Yonder: Melanoma, child and family liaison, gastric bypass surgery, and QOF

Ahmed Rashid

doi:10.3399/bjgp17X689725

Yonder: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature

Melanoma.

The number of melanoma cases in the UK is increasing and it is a cancer where early diagnosis and treatment make a dramatic difference to patient outcomes. The reasons for delayed presentations are, as ever, complex. A recent research study from Leeds sought to measure the nature and duration of melanoma symptoms in a group of patients diagnosed with melanoma within the preceding 18 months and to identify the symptoms and barriers associated with a delay in presentation.¹ They distributed questionnaires to a random sample of 200 patients, of whom 159 responded. The most commonly reported presenting symptom was ‘a mole growing bigger’ and this was the only symptom significantly associated with delay. The authors argue that patients find it challenging to identify concerning changes because even normal moles can change and benign lesions also commonly develop on ageing skin. Promoting public awareness about changing skin lesions, they suggest, is much needed.

Child and family liaison.

Liaison roles are increasingly being used to improve communication between healthcare services and professionals, and to enable access to support for individuals and families in need. Little is known about these roles in community-based child and family health services. A recent Australian research study sought to explore the characteristics and functions of a nursing liaison role in child and family health services in Australia, interviewing 40 professionals in total.² Their findings highlight three key components to the role: being a ‘bridge’ between services and professionals, providing direct support to families, and providing support for clinicians. However, they also highlight that the liaison role is limited by the skills and training of the nurses, resistance from other professionals, and limited funding.

Gastric bypass surgery.

As obesity rates soar and the evidence base supporting the use of gastric bypass surgery grows, it is likely to be an increasingly common management option in the decades ahead. However, although it has been shown to have positive effects on a variety of physical conditions, concerns have been raised about adverse psychiatric outcomes. A Swedish research team recently examined the risk of self-harm, hospitalisation for depression, and death by suicide after gastric bypass surgery using a nationwide cohort study of 22 539 patients.³ They found that the increased risk of post-surgery self-harm and hospitalisation for depression were mainly attributable to patients who have a diagnosis of self-harm or depression before surgery. Primary care clinicians referring patients for this type of surgery should systematically be identifying vulnerable individuals with a history of self-harm or depression, and considering how they can be best offered adequate mental health support in the postoperative phase. Furthermore, this research raises questions about the extent to which existing mental health conditions should be a consideration when choosing which individuals should be offered surgery,

QOF.

The rationale for the QOF pay-for-performance system is that GPs’ gatekeeper roles make them extremely important to overall NHS performance and that income is an important motivating factor. However, as financial incentives become greater, negative effects such as loss of intrinsic motivation and cheating become important. There is a balance to be found between incentives sufficient in size to positively change behaviour, but not so large as to induce unintended effects. A Manchester research team recently examined whether changes in GPs’ job satisfaction before and after the introduction of the QOF scheme in 2004 were correlated with the proportion of their income that became exposed to the scheme.⁴ They studied 1920 GPs using a bespoke linked dataset that they created by linking QOF data with the GP Worklife Survey. They found that the proportion of income exposed to QOF did not relate to job satisfaction or other aspects of working lives. Policies that influence the proportion of income linked to QOF, they conclude, would be unlikely to make a difference to GP satisfaction.

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