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
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.
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.
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.
THYROID 1. The practice can produce a register of patients with hypothyroidism1
THYROID 2. The percentage of patients with hypothyroidism with thyroid function tests recorded in the preceding 15 months650–90%
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:
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.
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:
1.1Manage appropriately primary contact with patients who have a metabolic problem
1.3Know 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
1 Bow Churchyard
Chair of Postgraduate Training Board
Curriculum & Evaluation,
General Medical Council,
350 Euston Road,
London NW1 3JN