Essential Primary Care E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: essentials
• Sprache: Englisch

Seitenzahl: 1120

Veröffentlichungsjahr: 2016

Beschreibung

Essential Primary Care aims to provide undergraduate students with a comprehensive overview of the clinical problems encountered in primary care. It covers the structure of primary care in the UK, disease prevention and the management of common and important clinical presentations from infancy to old age. Case studies are used in every chapter to illustrate key learning points. The book provides practical advice on how to consult with patients, make sense of their symptoms, explain things to them, and manage their problems.

Essential Primary Care is structured in five sections:

• The building blocks of primary care: its structure and connection with secondary care, the consultation, the process of making a diagnosis, prescribing, and ethical issues
• Health promotion
• Common and important presenting problems in roughly chronological order
• Cancer
• Death and palliative care
• Gives advice on how to phrase questions when consulting with patients and how to present information to patients
• Provides advice on how management extends to prescribing - often missing from current textbooks
• Contains case studies within each chapter which reflect the variety of primary care and provide top tips and advice for consulting with patients
• Supported by a companion website at www.wileyessential.com/primarycare featuring MCQs, EMQs, cases and OSCE checklists

Leseprobe

Table of Contents

Cover

Title Page

Contributors

Foreword

Preface

How to use your textbook

Features contained within your textbook

About the companion website

Part 1: The key features of primary care

CHAPTER 1: The structure and organisation of primary care

What is primary care?

Organisation of primary care in the UK

What can be done in primary care?

CHAPTER 2: The GP consultation

The consultation in general practice

The effective consultation

Structuring a consultation (process and content)

Preparing for the consultation

Gaining rapport

Agreeing on the purpose of the consultation

Gaining knowledge about the issues through questioning

Gaining knowledge about the patient through examination

Gaining knowledge about the patient’s perspective

Gaining knowledge about the patient’s context

Understanding: what is going on and what do we do about it?

Reaching a shared decision and aiding the patient’s understanding

Reflecting on our consultation skills

CHAPTER 3: Making a diagnosis

What is a diagnosis?

Science and art in diagnosis

Diagnosis-making as ‘labelling’

Models of diagnosis-making

Processes for reaching a diagnosis

Pitfalls of the diagnostic process

Preventing diagnostic errors

Learning to make a diagnosis

CHAPTER 4: Prescribing

Introduction

The cost of prescribing

Adherence

Safe prescribing using the 10 steps

Prescribing errors

Reporting adverse drug reactions

CHAPTER 5: The interface with secondary care

Introduction

Referring patients to secondary care

Admitting patients to hospital

Discharge from hospital

CHAPTER 6: The everyday ethics of primary care

Introduction

Concepts in medical ethics

Core values in primary care

Responsibilities of the GP

Approaching ethical issues

Five case studies in everyday ethics

Part 2: Healthy living and disease prevention

CHAPTER 7: Behaviour change

The role of the GP in health behaviour change

Barriers to health behaviour change

Assessing readiness to change

Brief motivational interviewing

Taking action: goal-setting

Relapse

CHAPTER 8: Alcohol and drug misuse

Identifying patients whose alcohol consumption is problematic

Helping people whose level of alcohol consumption is harmful

Detoxification and relapse

The role of the GP in helping people who misuse drugs

CHAPTER 9: Preventing cardiovascular disease

The burden of cardiovascular disease

Estimating the risk of a patient developing cardiovascular disease

Smoking cessation

Blood pressure

Cholesterol reduction

CHAPTER 10: Caring for people with learning disabilities

Types of learning disability

Inequalities of health experienced by those with a learning disability

Conducting a consultation with someone who has a learning disability

Common problems in people with a learning disability

Annual health checks for people with a learning disability

Supporting carers

Part 3: Common presenting problems

CHAPTER 11: Tiredness

Tired all the time

Thyroid disease

Type 2 diabetes mellitus

Anaemia

Chronic fatigue syndrome

Childhood

CHAPTER 12: Child health in primary care

The healthy child

Screening and developmental reviews

Immunisations

Consulting with children

Child health promotion

Vulnerable families and children at risk

Child abuse

CHAPTER 13: Managing the feverish and ill child in primary care

Assessment of the ill child in primary care

Red flags and assessing the likelihood of serious illness

Childhood fever

Dehydration in children

Antibiotic use and parental expectations

Coughs, colds and influenza

Sore throat in children

Earache in children

Urinary tract infections in children

Suspected cancer in children

CHAPTER 14: Managing common conditions in infancy

Introduction

Assessing growth in infants

Rashes, jaundice and skin problems

Feeding, vomiting and crying

Sleep and preventing sudden infant death

Prematurity

CHAPTER 15: Managing chronic conditions in childhood

Recurrent wheeze and asthma

Acute asthma in children

Eczema in children

Glue ear (chronic otitis media)

Recurrent abdominal pain and constipation

Bedwetting

Behavioural issues in children

CHAPTER 16: Teenage and young-adult health

Consulting with teenagers

Confidentiality and consent

Puberty

Drugs and alcohol

Mood

Eating disorders

Early adulthood

CHAPTER 17: Respiratory tract infections

Coughs and colds

Lower respiratory tract infections: bronchitis and pneumonia

Sinusitis

Sore throat: pharyngitis and tonsillitis

Glandular fever

CHAPTER 18: Low back pain

The burden of back pain

Assessing back pain in primary care

Nerve root pain (radiculopathy) assessment and management

Other causes of back pain

Managing chronic nonspecific back pain

CHAPTER 19: Heartburn and dyspepsia

Definition of heartburn and dyspepsia

Diagnosing and managing heartburn

Diagnosing and managing dyspepsia

CHAPTER 20: Diarrhoea and rectal bleeding

Causes of diarrhoea

Conducting a consultation about diarrhoea

Irritable bowel syndrome

Rectal bleeding

CHAPTER 21: Common skin conditions

Introduction

Inflammatory dermatoses

Psoriasis

Acne

Other inflammatory dermatoses

Pigmented lesions

Common skin infections

CHAPTER 22: Headache

Types of headache

Causes of headache that should not be missed

Giant-cell arteritis (temporal arteritis)

Carbon monoxide poisoning

CHAPTER 23: Fits, faints and funny turns

Transient loss of consciousness

Epilepsy

Dizziness

CHAPTER 24: Depression, anxiety and self-harm

Introduction

Definition

Epidemiology

Diagnosis

Variations in presentation

Management

Controversies in depression and anxiety

Personality disorder, depressed mood and recurrent self-harm

CHAPTER 25: Sexual health and dysuria

Sexually transmitted infections: a historical perspective

Dysuria and urinary tract infections

Vaginal and penile discharge

Sexual health epidemiology and sexual health services

Taking a sexual history in primary care

The National Chlamydia Screening Programme

Other sexually transmitted infections

Bloodborne sexually transmitted infections

CHAPTER 26: Menstrual problems, contraception and termination of pregnancy

Introduction

The menstrual cycle

Taking a menstrual history

Common menstrual problems

Postponing menstruation

Assessing contraception needs

The combined oral contraceptive pill

Progesterone-only methods of contraception

Postcoital contraception

Termination of pregnancy

CHAPTER 27: Pregnancy

Preconceptual advice

Subfertility in primary care

The antenatal screening programme

Common problems in the second and third trimesters

The onset of labour

Problems in the puerperium

CHAPTER 28: Domestic violence and abuse

What is domestic violence and abuse?

The scale of the problem

Health impact

Asking about domestic violence and abuse

Responding appropriately to disclosure

Offering referral

Children exposed to domestic violence and abuse

Middle and old age

CHAPTER 29: Cardiovascular disease

Introduction

Atrial fibrillation

Angina

Myocardial infarction

Strokes and transient ischaemic attacks

Peripheral arterial disease

CHAPTER 30: Breathlessness

Introduction

Acute breathlessness in primary care

Diagnosing and managing chronic asthma

Chronic breathlessness

Diagnosing and managing left ventricular failure

Diagnosing and managing chronic obstructive pulmonary disease

CHAPTER 31: Joint pains and stiffness

Osteoarthritis

Rheumatoid arthritis

Polymyalgia rheumatica

CHAPTER 32: Urinary problems and prostate disease

Haematuria

Haematospermia

Lower urinary tract symptoms in men

Urinary incontinence

Testicular problems

Erectile dysfunction

CHAPTER 33: The menopause

Symptoms of the menopause

Identifying the menopause

Managing menopausal symptoms

Hormone-replacement therapy preparations

Postmenopausal bleeding

CHAPTER 34: Multimorbidity and polypharmacy

Epidemiology of multimorbidity

The impact of multimorbidity on patients, GPs and the health system

Managing patients with multimorbidity

Polypharmacy

CHAPTER 35: Falls and fragility fractures

Falls

Osteoporosis and bone protection

CHAPTER 36: Visual and hearing loss

Identifying people with visual problems

Assisting people with visual loss

Common causes of visual loss

Conditions that require immediate action to prevent sight loss

Assessing someone who complains of poor hearing

Wax and ear-syringing

Conducting a consultation with someone who has a hearing loss

CHAPTER 37: Dementia

Diagnosing dementia

Finding the cause of dementia

Giving the diagnosis

Creating a power of attorney and a will

Supporting the family and carers of those with dementia

Creating the right environment at home

Medication for dementia

Monitoring patients with dementia

Part 4: Cancer

CHAPTER 38: Spotting patients with cancer

Introduction

The common risk factors for cancer

The role of screening

The National Awareness and Early Diagnosis Initiative

Defining the predictive value of symptoms, signs and tests

Rarer cancers

Missing a diagnosis of cancer in primary care

CHAPTER 39: Looking after patients with cancer

The role of the GP in the treatment of patients with cancer

Other problems encountered by patients with cancer

Cancer survivorship

Spotting patients who have a recurrence of their cancer

Surveillance of patients with cancer

Part 5: Palliative care and death

CHAPTER 40: Palliative care and death

What is palliative care?

Identifying those in need of palliative care

Symptom relief in palliative care

Allowing natural death

After death

Bereavement

Self-care

Index

End User License Agreement

List of Tables

Chapter 01

Table 1.1 Facts and figures on primary care workforce in NHS, England, 2014.

Table 1.2 The practice team.

Table 1.3 The wider primary care team.

Chapter 02

Table 2.1 Consultation models.

Chapter 03

Table 3.1 Examples to illustrate the use of the term ‘diagnosis’.

Table 3.2 Examples of scoring systems used to make diagnoses.

Table 3.3 Predictive value of symptoms by disease prevalence.

Table 3.4 Examples of pathognomonic symptoms and signs.

Table 3.5 Tips for avoiding cognitive errors.

Chapter 04

Table 4.1 Medicines available over the counter.

Table 4.2 People who are exempt from prescription charges in England.

Table 4.3 10 stages of prescribing.

Table 4.4 Routes of administration of drugs.

Table 4.5 Latin abbreviations commonly used on prescriptions.

Table 4.6 Medicines that need monitoring with blood tests.

Table 4.7 Markers of dangerous/poor prescribing.

Chapter 05

Table 5.1 Factors associated with referral rates.

Table 5.2 Risk groups to whom influenza vaccine is offered every year.

Table 5.3 The discharge summary.

Chapter 06

Table 6.1 The four-principles approach.

Chapter 07

Table 7.1 Benefits of health behaviour change.

Table 7.2 Behaviour change consultations.

Table 7.3 Exploring reasons to change.

Table 7.4 Enabling a patient to make changes.

Chapter 08

Table 8.1 Problems caused by alcohol.

Table 8.2 Scoring AUDIT-C.

Table 8.3 Interpreting the AUDIT questionnaire.

Table 8.4 Investigation of abnormal LFTs.

Table 8.5 Crude death rates before, during and after opiate substitution therapy.

Chapter 09

Table 9.1 Summary of antihypertensive medication.

Chapter 10

Table 10.1 Causes of learning disability.

Table 10.2 Physical problems that are more common in people with Down’s syndrome.

Table 10.3 Things to cover in an annual health check.

Chapter 11

Table 11.1 Causes of tiredness.

Table 11.2 Principles behind dietary advice for someone with type 2 diabetes.

Table 11.3 Annual review of a patient with type 2 diabetes.

Table 11.4 Medicines for lowering blood glucose.

Table 11.5 The common and important causes of anaemia.

Table 11.6 Causes of microcytic, normocytic and macrocytic anaemia.

Table 11.7 Tests to use when investigating the cause of anaemia.

Chapter 12

Table 12.1 Taking the history at the 6–8-week check.

Table 12.2 The physical examination in the 6–8-week check.

Table 12.3 UK childhood immunisation schedule.

Table 12.4 Recognising child abuse.

Chapter 13

Table 13.1 History in the unwell child.

Table 13.2 Vital signs to check in an unwell child.

Table 13.3 Identifying serious illness in infants.

Table 13.4 Viruses and rashes.

Table 13.5 Causes of persistent or recurrent fever in children.

Table 13.6 Assessing and managing a dehydrated child.

Table 13.7 When should antibiotics be used?

Table 13.8 Commonly implicated microbes in common RTIs.

Table 13.9 Childhood cancers in primary care.

Chapter 14

Table 14.1 Underlying causes of failure to thrive.

Chapter 15

Table 15.1 Eczema treatment escalator for increasing severity of disease.

Table 15.2 Assessing functional abdominal pain.

Table 15.3 Diagnosing and managing functional constipation in children.

Table 15.4 Assessing children’s behaviour.

Table 15.5 Diagnosing ADHD.

Chapter 16

Table 16.1 Stages of puberty (based on Tanner’s stages).

Table 16.2 Causes of delayed puberty.

Table 16.3 Assessing eating disorders in primary care.

Chapter 17

Table 17.1 FeverPAIN scoring system for sore throat.

Chapter 18

Table 18.1 Definition of low back pain.

Table 18.2 Management of serious causes of back pain.

Chapter 19

Table 19.1 Medicines that can contribute to dyspepsia and reflux symptoms.

Table 19.2 Alarm symptoms in dyspepsia and uninvestigated reflux.

Table 19.3 Differential diagnosis of chronic dyspeptic symptoms.

Chapter 20

Table 20.1 Causes of diarrhoea.

Table 20.2 Issues to ask about in someone who presents with diarrhoea.

Table 20.3 Medication used for managing IBS.

Chapter 21

Table 21.1 Common dermatology terminology.

Table 21.2 Mechanism of actions of different acne treatments.

Table 21.3 Assessment of acne severity.

Table 21.4 Treatment options for people with acne, according to severity.

Table 21.5 ABCDE checklist for melanomas.

Chapter 22

Table 22.1 International Headache Society’s diagnostic criteria for migraine without aura.

Table 22.2 Medication for preventing migraine.

Table 22.3 Features indicative of a serious diagnosis.

Table 22.4 Examination of someone with a headache.

Chapter 23

Table 23.1 Differentiating neurogenic syncope, cardiac syncope and epilepsy.

Table 23.2 Abnormalities on 12-lead ECG that suggest cardiac syncope.

Table 23.3 Classification of epilepsy.

Chapter 24

Table 24.1 Management of somatic symptoms associated with psychological distress.

Table 24.2 Biopsychosocial assessment.

Table 24.3 Stepped care for depression.

Table 24.4 Stepped care for generalised anxiety disorder (GAD).

Table 24.5 Thought distortions.

Table 24.6 Questioning negative thoughts: a process and a technique that can be learned.

Chapter 25

Table 25.1 Noninfective causes of dysuria in men and women.

Table 25.2 Infective causes of dysuria in men and women.

Table 25.3 Noninfective causes of abnormal vaginal discharge.

Table 25.4 Infective causes of abnormal vaginal discharge.

Table 25.5 Assessment of sexual health problems.

Chapter 26

Table 26.1 Causes of amenorrhoea.

Table 26.2 Comparing methods for contraception.

Table 26.3 Contraindications to the COC pill.

Chapter 27

Table 27.1 Giving preconceptual advice.

Table 27.2 Initial history-taking to assess infertility in primary care.

Table 27.3 Investigations and causes of infertility.

Table 27.4 Reference ranges for semen analysis.

Table 27.5 UK antenatal screening.

Table 27.6 Infectious diseases in pregnancy.

Chapter 28

Table 28.1 Potential presentations of DVA.

Table 28.2 What women who have experienced DVA say they want from clinicians.

Chapter 29

Table 29.1 CHA

2

DS

2

-VASc score.

Table 29.2 Colours of warfarin tablets in the UK.

Table 29.3 Deciding whether chest pain is cardiac in origin.

Table 29.4 ABCD

2

rule for assessing patients who may have had a TIA.

Chapter 30

Table 30.1 Causes of acute breathlessness in primary care.

Table 30.2 Review of heart failure in primary care.

Chapter 31

Table 31.1 Normal range of movement in hip.

Table 31.2 Comparison of osteoarthritis with rheumatoid arthritis.

Table 31.3 Annual review for patients with rheumatoid arthritis.

Table 31.4 Interpretation of DAS28 CRP score.

Table 31.5 Extra-articular manifestations of rheumatoid arthritis.

Table 31.6 Example of steroid regime for treating polymyalgia rheumatica.

Table 31.7 Differential diagnosis of shoulder pain and stiffness.

Chapter 32

Table 32.1 Causes of haematuria.

Table 32.2 Storage versus voiding symptoms.

Table 32.3 Differential diagnoses of testicular lumps.

Chapter 33

Table 33.1 Alternatives to HRT for vasomotor symptoms.

Table 33.2 Annual review of HRT.

Chapter 34

Table 34.1 The ‘NO TEARS’ mnemonic for rationalising a patient’s medications.

Chapter 35

Table 35.1 Assessment of someone who has recurrent falls.

Table 35.2 Risk factors for low bone mineral density.

Table 35.3 Fragility fractures.

Table 35.4 Results of Mrs Kaufman’s DEXA scan (Case study 35.1).

Table 35.5 Groups in which to consider calculating 10-year fracture risk.

Table 35.6 Investigating possible secondary causes of osteoporosis.

Chapter 36

Table 36.1 Certification of visual impairment.

Table 36.2 Medication for lowering IOP in glaucoma.

Table 36.3 Causes of hearing loss.

Chapter 37

Table 37.1 Comparison of different tests of cognitive function.

Table 37.2 Causes of delirium.

Table 37.3 Blood tests that should be done to exclude reversible causes of memory loss.

Table 37.4 Anticholinergic drugs.

Table 37.5 Components of an annual review of someone with dementia.

Chapter 38

Table 38.1 Risk factors for cancers.

Table 38.2 Screening timetable.

Table 38.3 Symptoms, signs and test results requiring urgent investigation for suspected cancer

Chapter 39

Table 39.1 Side effects of treatment for breast cancer.

Table 39.2 Side effects of treatment for prostate cancer.

Chapter 40

Table 40.1 Symptom relief in palliative care.

Table 40.2 Features of opioid toxicity.

List of Illustrations

Chapter 01

Figure 1.1 Training pathway for GPs in UK.

Figure 1.2 Consultations in primary care.

Chapter 03

Figure 3.1 Normal distribution.

Figure 3.2 The diagnostic process used by an experienced clinician.

Figure 3.3 Heneghan’s three stages to making a diagnosis.

Chapter 04

Figure 4.1 FP10 prescription form.

Chapter 06

Figure 6.1 ‘Stress in Medical Practice’ by Jack Day. Medical practice can be emotionally exacting, and we all need ways to nurture our emotional health as practitioners.

Figure 6.2 ‘Postcodes: Are They a Prescribing Destiny?’ by Rachel Murphy. This artwork reflects on the differences in funding for fast-track cancer referrals in different UK regions – an artistic take on the principle of distributive justice.

Figure 6.3 ‘Disability in Healthcare’ by Fatima Rashed. Accessibility is a core value of general practice, and practices must take active steps to prevent a person’s disability (seen or unseen) from blocking access to care.

Chapter 08

Figure 8.1 Interplay between alcohol, mental illness and life events.

Figure 8.2 Signs of alcoholic liver disease.

Chapter 09

Figure 9.1 Devices for measuring blood pressure: (a) desktop anaeroid sphygmanometer; (b) portable anaeroid device; (c) automatic device.

Figure 9.2 Key steps in measuring blood pressure.

Chapter 10

Figure 10.1 Physical characteristic linked to Down’s syndrome.

Figure 10.2 Physical characteristics linked to Fragile X syndrome.

Chapter 11

Figure 11.1 Classical symptoms of hypothyroidism.

Figure 11.2 Options when trying to lower blood glucose.

Chapter 12

Figure 12.1 Assessing for congenital dislocation of the hips.

Chapter 13

Figure 13.1 Examination of the unwell child.

Figure 13.2 The recovery position.

Figure 13.3 Acute otitis media (AOM): an inflamed eardrum.

Chapter 15

Figure 15.1 Facial atopic dermatitis.

Chapter 17

Figure 17.1 Sinusitis.

Figure 17.2 How to apply topical nasal treatments. This can be done in two positions. Insert the nozzle into the nostril and angle at 30°.

Chapter 18

Figure 18.1 Sciatica caused by compression of the lumbar nerve roots.

Chapter 19

Figure 19.1 Causes of heartburn and dyspeptic-like symptoms.

Chapter 21

Figure 21.1 Psoriatic plaques on the trunk.

Figure 21.2 Closed comedones.

Figure 21.3 Inflammatory papules and pustules in acne.

Figure 21.4 Rosacea.

Figure 21.5 Superficial spreading melanoma.

Figure 21.6 Oncychomycosis.

Figure 21.7 Verruca.

Figure 21.8 Impetigo.

Chapter 22

Figure 22.1 ‘Another Wasted Day’.

Chapter 23

Figure 23.1 Hallpike manoeuvre.

Figure 23.2 Epley manoeuvre.

Chapter 24

Figure 24.1 Patient Health Questionnaire-9 (PHQ-9). A score of >10 has 88% sensitivity and specificity for identifying a major depressive disorder. The score increases with severity of depression. Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.

Chapter 25

Figure 25.1 Urine testing strip, showing positive for nitrites (pink) and leucocytes (purple).

Figure 25.2 Percentage of STIs diagnosed in young people (16–24 years), United Kingdom, 2008.

Figure 25.3 Diagnoses of uncomplicated chlamydia infection in genitourinary clinic by sex and age group in the United Kingdom, 1999–2008.

Figure 25.4 Genital warts.

Figure 25.5 Genital herpes.

Chapter 26

Figure 26.1 A cervical ectropion.

Chapter 27

Figure 27.1 Pruritic urticarial papules and plaques of pregnancy (PUPPP) on abdomen.

Chapter 28

Figure 28.1 Factors associated with violence against women.

Figure 28.2 Crime Survey for England and Wales 2011/12.

Chapter 29

Figure 29.1 ECG showing atrial fibrillation.

Figure 29.2 Results of Doppler study for Case study 29.3 (Mr Rudman).

Chapter 30

Figure 30.1 COPD treatment flowchart in primary care.

Chapter 32

Figure 32.1 Investigation and referral of haematuria.

Figure 32.2 Prostate examination.

Figure 32.3 Treatment options for women with urinary incontinence.

Chapter 34

Figure 34.1 Number of chronic disorders by age group.

Figure 34.2 Selected comorbidities in people with four common important disorders, from the most affluent and most deprived decile.

Chapter 36

Figure 36.1 Snellen chart.

Figure 36.2 Audiogram showing age-related hearing loss in the right ear.

Chapter 37

Figure 37.1 Attempt by a patient to draw a clockface showing the time at half past four.

Chapter 38

Figure 38.1 Brush and pot used for cervical screening.

Figure 38.2 Flow chart for dealing with the result of cervical screening in England.

Figure 38.3 Possible causes of delay in cancer diagnosis.

Figure 38.4 Top 10 cancers in men and women in the UK (by incidence).

Chapter 40

Figure 40.1 Causes of death.

Figure 40.2 Trajectories of decline. Diagnosis to death.

Figure 40.3 Transition from active treatment to palliative care.

Figure 40.4 The analgesic ladder.

Figure 40.5 Cause of death on a death certificate.

Guide

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This book is dedicated to

Mina, Robbie and Laura Blythe

Walter, Sam, Isobel and Rufus Buchan

With our love

Andrew Blythe and Jessica Buchan

This title is also available as an e-book.

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Essential Primary Care

Edited by

Andrew Blythe

General Practitioner at Gaywood House Surgery, Bristol;Director of Assessments and Feedback for the MB ChB Programme,Faculty of Health Sciences, University of Bristol

Jessica Buchan

General Practitioner;Teaching Fellow, University of Bristol

This edition first published 2017 © 2017 by John Wiley & Sons, Ltd

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Library of Congress Cataloging-in-Publication Data

Essential primary care / edited by Andrew Blythe, Jessica Buchan.  p. ; cm. Includes bibliographical references and index. ISBN 978-1-118-86761-7 (pbk.)I. Blythe, Andrew, 1965–, editor. II. Buchan, Jessica, editor. [DNLM: 1. Primary Health Care–Great Britain. W 84.6 FA1] RA440 362.1071422′6–dc23

         2015033626

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

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Contributors

All of the contributors are practising GPs and are members of the Centre for Academic Primary Care at the University of Bristol.

Andrew BlytheSenior Teaching Fellow

Jessica BuchanTeaching Fellow in Primary Care

Polly DuncanAcademic Clinical Fellow

Gene FederProfessor of Primary Care

Alastair HayProfessor of Primary Care

Sarah JahfarTeaching Fellow in Primary Care

Lucy JenkinsTeaching Fellow in Primary Care

David KesslerReader in Primary Care Mental Health

Barbara LaueSenior Teaching Fellow in Primary Care

Matthew RiddConsultant Senior Lecturer in Primary Care

Trevor ThompsonReader in Healthcare Education

Simon ThorntonAcademic Clinical Fellow

Foreword

For many medical students, the first place they will encounter patients will be in general practice. Later in their course, they will have extended attachments to practices and will have the chance to consult with patients themselves. The experience can be exciting and interesting, but also a bit overwhelming. Patients come to the GP to talk about anything and everything. They present with physical, psychological or social problems, and sometimes all three types of problem at once. They do not turn up and describe a neatly packaged problem, but often have a jumble of symptoms which don’t obviously correspond to any of the anatomical or physiological systems. How can a medical student know where to start when faced with such a wide range of potential problems?

This book is designed to help medical students and doctors in training for a career in general practice by providing an essential guide. If you know what the patient is likely to be coming to discuss, reading about the topic beforehand can help you feel prepared. But one of challenges of general practice is that you rarely know in advance what problem you are going to be faced with. If you read the relevant section of this book after seeing a patient, it will help you to make sense of what you have just encountered. Many students find that it’s much easier to remember about a medical condition if they read about it soon after experiencing a real case.

All of the chapters in this book have been written by colleagues from the Centre for Academic Primary Care involved in teaching medical students at the University of Bristol. The content and the approach reflect their many years of teaching medical students at all stages of the curriculum. The content is practical and pitched at an appropriate level, but is also evidence-based.

General practice is the first point of contact with the health service for most people when they become ill. It accounts for the vast majority of patient–doctor contacts, with about a million consultations in general practice every working day in England. GPs are trusted more than any other group of professionals. General practice is also the most common career destination for medical students, so it’s important that they have every opportunity to make the most of their attachments in primary care.

My hope is that this book will inspire students and doctors in training to gain a better understanding of the variety, challenge, responsibility and enjoyment of working in general practice.

Chris SalisburyProfessor of Primary Health CareHead, Centre for Academic Primary CareUniversity of Bristol

Preface

This book is written primarily for medical students. It grew from the teaching of primary care that we give to our students at the University of Bristol, from their first year through to their final year of study. All the authors are GPs who work within the Centre of Academic Primary Care at the University of Bristol. We hope this is a book which students will want to refer to throughout their time at medical school and in their foundation years. For those who choose to enter general practice as a career, it should be helpful during their time as a GP registrar.

Studying primary care can seem daunting because it encompasses the entire breadth of medicine: from birth to death, from minor to life-threatening illness. It considers the social, physical and psychological aspects of health and disease. So, where should you start? The purpose of this book is to provide a basic grounding, giving a realistic perspective of what is common, without focussing on detail at the expense of missing the big picture. It is designed to provide practical advice on how to consult with patients, make sense of their symptoms, explain things to them and manage their problems.

We have tried to make the chapters enjoyable and easy to read. They contain case studies which reflect the variety of primary care and top tips for consulting with patients. In the case studies, we present the reader with questions about what to do next and then offer advice. The online version of this book also contains an extensive range of self-test questions (best-of-five questions, extended-matching questions, true/false questions and scenarios for objective structured clinical examinations) which should help to consolidate the reader’s learning and prepare them for their undergraduate exams, including finals.

The book has five parts. Part 1 covers the building blocks of primary care: its structure and its connection with secondary care, the consultation, the process of making a diagnosis, prescribing and ethical issues. Part 2 deals with some key topics in health promotion. Part 3 deals with patients’ problems in roughly chronological life order. Part 4 is on cancer and Part 5 discusses death and palliative care.

You don’t have to read all the chapters in order. You should be able to dip into sections at any stage of your learning. For example, if you are going on a GP attachment and have not yet studied child health, the chapters in this book should be enough to get you started and help you to get the most out of your attachment. Re-reading these chapters should provide you with a solid foundation for your revision. Each chapter has a list of references which, if you want to pursue a topic in greater depth, should be a good place to start.

Writing any book is a major undertaking, and this one was no exception. In addition to all our co-authors, we are particularly grateful to Barbara Laue for helping with the final reading. Most of all, we are very grateful to our families for all the support and time they have given throughout the long gestation. This book is dedicated to them.

Andrew Blythe and Jessica BuchanBristol

How to use your textbook

Features contained within your textbook

Every chapter begins with a list of Key topics and of the chapter’s Learning objectives.

Key topics give a summary of the topics covered in the chapter.

Learning objectives describe the main learning points in the chapter.

Top tips highlight key information to be aware of.

Case studies give further insight into real-life patient scenarios.

Your textbook is full of illustrations and tables.

The website icon indicates that you can find accompanying self-assessment resources on the book’s companion website.

About the companion website

Don’t forget to visit the companion website for this book:

www.wileyessential.com/primarycare

There you will find valuable material designed to enhance your learning, including:

Cases

EMQs

MCQs

OSCE checklists

PowerPoint slides of all the figures from the book, for you to download.

Scan this QR code to visit the companion website:

Part 1The key features of primary care

CHAPTER 1The structure and organisation of primary care

Andrew Blythe

GP and Senior Teaching Fellow, University of Bristol

Key topics

What is primary care?

Organisation of primary care in the UK

What can be done in primary care?

Learning objectives

Understand the benefits of a health service that is based on primary care.

Understand the scope and limitations of primary care in the UK.

Appreciate how primary care is evolving in the UK.

What is primary care?

Primary care is first-contact care provided by health care professionals to local populations. Primary care attempts to manage the health needs of individuals within these defined populations in a coordinated, comprehensive and continuous fashion from birth until death. Because patients present with unsorted problems, primary care health care professionals must be generalists who have an expert understanding of the causes of health and illness throughout a person’s life.

In many countries primary care provides the foundation upon which the rest of the country’s health system is built. This is certainly true in the UK. Everyone in the UK is entitled to register with a local general medical practitioner (GP). Once registered, the person is entitled to consult with a GP or nurse in the practice to which that GP belongs as often as they like. Most of the time, the GP is able to manage the patient’s problem within the primary care team. Sometimes, the GP needs to refer the patient to the next tier of the health service – secondary care – for further investigation and treatment. In so doing, the GP acts as a ‘gatekeeper’ to the rest of the National Health Service (NHS), ensuring appropriate use of more expensive secondary care services, which are normally based in hospital.

The importance of primary care

The importance of having a strong primary care sector in every country was highlighted by the World Health Organization (WHO) in 1978 at an international conference at Alma-Ata, in what is now known as Uzbekistan.1 The Alma-Ata declaration set out the aspiration of providing health for all by a primary care-led service. Here is its definition of primary care:

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.

Article VI, Alma-Ata Declaration, WHO, 19781

The aspirations of the Alma-Ata declaration have not yet been fully realised, but many countries are attempting to improve the health care that they offer their citizens by building a stronger base in primary care. China, for example, aims to train a further 300 000 GPs over the next 10 years, so that there will be 1 GP for every 3000–5000 people.2

The last 2 decades have seen the publication of a lot of evidence suggesting that countries which have a strong primary care sector have better health care outcomes. Professor Barbara Starfield, from the Johns Hopkins School of Public Health in the USA, published a seminal paper on this topic in 1994,3 in which she ranked developed countries according to their health care outcomes and the strength of their primary care services. Countries which had the most developed primary care services had the best health care outcomes. The USA, which had the least developed primary care system at the time, had the worst health care outcomes. In the same paper, Professor Starfield showed that the countries which spent the least per capita on health care were the countries which had the most developed systems of primary care.

A more recent analysis of data from 31 European countries4 has confirmed that health care outcomes are better in those countries which have a strong primary care base, as measured by the density of primary care providers and the quality of their environment. However, this analysis has not confirmed that these better outcomes are provided more cheaply. Today, countries in Europe which have well-developed primary care services tend to spend a larger proportion of their gross domestic product (GDP) on health than countries with less robust primary care services. According to the World Bank, in 1995 the UK spent 6.8% of its GDP on health; by 2012, it was spending 9.4%.5

Knowing the patient

In hospitals the diseases stay and the people come and go; in general practice, the people stay and the diseases come and go.

Iona Heath, Past President of the Royal College of General Practitioners6

One of the central features of primary care in the UK has been the relationship between the patient and ‘their GP’. Patients are registered with a GP for years (the mean is 11 years), and in this time GPs often get to know their patients well. GPs’ knowledge of their patients helps them with diagnosing and addressing the patients’ worries. When a new diagnosis is made, patients want to know why and how it has happened to them. Knowledge of the patient makes it easier for the GP to provide this explanation and help the patient chose the best plan of action.

In many instances knowing the person who has the disease is as important as knowing the disease that person had.

James McCormick7

Case study 1.1 may help to explain why knowledge of the patient is so important in primary care.

Case study 1.1

Stephen Stockman is a 60-year-old widower who works on the railways. He is on treatment for high blood pressure. Recently, he saw the practice nurse for a blood pressure check; it was high, so the nurse told him to consult his GP. Last week he also went to see his optician for a routine eye check and was told that he might need referral to the Eye Hospital because the appearance of the back of his right eye indicated that he might have glaucoma. He hasn’t noticed any change in his vision.

What finally prompts him to make an appointment with the doctor is neither of these things: it’s the fact that he has a cough that has gone on for 3 weeks. He could have made an appointment to see one of the other doctors in the practice a bit sooner, but he decides to wait for the next available appointment with his usual GP, Dr Jones. When he comes to the GP, he starts out by mentioning the cough.

How does the GP’s prior knowledge of this patient help to sort out these problems?

Dr Jones got to know Mr Stockman well when his wife was dying of lung cancer. Dr Jones made regular home visits to provide palliative care and issued the death certificate. Afterwards, she had a few consultations with Mr Stockman to support him through his bereavement. The GP established a strong, trusting relationship with Mr Stockman.

Knowing that his wife died of lung cancer, Dr Jones suspects Mr Stockman is worried that his cough is the first sign of cancer, so she takes particular care to check out this possibility.

Dr Jones holds the entire set of medical records for Mr Stockman, dating back to childhood. Dr Jones knows when Mr Stockman was diagnosed with hypertension and has records of the medication he has tried so far and the tablets he had to stop because of side effects. Thus, Dr Jones is in the best position to decide what new or additional tablet Mr Stockman could try to control his blood pressure better.

Amongst the medical records are all the consultant letters from visits to hospital. One of the letters is from a consultant whom Mr Stockman saw at the Eye Hospital 6 years ago. In this letter, the consultant describes the same appearance of the right fundus that the optician is describing now. The consultant had ruled out glaucoma. Mr Stockman had forgotten this.

Organisation of primary care in the UK

The UK has a national network of GP practices. All GP practices operate as independent small businesses that are subcontracted by the NHS to provide primary care services to specified geographical areas. There are restrictions on the number of practices in a given area. In many parts of the country, particularly in urban areas, there are several practices with overlapping boundaries. Therefore, many patients have a choice about which practice they register with. Members of a given household tend to be registered with the same practice, but this is not always the case. About 98% of the UK population is registered with a GP.

The GP workforce

The number of full time-equivalent GPs in the UK has grown very slowly in recent years, but the way in which they have been organised has changed quite rapidly. The number of single-handed practices continues to fall, as practices merge and grow. All GPs used to work as partners, but a change to the GP contract in 2004 made it financially advantageous for partnerships to employ salaried doctors. Now, over a quarter of the GP workforce is salaried. The average number of patients registered per full time-equivalent GP is about 1500, but this is considerably smaller in rural areas, where the population is much more sparsely scattered. Other key statistics on general practice in England are presented in Table 1.1.

Table 1.1 Facts and figures on primary care workforce in NHS, England, 2014.

Source: NHS Workforce: Summary of staff in NHS: results from September 2014 census. 25 March 2015. www.hscic.gov.uk.

Number of full time-equivalent,

fully-trained GPs

32 628 (23 763 GP partners + 8 865 salaried/locum GPs)

Number of full time-equivalent nurses in general practice

15 062

Number of full time-equivalent other staff working in general practice

73 334

Number of practices

7 875

Average number of patients registered at each practice

7 171

Number of GPs per 100 000 patients

66.5

Before they can start work as independent GPs in the UK, doctors must complete 3 years of further training following the 2-year foundation programme. They must also pass the membership exam of the Royal College of General Practitioners (MRCGP). The Royal College of General Practitioners would like training for GPs to be extended to 4 years, and the Department of Health says it shares this aim. At present, the funds that would be needed to make this happen have not been identified. Figure 1.1 shows the current training pathway for GPs in the UK.

Figure 1.1 Training pathway for GPs in UK.

The practice primary care team

GPs employ many people in order to provide comprehensive care, including practice nurses, health care assistants, receptionists, secretaries, data clerks and practice managers. Their roles are summarised in Table 1.2.

Table 1.2 The practice team.

Member

Responsibilities

Practice nurse

Wound management, vaccinations, minor illness clinics, chronic disease clinics, cervical smears, contraceptive services

Health care assistant

Phlebotomy, weight-loss clinics, smoking-cessation clinics, health checks

Receptionist

Booking appointments, processing requests for repeat prescriptions

Secretary

Typing referral letters and reports, booking hospital appointments, chasing results, reports and appointments at hospital

Data clerk

Summarising notes, coding information in letters and discharge summaries

Prescribing advisor

Conducting audits, reviewing quality and cost-effectiveness of prescribing

Practice manager

Managing the team (human resources), managing practice accounts and contracts

Practice nurses

The role of the practice nurse expanded significantly when practices took on responsibility for a large part of chronic disease management. In most practices, it is the practice nurses who run the asthma, chronic obstructive pulmonary disease (COPD), hypertension and diabetes clinics, with support and advice from a GP.

Increased workload, resource constraints and changes to legislation have led to a blurring of boundaries between roles. Much work previously done by GPs has been taken up by nurses, and nurse tasks are being carried out by health care assistants (HCAs) and phlebotomists

Some practice nurses have had extended training and are able to write prescriptions and work as nurse practitioners; these nurses can run minor illness clinics and assist with running urgent surgeries.

An increasing volume of work in primary care is being undertaken by practice nurses; in 2008–09, practice nurses were doing 34% of all consultations. There is evidence to support this expansion of the nurse role: practice nurses are effective in giving lifestyle advice;8 they have been shown to be instrumental in improving outcomes in chronic diseases such as diabetes;9 and patient satisfaction with nurse consultations is high.10

Consultations with practice nurses are longer, which increases patient satisfaction but counterbalances the lower salary costs. As yet, there is no evidence that substituting GPs with nurses is cost-effective. GPs run shorter appointments, deal with several problems in a single consultation and have expertise in managing undifferentiated symptoms.

Attached to each practice or group of practices is a team of district nurses. Sometimes these nurses have a base in the same building as the GPs; sometimes they are located elsewhere. Patients can be referred to a district nurse by a GP or can refer themselves directly. District nurses provide medical care to patients who are housebound. Patients may be housebound temporarily, such as after a major operation, or they may be permanently confined to their houses, as the result of a disability or terminal illness. The district nursing service is under considerable pressure and is constantly exploring new ways of working. Most district nursing teams have a skill mix from the most highly trained and experienced community matrons to workers with less training, such as HCAs and phlebotomists.

A number of other professionals work in the community with the primary care team, but are usually based and employed outside the GP practice; these are listed in Table 1.3.

Table 1.3 The wider primary care team.

Member

Responsibilities

District nurses

Visit housebound patients to give palliative care, insulin and other injections and wound care

Community matron

Visit housebound patients and monitor patients with multiple chronic diseases; emphasis on admission avoidance

Health visitors

Provide advice to parents and conduct surveillance of children under 5, often focussed on those on the child protection register; some health visitors specialise in providing care to older people

Pharmacists

Give advice on and dispense medication

Drug and alcohol workers

Counsel those who want to come off drugs and/or alcohol; give advice to GPs on prescribing and caring for these patients

Physiotherapist

Assess and treat musculoskeletal problems

Podiatrist

Foot care, especially for patients with diabetes

Midwives

Antenatal, intrapartum and postnatal care

Dieticians

Assess diet of those with long-term illnesses and monitor total parenteral nutrition (TPN)

Occupational therapists

Provide home aids for people with disability

The demand for consultations

In England, about 340 million consultations take place in primary care every year; that’s about five to six consultations per patient per year. Consultation rates are much higher for young children and the elderly. Women consult more often than men.

All practices have to provide appointments between 8 am and 6.30 pm Monday to Friday. During these hours, practices have to offer a mix of urgent (book-on-day) slots and pre-bookable appointments for managing routine and ongoing problems.

There is constant pressure on GP appointments. Increased responsibility for managing chronic illnesses and more patients with multiple and complex problems have led to an increase in appointment length.

Many consultations are conducted over the telephone and some are done by e-mail. Figure 1.2 shows who provides the consultations in primary care and where they take place.

Figure 1.2 Consultations in primary care.

Surgeries are incentivised to provide appointments outside the hours of 8 am–6.30 pm: early morning, late evening and at weekends. Patient surveys show that there is demand for more of these appointments.

In an attempt to provide greater choice and convenience for patients, walk-in centres were set up in 1999. The distribution of walk-in centres across the UK is uneven. They are run by nurses, and most are open 365 days a year, but not for 24 hours. They offer an alternative for patients who have a minor ailment or injury. The nurses can prescribe medication for a limited number of conditions and emergencies, such as an asthma attack. Patient satisfaction with walk-in centres is high. Most of the people who use them are registered with a local GP surgery. Typically, they present to walk-in centres on the first day of their illness and are less concerned about continuity of care than patients who present to general practice.

Providing primary care out of hours

GPs used to be responsible for providing 24-hour care 7 days a week. The demand for care out of hours was considerable. A study by Salisbury in 2000 of 1 million patients in the UK11 showed that there were 159 requests for out-of-hours GP care each year for every 1000 patients. Amongst the under 5s, the rate was four times higher, and amongst people living in deprived areas, the rate was twice as high. In 2005, GPs were allowed to opt out of having 24-hour responsibility for their patients in return for a cut in pay. Since then, out-of-hours care, aimed at dealing with urgent problems only, has been managed by separate, independent providers who employ GPs to do this extra work. All the providers use a similar system of triage to manage the demand: patients are offered telephone advice, a face-to-face consultation in an out-of-hours centre or a home visit.

In 2013, the system of out-of-hours care changed again. Now, if a patient requests care out of hours, they must dial 111. A trained advisor or nurse takes their call and directs them to the most appropriate source of care. This might involve going to a pharmacist, going to accident and emergency or consulting with the out-of-hours GP provider.

The repeated changes to the provision of out-of-hours services and the introduction of walk-in centres has created confusion for patients. Out-of-hours care used to be reserved for urgent problems that could not wait until the GP surgery opened again. It is unclear if this is still the case. Should the NHS provide routine primary care round the clock? A similar question is being asked of secondary care.

What can be done in primary care?

Primary care in the UK has many resources at its disposal.

GPs can prescribe almost anything that is listed in the British National Formulary (BNF); 90% of all prescriptions are issued in primary care. GPs have a notional budget for their prescribing and are under pressure to stick to this. Trained pharmacists work within the practice as prescribing advisors to ensure cost-effective prescribing.

GPs can refer patients to almost any hospital in the UK through a national booking system called Choose and Book.

GPs have the right to admit patients to their local district hospital, where their care is transferred to a consultant. Some GPs also have access to beds in community hospitals, where they can continue to look after their own patients.

Record-keeping

GPs are the guardians of the entire set of their patients’ medical records. They are the only people who hold this record. When the NHS was created, it was decided that whenever someone is seen within the service, a report of that encounter should be sent to their GP. GPs used to keep all these reports in cardboard wallets together with their own paper records. Medical records are often fascinating historical documents, and tell a story of a patient’s life. Now all the letters are scanned and stored electronically. All GP practices have computer systems to hold their patient records. Initially, these computer systems were set up to cope with the volume of repeat prescriptions, but soon they were used to hold disease registers and the notes written by GPs at each consultation. Every component of the patient record can be coded, which means the records can be searched easily. For instance, with a few clicks, any practice can tell you how many patients they have who are taking a particular medicine and how many have had their blood pressure checked in the last 6 months. This is a powerful tool for research. This information is also sought by insurance companies, who want to know what risk they are taking on when offering life insurance. Patients, of course, have to give their permission for this information to be disclosed and have the right to withhold it.

Legal powers

GPs have considerable legal powers. They have the right to issue death certificates (see Chapter 40