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Will clinical care fall between two stools?

How can GPs ensure sound clinical care doesn't conflict with the demands of the contract? Dr Toby Lipman offers some solutions

All over the country GPs are setting up their computers to collect the data they will need to justify their claims in the quality and outcomes framework.

The range of indicators is broad and includes many of the most important processes known to produce substantial health benefits. Even 130 indicators, however, cannot possibly cover all of primary care1. So there are two aspects to the contract's impact on the care we give:

nHow will the quality indicators affect care in those domains covered by the framework?

nAnd how will it do so in those that are not?

Evidence vs judgment

It is often assumed that, because many of the clinical indicators are derived from research evidence, they will result in evidence-based practice. This is not strictly true.

Evidence-based practice is the explicit and judicious use of current best evidence in decisions about the care of individuals. An evidence-based decision is one in which clinicians use their experience and judgment to balance the patient's needs and wishes, the clinical situation and any applicable evidence2,3. This fits rather well with the Pendleton model of the consultation, in which addressing the patient's agenda and building the consultation around it are paramount4.

The consultation is therefore the core of general practice. If conducted well it enables GPs to negotiate the relationship between perceived illness and objectively demonstrated disease in each unique individual and to place them in the context of each person's social and psychological situation5. When we see patients, this is what we aspire to as GPs.

The Q&O, on the other hand, is based on a population view of health. It aims to ensure a specified proportion of the population with clearly defined diseases is identified, monitored and given interventions to achieve measurable outcomes, such as reduction in blood pressure.

In the course of this GPs must record many biomedical and administrative parameters, such as BMI in diabetes, and disease registers. Indeed, evidence shows that some of these interventions lead to benefits, such as reduction in the risk of stroke ­ we can anticipate that implementing the Q&O will reduce the number of such adverse events in populations to which it is applied.

Most practices will be using electronic checklists in the form of templates. Some colleagues say that, provided we have appropriate systems set up, we will be able to record the necessary data as we go along without too much change in our consulting style. I am not so sure.

Consulting style

A randomised controlled trial of computerised guidelines found that guidelines were ignored ­ the computerised system functioned in the context of routine surgeries, not other settings (such as clinics dedicated to disease management). So patients could present with any clinical problem, such as arthritis or depression, but despite having asthma or angina they might not wish to discuss it, even though the computerised system might suggest this was appropriate6.

The GPs in the trial did not stand to gain financially from following the electronic guidelines and so they ignored them. Colleagues, however, tell me of more recent experiences when, in anticipation of the new contract, they have broken across the patient's agenda to check their blood pressure or record smoking and drinking data.

If we try to integrate disease management into routine consultations there is a danger we will fall between two stools, neither thoroughly covering the disease management checklist nor adequately addressing the patient's own agenda. Systematic, protocol-driven disease management is a different process from patient-centred consulting and needs to be separate from it.

The ideal solution, where resources allow, is to use nurses to review compliance with the checklists and GPs to address patients' wishes and needs following the review. It is a notable failing of the contract that it does not recognise the need for this, nor offer extra points to practices that organise such a separation.

I have some experience of this with nurse-led diabetes and IHD reviews, and it works well. Following the review one can scan the data rapidly, noting perhaps a high HbA1c or 'missing' medication, such as a statin. Patients can then present their problems as they perceive them and the GP can address them, bringing in disease management issues as they relate to the totality of the patient's experience, rather than as an end in themselves.

At this stage the GP should ideally be able to present the management options in terms of benefit and harm, which requires a knowledge of evidence-based practice and clinical epidemiology7.

This is where the clash between population and individual risk must be negotiated. For the population, a reduction of 3 per cent in the absolute risk of stroke over five years means that for every 100 treated patients there will be three fewer strokes. For the individual it means the treatment has a 97 per cent probability of making no difference whatsoever to the outcome.

This is particularly relevant at the margins of the Q&O where, for example, a patient with a systolic blood pressure of 160 fails to contribute to the practice's quality target, but in whom the absolute risk reduction achieved by meeting the target may be only 1 or 2 per cent. Should we attempt to persuade a reluctant patient to be labelled 'hypertensive' and take medication which has a much higher probability of causing unpleasant side-effects than it does of benefiting them?

Is there a danger of medicalising large numbers of people who are at low risk, given that there is evidence that many are prepared to accept higher risks than guidelines committees think appropriate8?

Beyond the Q&O

The clinical content of general practice not covered by the Q&O vastly exceeds that covered by it. It is important that achieving points in the Q&O should not take up so much time that we neglect areas not included in it.

In 1998 in a study of 413 consultations there were 158 separate problems, of which 10 took up a third of consultations, 26 a further third, and 122 the remaining third9. Understandably, the contract concentrates on conditions of high morbidity and mortality, but disappointingly there is little or nothing in it to encourage the GP's traditional role as an interpreter of the interface between illness and life.

Nor does it have anything useful to say about what new skills and knowledge GPs will need to acquire or what the role of the generalist should be in the 21st century.

I hope nevertheless that GPs will respond creatively to it, that they will preserve and develop their professional culture and that in the future the contract may be modified to take these issues into account.

References

1 Shekelle P. New contract for general practitioners. BMJ 2003;326(7387):457-458

2 Sackett DL et al. Evidence-based medicine: what it is and what it isn't. BMJ 1996;312(7023):71-2

3 Haynes RB et al. Physicians' and patients' choices in evidence-based practice. BMJ 2002;324:1350

4 Pendleton D et al. The Consultation: An Approach to Learning and Teaching. Oxford: Oxford University Press; 1984

5 Heath I. The Mystery of General Practice. London: Nuffield Provincial Hospitals Trust; 1995

6 Eccles M et al. Effect of computerised evidence-based guidelines on management of asthma and angina in adults in primary care: cluster randomised controlled trial.

BMJ 2002;325(7370):941-

7 Lipman T. Evidence-based practice in general practice and primary care. In: Trinder L, Reynolds S (eds) Evidence-Based Practice: a Critical Appraisal. Oxford: Blackwell Science; 2000. p.35-65

8 Devereaux PJ et al. Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study Commentary: Varied preferences reflect the reality of clinical practice.

BMJ 2001;323(7323):1218-

9 Lipman T. Discrepancies exist between general practitioners' clinical work and a

guidelines implementation programme [letter].

BMJ 1998;317(7158):604

Toby Lipman is a GP in Newcastle upon Tyne and R&D lead for Newcastle upon Tyne Primary Care Trust

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