David Jewell

A randomised controlled trial of flexibility in routine antenatal care

Objective To assess changes in satisfaction associated with a flexible approach to antenatal care schedules offered to women at low obstetric risk.

The views and anticipated needs of women in early pregnancy

Objective To assess the expectations of antenatal care of pregnant women at the outset of pregnancy.

Helping parents identify severe illnesses in their children : Baby Check may not do this but it can improve the quality of a consultation

General practice p 1740 The management of sick children is both a microcosm of primary care and a test of its success—if we cannot get this right we cannot justify any claims to excellence. General practitioners see lots of children, and most of them have minor, self-limiting illness. The fourth national morbidity survey reports a consulting rate of 4.97 for children aged 4 and under, a rate exceeded only by those aged 75 and over. When the illnesses are classified as minor, intermediate, or serious the consulting rate for minor illness is the highest of any age group.1 General practitioners have the task of dealing with this high volume of work quickly and efficiently, without overtreating the children or making parents feel they have been the victims of perfunctory or, worse, incompetent care. At the same time, and most important of all, they must be able to identify the small numbers of children with serious illness. For many general practitioners the amount of time that work with minor illnesses takes up, among adults as well as children, is a …

Work patterns in UK general practice: turning the clock back?

The 1966 contract for UK GPs can be judged to have brought about a remarkable renaissance in primary care. For those unfamiliar with the history, it is worth recalling what it was like before then. Most practices were single-handed, and there was no incentive to invest in staff or premises. GPs were memorably faced with the choice of maximising their income by looking after large lists of patients, or having smaller lists, employing staff, and investing in their premises and surviving on lower incomes. Significantly, the 1966 contract marked the end of the ‘assistant with a view’. These were doctors unable to get a practice of their own, and employed by existing doctors ‘with a view’ to taking over the practice in due course. Such doctors ended up trapped, waiting for a partnership that came late or not at all, and working for another doctor at a lower rate of pay. The 1966 contract introduced a fee structure with a number of different elements, specifically rewarding doctors working in partnerships, providing generous arrangements for investing in premises, and reimbursement for employing staff. Over time, much of this complex structure has been eroded, first with the 1990 contract, followed by personal medical services (PMS) contracts. The 2004 changes found in the new general medical services (GMS) …

Asthma care in general practice.

Mark Levy is to be congratulated for completing the review of asthma deaths.1 However in the way that they take a narrow specialist perspective, the recommendations seem to have been written by specialist physicians rather than primary care generalists. Specialist asthma clinics were largely abandoned both because the profusion of different …

Commissioning maternity care: little room for manoeuvre?

![][1] At the time of writing, the Bill set to ‘reform’ the NHS is shortly to be debated in the House of Commons. Gazing into the uncertain future, it seems inescapable that GPs in England will collectively be taking on at least part of the responsibility for commissioning medical care. In this months BJGP , three papers, all studying different aspects of maternity care, illustrate some of the questions that commissioners are going to have to grapple with when that happens. Pierce and colleagues report a study where clinicians were asked about their follow-up of women who had experienced gestational diabetes mellitus.1 Not surprisingly, the authors identified considerable variety in practice, and found that the guidelines from the National Institute for Health and Clinical Health (NICE) were not being followed consistently. Non-compliance with authoritative guidelines is a familiar finding, and such a conclusion raises again the vexed question of precisely what guidelines are, and how far clinicians are expected to follow them.2 The question will still be a live one for clinicians, though it may not trouble commissioning groups much. Where NICE gives very clear instructions it is very likely that they will be followed to the letter in commissioning contracts. The particular guidelines that are the starting point for this study include specific recommendations for gestational diabetes: not to screen routinely by urine analysis for glucose; also for a 6-week follow-up with a single fasting blood glucose and not a glucose tolerance test. They should therefore be welcomed, since they limit activity rather than encourage more.3 NICE has also … [1]: /embed/graphic-1.gif

Books: The State Of Medicine: The Gulf Between Policy and Implementation

The State of Medicine Margaret McCartney Pinter & Martin, 2016, PB, 272pp, £11.99, 978-1780664002 Nobody who follows the news in Britain, and most especially anyone who has had to use the system recently, can be unaware of the current problems facing the NHS. Those of us who have worked in the NHS over the last 15–20 years are all too familiar with the long history of reorganisations, wasteful initiatives, ill thought out policies, and simple errors. And here they all are, set out in densely referenced detail. Margaret McCartney’s latest book is a truly impressive achievement in the scope and unblinking gaze it fixes on our travails. Even more impressive, it was an easy read, with little that I didn’t know already, and almost nothing to disagree with. …

Palestine: a week in November

The Occupied Palestinian Territories (population 4.5 million) has no system of postgraduate training for family practice. Primary care is provided by GPs without specific training and specialists based in the community. The hero of this story, Dr Samar Musmar, is a Palestinian who was trained and licensed as a family practitioner in Florida, and has returned to her first home to build specialist family medicine there. An invitation for her to speak at a Society of Academic Primary Care meeting in 2011 and then at a ‘dangerous ideas’ session at the Royal College of General Practitioners conference in Glasgow in 2012 sparked off a commitment from some UK doctors to support her efforts. With Samar having set up a training programme for 19 primary care doctors, the first step was to plan an intensive 1-week …

Observation: After the ball is over

> ‘ The tumult and the shouting dies The Captains and the Kings depart … ’ > > Rudyard Kipling (1865–1936) So will the glorious, heart-warming success inspire a generation? And if so which generation? One abiding lesson from watching numerous interviews with those who did and …

The QOF, NICE, and depression.

In his defence of the depression parts of the QOF, Alan Cohen also unwittingly illustrates some of the problems of the whole process.1 For instance, when he states that patients like the use of questionnaires, it is because ‘they feel as though their symptoms are being taken seriously’, not because he can quote more substantive evidence that it makes a difference to harder outcomes. Too much concentration on process and not outcomes. Note that Dr Cohen is not claiming GPs are taking the symptoms more seriously; the implication is that the designers …