Published: 07/10/2004, Volume II4, No. 5926 Page 31
My overweight patients change their eating habits, the parents of asthmatic children smoke outside, and Mrs Jones never forgets her tablets.Alas, such certainty is rare and primary care medicine is more about understanding and making sense of doubt.
Most meetings with patients throw up at least one dilemma. Should I refer? Should I prescribe? Should I investigate, reassure or do nothing?
Coping in this environment depends on GPs being able to combine common sense and experience with evidence and guidelines.
There are particular difficulties in primary care, where serious diseases such as cancer and heart disease are much rarer than in secondary care. There is therefore more reliance on symptoms, and GPs are constantly bombarded with guidelines that ignore the primary care context.
As a newly appointed primary care trust medical director I now have a new set of dilemmas. In seeking to address the variations in prescribing or referrals across primary care, my corporate position would encourage me to sign up to all the guidance emanating from the National Institute for Clinical Excellence. But my professional experience may tell me differently.
Is it right for patients with new onset dyspepsia that have not responded to acid suppression therapy only to be offered endoscopy at the age of 55? Should patients with an osteoporosis-related fracture be denied therapy until they have had a dual energy X-ray absorptiometry (DEXA) scan (see feature, left)? The challenge now is how to manage the gap between the simplistic certainty of NICE guidance and the complex uncertainty of day-to-day practice.
Under the new GP contract, PCTs have taken on new roles.
Enhanced services, in particular, are seen by PCTs as a golden opportunity to drive forward patient choice, access and the management of secondary care demand. But with power comes responsibility. PCTs have to ensure that 'patients are offered the range of services they enjoyed under the previous contract' and to secure the provision of services in areas including childhood immunisation, influenza/pneumococcal immunisation and minor surgery.
The dilemma for a PCT medical director is balancing change against an awareness that hasty service developments may be as detrimental to patients as poor clinical care by frontline clinicians. But having a choice does not necessarily mean better quality.
Patients may decide to have warfarin treatment monitored by near patient testing in the community or have their skin lesion excised in general practice. But if the warfarin monitoring service has not signed up to the quality control scheme or the skin lesion is not submitted for examination, patients are being short-changed. Improving care access is imperative and yet setting access targets has meant that many patients have been unable to book appointments more than a day in advance.
The healthcare environment is complex: doubts have to be expressed and the possible consequences of clinical or managerial decisions have to be considered.Whether I am working as a GP or as a PCT medical director, the only real certainty is that I will get it wrong sometimes.
Dr Nick Summerton is a GP and reader in public health and medical director of Yorkshire Wolds and Coast PCT.