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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

Advantages
  • 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
Disadvantages7
  • 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.
Examples of clinics which are provided in primary care clinic
  • 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

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

History

Take full history to include:

  • Past medical history
  • Family history
  • Drugs

Examination



Investigations

Lifestyle advice

  • 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

Management

  • 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

Targets

  • 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

Education
Basic information about the causes and management of asthma.

Review This will be an opportunity to reinforce the educational messages, assess symptom severity, inhaler technique and medication.


Document references
  1. Hutton J - Speech by Rt Hon John Hutton MP, Minister of State (Health), 15 June 2004: British Association of Medical Managers AGM
  2. Castlefields Health Centre; The NatPACT programme: Chronic Disease Management 2004; Link to word document
  3. Ismail H, Wright J, Rhodes P, et al; Quality of care in diabetic patients attending routine primary care clinics compared with those attending GP specialist clinics. Diabet Med. 2006 Aug;23(8):851-6. [abstract]
  4. Campbell SM, Roland MO, Middleton E, et al; Improvements in quality of clinical care in English general practice 1998-2003: longitudinal observational study. BMJ. 2005 Nov 12;331(7525):1121. Epub 2005 Oct 28. [abstract]
  5. RCGP; Clinicians, services and commissioning in chronic disease management in the NHS. The need for coordinated management programmes - Report of a joint working party of the Royal College of Physicians of London, the Royal College of General Practitioners and the NHS Alliance (2004)
  6. Raftery JP, Yao GL, Murchie P, et al; Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomised controlled trial. BMJ. 2005 Mar 26;330(7493):707. Epub 2005 Feb 16. [abstract]
  7. Goodwing N; Disease Management in the European Context 2007; Powerpoint presentation

Internet and further reading Acknowledgements EMIS is grateful to Dr Laurence Knott for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 4137
Document Version: 21
DocRef: bgp747
Last Updated: 9 May 2007
Review Date: 8 May 2009










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PS - Health and Poverty

Perhaps the biggest cause of ill health in the world is poverty. Help to Make Poverty History. For example, why not lend some of your money to disadvantaged communities to enable them to trade their way out of poverty through schemes such as Shared Interest.

See also MAKEPOVERTYHISTORY North East for details and links to campaigns against poverty.

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