General Practice: Still Waiting for Green-paper

General Practice: Still Waiting for Green-paper

361 cautious examination is required before we can advise the general population to increase dietary calcium intake and restore the pint of milk a da...

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cautious examination is required before we can advise the general population to increase dietary calcium intake and restore the pint of milk a day to its previous position as a component of the "healthy diet".

General Practice: Still

Waiting for Green-paper

December, 1984, The Lancet acknowledged the improvement in quality of general practice in the UK between 1959 and 1984, while lamenting the failure to IN

provide structured anticipatory care to "populations at risk" such as hypertensives, asthmatics, epileptics, and diabetics.’ Attention was focused on the extraordinary variability in standards of general practice, and on demands for accountability. Proposals for change were reviewed, including Hart’s new kind of doctor,2 the Royal College of General Practitioners’ (RCGP) quality initiatives, Varnam’s call for strategic planning and Robson’s case for a salaried service.4 And early 1985 was suggested as the likely publication date for the long-delayed Government green-paper on a new general practitioner contract, possibly linked to performance, which it was hoped would "be fashioned not only to save money, but also to secure better public health through more effective and accountable general practice". Although the green-paper was not published in 1985, expectation that this event might be imminent (allied to imposition of the limited list, memories of the battle over deputising services, and the recommendation in the RCGP consultation document of a link between performance and remuneration) stimulated much professional soul-searching under the implied threat: reform or be reformed. The RCGP quality initiative has been gathering momentum,’ but has met with charges of elitism.6 An article in this issue (p 370) from the planning subcommittee of a local medical committee (LMC) in Newcastle is therefore of great interest. It is more a manifesto than a local planning document, but it addresses many of the important issues which have surfaced in the absence of the green-paper and upon which progress towards better general practice depends. The Newcastle group identify five major problems in general practice-lack of direction, lack of accountability, poor measurement of outcome, inconsistency of service provision, and difficulty of reconciling the salaried community health service with an independent general practitioner service. Their solution is to make each practice collectively accountable to the family practitioner committee -

1 Editorial Towards better general practice. Lancet 1984; ii: 1436-38. 2 Hart JT. A new kind of doctor. J R Soc Med 1981; 74: 871-83. 3 Varnam MA Should general practitioners be planners? Br Med J 1982; 285: 479-80. 4 Robson J. Salaried service-a basis for the future? Br Med J 1981; 283: 1225-27. 5 Royal College of General Practitioners Quality in general practice. Policy statement 2 1985. 6 Towards quality 291: 987-88.


general practice. GMSC discusses RCGP

paper. Br

Med J 1985,

(FPC) for the attainment of agreed standards of acute, chronic, and anticipatory care. Standards would be set by the FPC in discussion with the LMC (as part of a strategic planning process) and in close liaison with health authority community services. Achievement would be monitored by establishment of a computerised information system linked to the FPC register, although the subcommittee could reach no consensus on the action to be taken should a practice fail to meet the required standard. A cogent argument is presented that the proposals could form the basis of a new contract for general practitioners. Is this simply a flight of fantasy? Although the tripartite structure of the National Health Service is a monument to the power of medical pressure groups who would oppose any contractual change, Dr J. Muir Gray has warned the profession against "mural dyslexia" (failure to see the writing on the wall). Need for an enhanced role for FPCs in performance review has already been voiced,5’ and the limited list has been imposed despite opposition from some quarters of the profession. Standards of professional competence are now specifically discussed in the revised GMC guidelines.8 Establishment of FPCs with management responsibility for the professional performance of general practitioners is therefore no longer a political

impossibility. How would it work in practice? There are three obstacles to the Newcastle plan. The first is most obvious-a minority of practitioners, especially those whose performance is inadequate, will never cooperate with a system of external review in the suggested spirit of "mutual enthusiasm and support". Although the concept of practice responsibility may diminish this problem, recalcitrant independent contractors are free to clone themselves by recruiting junior partners of similar outlook. Moreover, even where there is a desire to cooperate in formulating agreed treatment protocols, this is not easy. The difficulties of defining criteria of care for chronic conditions are well described by Watkins,9 who suggests that it is necessary to state specific objectives for each patient and base the audit on the extent to which these are met. Emphasis in defining standards might then be on questions to be asked rather than on treatment policies adopted. Secondly, as presently constituted, FPCs are administrative bureaucracies incapable of performing a true management function or servicing an information system. This is not to deny the enthusiasm of many FPC administrators for participating in performance review and taking "a more vigorous stance in administering contracts",’ but enthusiasm is not an adequate substitute for expert knowledge and resources. Lastly, most general practitioners have little 7 Parr CW. Performance

Contribution from the family practitioner committees. 460-61. 8. General Medical Council. Professional conduct and discipline: Fitness to practice. 1985. 9. Watkins CJ. Medical audit in general practice-fact or fantasy? J R Coll Gen Pract review:

J R Coll Gen Pract 1985; 35:

1981; 31: 141-45.


experience in population medicine; management of the preventive health programme and information system described will require further training and a substantial time commitment. Stocking1O argues that in the absence of extra resources it may be preferable for general practitioners to relinquish some patient contact for a role as "central manager and referral agency" within the practice. Clearly there is considerable scope for substituting less expensive (and in some instances more appropriate) manpower resources for many tasks currently undertaken by general practitioners." None of the obstacles is insurmountable, and some should be addressed for other reasons. However, ploughing money into FPCs to create the sort of management structure and proficiency that already exists in (often coterminous) health authorities would appear to be both exceptionally wasteful and extremely unlikely in the present economic climate. Reintegration of FPCs and health authorities would be the sensible option, not only to provide a viable management structure for general practice but also to secure the advantages of planned community health care which a closer relation between general practice and community medicine would allow.’2 Even if a new contract was established linking remuneration to performance monitored by FPCs or district health authorities, would it lead to an improvement in the quality of care? Preventive lends medicine itself to objective external assessment-it is possible to measure immunisation rates and screening coverage, for example, with the benefit of a computerised population register-and better care should follow. It is also probable that external audit of accessibility would be a major advance, especially in deprived urban areas. Nevertheless, external audit of disease management is not without difficulty. Lessons can be learned from the experience of recertification and peer review organisations in the USA.13 At best, external audit can monitor minimum standards, but the highest standards of care must ultimately depend on fostering enthusiasm and stimulating participation in education and research in general practice. continuing And good general practice demands qualities such as kindness and understanding which are not encompassed by performance indicators. The peer review procedure envisaged by the RCGP’4 appears to hold out the best chance of attaining this wider vision of quality of care, and would complement a more formal line of accountability. On balance, it seems likely that the people of Newcastle will benefit if their general practitioners are contractually required to provide services to agreed 10.

11. 12.

13. 14.

Which way general practice? A view from outside. Br Med J 1983; 286: 1400-02. Hart JT. Nurse practitioners: An underused resource? J R Coll Gen Pract 1985; 290: 1181. Mant D, Anderson P. Community general practitioner. Lancet 1985; ii; 114-17. Dans PE, Weiner JP, Otter SE. Peer review organisations: Promises and potential pitfalls. N Engl J Med 1985; 313: 1131-37. Royal College of General Practitioners. What sort of doctor? Report from general practice no 23. 1985.

standards of minimum performance, especially if the organisation to which the practitioners are accountable is not only equipped with teeth but also is capable of making a rational decision about whom to bite. But if we must wait for the end of the tripartite structure in order to achieve this, then perhaps "waiting for Greenot" is a more apposite description of where we stand.

RIBAVIRIN AND RESPIRATORY SYNCYTIAL VIRUS RIBAVIRIN is an investigational synthetic triazole nucleoside of value in the treatment of Lassa feverl and certain viral respiratory infections. First synthesised in 1972, it possesses an unusually broad spectrum of antiviral activity, inhibiting under laboratory conditions a wide variety of RNA and DNA viruses, including among respiratory viruses influenza types A and B, parainfluenza types 1, 2, and 3, respiratory syncytial virus (RSV), and possibly coronavirus. Its antiviral effect is expressed at various points in the replicative cycle but generally involves alterations of nucleotide pools and interference with the guanylation step required for 5’ capping of viral messenger RNA.22 Ribavirin has low cellular toxicity and is well tolerated by human beings, the primary adverse effects being haematological with raised unconjugated bilirubin levels in 25% of subjects on 1 g orally per day and an occasional drop in haemoglobin on 4 g daily. These effects are rapidly reversible and may be related to the accumulation of drug or metabolites in red blood cells. Ribavirin is embryotoxic and teratogenic in laboratory animals, though not in baboons. In temperate climates, RSV is the most frequent cause of acute lower respiratory tract disease in infants and young children. In Britain RSV accounts for yearly hospitaladmission rates of 12 - 5 to 24’ 5 per 1000 among infants aged 1-3 months;3 and in North Carolina it is responsible for 24-50% of all admissions for pneumonia in children under 5 years of age.4 In hospital roughly 14% of RSV-infected infants require intensive care and 5% need assisted ventilation.s Although the mortality from RSV infection is generally low, it is especially high in infants with underlying congenital heart disease (37%, rising to 73% with concomitant pulmonary hypertension),5 and in the immunocompromised (23%),6 and is almost certainly raised in infants with bronchopulmonary dysplasia and cystic fibrosis. Outbreaks among the elderly in nursing homes have also been associated with serious illness and a case fatality rate 7 as high as 53°7o has been reported. The efficacy of aerosolised ribavirin in RSV-infected infants has been examined mostly in double-blind trials involving normal children and those with underlying disease. In normal infants with illness for several days, therapy over 1. McCormick JB, King

IJ, Webb PA, et al. Lassa fever. Effective therapy with ribavirin

N Engl J Med 1986, 314:


2. Smith RA. Mechanisms of action of ribavirin In: Smith


Stocking B.


5. 6. 7.

RA, Kirkpatrick W, eds Ribavirin; a broad spectrum agent. New York: Academic Press, 1980: 99-118 Report to the Medical Council Subcommittee on respiratory syncytial virus vaccines Respiratory syncytial virus infection: admissions to hospital in industrial, urban, and rural areas. Br Med J 1978; ii: 796-98. Murphy TF, Henderson FW, Clyde WL, et al. Pneumonia: an eleven-year study in a pediatric practice. Am J Epidemiol 1981; 113: 12-21. MacDonald NE, Hall CB, Suffin SC, et al. Respiratory syncytial viral infection in infants with congenital heart disease. N Engl J Med 1982: 307: 397-400. Hall CB, MacDonald NE, Klemperer MR, et al Respiratory syncytial virus in immunocompromised children. Pediatr Res 1981; 15: 613. Communicable Disease Surveillance Centre. Respiratory syncytial virus infection in the elderly 1976-82. Br Med J 1983; 287: 1618-19.