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 (QoF) 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

The QoF system can however have unpredictable effects. A study of Shropshire patients found that whilst an overall in glycaemic control of diabetic patients was achieved, smaller practices were able to deliver certain diabetic care targets better than larger practices.³

• 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 found a generalised improvement in the care of diabetic patients after the introduction of QoF.⁴ 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.⁵
• One 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.⁶ Another found that the introduction of QoF has been associated with better and more equitable management of coronary heart disease across ethnic groups⁷ and in a narrowing of the gap in standards of care of hypertensive patients in the least and most deprived areas of the UK.⁸
• Nurses working to local or national protocols provide high-quality structured care and this reduces the chance of omissions.⁹
• Primary care clinics are cost-effective compared with most interventions in healthcare.¹⁰ One study of nurse-led coronary heart disease and chronic heart failure patients considered that they delivered a cost-effective service when measured in Quality of Life Years (QALYs).¹¹
• The introduction of structured care leads to the institution of disease registers. On a wider scale these can contribute to information about national disease prevalence.¹²

• The reality does not always match the theory and claims regarding benefits may be unrealistic. Primary care can only do so much and one study found that whilst improving the quality of primary care services led to modest reductions in demand for hospital services among older diabetic patients with diabetes, low neighbourhood socioeconomic status was more strongly associated with hospital admission rates.¹⁴
• 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

.