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‘And what should they know of England who only England know?’
R Kipling – The English Flag 1892
Some RCGP members who recently answered a survey about their reading habits (and many thanks to all who did so), expressed surprise about the numbers of papers we publish that come from overseas. They concluded that this shows how easy it is to get a paper published in the BJGP and that there are simply not enough from the UK to fill the journal. Not so. The aim is to be an international journal — we cannot survive if we only publish papers coming from the UK, and it is an oddly parochial view to believe we have nothing to learn from primary care elsewhere, or indeed to give to the rest of the world (page 437).
This month, for instance, we have a study from Belgium documenting a striking reduction in the incidence of peptic ulceration, with the rate of prescriptions for proton-pump inhibitors (PPIs) rising sharply in the same 10-year period (page 497). The authors are cautious about interpreting the data, although they are surely correct to suggest that such dramatic changes, over such a short period, are unlikely to be the result of biological changes. Nor is the answer fewer diagnoses being made as a result of better symptom control and therefore fewer endoscopies.
The rise of PPI prescriptions makes me wonder whether such effective drugs encourage us all to be less stoical about pain, but the report of endometriosis and how long the symptoms can be endured before the diagnosis is made would suggest otherwise (page 470). For peptic ulceration we seem to have moved from treatment of established disease to treatment of symptom patterns. The study of smokers from the Netherlands (page 477) makes a similar point, emphasising that physical functioning correlates better with overall quality of life than objective measures of lung function.
Back here the contract for GPs continues to preoccupy us and to be a focus for much research. On page 441 Ashworth and colleagues report that over the 2 years of its operation, the gap in QOF scores between practices in least and most deprived areas narrowed, but didn't completely disappear. The average difference is small, and this is against a background of the practices in the most deprived areas having higher list sizes per full-time equivalent GP.
A study from Shropshire (page 483) reports steadily improving indicators of care for patients with diabetes while the new contract has been in operation, although the authors admit they cannot be sure the QOF formula is solely responsible. The study on page 455 with a wider geographical spread and a longer timescale finds that moving from oral agents to insulin improved control, and the change from pills to insulin should be considered earlier in the course of the disease. However with diabetes, as with every other illness, we are always dealing with individuals, and the study on page 461 underlines the importance of understanding individuals and their beliefs. Particularly striking is the section in this paper on fear, denial, and acceptance of complications, which shows a very wide range of views (page 466).
Emyr Gravell on page 514 fears the consequences of reducing patients and their problems to sets of numbers, but it's only one of the unintended consequences of the current contract. Iain Carey and colleagues (page 486) have noted a fall in the reported rates of coronary heart disease that they attribute to data cleaning following the introduction of the new contract. Since the purpose of the contract was to reduce the rate of heart disease, some might be tempted to claim it as an unexpectedly early result of the contract's effectiveness. Or perhaps not. On page 449 there is the suggestion that improvements in the quality of care for conditions where incentives exist have not been accompanied by improvements elsewhere. Paul Hodgkin echoes this with his account of trends in child health on page 505. There is the worry that some activities, most notably staff training which was previously protected by ring-fenced funding, may be threatened by current arrangements which, as one colleague with a long memory recently pointed out, threaten to return us to the dark days of the pre-1966 contract (page 439). But for the fiercest attack on the contract turn to the editorial on page 435. Nothing to add really, except to remind anyone reaching for their keyboard that the BJGP has editorial independence and these are not necessarily the views of the RCGP.