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Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our health articles more useful.

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The last decade has seen an increase in the incidence of chronic disease in the UK and the trend looks likely to continue. This is partly due to a reduction in communicative diseases, an increase in diabetes, obesity and hypertension and an increase in the average age of the population.The Government's strategy in response to this trend - which has been mirrored by other countries in Europe - is to encourage more patients with chronic diseases to be managed in primary care.[1] It backed up its aspirations with investment in primary care via the Quality and Outcomes Framework (QoF) established as part of the new GP contract in 2004. Castlefields Health Centre is a notable example of a practice which provides structured care for the majority of its patients with chronic disease via primary care clinics.

The QoF system can however have unpredictable effects. A study of Shropshire patients found that whilst an overall in glycaemic control of diabetic patients was achieved, smaller practices were able to deliver certain diabetic care targets better than larger practices.[3]

  • Patients attending chronic disease primary care clinics do as well as and for some clinical parameters better than, patients attending specialist hospital clinics. One study found a generalised improvement in the care of diabetic patients after the introduction of QoF.[4] One study compared diabetic patients attending either a hospital clinic or a primary care clinic and found that both cohorts did equally well in terms of cholesterol HbA1c and blood pressure reduction. The primary care cohort lost more weight.[5]
  • One study looking at care provided by 42 general practices found a signficant improvement in clinical outcomes in coronary heart disease, asthma and type 2 diabetes over a 5 year period.[6] Another found that the introduction of QoF has been associated with better and more equitable management of coronary heart disease across ethnic groups[7] and in a narrowing of the gap in standards of care of hypertensive patients in the least and most deprived areas of the UK.[8]
  • Nurses working to local or national protocols provide high-quality structured care and this reduces the chance of omissions.[9]
  • Primary care clinics are cost-effective compared with most interventions in healthcare.[10] One study of nurse-led coronary heart disease and chronic heart failure patients considered that they delivered a cost-effective service when measured in Quality of Life Years (QALYs).[11]
  • The introduction of structured care leads to the institution of disease registers. On a wider scale these can contribute to information about national disease prevalence.[12]
  • The reality does not always match the theory and claims regarding benefits may be unrealistic. Primary care can only do so much and one study found that whilst improving the quality of primary care services led to modest reductions in demand for hospital services among older diabetic patients with diabetes, low neighbourhood socioeconomic status was more strongly associated with hospital admission rates.[14]
  • Some management initiatives are untested and once established, clinics may be difficult to disband despite lack of benefit.
  • Channelling the majority of management through a primary care clinic may restrict patient autonomy and choice.
  • Primary care clinics may be seen in the secondary sector as a threat to the 'whole systems approach' and there may be concerns about disinvestment in specialist hospital services.


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Further reading and references

  1. Hutton J - Speech by Rt Hon John Hutton MP, Minister of State (Health), 15 June 2004: British Association of Medical Managers AGM

  2. Tahrani AA, McCarthy M, Godson J, et al; Impact of practice size on delivery of diabetes care before and after the Quality and Outcomes Framework implementation. Br J Gen Pract. 2008 Aug58(553):576-9.

  3. Vaghela P, Ashworth M, Schofield P, et al; Population intermediate outcomes of diabetes under pay-for-performance incentives in England from 2004 to 2008. Diabetes Care. 2009 Mar32(3):427-9. Epub 2008 Dec 23.

  4. Ismail H, Wright J, Rhodes P, et al; Quality of care in diabetic patients attending routine primary care clinics compared with those attending GP specialist clinics. Diabet Med. 2006 Aug23(8):851-6.

  5. Campbell SM, Roland MO, Middleton E, et al; Improvements in quality of clinical care in English general practice 1998-2003: longitudinal observational study. BMJ. 2005 Nov 12331(7525):1121. Epub 2005 Oct 28.

  6. Millett C, Gray J, Wall M, et al; Ethnic disparities in coronary heart disease management and pay for performance in the UK. J Gen Intern Med. 2009 Jan24(1):8-13. Epub 2008 Oct 25.

  7. Ashworth M, Medina J, Morgan M; Effect of social deprivation on blood pressure monitoring and control in England: a survey of data from the quality and outcomes framework. BMJ. 2008 Oct 28337:a2030. doi: 10.1136/bmj.a2030.

  8. Clinicians, services and commissioning in chronic disease management in the NHS. The need for coordinated management programmes; Report of a joint working party of the Royal College of Physicians of London, the Royal College of General Practitioners and the NHS Alliance (2004)

  9. Raftery JP, Yao GL, Murchie P, et al; Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomised controlled trial. BMJ. 2005 Mar 26330(7493):707. Epub 2005 Feb 16.

  10. Turner DA, Paul S, Stone MA, et al; Cost-effectiveness of a disease management programme for secondary prevention of coronary heart disease and heart failure in primary care. Heart. 2008 Dec94(12):1601-6. Epub 2008 May 1.

  11. Martin D, Wright JA; Disease prevalence in the English population: a comparison of primary care registers and prevalence models. Soc Sci Med. 2009 Jan68(2):266-74. Epub 2008 Nov 18.

  12. Bottle A, Millett C, Xie Y, et al; Quality of primary care and hospital admissions for diabetes mellitus in England. J Ambul Care Manage. 2008 Jul-Sep31(3):226-38.