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There are two interlocking themes in this month's journal, about who does what, and how cost informs that debate. We're all familiar with the increasingly important role of nurses in primary care in the UK, and familiar with the papers some years ago that showed them to be effective, much appreciated by patients, but not significantly cheaper. Such conclusions are supported by the article on page 34, which detects an association between levels of nurse staffing and QOF scores.1 More important, it looks as if higher levels of staffing are also linked to some clinical indicators affecting real health outcomes. It's not clear that this is the result of nurses replacing or supplementing doctors; for myself I would opt for supplementing, supporting the general argument for more investment in primary care. In the Netherlands, it looks as if they are going for the same model. The RCT on page 40 compared the performance of nurses and GPs managing cardiovascular risk.2 The results didn't find much difference between the groups, and the general failure to achieve treatment targets looks disappointing. Patients in the nurses' group had lower level of blood cholesterol which, given the simplicity of prescribing cholesterol-lowering drugs, is a surprise, especially in the context of increasing prescribing rates over time of drugs to prevent further myocardial infarction (page 47). Crucially, and in contrast to the studies from the UK, nurses in the Netherlands are reported to be less costly than the GPs (page 28),3 although one assumes that such conclusions are sensitive to small changes in the length of consultations in both groups.
Last month we published an editorial by Colin Bradley challenging pharmacists to think again about the role they fill in primary care.4 This month there are two articles from a trial examining the results of enhanced pharmaceutical care for older patients, which between them present a picture of contrasting results.5,6 The main study (page 14) found that the enhanced care package had no significant effect on the primary outcome measure — a score measuring the appropriateness of medication prescribed. On the other hand, the economic analysis suggests that the package delivers some overall health gain in a cost-effective way (page 21). It's difficult to see how these two results can be reconciled, but I wondered whether pharmacists were providing a form of interpersonal care that could be measured on a QoL index, without having a more specific influence on drug regimes. The editorial on page 7 examines the contrast from a more analytical perspective, comparing the different methods of measurement used in the two papers. This is quite a tough read, but will repay the effort required. Apart from shedding light on the two RESPECT papers, it also offers an insight into the processes that NICE follows in arriving at its recommendations. On page 55 Peter Toon also applies the NICE approach to costs of regular CPR updates mandated in the QOF. He surprises himself by arriving at the conclusion that it may well be a cost-effective intervention. It's a surprise because of the rarity of the event (death from ventricular fibrillation) that we are trying to prevent. In effect it becomes a preventive action, where we have to accept an NNT — in this case hours of training to prevent one death — that is high, and which means that a lot of the activity has no positive outcome that we can discern. In that it is similar to coronary prevention, and on page 3 Alys Cole-King is suggesting a similar approach to suicide prevention, where we might prevent some, but not necessarily all, suicides with a much broader approach towards risk factors.
Apologies. The December Focus column should have been my last. Roger Jones takes over soon, but with a short interregnum it has fallen to me to complete this one. One of my partners, the one who has been quoted before as keeping the BJGP in his toilet, suggested leaving the space blank but, as I told him, this is journalism and whatever the content it looks better to put something in. This really should be my last contribution.