three months. Membership is fluid, al-though always consisting of GPs derived fromthe ‘top 100’. The process has been very productive and

three smaller meetings (with locum funding)based on the original Deep End format werearranged for January 2010. These events weredesigned to draw on the experience and viewsof the GPs on the topic of unmet need, vulnera-ble families and the Scottish Government’s KeepWell initiative. Reports of the original GPs at the Deep End

event and the subsequent meetings describedabove will feature in the report of the RCGPScotland Short Life Working Group on HealthInequalities – the final draft will be presented toScottish Council members at the meeting on 5June this year.Engagement from the Scottish Government

has been present since the inception of the GPsat the Deep End Steering Group and a meetingwas arranged on 3 February between the ChiefMedical Officer, his colleagues and representa-tives from the Steering Group and the RCGPScotland Short Life Working Group to discussthe way forward. An early issue identified was the need to sup-

port further meetings like the original event.This meeting was successful in gaining a levelof support from the Scottish Government andsparked a further meeting to discuss how theScottish Government can work in conjunctionwith RCGP Scotland and the GPs at the DeepEnd Steering Group to help influence policy. It has been proposed that the Scottish

Government fund some events over the comingsix months with an issue-specific focus to helpinform their methods on tackling Health Inequalities. An exciting time lies ahead forhealthcare delivery in Scotland.

4 RCGP NEWS • APRIL 2009

NEWS

Dr Angela JonesChairRCGP Health Inequalities Standing Group

Research suggests that many GPs feel ill-equipped to manage people with complex andmultiple needs, especially when these needs fallinto the sociomedical domain, such as homelesspeople, refugees and asylum seekers, and otherexcluded groups. Delivery of primary care for excluded people

has been under the spotlight more recently. Astudy by the Cabinet Office, which reported on11 March this year, acknowledged the key rolethat primary care plays in addressing social ex-clusion through providing for health needs andhelping to coordinate other elements of care.Furthermore, the Marmot Report on Health In-equalities has focused on primary care as a keyarea of medical provision which is in a positionto address the woeful health inequalities whichexist in our society.So how are we to ensure that we have a work-

force, equipped in terms of knowledge, skillsand attitudes, to tackle health inequalities and toprovide real and meaningful universal access tohealthcare for socially excluded groups? Thecurrent consensus is to start young! Under-graduate curricula need to include opportunitiesto learn how to engage effectively with peoplewho are socially excluded, in order to avoid thefurther marginalisation that arises if people can-not access the healthcare that they need. Thisrequires a combination of experiential opportu-nities and positive role modelling of inclusivepractice during these very formative years.It has been acknowledged that there is a

dearth of inclusive role models available to undergraduates. Curricula are already over-crowded and space for extra sessions is difficultto find. Perhaps it is among those GP practices

that take medical undergraduates that manysuch teaching opportunities are to be found, anddelivered inclusively and universally, as part of‘normal’ practice rather than marking out suchapproaches as ‘extraordinary’ and only to be un-dertaken by specialists. It has also been acknowledged that public

health teaching can be somewhat dry and lack-lustre and fails to put across the immense op-portunity that public health measures offer formaking a difference to the lives of people andcommunities. Moves are afoot to allow more public health

specialists to maintain a clinical role. However,thought is also being put into ways of makingpublic health teaching ‘sexier’ and to inspiremore undergraduates to look at their work withmore of a public health focus than has been thecase up to now.The Health Inequalities Standing Group

(HISG) has put together a conference on 27April 2010 in Liverpool to look at these themesand we hope that as many GPs involved in undergraduate education as tutors, SSMs orcommunication skills teachers as possible willattend. The aim of the day is to share experience and

to produce a document, with the help of the undergraduate group MEDSIN, which encour-ages best practice in the training of undergrad-uates so that we can ensure that the doctors ofthe future enter the profession with the basictools they need to practice inclusively and totackle health inequalities in whichever field they ultimately work.

� Health Inequalities on the MedicalUndergraduate Curriculum is a one-day conference, taking place at the Liverpool Medical Institution on 27 April 2010. To book your place contact JonathanHamston at jhamston@rcgp.org.uk

done to tackle the healthcare of homeless peo-ple than I have in the past 30 years.”Angela Smith concluded: “GPs are doing

good in their own areas around the country. Weneed to bring them all together to lead the way.”

� Inclusion health: Improving the way we meetthe primary healthcare needs of the sociallyexcluded – www.cabinetoffice.gov.uk/social_exclusion_task_force_force.aspx

starting young is the answer to tackling health inequalities

How ‘frontline’ scottish gPsare addressing the problem

Including the excluded in healthcare

A united front: (left to right) Angela Smith MP; Rolande Anderson, Director General of the Office of the Third Sector; Dr David Colin-Thome; Professor Steve Field and

Rosemary Cook, Director of Queen’s Nursing Institute

RCGP Chairman Professor Steve Field says:“This agenda is part of my DNA. Myreasons for wanting to be a GP are thesame today as when I was at school – I wanted to make a difference and helppeople less fortunate than myself.

“Working in a particularly deprived area of inner city Birmingham is sorewarding – but incredibly frustrating. We have lots of disadvantaged groupsand I still feel we can do more to reachout and make sure we are providing the care they need and helping themlive as long and healthy lives as possible.

“We’ve acknowledged the need forclinical leadership and I’m delighted to have been asked to chair the newNational Inclusion Board. We need tothink differently about disadvantagedgroups and I’m determined that highquality general practice plays a key role in improving the health outcomesof all our patients.

“This is not just a commitment for GPsbut about inclusion across the entirehealthcare spectrum. We need to build on the good steps we’ve alreadytaken and work more closely with oursecondary care colleagues to delivermore integrated care. We can’t wait forbig investments, this is too important an issue to be lost in the politics.”

Christine Johnson FRCGPGP Adviser, National Patient Safety Agency

Communicating openly and honestlywith patients is a key part of providingcare. When a patient safety incidentoccurs, this open communicationneeds to continue.

Being Open about what happened and discussing promptly, fully and compassionatelycan help patients and clinicians to cope betterwith the after-effects. Openness and honesty canalso help to prevent such events becoming for-mal complaints and litigation claims. There arecase studies which demonstrate how BeingOpen (or open disclosure as called elsewhere)and improving patient safety can have economicbenefits. The programmes that appear to be most suc-

cessful take a comprehensive approach to promoting Being Open and include all stake-holders in this. For example, the University ofMichigan Hospital System has found that the

full-disclosure programme has halved the number of pending lawsuits resulting in a totalaverage annual savings of US$2m1.Being Open is when patients, their families

and carer get an acknowledgement that the in-cident has happened, an apology, an explanationor an expectation that there will be an explana-tion following an investigation, and reassurancethat lessons will be learned to prevent it hap-pening to someone else. NPSA guidance onBeing Open has been available since 2005 andthis was updated in 2009. Many professional bodies support Being

Open, including the Royal College of GeneralPractitioners, the Medical Defence Union, theMedical Protection Society and the GeneralMedical Council. It is a key objective in theMRCGP curriculum. Being Open is more than a one-off event; it is

a communication process with a number ofstages. The needs of the patients, their familiesand carers have to be central to this. The tablebelow outlines what the stages are in the BeingOpen process. Throughout this communication, there

should be no speculation, attribution of blame

or provision of conflicting information from dif-ferent individuals. Discussions should takeplace at the earliest practical opportunity andconsideration of the timing and location of themeeting should be made based on the patient’shealth and personal circumstances. The patient,their family and carers should be offered the op-portunity to share their understanding of whathappened and ask questions they have regard-ing the incident. Importantly contact detailsshould be provided so that if further issues ariselater the patient, their family and carers knowwho to address these to. Some of the main barriers to Being Open for

clinicians include the fear of litigation, concernthat it will not benefit the patient, having a lack ofconfidence in personal communication skills andshame or embarrassment about the incident2.

It’s important to remember that saying sorryis not an admission of liability and is the rightthing to do. Patients have a right to expect open-ness in their healthcare. In fact this has beenembedded and reinforced in the Putting ThingsRight project in Wales; and in the NHS Consti-tution for England which pledges to patientsthat ‘the NHS also commits when mistakes hap-pen to acknowledge them, apologise, explainwhat went wrong and put things right quicklyand effectively’. Supporting staff when things go wrong is

vital. Staff involved in an incident need a sup-portive team; they need help and advice on howto deal with it. These staff are often referred toas the ‘second victim’. In the guidance devel-oped by the NPSA, it is suggested that all or-ganisations providing care in the NHS shouldidentify ‘senior clinical counsellors’ who can pro-vide mentoring and support to their colleaguesinvolved in an incident and in communicatingwith patients as a result of an incident.

Further informationThe NPSA provides guidance and support onwhen and how clinicians can communicate withpatients and their carers in three of its activityareas, the Root Cause Analysis, Significant

Over 1,000 GPs around the countryhave taken part in RCGP workshops to help manage patients with healthand work issues – with hundreds more enrolled for the next round.

The interactive half-day workshops are provinga resounding success. One participant in Edin-burgh reported: “Excellent course, has defi-nitely increased my confidence in assessingfitness to work and addressed several related is-sues that I previously struggled with. I believemy assessment of fitness to work will change asa result of today’s teaching.” Another in Oxford said: “Very relevant. Good

mix of facts and consultation techniques. I willfind the motivational, interviewing and confi-dence-building skills very useful.” As a result of attending the workshops a

number of GPs have also expressed an interestin becoming workshop trainers.The workshops, which aim to increase GPs’

knowledge, skills and confidence in dealing withclinical issues relating to work and health, haverecently been revised to include material on the‘fit note’. The new content will provide furthersupport and guidance to prepare GPs for the ‘fit

note’ which is due to come into effect on 6 April.The workshops were piloted extensivelythroughout 2007, with content developed andpresented by Professor Sayeed Khan and DrDebbie Cohen. An independent evaluation ofthe workshop was extremely positive and led ledto the workshops being rolled out more widely.RCGP Chairman Steve Field said: “Tackling

health inequalities is a major priority for GPs andhelping people into employment is clearly one ofthe best ways of improving the mental, physicaland economic well-being for our patients. “I am delighted that there has been such an

excellent response to the workshops and that somany grassroots GPs are finding the training rel-evant and useful. I would urge all our members totake up this valuable opportunity and enrol.

“My thanks go to Professor Nigel Sparrow,Professor Sayeed Khan and Dr Debbie Cohenfor their commitment, energy and support onthis project. It’s really heartening to see CollegeMembers taking the initiative and creating innovative programmes that support GPs andimprove the lives of patients at the same time.”Dr Debbie Cohen said: “We knew from our

research that there was a need for this supportbut we have been surprised by the response. Weare now well on our way to achieving our targetto provide training and support for between

5RCGP NEWS • APRIL 2010

NEWS

Health and work workshops are in great demand with gPs

Being open on patient safety is crucial

Event Audit and the Being Open programmes.These alongside The Seven Steps to PatientSafety provide:� Information and guidance for clinicians on

how to investigate an incident� How to acknowledge, apologise and

explain when things go wrong� How to communicate effectively to

patients, their families and carers� How to provide support for those involved

to cope with the physical and psychologicalconsequences of what happenedTo help clinicians and organisations, a range

of resources have been developed by the NPSAand are available at www.nrls.npsa.nhs.uk/beingopen. Here, a free e-Learning tool can beaccessed to learn more about Being Open, including case studies. Being Open trainingworkshops have also been developed that in-clude interactive role play with actors and thetechnique of ‘forum theatre’. � Any queries about Being Open, or

for more information on the NationalPatient Safety Agency, please contactChristine.johnson@npsa.nhs.uk

References1. Boothman RC, Blackwell AC, Campbell DA Jr, Commiskey E, Anderson S. A better approach to medical

malpractice claims? The University of Michigan experience. J Health Life Sci Law. 2009; 2: 125-1592. Gallagher TH. A 62 year-old woman with skin cancer who experienced wrong-site surgery:

review of medical error. JAMA. 2009; 302: 669-6773. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too.

BMJ. 2000; 320:726-727.

APRIL20 Best Western Royal Beach Hotel

PORTSMOUTH21 Marriott Gosforth Park Hotel

GOSFORTH22 Hilton Garden Inn Hotel

Luton North, LUTON27 Holiday Inn Northampton West

NORTHAMPTON28 The Hallmark Hotel, CARLISLE29 Prince Rupert Hotel, SHREWSBURY

MAY4 Holiday Inn, LINCOLN11 Best Western Huntingtower Hotel

PERTH13 Park Inn Hotel, LEIGH18 Highpoint Conference Centre

LEICESTER19 Walnut Tree Hotel, TAUNTON26 Latton Bush Centre, HARLOW27 Windermere Hydro Hotel

BOWNESS ON WINDERMERE

Dr Debbie Cohen: On target to provide trainingfor 3,000 to 4,500 GPs in the next two years

OVERVIEW OF THE BEING OPEN PROCESS

Incident detection or recognition

Preliminary team discussion

Initial Being Open discussion

Follow-up discussions

Process completion

Detection andnotification

throughappropriate

systems

Prompt andappropriate clinical care to prevent

further harm

Initial assessment

Establish timeline

Choose whowill lead

communication

Verbal and written apology

Provide knownfacts to date

Offer practical and emotional

support

Identify next steps

for keepinginformed

Provide update on

known facts at regular intervals

Respond to queries

Discuss findings of investigation

and analysis

Inform oncontinuity

of care

Share summarywith relevant

people

Monitor howaction plan isimplemented

Communicatelearning with staff

Record investigation and analysis related

to incident

Provide written records of all

Being Open discussionsDocumentation

3,000 and 4,500 GPs across Great Britain overthe next two years.We were determined that the content of the

workshops should reflect what we were hearingfrom GPs in their surgeries and it’s very reas-suring that participants are telling us that theycan apply their learning and strategies directlyto their consultations back in practice.”� To make registration easier, the schedule

of future workshops has now been uploadedto the online booking system on the RCGPHealth and Work in General Practicewebsite: www.rcgp.org.uk/healthandwork

66

CLINICAL UPDATE

RCGP NEWS • APRIL 2010

gPs urged to continue support for organ donation

Maudsley Prescribing Guidelines is the mostwidely-used guide to prescribing psychiatric med-icines. The tenth edition has been revised and up-dated and is indispensable for the prescribingcommunity. It provides practical advice for use incommon and more rarely encountered clinical sit-uations. Key sections include:� Plasma level monitoring of

psychotropics and anticonvulsants� Schizophrenia� Bipolar disorder� Depression and anxiety� Children and adolescents� Substance misuse� Use of psychotropics in special patient groups� Miscellaneous conditions and substances

Where possible, guidance has been alignedwith the most recently issued guidelines fromNICE and the latest Cochrane reviews. Thebook also anticipates new drug introductionsand changes in Product Licences.

� RCGP members can benefit from a 10 percent discount and free delivery by visitingwww.informahealthcarebooks.com/maudsley.htmlSpecial discounted price: £45/€56.70/$90Quote code HJMAUD at the checkout. Alternatively, if you’d like a copy for each GP in your practice order the special five-pack offer at £175/€219/$350 fromwww.informahealthcarebooks.com/maudsley5pack.htmlISBN: 9781841847108

The College has teamed up with GP newspaper to publish a series of five factsheets to support the diagnosis andmanagement of headache in primary care. Written by RCGP Clinical Champion for Headache Dr David Kernick andleading headache specialist Professor Peter Goadsby, they are available from www.healthcarerepublic.com/go/rcgp

WHAT DO PATIENTS WANT?� To be taken seriously by sympathetic

doctor. � To have their ideas, concerns and

expectations explored.� To have their problem explained in

terms they understand.� To be offered informed choice about

treatment with a clear management plan.� Not to be abandoned. Follow-up is

important.

HEADACHE HISTORY� How many different types of headache

do you get? Patients can often identify anumber of separate headaches. Examineeach one in turn.

� Time questions.Why consulting now?How recent is onset? The temporalpattern?

� Character questions. Intensity; natureand quality; sight; associated symptoms(particularly nausea, phonophobia,photophobia, movement sensitivity).

� Cause questions. Predisposing or triggerfactors; family history of similar headache.

� Response questions.What do you dowhen you get a headache? (tension-typeheadache keeps going; migraine wants tolie down; cluster headache wants to bangtheir head against the wall). Whatmedication has been used and is beingused?

� State of health between attacks.Concerns, anxieties, co-morbid anxiety,depression.

THE HEADACHE EXAMINATIONFundoscopy and blood pressure measurementsare minimal. The panel below shows a simpleexamination proforma that would exclude mostpathologies. Subtle neurological nuances arerarely helpful in headache examination.Headache diaries are invariably useful. Scoressuch as MIDAS and HIT can assess impact andmonitor treatment.

Headache care in general practice

INVESTIGATING THE HEADACHE IN PRIMARY CAREBlood testsPrimary investigations� Full blood count – anaemia, leukaemia

and infection can cause headache � Thrombocytopenia� ESR and CRP – if raised can indicate

temporal arteritis or systemic disease� Creatinine – renal failure can cause

headache� Calcium – to exclude hypercalcaemia � Thyroid function test – headache

can be associated with hypothyroidism� Liver function test – could indicate

metastatic disease� Carbon monoxide level where relevant

Secondary investigations� VDRL � HIV � Lyme antibodies� Antinuclear antibodies, lupus

anticoagulant, anticardiolipin antibodies

Imaging � CT is more accurate for haemorrhage

up to five days after the event but will miss approximately ten per cent of space occupying lesions particularly in the posterior fossa

� Ten per cent of patients will experienceproblems with claustrophobia with MRI

� Three per cent will show incidentalabnormalities which invariably give causefor unnecessary concern

FACT FILE 2: HEADACHE HISTORY EXAMINATION AND INVESTIGATION

� Pupillary responses and fundoscopy� Visual fields � Eye movements (superior, inferior, lateral)� Facial movements

(wrinkle forehead, grimace with teeth)� Protrude tongue� Outstretch arms, palms upwards

for palmar drift� With eyes closed, touch nose with finger

(upper limb pyramidal, posterior column)� Finger dexterity (play piano)� Rapid hand movement, tap fingers

of one hand on opposite palm and vice-versa (cerebella co-ordination)

� Limb and plantar reflexes� Standing – feet together and eyes

closed for balance (Romberg’s test)� Walk heel to toe along a straight line� Walk on heels, walk on toes� Check for trigger points

particularly over occiput, posterior neck and upper shoulders

� Active neck movement (rotation, lateral flexion)

� In the acute setting, include temperature, rash, neck stiffness, temporal artery tenderness if over 50

A SIMPlE ExAMINATION PROFORMA

� Annual incidence in population – 6-10 per 100,000.� Headache presentation to GP – 1 in 1,000.� Headache presentation to GP if migraine or tension type headache can be diagnosed – 1 in

2,000.� Risk of tumour in isolated headache where diagnosis cannot be made after eight weeks –

approx 0.8 in 100.� Risk of discovering incidental abnormality on investigation – 0.6-10 in 100 depending on age.� Suggested risk of tumour for which investigation should take place – 1 in 100.

SOME TuMOuR RISkS TO BEAR IN MIND

RED FLAGS: Presentations where the probability of an underlying tumour is likely to be greater than one per cent. These warrant urgent investigation. Headache with:� Papilloedema or focal neurological signs.� Alterations in consciousness, memory, confusion or co-ordination.� New onset cluster headache (imaging particularly of the region of the pituitary fossa

required but non-urgent).� A history of cancer elsewhere, particularly breast and lung.

ORANGE FLAGS: Presentations where the probability of an underlying tumour is likely to be between 0.1 and one per cent. These need careful monitoring and a low threshold for investigation. Headache:� Where a diagnostic pattern has not emerged after eight weeks from presentation.� Is aggravated by exertion or Valsalva manoeuvre.� Has been present for some time but has changed significantly, particularly

a rapid increase in frequency.� Headaches that wake from sleep.� New headache in a patient over 50

GuIDANCE FOR INvESTIGATING FOR TuMOuR IN PRIMARy CARE

Lynda HamlynChief ExecutiveNHS Blood and Transplant

The UK’s organ donation campaign already hashigh levels of GP support, with more than fourmillion patients having joined the NHS OrganDonor Register through promotional leafletspicked up in waiting rooms and through the GPregistration process. But with three patients dying every day in

the UK for want of an organ transplant, a newnational Prove It campaign has been launched toencourage more people to sign up, and GPs arebeing urged to continue playing their part inproviding opportunities for the public to join.NHS Blood and Transplant (NHSBT) has en-

joyed a long and successful relationship withGPs in promoting the importance of organ do-nation. Many practices provide invaluable sup-port by simply displaying organ donationliterature. Last year alone, 10,000 patientssigned up to the Register as a result of leafletsthey picked up at their surgery. People are now encouraged to sign up to the

confidential computerised Organ Donor Regis-ter rather than the previous card-carrying sys-tem. Registering makes it easier for the NHS toestablish a person’s wishes as cards can get lostor damaged. Currently there are over 16.9 million people

on the NHS Organ Donor Register – 28 per centof the population. The need for more people tojoin is borne out by the statistics – more than10,000 people in the UK currently need a trans-plant. Of these, 1,000 each year will die waitingas there are not enough organs available. Thenumber of people needing a transplant is ex-pected to rise steeply over the next decade dueto an ageing population, an increase in kidneyfailure and scientific advances resulting in more

people being suitable for a transplant. In meet-ing this need, NHSBT relies entirely on the gen-erosity of donors and their families.One donor can save the life of nine people, re-

store the sight of two others and improve thequality of life of many more people. People canopt for any part of their body to be transplantedor for specific organs only – kidneys, heart,lungs, liver, pancreas and eyes. Tissues – in-cluding corneas, skin, bone, tendons, cartilageand heart valves – can also be donated. There isno upper or lower age limit to joining – the old-est recorded solid organ donor recorded in theUK was 84 years old.

NHSBT has set itself a target of increasingthe numbers of registrations to 20 million by theend of 2010 and to 25 million by 2013. As in past years, the NHSBT will be sending

organ donation literature to all GP practices,

pharmacies and libraries. This is an importantelement of the Prove It campaign which will con-tinue throughout this year. A black and ethnic minority-focused element

of the campaign has just been launched to tar-get sections of the population which tradition-ally have low levels of organ donor registration.In this year’s mailing, practices will find

leaflets and posters for use in their surgeries.Further supplies and a wider selection of litera-ture are always available, free of charge from theNHSBT website: www.organdonation.nhs.ukGPs everywhere are urged to support the

organ donation campaign by making the mate-rial available. Together, more lives can be saved.

� The RCGP is to appoint a dedicatedclinical lead to champion the value oforgan donation within primary care.

Useful resourcesSIGN guidelines: www.sign.ac.uk Excellent review of evidence-based headache care.The British Association for the Study ofHeadache: www.bash.org.uk Contains UK headache management guidelines from a more pragmatic perspectiveExeter headache clinic website:www.exeterheadacheclinic.org.uk Clinicalguidance and patient drug informationtreatment sheets that can be downloaded.Information from patient support groups:Migraine Action: www.migraine.org.uk Migraine Trust: www.migrainetrust.org

Maudsley Prescribing guidelines – new edition

Test Rationale

Bloods for U&Es, fasting glucose and lipids

High K+ indicates possible endocrine causeHigh or rising creatinine for renal impairmentRaised glucose to identify diabetesLipids for overall CVD risk

Urine for blood and protein Parenchymal renal disease

ECGHigh voltages indicate possible LV hypertrophy, or identify other changes

Dr Ivan Benett FRCGP(GPwSI in cardiology)Primary Care Cardiovascular Society

In 2008 the Department of Health launched itsdocument Putting Prevention First1 The idea isto identify those at risk by creating vascularchecks for all aged 40 – 74 years, includingblood pressure measurement. Cardiovascular risk increases with increasing

blood pressure levels > 115/752. The WHO esti-mates that raised blood pressure accounts forabout two in three strokes, and half of all coro-nary events3. Treating hypertension reducescardiovascular outcomes.The rule of halves, addressed by Dr Julian

Tudor Hart4, asserts that for chronic diseases,only half the cases are ascertained; half of thoseare treated; and of those treated only half aretreated effectively. The Quality and OutcomesFramework (QOF) has led to the prevalence ofhypertension in English practices beingrecorded as 12.5 per cent in 2006/7, rising to13.1 per cent in 2008/9. This is about three-quarters of the estimated prevalence5. The per-centage of people with hypertension seen in thepreceding nine months actually fell from 92.4per cent in 2006/7 to 91.9 per cent in 2008/9.The percentage managed to the target of 150/90mmHg was 77.6 per cent in 2006/7 and 78.6 percent in 2008/96. The threshold for diagnosis (BP>140/90) de-

pends on repeated measurements after rest andwith validated, well maintained and recently cal-ibrated monitors. In the presence of end-organdamage, such as left ventricular hypertrophy orproteinuria, there is no need for repeated meas-ures. ‘Masked’ hypertension, where the BP isnormal in clinic but high at other times, and‘white coat’ hypertension may not be as benignas once thought. High normal BP <140/90 but >120/80 also carries a higher cardiovascularrisk, and risk of developing hypertension7. Most secondary causes of hypertension such

as renal and endocrine causes are rare andoccur less than once in a clinical lifetime. His-tory, examination, simple investigation (Box 1),or resistance to treatment can help identifythem. The exception is hyperaldosteronism,which affects about one in eight of people withhypertension. Serum potassium is usually nor-mal and the condition only becomes apparentwhen there is resistance to treatment. In these cases a small dose of spironolactone

25mg daily, with careful monitoring of serumpotassium, will often produce dramatic im-provements. Referral to secondary care, or a GPwith an interest, should be made if there is re-sistance to treatment or a suspected serious sec-ondary cause. Box 1 highlights the initial investigations re-

quired with the hypertensive patient.Lifestyle advice remains the cornerstone of

initial and ongoing management. Smoking ces-sation is the most important of all. The benefitsof physical activity are increasingly recognised.A diet rich in fruits and vegetables, with low-fatdairy products and reduced saturated and totalfat, also significantly reduces blood pressure.This Dietary Approaches to Stop Hypertension(DASH) diet is even more effective if combinedwith weight loss and exercise8. We know that ahigh salt intake is associated with raised bloodpressure and reduction of dietary salt intakelowers it. Reducing dietary salt by 3g per day,especially in people of African origin, is alsolikely to be beneficial at a population level.The National Institute for Health and Clinical

Excellence (NICE) updated its advice on drugtreatment of hypertension9. �ß-blockers weredropped mainly following the publication of theASCOT trial10. ACE Inhibitors are to be usedfirst line in those under 55 years and white. Therest (most) should start with calcium channelblockers or thiazide diuretics. Large individualtrials have given mixed messages about whichdrugs or combinations work best.A recent meta-analysis concludes that essen-

tially all groups provide similar reductions incardiovascular outcomes, with the exception of�ß-blockers which are particularly protectiveafter myocardial infarction11. Benefit is achieveddown to BP 110/70 and combinations of lowdose drugs may have greater effect than singledrugs at maximum doses.Treatment targets vary slightly and are sum-

marised in Box 2

Making lifestyle changes and taking medica-tion is important. Good communication mustexist between the physician and patient. Peoplemust understand why they need to make thesechanges, and their ideas, concerns and expec-tations must be addressed. They have to buyinto the changes. This is what GPs are good at,but perhaps need to do better when dealing withthis symptomless disease. Box 3 indicates sug-gestions from SIGN for improving concordance.

No discussion on Chronic Disease Manage-

ment is complete without an encouragement toaudit the care provided to the whole population.My personal feeling is that QOF measures theappropriate domains but uses inappropriate cri-teria. I would suggest targets of <140/90 and130/80 if they have diabetes or CKD. ACEI orARB should be used if there is significant pro-teinuria, or microalbuminuria in people with di-abetes. Implementation research is now alsourgently needed. We know what to do, but wenow need to know the best way of doing it.

References

1. www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_083823.pdf

2. Lewington S, Clarke R, Qizilbash N, Peto R,Collins R. Prospective Studies CollaborationAge-specific relevance of usual blood pressureto vascular mortality: a meta analysis ofindividual data for one million adults in 61prospective studies. Lancet 2002; 360:1903-1913

3. WHO. The World Health Report 2002.Reducing risks, promoting healthy life. 2002www.who.int/whr/2002/en/

4. Hart JT Rule of halves: implication ofincreasing diagnosis and reducing dropout forfuture workload and prescribing costs inprimary care BrJGP 1992;42;116-119

5. Wolf-Maier K, Cooper RS, Banegas JR et al.Hypertension prevalence and blood pressurelevels in 6 European Countries, Canada, andthe United States. JAMA. 2003; 289:2363-2369.

6. www.qof.ic.nhs.uk/search.asp.7. Franklin SS et al. Predictors of new onset

diastolic and systolic hypertension. TheFramingham Heart Study. Circulation2005;111:1121-27

8. Blumenthal JA, Babyak MA, Hinderliter A etal. Effects of the DASH diet alone and incombination with exercise and weight loss onBP and CV biomarkers in men and womenwith high BP. The ENCORE study. Arch InternMed 2010; 170:126-135.

9. NICE Clinical Guideline Group. Hypertensionmanagement in adults in primary care. NICECG34 2006.

10. The ASCOT investigators. Prevention ofcardiovascular events with anantihypertensive regimen of amlodipineadding perindopril as required versus atenololadding bendroflumethiazide as required, inthe Anglo-Scandinavian Cardiac OutcomesTrial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlledtrial. Lancet 2005;366:p895-906

11. Law MR , Morris JK, Wald NJ, Use of bloodpressure lowering drugs in the prevention ofcardiovascular disease: meta-analysis of 147randomised trials in the context ofexpectations from prospective epidemiologicalstudies. BMJ 2009338:b1665

12. Scottish Intercollegiate Guideline Network2001. Hypertension for older people. SIGNPublication No. 49 ISBN 1899893423 2001.

13. NICE Clinical Guideline Group. Themanagement of Type 2 Diabetes. NICE CG662008

14. NICE Clinical Guideline Group. ChronicKidney Disease CG73. 2008

15. www.escardio.org16. National Institutes of Health. The seventhReport of the Joint National Committee onPrevention, Detection and Treatment of highBlood Pressure. NIH 2003.www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

7RCGP NEWS • APRIL 2010

CLINICAL UPDATE

guidelines for managing hypertension

a decade of progress on coronary heart diseaseDr Mike Knapton FRCGP

Associate Medical DirectorBritish Heart Foundation

Last month marked the tenth anniversary of thepublication of the National Service Frameworkfor Coronary Heart Disease and the five-year an-niversary of the additional Chapter 8 on CardiacArrhythmias. It is therefore a propitious time totake stock of the progress of cardiac servicesand, more importantly, look at those areaswhere there needs to be more effort.In England, there have been considerable

achievements, particularly in improving themanagement of acute myocardial infarction withrapid access to thrombolisis and more recentlyprimary percutaneous interventions. Preventionof cardiovascular disease, diabetes and chronickidney disease is being addressed through theNHS Healthcheck programme. There has beena reduction in premature mortality from coro-nary heart disease by about 50 per cent on the2000 baseline. This progress has been sup-ported by policy and legislative change, notablythe introduction of the smoking ban in publicplaces.However, cardiovascular diseases still ac-

count for more deaths than any other set of con-

ditions and there are around 53,000 prematuredeaths in the UK, and progress has not been somarked in other areas and many of these aresalient to the practice of primary care. The recent National Audit for Cardiac Reha-

bilitation suggests that only just over 40 per centof eligible patients (that is patients followingheart attack, angioplasty and cardiac surgery)receive cardiac rehabilitation. This is disap-pointing given the target set in the NSF was 85per cent. Cardiac rehabilitation is an evidence-based intervention that at five years can achievea 27 per cent reduction in mortality and improvequality of life. Further work also needs to be done to im-

prove the management of heart failure. TheBritish Heart Foundation (BHF) has investedheavily in specialist heart failure nurses to im-prove the management of patients with left ven-tricular systolic dysfunction. However, heartfailure services have not received the same at-tention from the NHS as those for acute my-ocardial ischaemia and infarction. There are also several ‘open goals’ where the

NHS could reduce the risk of large groups ofpeople at particular risk of cardiac problems. Anestimated 46 per cent of patients with atrial fib-rillation are not currently receiving Warfarin

and are therefore at an unnecessarily increasedrisk of stroke. Similarly, implementing a cascade screening

programme amongst the relatives of people di-agnosed with familial hypercholesterolaemiawould help identify the estimated 100,000 peo-ple living in the UK who are unaware they havethis treatable condition. The BHF, in partner-ship with the Welsh Assembly government, hasdeveloped a cascade screening programme inWales. We hope that this will act as an exemplarand a pilot site for the rest of the UK. The NHS is going to face considerable chal-

lenges over the next five years as public sectorspending is likely to constrain investment. Withthe inevitable emphasis that this will put on re-duction of waste, increases in efficiency and pro-ductivity, I think it is clear that the BHF will alsowant to emphasise the importance of quality ev-idence-based medicine and rational decision-making in the NHS. We are delighted to be working with the

RCGP to review the BHF ‘factfile’ programme,which provides concise and authoritative up-dates to GPs on cardiovascular issues. I wouldbe very grateful to have feedback on this seriesor other publication we produce. They are allavailable from www.bhf.org.uk

Box 1: Initial investigations required of the hypertensive patient

Guideline Blood pressure target Special comment

NICE9 < 140/90

SIGN12 <140/90 Older people > 60 years

NICE – Diabetes13 <140/80 <130/80 if evidence of end organ damage incl. microalbuminuria

NICE – Chronic Kidney Disease14 139-120/<90 120-129/<80 if diabetes

or proteinuria and use ACEI

European15 < 130/80 Lower limit 120/70

American16 <140/90 - 130/80 for diabetes or CKD Use ACEI/ARB if microalbuminuria

Box 2: Target blood pressure according to guidelines

Box 3: How to improve concordance 12

� Involve the patient in making treatmentdecisions

� Increase the patient’s knowledge abouttreatment regimens and the rationale for treatment

� Patient counseling and informationleaflets

� The use of single-daily or (if not available)twice-daily dosing combination tablets

� Minimising poly-pharmacy� Use of compliance aids (eg dosette box)� Considering side-effects which may

cause discontinuation of drug use andchanging the drug regimen promptly.

SUMMARY KEY POINTS

� Much is known about what works toreduce cardiovascular outcomes in people with hypertension.

� Vascular checks should identify more people with hypertension.

� Improving concordance is key tomaintaining life style changes andadherence to medication regimes.

� QOF criteria and standards need tochange if we are to impact further on the rule of halves.

� We need to know the best systems for ascertainment and deliveringinterventions

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RCGP News invites your comments or letters...Please write to: The Editor RCGP NewsRoyal College of General Practitioners14 Princes Gate Hyde Park London SW7 1PUemail: rcgpnews@rcgp.org.uk

ISSN 1755-7720© Royal College of General Practitioners.All rights reserved.Published monthly by the Royal College of General Practitioners14 Princes Gate, London SW7 1PUemail: rcgpnews@rcgp.org.ukwebsite: www.rcgp.org.uk

RCGP NEWS • APRIL 2010

NEWS

The Royal College of General Practitioners is searching for anenthusiastic clinician/medical editor to join the successful e-GP team. The responsibilities of this exciting and challenging new role will focus on the editorial review and quality assurance of the e-GP e-learning programme.This will involve performing the detailed editorial review and editing of the near-complete e-learning sessions and working with the contentdevelopment and technical teams to develop these into engaging and high quality finished resources. Other responsibilities will involve evaluating, updating and improving current content and contributing to the creation of publicity and other project-related materials.This post holder will work under the guidance of the e-GP Clinical Lead and will report to the e-GP Executive Board. We anticipate a commitment of two sessions per week over a 12-month period in the first instance. In addition to the sessional reimbursement, travel and subsistence expenses will be reimbursed. The post is available for one year in the first instance.

Applications should be submitted by 5pm on 9 April to Heidi Cook at the email address below. They should include a current CV and a covering letteroutlining suitability for the role, based on the role description (available on request from e-GP@rcgp.org.uk). Although some familiarity with online educational technologies and approaches is desirable, advanced IT skills are not required for this role. However, strong writing and editing skills and an eye for detail are essential. Shortlisted candidates will be asked to complete some short editorial exercises.

Contact details: Heidi Cook (e-GP Administrator)RCGP 14 Princes Gate London SW7 1PUTel: 0845 456 4041e-GP@rcgp.org.uk

Background to the e-GP projectLaunched in July 2009, e-GP: e-Learning for General Practice is acomprehensive, free-to-access, high quality programme of online learningsessions structured around the GP curriculum, developed in a collaborationbetween the Royal College of General Practitioners and e-Learning forHealthcare (Department of Health). Covering around 500 primary care topics, e-GP provides a comprehensive programme of e-learning modules to support specialty training for UK general practice. It also assists thecontinuing professional development of qualified General Practitioners and is of interest to other healthcare professionals working in primary care. Further information is available at www.e-GP.org

Invitation to apply for the role of

MEDICAL EDITOR

RCgP manifesto puts patients first

Better leaders, better doctorsSign up now for the RCGP leadership programme 2010/2011

Designed specifically to help GPs develop as leaders in the ever-changing NHS, the Leadershipprogramme provides opportunities to meet and debate with a number of leading figures from the fields of healthcare, government, industry and leadership development. � For more information contact Katie Hopkins at leadershipprogramme@rcgp.org.uk

Patients in partnership: Members of the Patient Group are looking for a new voice to join them

RCgP Patient group seeks new lay memberThe College is seeking a new lay member to join its patient group, which meets four times a yearto discuss issues regarding general practice and the NHS. The group also provides patient perspectives on College and government healthcare policy. � For further details please call 0207 344 3050 or e-mail jcheong@rcgp.org.uk.

Closing date for applications is 7 April 2010.

NI tackles VTe RCGP Northern Ireland will provide a primary care perspective on venous thrombosis at its 2010Symposium on 28 April.

Speakers include Professor Beverley J Hunt,Professor of Thrombosis and Haemostasis atKing’s College London.Jointly hosted with the Royal College of Nurs-

ing, the seminar will address epidemiology, prevention, monitoring and treatment in light ofthe recently published NICE guidelines on VTE.The venue is the Royal College of Nursing,

Windsor Avenue, Belfast from 1pm – 5.30pmand costs £10 for RCGP members.� For further details please contact

Angela McLaughlin on 028 9023 005 or e-mail amclaughlin@rcgp.org.uk

gP expertise neededThe National Clinical Guidelines Centrefor Acute and Chronic Conditions(NCGCACC) is looking for a GP to help develop its clinical guideline on Rehabilitation after Stroke.

Guideline Development Group members are expected to attend meetings every six to eightweeks for approximately 18 months from thelast week of April 2010.

Previous experience of guideline develop-ment, working with committees and knowledgeof NICE and guideline development process,critical appraisal methods and the role of healtheconomics are desirable� Further details and application form

from NICE website: www.nice.org.uk/getinvolved/joinnwc/join_a_nice_committee_or_working_group.jsp

The manifesto, entitled Leading the Way: HighQuality Care For All Through General Practice,makes a number of recommendations to raisestandards of patient care and help produce ahealthier society – whatever the result of theGeneral Election.It is divided into three sections, with calls for

action under each heading:q High-quality GP care for allw Care for patients closer to homee Improving the health of the nation

Central to the RCGP manifesto are :� Longer consultation times� Longer training for GPs� Better round-the-clock care� Continued support for the

development of GP Federations� Improved and faster access

to diagnostic tests� Better services for

socially-excluded groups� GPs to continue playing a key role in

the care of patients from cradle to graveThe manifesto supports action to tackle

smoking and alcohol misuse, including mini-mum price levels for alcoholic drinks and a banon smoking in motor vehicles (including privatecars) with young children. Tackling climatechange also takes priority.

RCGP Chairman Professor Steve Field said:“Any political party coming into power in any of the countries of the UK faces enormous, un-precedented financial pressures.“Our health service faces a huge challenge:

how to respond to reduced funding without re-ducing the quality of the services we provide, orthe quality of the care our patients deserve.

“GPs and their primary healthcare teams arepart of the solution. Strong general practice, de-livering healthcare that patients need and wantis the way forward. The RCGP is up for the chal-lenge and is already leading the way in showinghow high-quality, cost effective care can be avail-able to all.”

� For more information visit www.rcgp.org.uk

The RCGP has launched a uk-wide manifesto calling on all political parties to make patient care their top priority.

Professor Steve Field: Strong general practice,delivering healthcare that patients need

and want is the way forward