Intermediate care clinics in headache Support for PCTs

Introduction There are both economic and clinical arguments to develop headache services delivered by General Practitioners with a special interest in headache (GPwSI). However there is inevitably a gap between policy rhetoric and clinician reality. This paper offers support to PCTs who are considering setting up a GPwSI service in headache written from the perspective of GPs who have experience in delivering such a service.

Background Headache the unmet need The economic, social and personal burden of headache in the community is substantial.1 Migraine alone affects 7.6% of males and 18.3% of females in

England.2 Measures of health-related quality of life are similar to patients with other chronic conditions such as arthritis and diabetes with asthma.4 controls their life
5 3

and worse than those

One in three migraine sufferers believe that their problem and the impact extends to family and friends.6

The majority of headache sufferers are reluctant to seek help with only 6.4/100 female and 2.5/100 men consulting per year and the condition is often poorly managed by the GP.7 Although the majority of headaches are managed in

primary care, because of the high prevalence of headache compared to other neurological conditions, up to 30% of neurology referrals are for headache but only a small number of neurologists have a special interest in the area and many referrals are inappropriate for a secondary care setting. 8 The development of intermediate care Reflecting these concerns, it has been suggested that intermediate care headache clinics staffed by general practitioners with a special interest (GPwSI) should support GP colleagues who would continue to provide first-line headache

Page 1

care.9

10

This development is in line with NHS policy where despite the paucity of

evidence, the hope is that intermediate care will provide more effective and efficient service delivery in local settings. 11 A GPwSI is a general practitioner who has developed enhanced skills so as to provide a variety of extended services in a primary or intermediate tier care setting that has traditionally been provided in secondary care. Figure 1 shows a more comprehensive definition although there has been considerable debate over this concept.12 GPs are already specialists in family medicine and it has been argued that this development would undermine the essence of general practice.

General practitioners with special interests supplement their important generalist role by delivering high quality improved access services to meet the needs of a single PCT or group of PCOs. They may deliver a clinical service beyond the

normal scope of general practice, undertake advanced procedures or develop services. They will work as partners in a managed service not under direct They do not offer a full

supervision, keeping within their competencies.

consultant service and will not replace local consultants or interfere with access to consultants by local general practitioners.

Figure 1. Definition of a GPSI. Some practical advantages claimed for intermediate care are: Increased patient throughput and clinical capacity Services are more accessible to patients Encourages professional development May facilitate retention of medical staff by offering a broader range of interests Could release resources from secondary care to see more appropriate cases The economics of intermediate care From an economic perspective, when an intermediate care service is proposed, there are a range of inputs to be considered13:

Page 2

The aims and objectives of the service change and whether the shift is acceptable to all stakeholders. For example, is the aim an addition to the services in existence, complementation, substitution or a combination of all three? Is the objective of the service to manage headache cases or just to exclude serious pathology and offer advice to the GP on ongoing management?

What are the implications for other services that may be affected directly or indirectly? For example, the introduction of a new service may de-stabilise the delivery of secondary care services.

What is the best increment in service development to undertake and how should the service be configured? What are the local values placed on the potential changes in outcome (clinical and non-clinical) and how do they reflect national priorities?

Are new resources available or is disinvestment required from secondary care? If so, is this a practical option and can the released resources be identified?

The effectiveness of intermediate care The difficulties in obtaining a rigorous and generalisable evidence base to address these questions are well recognised.14
15

In particular, there are

difficulties in conflating outcomes into a single measure and there is a lack of both research resources and technical expertise. Developments will also depend on the local context of the health economy and the relationships between local stakeholders. There is only one study on the effectiveness of headache care delivered in an intermediate care setting. 16 as those seen in secondary care at lower cost. It was found that a GPwSI headache service can satisfy patients with similar headache impact

Setting up an intermediate headache care clinic Key general background policy and implementation papers are: Implementing a scheme for general practitioners with a special interest. Department of Health/Royal College of General Practitioners April 2002. http://www.gencat.cat/ics/professionals/recull/bibliografic/2007_3/Impleme nting.pdf Assessment of the clinical effectiveness, cost and viability of NHS general practitioners with a special interest service. Department of Health, www.sdo.nihr.ac.uk/files/adhoc/34-34-briefing-paper.pdf

Page 3

 The process of planning, development and implementation of a General Practitioner with a Special Interest service in Primary Care Organisations in England . www.sdo.nihr.ac.uk/files/project/99-final-report.pdf NatPaCT provides a number of useful documents on setting up a general practitioner with a special interest including a step by step guide and an impact assessment framework - www.natpact.nhs.uk/cms/352.php Headache specific support can be found in the Action on Neurology project that provides useful general background information in the area of neurology. http://www.natpact.nhs.uk/uploads/2005_Apr/Action_On_Neurology.pdf Detailed descriptions of pilot headache intermediate care services can be found in: Action On Neurology. GPwSI Headache Clinic Pilot Site. Yorkshire Wolds and Scarborough, Whitby and Ryedale Coast Primary Care Trust, 2005. Action on neurology. Intermediate services for patients with headache and epilepsy Salford NHS Primary Care Trust and North East Yorkshire Healthcare NHS Trust, 2005. Competency requirements Guidelines have been developed by the Royal College of General Practitioners in consultation with other key stakeholders, defining the competencies required and governance arrangements. (www.doh.gov.uk/pricare/gpspecialinterest). Specific guidance has also been developed for headache. However, in practice areas of this guidance may prove impractical and it may be more appropriate for alternative competency frameworks to be developed by local stakeholders that reflect local circumstances. The appendix contains an example of accreditation policy for a GpwSI supplied by Devon PCT. Practical points to consider When a contract is being prepared, there are a number of practical points to consider: i) ii) What are the referral criteria to the clinic? Does it include children, acute onset headache What diagnostic resources are available, in particular access to imaging?

Page 4

iii)

GPwSIs will need an identified mentor but what is the relationship with local secondary care providers? If the mentor is different from local specialists, they will also need to provide advice where needed.

iv) v) vi) vii) viii)

How long will appointments be? Headache presentations are invariably complex and 30 minutes is minimum, 45 minutes ideal. What are the minimum audit criteria? For example, follow up rates, imaging rate, onward referral for tertiary opinion, diagnosis. What are reasonable waiting list targets? Is the GPwSI available for email or telephone advice? Skill mix is an important issue. A headache nurse is a valuable contribution to a service and may provide a effective and cost effective addition - see Figure 2.

ix)

Headache is co-morbid with anxiety and depression. Is there a referral pathway to pychology services?

Greater discussion about the patients understanding of the diagnosis & suggested management plan Time for the client to express concerns, worries and ask questions More detailed discussion about proposed medication use acute & prophylactic treatment The opportunity to carry out a lifestyle assessment using listening and negotiating skills to understand the patients lifestyle and agree a process of change necessary to achieve improvement in the headache profile Partnership working with the client to agree a preparation and action plan for the withdrawal of medication (medication overuse headache) Patients requiring extra support to have follow up Onward referral and communication with other healthcare professionals and specialities such as a physical activity co-ordinator and smoking cessation therapist.

Figure 2 some potential advantages of a nurse working in an intermediate care headache clinic Clinical resources and support Guidelines SIGN guidelines - www.sign.ac.uk/guidelines British Association for the Study of Headache guidelines - www.bash.org.uk

Page 5

Support material Headache: a practical manual. Kernick D, Goadsby P (Eds) Oxford University Press 2008. A manual directed at the general practitioner with a special interest. The University of Lancaster run modular diplomas in headache. These are dependent on demand. www.exeterheadacheclinic.org.uk - contains patient information and advice sheets particularly for medication use which can be downloaded. BASH has a GPwSI group. (Contact david.kernick@nhs.net) Patient organisations Migraine Trust - www.migrainetrust.org Migraine Action Association - www.migraine.org.uk

Page 6

APPENDIX

Policy and Procedure for the Accreditation of General Practitioners with a Special Interest

Page 7

Document Status: Version:

Draft V1 DOCUMENT CHANGE HISTORY

Version Draft V1 Draft V1.2 Draft V1.3

Date

Comments (i.e. viewed, or reviewed, amended, approved by person or committee Draft policy for comment PEC for comment Final draft

13/09/08 12/11/08 14/01/09

Authors:

October 2008 Jenny Winslade Assistant Director Patient Safety and Quality Names and roles of Contributors, user engagement etc Denise White, James Wright, Anne Cameron Document Standards For Better Health Relevant to standard(s):- C7a Reference: Relevant to Trust objective:Directorate: -Provider Development. Review Date January 2010 of approved document: EINA Date:

Linked strategies, policies and other documents Disseminatio n requirements Devon PCT has made every effort to ensure this policy does not have the effect of discriminating, directly or indirectly, against employees, patients, contractors or visitors on grounds of race, colour, age, nationality, ethnic (or national) origin, sex, sexual orientation, marital status, religious belief or disability. This policy will apply equally to full and part time employees. All Devon PCT policies can be provided in large print or Braille formats if requested, and language line interpreter services are available to individuals of different nationalities who require them.

Page 8

Contents Section 1 2 3 4 5 6 7 8 9 10 11 12 13 14 A Introduction Purpose Scope Responsibilities Definitions Recruitment and Selection Assessment Guidance and Training Training Governance Service Accreditation Patient Safety Audit and Monitoring Implementation References and Further Reading Accreditation Process Pag e 1 1 2 2 2 3 5 6 6 7 8 8 9 9 10

Appendices

Jenny Winslade
1. 1.1

Page 10

12/06/2013

Introduction The Department of Health released guidance in 2007 in relation to the accreditation for General Practitioners with a Special Interest (GPwSI) and Practitioners with a Special Interest (PwSI). The guidance sought to ensure that all GPwSIs & PwSIs have the required combination of training and experience that will enable them to practice safely and to take on new and expanded roles. This policy will ensure that governance structures are in place for GPwSIs and PwSIs so that services provided by GPwSIs and PwSIs deliver high quality care within the community. of the PCTs strategy to enable faster local access to services that will deliver high quality services and reduce waiting times. Convenient and accessible communitybased services enable patients to receive the right care in the most appropriate location.

1.2 The appointment of GPs and Practitioners with special interests is an important part

1.3 Clinicians will also benefit from the opportunity to develop their specialist knowledge,
skills and competencies, which will enable them to undertake a greater variety of work. GPwSIs and PwSIs ultimately supplement their core generalist role by delivering additional high quality services that are designed to meet the needs of patients within the community. 2. 2.1 Purpose The purpose of this policy is to set out the framework by which the PCT will ensure that there are robust processes for the recruitment of clinicians as GPwSIs or PwSIs and through the development of services that a high quality, safe and efficient service is provided to patients. The policy will also set out the process of reaccreditation, which should be defined in the terms of the contract and should be an explicit period, at the end of which the clinician (and the service in which they work) should be re-accredited.

2.2 The process of accreditation should assure patients and commissioners that clinical services are operating within a clear and quality assured clinical pathway where the highest possible standards of Patient Safety are maintained. 2.3 This document sets out a framework for addressing the quality standards required in the design of new services to be led by a GPwSI or a PwSI and may also be used as a checklist for clinicians and managers working to develop these services. The principles addressed within this policy are transferable to policy formulation for all practitioners with a specialist interest. 2.4 This policy represents best practice when redesigning services and is relevant to any service development that requires groups of practitioners to undertake specific work on behalf of the PCT or practices e.g. employed medical practitioners or consultants. These clinicians may form part of practice based commissioning bids or local enhanced services that involve contracting with clinicians

3. 3.1

Scope The scope of the policy will cover the identification of suitably qualified General Practitioner/ Practitioners who operate outside of the scope of normal practice and includes: The appointment process for suitable candidates

Page 10

Jenny Winslade

Page 11

12/06/2013

Maintaining clinical standards (CPD, accreditation, revalidation and supervision processes) Clinical/ Service audit to ensure the service need is being met and desired outcomes are achieved

The care pathway for the GPwSI & PwSI service must define the specifics of the practitioners activity, including who they will treat and how 3.2 The policy will apply without exception to all new GPwSI services and in addition must be regarded as best practice for current GPwSI and employed specialist services. Where a medical contractor or GPwSI has been providing specialist community services for an extended period a judgement should be made regarding the competence and experience of the practitioner and the accreditation process described within the policy. Where a service is clearly providing high quality care in the community that service should not be interrupted in the implementation of the policy. 4. Responsibilities 4.1 Duties within the Organisation Directors are responsible for the implementation of this policy within their own directorates. Clinicians and managers who are developing services will need to ensure that the policy for accreditation of GPwSI is adhered to as part of the commissioning process. The contracting process should ensure that reaccreditation is defined within the terms of the contract and is an explicit and reasonable period. 4.2 Consultation and Communication with Stakeholders The policy will be agreed and consulted upon with key stakeholders who will include the Local Medical Committee and the Joint Staff Partnership Forum. 5. Definitions The definition of a General Practitioner or Practitioner with a Special Interest is defined by the department of health as: A GP or a Pharmacist with a Special Interest who supplement their core generalist role by delivering an additional high quality service to meet the needs of patients. Working principally in the community, they deliver a clinical service beyond the scope of their core professional role or may undertake advanced interventions not normally undertaken by their peers. They will have demonstrated appropriate skills and competencies to deliver those services without direct supervision. (Department of Health, 2007) 6. 6.1 Recruitment and Selection Recruitment & Selection Recruitment and selection will meet the Department of Health Safer Recruitment Guidelines (2005) which will include Criminal Records Bureau Disclosure, Work Permits and Occupational Health Screening. It is expected that contractors will meet the same immunization standards required of NHS employees. The knowledge, skills and formal qualifications required for the service will be defined. For GPwSI this may include one or more of the following: Formal Medical qualifications and full registration with the GMC with any additional qualifications being evidenced. Clinical assistant post for at least 6 months duration, in the chosen speciality, within the last 12 months. This should include at least one session per week within the speciality under the supervision of an appropriate practitioner for example a Consultant or a suitably experienced GPwSI .

Page 11

Jenny Winslade

Page 12

12/06/2013

A reference, which details suitability for the post from a Consultant in the named specialty or a suitably experienced GPwSI. The reference must be from an individual who has supervised the GPwSI within the last 12 months and can vouch for their competence. It should also detail the type of supervision provided

The competencies and formal qualifications required for each post will be defined through the clinical pathway. Applications to become a GP Specialist Practitioner will include evidence of the following: 6.2 Description of the service the applicant will provide a detailed description of the service and their role within that service. Education, training and development submission of evidence to include mandatory training i.e. resuscitation, courses attended and personal development plans aligned to the role. Clinical governance and quality activities to be undertaken with a minimum of one project to be submitted annually to ensure patient safety and a focus on clinical and cost-effectiveness. Demonstration of clinical support, a clinical support proforma should be completed by supporting clinician

Membership Membership of the Royal College of GPs or Physicians is encouraged.

6.3

Pre-accreditation The PCT where appropriate in order to develop specific expertise and services within community settings may approve a provisional accreditation period. This will have a defined scope that will regulate the scope of practice for the clinician and will include training and development and supervision of practice. The accreditation panel will decide on the appropriateness of a pre-accreditation phase on a case by case basis.

6.4

Interview Process If the clinician is deemed to have successfully met the minimum criteria an interview panel will be convened which will formally assess the knowledge, skills and competencies of the clinician within the field of practice, evidence of continuous professional development and their organisational and managerial competence. The Panel will include: a director of the PCT or appropriate deputy PCT Medical Advisor a senior commissioner; a senior professional representative from the PEC or Local Pharmacy Committee; a representative of the LMC PCT Lead Pharmacist or a GP from the local faculty of the RCGP a lay person or Non-Executive Director a senior clinician, ideally the local lead clinician from within the relevant speciality.

The clinician must demonstrate through the interview process appropriate and necessary levels of skill and competence to fulfil the role described

Page 12

Jenny Winslade

Page 13

12/06/2013

a clear understanding of the role that they are being asked to fulfil in depth knowledge of the appropriate local clinical pathway commitment to ongoing training, clinical updates and education through appraisal and use of Personal Development Plans; Have in place appropriate peer review and mentoring arrangements from an appropriate clinician within the field of practice with references or reports from clinical assessors

6.5

Service Visit An inspection or assessment visit may be required where the service is dependent upon premises and equipment, such as the Primary Care Surgical Scheme (PCSS). Visits may be undertaken as part of the contractual review process and should include Infection Control.

6.6

Contracts All contracts for GPwSI and PwSI will include sufficient detail to ensure that Patient Safety is maintained and that services improve quality through ensuring that appropriately qualified practitioners are delivering the service. The Patient Safety and Quality Lead, the PEC Chair and members of the PEC will be able to provide advice on the frequency of supervision sessions, appropriate supervisors and appropriate Continuing Professional Development. The contract will also need to demonstrate evidence of current professional indemnity insurance that, takes full account of the GPwSI or PwSI role. The PCT will further ensure through the contract that there is a review of the cost effectiveness of the services to demonstrate appropriate use of resources. Remuneration will be agreed as part of the contracting process. The contract will also specify named consultant or GPwSI back up for the clinician that should be available at all times.

7. 7.1

Assessment Guidance and Training Competency Based Assessment The content of the assessment will be based on areas of Good Medical Practice and will be based on the following principles The overall assessment system must be fit for a range of purposes; The individual components used will be selected in light of the purpose and content of that component of the assessment framework.

7.2

Method of Assessment The methods that will be used will comprise of: GPwSI/ PwSI prepared self assessment systematic observation of clinical practice by an appropriate clinician and structured evaluation, which may include other appropriate multimedia e.g. video.

Introducing a system of competency assessment within the workplace has the following advantages:

Page 13

Jenny Winslade

Page 14

12/06/2013

The assessment of working practices is based on what is actually done in the workplace, and predominantly carried out in the workplace itself Better reflection of routine performance Allows assessment of several aspects of the clinicians knowledge; skill and performance The panel assessment will also include objective assessment via audit or other methods in outcomes of care, process of care and volume

7.3Self Assessment Accreditors must ensure the GPwSI/ PwSI has prepared a self-assessment that includes: statistical summary of service provided clinical audit data and resultant actions of follow up audit of patients experience critical re-appraisal of how service could be further improved considering a cross-section of structure, process, outcome and patient experience a strategy for further improving the quality of the service participate in at least one service quality and governance project provision of a minimum of three such projects over a three-year period additional training or development requirements

7.4Assessment and Evaluation to: Evaluation within the assessment framework will include judgements in relation Consultation with simulated and actual patients Case record review, including out patient letters and letters to referring practitioners Case based discussions Oral presentations 360 degree assessment Patient surveys Audit projects Significant event audit

In addition where a pre-accreditation phase has been agreed clear training, professional development and supervision records should be produced and assessed. 7.5Reaccreditation Reaccreditation should take place every three years as a minimum and a formal process will be followed that must be related to the service to be delivered. The applicant must provide a detailed description of their role within the proposed service The GPwSI/ PwSI application should be submitted at least one month before reaccreditation is required.

Page 14

Jenny Winslade

Page 15

12/06/2013

8. 8.1

Training Training will include requirements for Continuing Professional Development and regular professional updates. The clinician is responsible for ensuring this takes place, the PCT may provide assistance in access to training which would be negotiated as part of the contracting process. Training programmes must be approved and accredited by an appropriate body. The GPwSI/ PwSI must provide evidence that this has been done prior to appointment and that it will continue after appointment. The GP/practitioner must undergo annual appraisal with a trained appraiser in that specialty. The contract must detail the named clinician support for the specialist practitioner. Governance Context The function of accreditation is to ensure fitness for purpose through accreditation of both the services themselves and the individual practitioners working within them.

8.2

9. 9.1

9.2

Accountability In order to avoid conflicts of interest there will be clear accountability to the PCT Board through the PEC and the Patient Safety and Quality Scrutiny Committee from the accreditation panel. Accountability will also be demonstrated through Director level membership of the accreditation panel.

9.3

Monitoring The PCT will set up and manage a locally held list of accredited GPwSIs and PwSIs to include length and dates of accreditation, details of speciality and ensure it is made available for public inspection. In addition the PCT will record the verification of registration, Continuing Professional Development and annual appraisal

9.4Discontinuation If the GPwSIs/ PwSIs work is discontinued, or the individual is unable to use their specialist skills for a period longer than twelve months, they must be reaccredited before they can work again as a GPwSI/ PwSI. This may include absence for ill health or extended maternity leave. 10. 10.1 Service Accreditation Governance The services within which GPwSIs and PwSIs work are also required to be accredited. GPwSI/ PwSI services will only be safe and effective when delivered within a high quality and safe environment. 10.2 Regulation The Healthcare Commission (or its successor, Care Quality Commission) define the standards required of all providers of NHS services within Standards for Better Health. All contractors will be expected to be compliant with Standards for Better Health.

Page 15

Jenny Winslade

Page 16

12/06/2013

10.3

Specific Guidance The PCT will also utilise specialty specific guidance to identify any requirements relating to specific services.

10.4

Premises All premises must be accredited prior to the commencement of the service. Contracts cannot be issued until this process is complete and compliance is demonstrated. Within six months of starting, a subset of the accreditors group may wish to visit the service. For details of the pathway for individual and service accreditation, see Appendix A.

11. 11.1

Patient Safety Incident Reporting The GPwSI and PwSI will be required to identify report and learn from all patient safety incidents through significant event audit and must meet the requirements set out by the Healthcare Commission in accordance with Standards for Better Health. All incidents must be reported to the PCT as set out within the contract and it is expected that the clinician will work in accordance with Devon PCTs Incident and Serious Untoward Incident (SUI) Reporting Policy.

11.2

Record Keeping Accurate, contemporaneous and comprehensive records are essential in the delivery of high quality patient care. Information about the clinical care of patients should be recorded in their clinical records including presenting symptoms, diagnosis and records of treatment documenting each episode of care. Records are also utilised for teaching, research and clinical audit as well as providing evidence in the event of litigation. GPwSI and PwSIs are required to work with the commissioners in line with the PCT's Record Management Policy

11.3

Complaints The GPwSI/ PwSI should ensure that a full and positive response is provided to all complainants, whether their complaint was made verbally or in writing, in line with the PCT complaints policy. Complaints are valuable feedback as part of the service improvement programme and must be reported to Devon PCT. Lessons learnt will be shared across the Trust in order to rectify mistakes, omissions or misunderstandings and to learn from those experiences to improve the quality of services in the future.

12. 12.1

Audit and Monitoring Clinical Audit

Page 16

Jenny Winslade

Page 17

12/06/2013

Evaluation of the programme where the GPwSI/ PwSI is operating is essential to the improvement of quality and will be built into the commissioning process. In addition to this, the clinician must produce at least one audit per year that relates to their activity within the service e.g. record-keeping audit or evidenced-based practice. This will include dissemination of the results to others to ensure learning from outcomes. 12.2 Monitoring The clinician should agree the areas for quality monitoring and audit with the PCT. Audit/monitoring arrangements may include amongst others: Outcomes of Treatment Follow-up rates/complication rates/complaints Onward referral rates to Consultants and other professionals Investigations Access times Patient satisfaction Cost effectiveness Premises and Equipment Referral rates DNA rates 13. 13.1 13.2 14. Implementation Re-accreditation process to begin as soon as possible for all GPwSIs/ PwSIs in accordance with the national guidance. All new GPwSIs/ PwSIs are required to be accredited in accordance with the national guidance. References and Further Reading

Implementing a Scheme for General Practitioners with Special Interests (DH and RCGP, April 2002) www.dh.gov.uk/pricare/gp-specialists/gpwsiframework.pdf Implementing a scheme for Nurses with Special Interests in Primary Care (DH April 2003) http://www.dh.gov.uk/assetRoot/04/06/60/13/04066013.pdf Implementing a scheme for Allied health professionals with Special Interests (DH April 2007) http://www.dh.gov.uk/assetRoot/04/06/60/14/04066014.pdf Implementing Care Closer to Home: Convenient Quality Care for Patients: accreditation of GPs and Pharmacists with Specialist Interests (DH: April 2007) www.dh.gov.uk Policy and Procedure for the Recruitment and Accreditation of GPs and Practitioners with Special Interests. Lincolnshire PCT Safer Recruitment guidelines for NHS Employers (2005) http://www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesandtraining/Moderni singprofessionalregulation/Preandpostemploymentchecks/index.htm Related PCT Policies, Procedures and Documents Patient Safety and Quality Strategic Framework (2008), Devon PCT Incident Reporting Policy Corp 10, Devon PCT

Page 17

Jenny Winslade

Page 18

12/06/2013

Records Management , Devon PCT, CG008 PCT Complaints Policy, Devon PCT Equality Strategy 2007-2010, Devon PCT Independent Practitioner Performance, HR 26 Devon PCT GP Appraisal, HR 27 Devon PCT Devon PCT Records Management Policy 2007

Page 18

Appendix A Accreditation Process

Source Implementing Care Closer to Home: Convenient Quality Care for Patients: accreditation of GPs and Pharmacists with Specialist Interests (DH: April 2007) www.dh.gov.uk

David Kernick/Intermediate care 21/10/09

19

References

David Kernick/Intermediate care 21/10/09

20

Terwindt GM, Ferrari MD, Tijhus M, Groenen S. The impact of migraine on quality of life in the general population - The GEM Study. Neurology 2000;55:624-629. Steiner T, Scher A, Stewart F, Kolodner K, Liberman J, Lipton R. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia 2003;23(7):519-27. Solomon G, Skobierand F, Gragg L. Quality of life and well being of headache patients: measurement by the medical outcome study. JAMA 1989;262:907-13. Terwindt G, Ferrari M, Tijhus M, Groenen S, Picavet H, Launer L. The impact of migraine on quality of life in the general population - The GEM Study. Neurology 2000;55:624-629. Dowson A, Jagger S. The UK migraine patient survey: quality of life and treatment. Curr Med Res Opin 1999;15(4):241-253. Lipton R, Bigal M, Kolodner K, Stewart W, Liberman J, Steiner T. The Family Impact of Migraine: Population-based Studies in the US and UK. Cephalalgia 2003;23(6):429-440. Forward SP, McGrath PJ, McKinnon D, Brown T, et Al. Medication patterns of recurrent headache sufferers: a community study. Cephalalgia 1998;18:146-51. Sender J, Bradford S, Watson D, Lipscombe S, Reece T, et al. Setting up a specialist headache clinic in primary care: general practitioners with a special interest in headache. Headache Care 2004;1(3):165-171. Dowson A. Lipscombe S, Sender J, et al. New guidelines for the management of migraine in primary care. Curr Med Res Opin 2002;18:414-39. Recommendations for the organisation of headache services. British Association for the Study of Headache: London, 2001. Implementing a scheme for General Practitioners with a special interest. Dept of Health and Royal College of General Practitioners: London, 2002. (www.doh.gov.uk/pricare/gp-specialinterest) Shaping tomorrow. British Medical Association. London, 2002. Kernick D. Developing intermediate care provided by general practitioners with a special interest: the economic perspective. British Journal of General Practice 2003;53:553556. OCathain A, Musson G, Munro J. Shifting services from secondary to primary care: stakeholders views of the barriers. Journal of Health Service Research and Policy 1999;4:154-160. Kernick D, Mannion R. Developing an evidence base for intermediate care delivered by GPs with a special interest. British Journal of General Practice 2005;55(521):908-909. service.

10

11

12

13

14

15

Ridsdale L, Doherty J, McCrone P. A new GP with a special interest headache British Journal of General Practice 2008;58:478:2483.
16