Primary Care Clinics

The last decade has seen an increase in the incidence of chronic disease in the UK, and the trend looks likely to continue. This is partly due to a reduction in communicative diseases, an increase in diabetes, obesity and hypertension, and an increase in the average age of the population.The Government's strategy in response to this trend - which has been mirrored by other countries in Europe - is to encourage more patients with chronic diseases to be managed in primary care.¹ It backed up its aspirations with investment in primary care via the Quality and Outcomes Framework established as part of the new GP contract in 2004. Castlefields Health Centre is a notable example of a practice which provides structured care for the majority of its patients with chronic disease via primary care clinics.²

• Patients attending chronic disease primary care clinics do as well as, and for some clinical parameters better than, patients attending specialist hospital clinics. One study compared diabetic patients attending either a hospital clinic or a primary care clinic, and found that both cohorts did equally well in terms of cholesterol HbA1c and blood pressure reduction. The primary care cohort lost more weight.³
• Another study looking at care provided by 42 general practices found a signficant improvement in clinical outcomes in coronary heart disease, asthma and type 2 diabetes over a 5 year period.⁴
• Nurses working to local or national protocols provide high-quality structured care and this reduces the chance of omissions.⁵
• Primary care clinics are cost-effective compared with most interventions in healthcare.⁶

• The reality does not always match the theory, and claims regarding benefits may be unrealistic.
• Some management initiatives are untested, and once established, clinics may be difficult to disband despite lack of benefit.
• Channelling the majority of management through a primary care clinic may restrict patient autonomy and choice.
• Primary care clinics may be seen in the secondary sector as a threat to the 'whole systems approach' and there may be concerns about disinvestment in specialist hospital services.

• Well-woman/well-man clinic
• Antenatal clinic
• Elderly medicine clinic
• Hypertension clinic
• Smoking cessation clinic
• Citizen's advice clinic
• Clinic for non-English speaking patients
• Osteoporosis clinic
• Diabetes mellitus clinic
• Asthma clinic

Some activities in a well-woman clinic

• Smoking and alcohol advice
• Cervical smear and breast examination
• Safer sex advice for HIV
• Breast examination/mammography
• Family planning/sterilisation
• Pre-conception counselling
• Diet and weight
• Blood pressure
• Rubella and tetanus vaccination
• Discussion of HRT issues

Diabetic clinic

Most Primary Care Organisations have produced their own local protocol. An example of the initial assessment of the type 2 diabetic patient follows:

Education

• Explain basic condition and discuss patient concerns
• Give out information pack
• Introduce primary care team

• Past medical history
• Family history
• Drugs

• Height, weight, body mass index (BMI), blood pressure
• Feet - pulses, callosities, skin changes, sensation with monofilament
• Visual acuity (dilated fundoscopy if competent)

Investigations

• Urinalysis for proteinuria
• HbA1c, urea and electrolytes, creatinine, liver function tests, thyroid function
• Fasting lipid profile (if abnormal repeat when glycaemic control improved)
• Electrocardiograph if hypertensive
• Calculate cardiovascular risk score

• Dietary intervention for 6 to 12 weeks before medication considered
• Refer to dietitian
• Smoking status and smoking cessation advice / referral
• Half hour of moderate intensity physical activity most days of the week, ideally daily

• Record date of diagnosis and enter on register
• Monitoring advice (urine or blood glucose)
• Metformin as first line
• Consider adding low dose aspirin
• Consider statins soon after diagnosis if 10 year cardiovascular risk >15%
• Refer to eye screening programme
• Agree goals

• Fasting blood glucose <7mmol/L, post-prandial <7 mmol/L, HbA1c 6.5 %-7.5%
• BP <140/80 mmHg
• BMI <25
• Cholesterol <5.0 mmol/l, low density lipoproteins (LDL) <3.0 mmol/l, triglycerides <2.2 mmol/l

Asthma clinic

The basic elements of an asthma clinic protocol are as follows:
Initial Assessment

• Asthma history
• Height
• Weight
• BMI
• Smoking habits
• Peak flow rate (PFR)
• Predicted PFR
• Severity assessment - daytime symptoms, nighttime symptoms, emergency hospital treatment
• Spirometry referral