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First, the plight of our elderly population in care: much has already been written on this topic in other journals and in the national press. Very little of this has touched upon matters of tissue viability. I am concerned by the prospect of the plans to increase the role and responsibility of the general practitioner (GP) in the NHS. With specific focus on our collective interests, the ‘failings’ of the current system do not inspire any confidence that much more of the same will bring improvements.

The ‘failings’ to which I refer are the standard of care of patients of all ages with tissue viability issues, and of the elderly with chronic conditions commonly associated with wounds. Precisely, sufferers with multiple sclerosis and similar at risk of, or suffering from pressure ulceration, those with diabetes with foot ulceration, elderly patients with leg ulcers, especially with coexisting lymphovenous oedema. There are more, but my attention is directed at these groups with particular emphasis on those in care, or being cared for, in their own homes in England.

The more I investigate and enquire, the more I see that GPs in general are largely ignorant of, and indifferent to, such patient groups. Ignorant, because of the woefully inadequate training in such pathologies. Indifferent, because of the time-consuming nature of the provision of adequate care. This latter point is compounded by the Quality and Outcomes Framework (QOF) system. This relies upon a points system depending on level of achievement for each of 146 clinical indicators.

The criteria are grouped into domains of clinical, organisational, patient experience and additional services. The criteria are designed around best practice and have a number of points allocated for achievement. The formula includes the number of patients and, in particular, the numbers diagnosed with certain common chronic illnesses. It was designed to stop the ‘haemorrhage’ of GPs out of the NHS (Bradshaw, 2008). Tim Burr (2008) of the National Audit Office has said: ‘There is no doubt that a new contract was needed and there are now 4,000 more GPs than five years ago’. However, having more GPs, more evenly spread throughout the country, does not necessarily make for better primary care.

The level of achievement recorded depends on the GP treating the patients with the relevant problem. In order for GPs not to lose points on account of circumstances that are ‘outside their control’, they can exclude those patients from counting towards their achievement by ‘exception reporting’ them.

This is allowed for:

  • 8 Patients who cannot, or refuse to attend
  • 8 Patients for whom chronic disease
  • reporting is inappropriate (e.g. terminal
  • illness, extreme frailty)
  • 8 Newly-diagnosed or recently
  • registered patients
  • 8 Patients who do not show improvement;
  • 8 Patients for whom prescribing a
  • medication is not clinically appropriate
  • 8 Patients not tolerating medication
  • 8 Patients refusing investigation or
  • treatment (informed dissent)
  • 8 Patients with supervening conditions
  • 8 Cases where diagnostic/secondary care
  • service is unavailable.


Those familiar with community tissue viability and ‘chronic’ wound care will immediately see that these criteria can (and do) include many such patients. Community tissue viability patients are often denied best clinical services but are rarely a subject of patient experience (PROMS) evidence. They are, in effect, disenfranchised in terms of primary care. Herein lies my main point, our patients in care (whether house-bound or
residential care) can readily be manipulated in residential care into meeting the criteria of exception reporting, thus abrogating the GP of the responsibility to deliver adequate care. According to Hart (1971), the availability of good medical care tends to vary inversely with the need for it in the population served.

This inverse care law operates more completely where medical care is most exposed to market forces. While this was
first stated 40 years ago, it still applies in a fashion today and, I believe, nowhere more evidently than in the patient population that I have outlined above.The responsibility for tissue viability services in primary care must be clearly established as a matter of urgency. GPs should be quite certain of their role in this respect.

References

Bradshaw B (2008) Fury as GPs get a 60% pay rise in three years for doing even LESS work. London Evening Standard. Available online
at: www.thisislondon.co.uk/news/article- 23444008-fury-as-gps-get-a-60-pay-rise-inthree- years-for-doing-even-less-work.do

Burr T (2008) Press Release — NHS Pay Modernisation: New contracts for general practice services in England. National Audit Office, London.

Hart, JT (1971) The Inverse Care Law. Lancet 1(7696): 405–12

This article first appeared in: Wounds uk, 2011, Vol 7, No 4

Written by Professor Richard White
Monday, 07 November 2011 12:12

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      AND access <= 1
  75. UPDATE `jos_session`
      SET `data` = '__default|a:7:{s:15:\"session.counter\";i:27;s:19:\"session.timer.start\";i:1330907045;s:18:\"session.timer.last\";i:1330911702;s:17:\"session.timer.now\";i:1330911706;s:22:\"session.client.browser\";s:89:\"Mozilla/5.0 (compatible; archive.org_bot +http://www.archive.org/details/archive.org_bot)\";s:8:\"registry\";O:9:\"JRegistry\":1:{s:7:\"\0*\0data\";O:8:\"stdClass\":0:{}}s:4:\"user\";O:5:\"JUser\":23:{s:9:\"\0*\0isRoot\";b:0;s:2:\"id\";i:0;s:4:\"name\";N;s:8:\"username\";N;s:5:\"email\";N;s:8:\"password\";N;s:14:\"password_clear\";s:0:\"\";s:8:\"usertype\";N;s:5:\"block\";N;s:9:\"sendEmail\";i:0;s:12:\"registerDate\";N;s:13:\"lastvisitDate\";N;s:10:\"activation\";N;s:6:\"params\";N;s:6:\"groups\";a:0:{}s:5:\"guest\";i:1;s:10:\"\0*\0_params\";O:9:\"JRegistry\":1:{s:7:\"\0*\0data\";O:8:\"stdClass\":0:{}}s:14:\"\0*\0_authGroups\";a:1:{i:0;i:1;}s:14:\"\0*\0_authLevels\";a:2:{i:0;i:1;i:1;i:1;}s:15:\"\0*\0_authActions\";N;s:12:\"\0*\0_errorMsg\";N;s:10:\"\0*\0_errors\";a:0:{}s:3:\"aid\";i:0;}}', `time` = 1330911706
      WHERE `session_id` = '7op7pud180fdav772gqv2ejns4'

32 Query Types Logged, Sorted by Occurrences.

SELECT Tables:
  1. 16 × select (b.id)id from jos_categories as a,jos_menu as b
  2. 8 × SELECT * FROM jos_categories
  3. 6 × select * from jos_content
  4. 6 × select (a.username)username,(a.email)email,(b.firstname)firstname,(b.lastname)lastname,(b.cb_org)cb_org,(b.cb_title)cb_title,(b.cb_jobtitle)cb_jobtitle,(b.avatar)avatar from jos_users as a,jos_comprofiler as b
  5. 5 × select * from jos_comprofiler
  6. 4 × SELECT extension_id AS "id", element AS "option", params, enabled FROM jos_extensions
  7. 2 × SELECT a.id as id,a.type as type,a.name as name,a.clickurl as clickurl,a.cid as cid,a.params as params,a.custombannercode as custombannercode,a.track_impressions as track_impressions,cl.track_impressions as client_track_impressions FROM jos_banners as a LEFT JOIN jos_banner_clients AS cl ON cl.id = a.cid LEFT JOIN jos_categories as cat ON a.catid = cat.id
  8. 2 × select id,title,catid,introtext,created_by from jos_content
  9. 1 × select * from jos_web_media
  10. 1 × SELECT m.id, m.title, m.module, m.position, m.content, m.showtitle, m.params, mm.menuid FROM jos_modules AS m LEFT JOIN jos_modules_menu AS mm ON mm.moduleid = m.id LEFT JOIN jos_extensions AS e ON e.element = m.module AND e.client_id = m.client_id
  11. 1 × SELECT * FROM jos_banners
  12. 1 × select * from jos_jcomments
  13. 1 × select * from jos_tag_term
  14. 1 × select * from jos_event_web as a inner join jos_web as b on b.id = a.webid
  15. 1 × SELECT id FROM jos_menu
  16. 1 × select (a.catid)catid,(b.level)level from jos_content as a, jos_categories as b
  17. 1 × select * from jos_web
  18. 1 × SELECT id, home, template, s.params FROM jos_template_styles as s LEFT JOIN jos_extensions as e ON e.element=s.template AND e.type='template' AND e.client_id=s.client_id
  19. 1 × SELECT * FROM jos_jcomments_setting
  20. 1 × SELECT m.id, m.menutype, m.title, m.alias, m.path AS route, m.link, m.type, m.level, m.language,m.browserNav, m.access, m.params, m.home, m.img, m.template_style_id, m.component_id, m.parent_id,e.element as component FROM jos_menu AS m LEFT JOIN jos_extensions AS e ON m.component_id = e.extension_id
  21. 1 × SELECT folder AS type, element AS name, params FROM jos_extensions
  22. 1 × SELECT * FROM jos_languages
  23. 1 × SELECT b.rules FROM jos_assets AS a LEFT JOIN jos_assets AS b ON b.lft <= a.lft AND b.rgt >= a.rgt
  24. 1 × SELECT * FROM `jos_jcomments_objects`
  25. 1 × SELECT count(*) FROM jos_jcomments AS c
  26. 1 × select * from jos_tag_term_content as a, jos_tag_term as b
  27. 1 × SELECT c.*,CASE WHEN CHAR_LENGTH(c.alias) THEN CONCAT_WS(":", c.id, c.alias) ELSE c.id END as slug FROM jos_categories as c LEFT JOIN jos_categories AS s ON (s.lft <= c.lft AND s.rgt >= c.rgt) OR (s.lft > c.lft AND s.rgt < c.rgt) LEFT JOIN (SELECT cat.id as id FROM jos_categories AS cat JOIN jos_categories AS parent ON cat.lft BETWEEN parent.lft AND parent.rgt
  28. 1 × SELECT a.id, a.asset_id, a.title, a.alias, a.title_alias, a.introtext, a.fulltext, CASE WHEN badcats.id is null THEN a.state ELSE 0 END AS state, a.mask, a.catid, a.created, a.created_by, a.created_by_alias, a.modified, a.modified_by, a.checked_out, a.checked_out_time, a.publish_up, a.publish_down, a.images, a.urls, a.attribs, a.version, a.parentid, a.ordering, a.metakey, a.metadesc, a.access, a.hits, a.metadata, a.featured, a.language, a.xreference,c.title AS category_title, c.alias AS category_alias, c.access AS category_access,u.name AS author,contact.id as contactid,parent.title as parent_title, parent.id as parent_id, parent.path as parent_route, parent.alias as parent_alias,ROUND( v.rating_sum / v.rating_count ) AS rating, v.rating_count as rating_count FROM jos_content AS a LEFT JOIN jos_categories AS c on c.id = a.catid LEFT JOIN jos_users AS u on u.id = a.created_by LEFT JOIN jos_contact_details AS contact on contact.user_id = a.created_by LEFT JOIN jos_categories as parent ON parent.id = c.parent_id LEFT JOIN jos_content_rating AS v ON a.id = v.content_id LEFT OUTER JOIN (SELECT cat.id as id FROM jos_categories AS cat JOIN jos_categories AS parent ON cat.lft BETWEEN parent.lft AND parent.rgt
  29. 1 × SELECT `data` FROM `jos_session`
OTHER Tables:
  1. 3 × UPDATE jos_banners SET impmade = (impmade + 1)
  2. 1 × UPDATE `jos_session` SET `data` = '__default|a:7:{s:15:\"session.counter\";i:27;s:19:\"session.timer.start\";i:1330907045;s:18:\"session.timer.last\";i:1330911702;s:17:\"session.timer.now\";i:1330911706;s:22:\"session.client.browser\";s:89:\"Mozilla/5.0 (compatible; archive.org_bot +http://www.archive.org/details/archive.org_bot)\";s:8:\"registry\";O:9:\"JRegistry\":1:{s:7:\"\0*\0data\";O:8:\"stdClass\":0:{}}s:4:\"user\";O:5:\"JUser\":23:{s:9:\"\0*\0isRoot\";b:0;s:2:\"id\";i:0;s:4:\"name\";N;s:8:\"username\";N;s:5:\"email\";N;s:8:\"password\";N;s:14:\"password_clear\";s:0:\"\";s:8:\"usertype\";N;s:5:\"block\";N;s:9:\"sendEmail\";i:0;s:12:\"registerDate\";N;s:13:\"lastvisitDate\";N;s:10:\"activation\";N;s:6:\"params\";N;s:6:\"groups\";a:0:{}s:5:\"guest\";i:1;s:10:\"\0*\0_params\";O:9:\"JRegistry\":1:{s:7:\"\0*\0data\";O:8:\"stdClass\":0:{}}s:14:\"\0*\0_authGroups\";a:1:{i:0;i:1;}s:14:\"\0*\0_authLevels\";a:2:{i:0;i:1;i:1;i:1;}s:15:\"\0*\0_authActions\";N;s:12:\"\0*\0_errorMsg\";N;s:10:\"\0*\0_errors\";a:0:{}s:3:\"aid\";i:0;}}', `time` = 1330911706
  3. 1 × UPDATE jos_content SET hits = hits + 1