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Apologies (again) to our overseas readers, but this month the focus is on revalidation. It has been a long time coming. Ever since I started working as a GP nearly 30 years ago (and long before Harold Shipman's crimes came to light) it was inevitable that we should have to introduce some procedure to reassure our patients that we remained competent, as opposed to being able to say that we were, once upon a time. Even so, rumblings are being heard from disgruntled GPs, worried at the prospect of having to seek retraining, alarmed at the amount of work involved, or just disgruntled at having to jump through even more hoops. The RCGP launched its provisional plans for revalidation in April, and the whole package will be in place in April next year, or possibly later with the difficulties of getting all the relevant staff in post still to be overcome.
On page 476 Martin Marshall describes the history and the package now being piloted. For him the key to the project's success is for GPs to assume ownership, and not to perceive it as foisted on them. While approving the scheme overall he points out some of the unanswered questions. There is a need for quality assurance of the whole nationwide package, and the group from Scotland report one method (page 484), though as with the whole package, this will require real resources. My own concern is whether the process will be good enough to identify the ‘unacceptable’ GPs, but here also two authors with experience of existing systems report that problems are obvious to assessors, and offer the idea that GPs lack of insight can be a major factor (page 550).
Comorbidity is one of the areas that has begun to concern GPs and is likely to stay on the radar for some years. The study on page 503 has looked at the needs of patients with learning difficulties who developed cancer, and it makes for sobering reading. It's a depressing catalogue of some old familiar problems: late diagnosis; poor communication; and well-meaning carers assuming that they know how to act in the best interest of the patients. It's not exclusively about how primary care fared with these particular patients, but it does pose a challenge to us all. Another challenge is with the after-care of cancer, only it is generally felt that the business of review belongs with secondary care. We're publishing two systematic reviews on the subject this month. The one comparing primary and secondary care follow-up found no differences in all the outcomes examined, and found a few pointers to increase primary care involvement (page 525). However, the second suggests that patients welcome the reassurance of regular follow-up from the secondary care centre which they recognise as the source of expertise (page 533). No doubt there are ways of squaring this particular circle, but they don't jump off the page. The leader on page 482 points out some areas where primary care is likely to be better placed to answer patients' needs but also concludes all too depressingly, that the evidence base to inform this crucial area of health care is ‘currently weak’.
Those GPs who are already feeling overworked may wonder at the keenness of the reviews' authors to take on additional work. It's easy to blame the patients for being too willing to want to consult us, and we need reminding occasionally how much self care goes on; how much thought goes on between experiencing symptoms and fetching up in our consulting rooms. The study on page 490 is such a corrective, showing the lengths patients go to in order to avoid having to see their doctors (and that with symptoms that I reckon would have me demanding emergency care within minutes). The study on page 496 gives one explanation, with patients showing how important it is for them not to be seen to be wasting doctors' time. The study is striking too for the personal attribution, with time only being wasted by other patients, never by oneself. The editorial on page 478 is a reminder that we have to see the process of such decision making through patients' eyes, and appreciate the irrational as well as the rational components if we are going to be able to understand what they want from us.