We read with interest the paper by Baker et al exploring the interrelationship between size of hypertension register, GP provision, and access (defined as the ability to get an appointment within 48 hours), assessed in 8052 practices.1 It suggests a conundrum in primary care: the ‘better’ a practice’s recognition and presumably management of hypertension, the worse the access, given finite staffing resources. The same inverse relationship may apply in other chronic diseases such as diabetes mellitus, where the recognition of risk factors or disease in often asymptomatic individuals also leads to additional workload. As acknowledged by the authors, no information was available on how different members of the primary healthcare team are used, but it appears that, ‘an extra GP per 1000 patients would be associated with a 6% increase in detected hypertension’.
The study used data from 2008–09, preceding publication of the NICE 2011 guidelines on diagnosis of hypertension. Where implemented, these guidelines may impact on the size of hypertension registers due to the use of out-of-office monitoring to reduce the white-coat effect, therefore a reduction in inaccurate labelling and an associated reduction in future workload.2,3 Furthermore, alternate methods may have better answered the research question: use of structural equation modelling would have allowed the authors to model their whole conceptual framework simultaneously, allowing fuller account to be taken of the internal interactions.
Nonetheless, the study does provide data supporting the interesting hypothesis that there is insufficient capacity in primary care to provide both good access, as well as detection and on-going care for long-term conditions. Additional resources seem unlikely under current financial constraints but novel interventions such as self-management4 and more creative use of the primary healthcare team, as well as better diagnostic methods may mitigate these effects.
- © British Journal of General Practice 2013