July Focus

David Jewell

One of my colleagues has found a use for the BJGP. He keeps it by his bedside as an infallible cure for his insomnia: a few minutes reading and he is fast asleep. Flicking through this month's issue many readers might share his reaction, feeling there is little new here to engage them. The nature of research is often not to break new ground, but to challenge or confirm previously held views.

The trial on page 511 has tested in primary care the value of near-patient testing for glycated haemoglobin. The immediate reaction of an impartial reader might be to wonder why anyone would ever think such an intervention would work, but that was the evidence from studies in secondary care. One reason that such results were not confirmed was that the baseline control of the participants in Khunti's study was already better than expected. The paper emphasises both the importance of not assuming that results produced in secondary care studies will always apply in primary care and, in the discussion, the need for cautious interpretation of the results.

A study from the Netherlands on page 504 looks at the drug regimes of elderly patients. Not surprisingly, they found a lot of drugs being prescribed (755 for 102 patients), and numerous ‘points of concern’. Even more surprising was that some of the changes recommended by the study's panel of experts involved prescribing more, not fewer, drugs. The same point is made in Jeff Aronson's leader on page 484, where he points out the need to distinguish between many drugs and too many drugs.

The study of the economics of nurse practitioners on page 530, drawing on data from a number of trials, has confirmed that having them provide front line care ‘is likely to cost the same or slightly more than employed doctors.’ A slightly odd conclusion to set alongside all the recent attempts to cast NHS doctors as the villains of our current financial crisis.

Several of the papers deal with the value of personal relationships that we take for granted. The views of patients consulting with psychological problems reported on page 496 are clear. The authors conclude that it is ‘essential to establish a working relationship in which the patient feels listened to and understood’, and that ‘patients [were] helped by clear explanations of their difficulties, particularly somatic manifestations of anxiety and depression’.

The patients with type 2 diabetes (page 488) even suggested better adherence and monitoring if the doctor was known to them, but there was also some evidence of the risks of too much familiarity. When it comes to dealing with patients suffering from more rare diseases, personal continuity may mean better support for patients able to act as experts (page 518). GPs continue to value personal continuity, but the general views they expressed in another Dutch study didn't seem to coincide with their views at each individual consultation (page 536).

Here in the UK, as the editorial on page 483 points out, the difficulties of trying to provide good personal continuity have just been accentuated by the contractual formula, which puts so much higher value on biomedical aspects of care, even as such research studies are at last providing the evidence to support what was previously a widely cherished belief.

The worry, of course, is that we only find what was really valuable once it has been lost. One mundane example is the way that we can lose effective protection against infectious illness by relaxing our vigilance — see the account of a mumps outbreak on page 526. Potentially much more profound are the changes that could accompany the forthcoming changes in England, with PCTs contracting with different private organisations to provide primary care.

On page 541 Ashley Liston shares his anxiety that all the hard work of the past few years will benefit a private carpetbagger. No doubt the new organisations will bring some benefits, but the benefits of the kind of personal and local commitment described won't be quantified until they have been dissipated. Like home delivery, whose benefits (despite what Neville Goodman says on page 551) are generally established and accepted, but no longer widely available to pregnant women in the UK. Stick to punctuation, Goodman!

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