A GP Has A Duty To Know About Current Knowledge Of The Diagnosis And Management Of Hypothyroidism

[NBob]

The preamble to Good Medical Practice gmc-uk.org/guidance/good_me... , states that a doctor must (i.e. the doctor has an overriding duty to):

Provide a good standard of practice and care

- Keep his/her professional knowledge and skills up to date

- Recognise and work within the limits of his/her competence

- Work with colleagues in the ways that best serve patients’ interests

Paragraph 14 of Good Medical Practice (2013) states that a doctor must (i.e. the doctor has an overriding duty) recognise and work within the limits of his/her competence.

A General Practitioner has to have hypothyroidism within the limits of his/her competence. Why? Because the General Medical Services Contract, the Quality Outcomes Framework and the General Medical Council itself together with the Royal College of General Practitioners say so.

General Medical Services Contract

The General Medical Services Global Sum Formula distributes the core funding, or the Global Sum, to general practices to cover the cost of providing routine primary care services to its registered list of patients.

Payments are made to practices according to the needs of their patients and the costs of providing primary care services, and are calculated using the Carr-Hill formula. These services are defined as “essential” and “additional” services in the contract and are listed below:

Practices are required to provide essential services. These cover the:

• management of patients who are ill or believe themselves to be ill with conditions from which recovery is generally expected

• general management of patients who are terminally ill

• management of chronic disease

nhsemployers.org/PayAndCont...

Quality and Outcomes Framework

Hypothyroidism is mainly dealt with in Primary Care (i.e. by a GP). This is specifically confirmed by the Quality and Outcomes Framework of the General Medical Services contract.

nhsemployers.org/Aboutus/Pu...

The Quality and Outcomes Framework (QOF) rewards practices for the provision of 'quality care' and helps to standardise improvements in the delivery of clinical care. Practice participation in QOF is voluntary but most practices on General Medical Services (GMS) contracts, as well as many on Personal Medical Services (PMS) contracts, take part in QOF. It was introduced as part of the new GMS contract in 2004.

nhsemployers.org/Aboutus/Pu...

Hypothyroidism is a Clinical Domain. The QOF states in the rationale that monitoring of hypothyroidism is almost entirely undertaken in primary care. Under the QOF a GP practice receives a payment if the practice reports the number of patients on its hypothyroidism disease register and the number of patients on its hypothyroidism disease register as a proportion of total list size. The practice receives a further payment The practice reports the percentage of patients on its hypothyroid register who have had a TSH or T4 undertaken in the preceding 15 months.

Within the Clinical Domain, the baseline £127.26 (2011/12) per point is adjusted up or down for each practice according to the prevalence of each clinical condition for that practice’s patients. With 7 points available, a general practice can be paid up to £763.56 for having a hypothyroid register and carrying out thyroid function testing of at least 90% and recording those thyroid function tests. QOF doesn’t state what thyroid function testing is.

Indi

Indicator Points Payment stages

Records

THYROID 1. The practice can produce a register of patients with hypothyroidism 1

Ongoing management

THYROID 2. The percentage of patients with hypothyroidism with thyroid function tests recorded in the preceding 15 months 6 50–90%

QOF also states that there is a clear consensus on how hypothyroidism should be treated, but does not state what or where that consensus is. NICE operates an online facility which allows stakeholders to comment on current QOF indicators. Comments will be used to review existing QOF indicators against set criteria which include:

• evidence of unintended consequences

• significant changes to the evidence base

• changes in current practice

Comments are fed into a rolling programme of reviews and considered by the Advisory Committee. The recommendations of the Committee will then be fed into negotiations between NHS Employers and the GPC. The online facility is available on the NICE website:

nice.org.uk/aboutnice/qof/c....

GMC and Royal College of General Practitioners

The GMC regulates all stages of doctors' training and professional development in the UK. The GMC promotes high standards and ensure that medical education and training reflects the needs of patients, the service, students and trainees.( gmc-uk.org/education/index....

In April 2010, the Postgraduate Medical Education and Training Board (PMETB) was

merged with the General Medical Council (GMC). The Medical Act 1983 requires the GMC to set the standards for training and the end-point to be achieved and demonstrated in order for a doctor to enter the GMC’s Specialist Register or General Practitioner Register. The GMC includes the curriculum produced by the Royal College of General Practitioners (RCGP) which defines the learning outcomes for the discipline of general practice in its List Of Approved Specialty And Subspecialty Curricula Systems.

gmc-uk.org/education/approv...

Two of the Key Messages of part 3.17 “Care of People with Metabolic Problems” gmc-uk.org/education/gp.asp in The Clinical Examples of the core curriculum, are

• As a general practitioner (GP) you should have an understanding of how common endocrine or metabolic disorders such as diabetes mellitus, thyroid or reproductive disorders can present. You must also be aware of rarer and important disorders such as Addison’s disease, which can be potentially life-threatening if missed

• Biochemical tests can be diagnostic and often necessary for monitoring metabolic and endocrine diseases, so it is important for GPs to know which tests are useful in a primary care setting and how to interpret these tests and understand their limitations

The RCGP curriculum states that, as a Learning Outcome, a GP should, with regard to hypothyroidism:

1.1 Manage appropriately primary contact with patients who have a metabolic problem

1.3 Know the indications for referral to an endocrinologist, metabolic medicine specialist or nephrologist for investigation of suspected endocrine disease, management of complex metabolic problems, or diabetic renal complications respectively

1.4 Understand the systems of care for metabolic conditions including the roles of primary and secondary care, shared-care arrangements, multidisciplinary teams and patient involvement

1.6 Understand the use and main limitations of tests commonly used in primary care to investigate and monitor metabolic or endocrine disease, e.g. fasting blood glucose, HbA1c, urinalysis for glucose and protein, urine albumin: creatinine ratio, ‘near patient testing’ (point of care testing) for capillary glucose, lipid profile and thyroid function tests, and uric acid tests

2.1 Be aware that non-concordance is common for chronic metabolic conditions, e.g. diabetes, and respect the patient’s autonomy when negotiating management

2.6 Recognise the potential for abuse of thyroxine and propose strategies to reduce dosage

3.2 Recognise that patients with metabolic problems are frequently asymptomatic or have non-specific symptoms and that diagnosis is often made by screening or recognising symptom complexes and arranging appropriate investigations

3.3 Demonstrate a logical, incremental approach to investigation and diagnosis of metabolic problems

6.3 Empower patients to self-manage their condition, as far as is practicable

The curriculum states that an Essential Feature of a GP is

EF1.1 Recognising your central role as a primary care physician in managing diabetes mellitus and hypothyroidism

Of 16 example texts given in the curriculum, none are thyroid (let alone hypothyroid) specific. Eight are diabetes specific, 2 are about obesity, 1 is the British National Formulary, 1 is about Motivational Interviewing and 1 is about Primary Care. Only 2 refer to endocrine disorders and they include diabetes in the title.

Of the Web Resources, 11 are diabetes related, one is about better testing, two are about obesity, one is the DVLA guidelines for doctors regarding driving licences for patients with medical disorders and one is the Institute of Chiropodists and Podiatrists.

Dr Bill Reith

RCGP

1 Bow Churchyard

London

EC4M 9DQ

Chair of Postgraduate Training Board

01925 646313

[e-mail]

Curriculum & Evaluation,

Education,

General Medical Council,

350 Euston Road,

London NW1 3JN

[e-mail]

[Issy]

tick box mentality - so all they need to do is the TSH and dole out thyroxine. They dont have to improve your quality of life.

[NBob in reply to Issy]

That's all they think they have to do.

Even if what they are taught is wrong they have a duty to keep up to date. This includes considering any properly researched material (such as appears on this forum and the main site) presented to them by patients.

They also have a duty to work with patients. See above.

Some say that GPs can be forgiven for not knowing about thyroid problems bit all the material above says that despite their teaching, they SHOULD know what we know.

Many GPs are afraid of being reported to the GMC but what is not generally known is that the GMC are unlikely to investigate a GP for simply prescribing thyroxine to a patient if their TSH is within the BTA reference range. The GMC commissioned a review of the last Fitness to Practice case against Dr Skinner after he won. The review concluded that (paraphrasing) there is a body of respectable medical opinion that WOULD prescribe thyroxine to patients within the BTA reference range. This removes the GMC case against such doctors who prescribe thyroxine to patients whose TSH is within the BTA reference range.

[Hidden]

Thank you for posting this. I'll be able to use some of it as a missive when I reply to my previous GPs' pathetic response to my complaint.

[Glynisrose]

You can lead a horse to water but you can't make it drink!! I sent 7 A4 pages of references as to why TSH is and should be supressed to my endo, this was nearly 2 years ago, STILL he keeps telling me he wants to reduce my meds because of supressed TSH!!! I just won't agree.....

[NBob in reply to Glynisrose]

You are absolutely right. Good phrase but perhaps it should be donkey rather than horse!

Because of what you have pointed out, that is why I am convinced that the next step is to make formal complaints about any GP or Endo who sticks to the orthodox way after being presented with good evidence and still refuses to change their ways.

Complaining, in my view, is about making change rather than punishing, unless there has been gross negligence.

That's why I put together the blog - to establish that GPs SHOULD know what we know.

Perhaps my next blog should be on why we need to make formal complaints

followed by how to make a formal complaint and what to do when that doesn't work.

Achieving change is going to be a hard struggle because doctors are the most arrogant professionals I have come across. For example, part of my remit in Public Health is to deal with noise complaints. Some times my team deals with people who can hear noises but when we investigate, there is no noise in the area but the complainant can still hear noise. We ask the complainant to describe the noise they can hear that we cant. The symptoms described are often those of pulsatile tinnitus. We write to their GP saying "this person has symptoms of pulsatile tinnitus outline our investigation and suggest referral to an ENT specialist.

What, on most occasions, does the GP do? Why, look in the patient's ear with an otoscope and pronounce the patients hearing to be fine. GRR!

With groups like this and the mounting evidence, change WILL come. In my view, we will have to wrestle for it. Medicine is full of instances of doctors arrogantly adhering to the orthodox even in the face of overwhelming evidence but change coming after a fight.

Think of the fights by Drs Skinner and Myhill, the GMC Kark report, the Scottish Parliament. Theres a momentum there that we need to build on.

A really good start is for organisations such as this to start producing CPD packs for GPs and doctors now that revalidation has been strengthened by the GMC (although only after the report into Dr Shipman).

[Glynisrose]

I would never complain about my endo even though he is an arse, for the simple reason that he prescribes NDT to me and if I complained he WOULD stop!! The so called NHS 'professionals' have us over a barrel and will continue to do so as long as unelected bodies such as the RCP and BTA have a stranglehold.

[NBob in reply to Glynisrose]

Hi Glynisrose,

That's great! I strongly believe that a person who does the right thing should not be discouraged from that even if that person is an arse.

As I am sure you know through your posts here, there are many other Endos who don't prescribe NDT or treat properly and they are the ones who deserve some formal attention.

[NBob in reply to Glynisrose]

PS even the GMC have realised that the BTA dont have the monopoly on thyroid treatment. See previous posts about the Kark report.

[Glynisrose]

You know it really doesn't matter what the GMC think when the ombudsman, MPs and the like still get their info from the BTA. It would be nice if they thought to cross reference with at least one sufferers website but is that ever going to happen?

[Susanne]

Thanks so much, Nbob, for posting all this extremely useful info which we hypo's can bring up when practicing assertiveness....

Most crucial of this info from the GP's training curriculum is:

1.4 and 2.1and 6.3 understanding need for patient involvement and autonomy when negotiating management, and empowering them to self-manage.

3.2 diagnosis by recognising symptom complexes, not just screening.(Emphasized also in 'care of' in 3.17)

1.6 understanding the limitations of tests! This is Dr Skinner's point - that if you are not converting or are partially cell resistant then T4 or T3 levels can show on testing as high and patients can still not be absorbing and using the hormones.

Ending up with our awareness that GPs have this duty to be up to date in their knowledge.

Complaint about a GP or Endo who doesn't respond might be necessary after this info has been given first verbally and then in writing.

[NBob in reply to Susanne]

You have picked out relevant points. I'm giving this to my GP along with print outs of the research. If necessary I will make a formal complaint using non compliance with this as evidence.

[Susanne]

PS NBob - are saying above that Dr Skinner has won his present case?? or are you refering to a past case?

[NBob in reply to Susanne]

Dr Skinner's present case rumbles on, amazingly. there is a difference between the Interim Orders Panel (IOP) and the Fitness To Practice Panel (FTP).

This time round, Dr S has faced the IOP twice and has yet to face the Fitness To Practice Panel. The IOP is something in the Interim between complaint and the FTP. Its the GMC form of "remand" before "trial".

I am certain that the Kark report was after Dr Skinners last FTP but until I get copy of it from the GMC I cant be certain.

The GMC have held off giving me a copy after my Freedom of Information request, citing legal privilege as an exemption from FoI. I will have another go and refer them to the Information Commissioners Office if they don't release the report.

[Susanne]

Thanks for explaining that, NBob, I'm concerned both for Dr Skinner, his patients, and for myself, as I'd like him to be able to carry on treating me......

When you get time, could you possibly explain briefly what the Kark report is, what a CPD pack for GPs would be, and what revalidation strengthened by the GMC is.....

(you may have explained this elsewhere, but I'm only just learning to use the site)

how could I get a quote from the GMC about it not being a sin to prescribe thyroxine within the ref range? This could be crucial for some of us to use in consultations.

er...........no hurry.....!