Plus ça change … 35 years ago I was working as the equivalent of a specialist registrar in renal medicine, a small part of an exceptional team of physicians and transplant surgeons in south London. We were pushing what were then the boundaries of renal medicine by including diabetic patients with end-stage kidney failure on the dialysis and transplant programme. For many reasons, particularly macrovascular disease and the threat of infection, diabetics were a very high-risk group, and the only other major centre offering them treatment at that time was in Minneapolis, US. Our concerns included diagnosis and prognosis, a number of ethical questions, and the importance of communication and concordance in managing the complexities of immunosuppression and insulin therapy. Our Lancet paper1 showed that for each individual patient, the decay graph of successively-plotted inverse serum creatinine measurements followed an individual straight-line course, enabling prediction of and preparation for end-stage disease. One of my bosses was concerned about the ethical issues related to pancreatic transplantation and asked me to bring this up when I travelled to Minneapolis to visit the renal programme. I raised the matter with a senior surgeon who replied, with some force ‘Goddammit Roger, it's unethical to say it's unethical!’, which I thought was an interesting analysis. And I can still vividly remember the type 1 diabetic in his mid-30s, at end-stage kidney failure, who, on the ward round at King's, when we wanted to discuss transplantation with his family, confessed that he had concealed his insulin dependence from his wife for several years.
These topics all remain salient today, and in this issue of the Journal we look at a range of aspects of renal disease, starting with a powerful message from the NHS Renal Czar and colleagues about the importance of an open, honest discussion of the diagnosis of chronic kidney disease (CKD). Two Research papers in the Journal examine this topic — McIntyre and colleagues have identified a low level of awareness of the diagnosis of CKD among patients, while Blakeman's study from Manchester explores the underlying difficulties faced by clinicians in sharing the diagnosis with their patients. We report on the predictive power of a renal failure risk calculator, QKidney®, and also present data from Julia Hippisley-Cox and Carol Coupland on the predictive ability of various factors to stratify patients for their risk of renal tract cancer.
In the context of current debates about generalism, integration, and skill mix in delivering cost-effective health services, it may be worth reflecting on the similarities, rather than the differences, between specialist and general medical practice. In common with many other long-term, serious conditions, the management of CKD demands continuity and coordination of care, underpinned by a strong, respectful relationship between doctors and patients, the avoidance of paternalism, and an inclusive approach that takes account of the family and social contexts of illness; these attributes of practice are not, and should not be claimed to be the exclusive preserve of primary care.
In a challenging editorial Alan Maynard looks at the meaning and impacts of private provision of health services, warning Clinical Commissioning Groups about the care that they will need to exercise in contracting with any provider, and also re-visits the ‘Nicholson challenge’ of cost reduction to allow services to be sustained during a period of zero financial growth. His article is nicely counter-pointed by a cautionary tale about the Private Finance Initiative in a south-west London hospital redevelopment.
Two excellent articles concern the training needs of general practice — Bill Irish and Mark Purvis take a hard look at the ways in which speciality and general practice training places are distributed, and need to change — while John Goldie and Jill Morrison make a strong case for a more appropriately situated GP training programme. It is clear that any vision of a 21st century NHS has to accommodate a major shift in the balance between hospital and community-based practice, and the concomitant re-balancing of training patterns.
The Review includes the work of two giants — William Carlos Williams, the early 20th century North American family doctor–poet, has a new biography which speaks to us from a long-forgotten era when US GPs did house calls — and Lucian Freud, of whom Frank Minns paints a less than flattering portrait. I can't help thinking that there is more than a touch of the grandeur of Rembrandt's late self-portraits about Freud's unflinching, entirely unflattering, examinations of himself and his other sitters.
- © British Journal of General Practice 2012
