Cancer diagnosis tool undergoes GP trial
A new electronic tool, aimed at aid early diagnosis of certain cancers, has been trialled at 21 practices in Wales. The initiative, which is being supported by the charity Macmillan Cancer Support, is designed to help GPs diagnose bowel, lung, oesophageal/upper gastrointestinal, ovarian and pancreatic cancers.

Commenting on the project in a blog, Macmillan GP adviser Dr Bridget Gwynne writes: “We know that as many as 4,000 to 7,500 deaths per year across the UK could be avoided with earlier diagnosis. There is also evidence that cancer is being detected and diagnosed later in Wales and that this plays an important part in the country’s poor survival rates.” 
The decision support tool, which runs alongside GPs’ clinical systems and is intended to be used during appointments, is based on two risk calculators for cancer: the risk-assessment tool, developed by Exeter professor of primary care diagnostics Willie Hamilton; and QCancer, developed by Nottingham professor of clinical epidemiology and general practice Julia Hippisley-Cox. 
The pilot, which ended in November, followed a 2012 pilot in GP practices where the tool focused on bowel and lung cancer. 
Cancer and the GP, a major new series, begins on page 15 of this issue
Mooted QOF changes prompt call for less bureaucracy 
NICE has opened a public consultation, open to all stakeholders, on potential new indicators for the 2015/16 Quality and Outcomes Framework (QOF). 
The new menu of 10 possible new indicators has been developed following recommendations from the watchdog’s QOF committee, and indicators are currently being piloted in representative practices across the UK to test their feasibility and acceptability. 
The additional suggested target areas include:
  • hypertension confirmed by ambulatory BP monitoring  
  • BP control in elderly patients with peripheral arterial disease (PAD), coronary heart disease, stroke or TIA  
  • pregnancy and contraception advice to women with diabetes  
  • memory assessment in patients with dementia 
The QOF advisory committee will consider the outcomes of the piloting and consultation phase in June 2014 and enter into negotiation with GPs before the final 2015/16 QOF indicators are published in late summer. 
In response to the plans, the BMA has stressed that any changes to GP indicators need to reduce bureaucracy. GPC Chair Dr Chaand Nagpaul (pictured) commented: “Any future changes need to continue on [the] pathway towards reducing — not increasing — bureaucracy. We need to move away from a target-driven culture to allow GPs time to respond to clinical need rather than box-ticking.” 
He added that in last year’s negotiations, some of NICE’s proposed indicators were rejected as part of the drive to free up GPs’ time to treat patients holistically. 
Meanwhile, changes planned for GPs in Scotland are set to remove a substantial amount of funding from the QOF and transfer it to the core GP contract.

NHS England outlines vision for tackling diabetes

 NHS England has set out a vision for how it wants the growing problem of diabetes to be tackled in 2014. The new plan, Action for Diabetes , outlines plans to achieve better prevention of Type 2 diabetes, earlier diagnosis of all diabetes, and self-management support for patients. 

Professor Jonathan Valabhji, National Clinical Director for obesity and diabetes at NHS England, said: “We are seeing huge increases in type 2 diabetes because of the rising rates of obesity, and we clearly need a concerted effort on the prevention, early diagnosis and management of the disease to slow its significant impact not only on individual lives but also on the NHS. 
The UK was recently shown to have the lowest rates of early death due to diabetes out of 19 comparable countries. But Professor Valabhji stressed there is much more that can be done to reduce the numbers of people developing Type 2 diabetes and to improve the care that all people with diabetes receive. 
This new push to improve diabetes care will be based on NHS England’s “House of Care” model of integrated services around the needs of the individual. 
Action for Diabetes sets out the breadth of activity NHS England is undertaking, including:
  • Continued collaboration with Public Health England on the roll out of NHS Health Checks, a programme aiming to prevent and diagnose thousands of cases of type 2 diabetes each year.
  • Helping GPs to provide optimum care and best practice  
  • Outlining resources available to commissioners of hospital-based care to improve treatment for people with diabetes.  
  • Collaboration between NHS Improving Quality and primary care services to trial and roll out new tools to help ensure earlier diagnosis and to develop ways of reducing the high death rates associated with diabetic foot disease. 
NHS England recently published an additional 40 general practice level indicators on the NHS Choices website, of which eight are directly related to diabetes care.

Clinical trials results ‘routinely withheld’
The BMA has called on the Department of Health to ensure greater transparency in clinical trials, following the revelation in a report from the Commons Committee of Public Accounts that information about the methods and results of studies is “routinely” withheld from doctors and researchers. 
The report reveals that important information about clinical trials is “routinely and legally withheld” from doctors and other stakeholders – in some cases including NICE – by drug manufacturers. 
“This now presents a serious problem, because the medicines in use today came on to the market—and were therefore researched—over the preceding decades. None of the latest proposals from regulators or industry adequately addresses the issue of access to the results of trials from previous years on the medicines in use today,” the authors state. 
The report recommends that full details should be made available regarding methods and results “for all trials on all uses of all treatments currently being prescribed in the UK”. The committee also calls for a register of all trials, both future and past. 
The BMA has issued a statement strongly agreeing with the recommendations of the report and urging the government to seek an EU- wide solution to the outlined problems.

Youth mental health is a priority, says RCGP 
There should be increased focus on equipping GPs to deal with the common mental health problems faced by younger people, according to a statement from the RCGP. The statement follows the publication late last year of new NICE quality standards for managing depression in this patient group (see BJFM November/December 2013). 

“The majority of GPs are skilled at supporting young people and families in their generalist role, but fewer than half of GPs are given the opportunity to undertake a paediatric or psychiatry training placement during their training,” said Dr Maureen Baker, Chair of the RCGP. 

“GPs have a crucial role to play in improving the mental health of younger people. It is also important that children and young patients feel comfortable approaching their GP and that their GP is sufficiently prepared to discuss what are often sensitive issues with confidence.” 

Statistics show that 75% of adults with mental health problems will have presented symptoms by the age of 18 – and 50% by the age of 15. The RCGP believes that GPs need support in honing their skills to improve mental resilience, manage anxiety, depression and self- harm, identify suicide risk and recognise early signs of psychosis. 
With youth mental health now a clinical priority for the RCGP, the College is embarking on a number of projects to raise awareness of youth mental health and assist GPs in ensuring younger patients have more positive experience. 
It has also proposed that all GP trainees should receive specialist-led training in both child health and mental health and is currently working with the Royal College of Paediatrics and Child Health, the Royal College of Psychiatrists and Young Minds to develop ways that GPs and specialists can train together. 

Depression and low mood in young people: towards best practice. Page 32 

Concussion linked to depression
Adolescents with a history of concussions are more than three times more likely to suffer from depression than those who have never had a concussion, according to findings from a study in the United States. 
Most research on concussion has focused on adults; however, many younger people experience concussions through sports injuries or accidents, and less is known about long-term complications in this group. 
The study used data from the 2007- 2008 National Survey of Children’s Health and included data from over 36,000 adolescents aged 12 to 17. Findings showed that about 10% of the adolescents studied had a full depressive disorder or subclinical depressive disorder six months after a concussion. It also found that those who had a history of concussion were more likely to develop attention-deficit hyperactivity disorder (ADHD) and have difficulties controlling their moods, especially anger.
Teenagers who were 15 years or older, lived in poverty or who had a parent with mental health problems were more likely to be depressed than other teens, the study found. When the data was adjusted for those factors, the association between depression and a history of concussion was unaffected. 
Dr Jeffrey Max, a psychiatrist specialising in traumatic brain injury, commented that the actual brain injury associated with concussions is probably a major cause of depression in the first few months after injury. 
Commenting on the paper, which is published in the Journal of Adolescent Health , lead study author Dr Sara Chrisman, a paediatrician at Seattle Children’s Hospital said: “What this study suggests is that teens who have had a concussion should be screened for depression.” 
Depression and low mood in young people: towards best practice. Page 32 
NICE has issued draft guidance recommending the use of simple, non-invasive tests to help diagnose and treat asthma. 
The guidance, currently undergoing consultation, recommends three devices, NIOX MINO and NIOX VERON (Aerocrine), and NObreath (Bedfont Scientific Ltd.), used for measuring the concentration of nitric oxide in the breath. The tests offer GPs an option to assist with the diagnosis of eosinophilic asthma in people who, after examination, are considered to have an intermediate probability of having asthma, and when a trial of bronchodilator reversibility testing is intended as part of the diagnosis. 
The tests are also recommended as an option to support the management of symptomatic asthma in people whose symptoms are being treated with inhaled corticosteroids. 
Fractional exhaled nitric oxide or (FeNO) has been shown to be elevated in patients with eosinophilic asthma and is reduced following effective treatment with corticosteroids. Thus, as well as aiding diagnosis, changes in FeNO levels can indicate how well patients are responding and adhering to corticosteroid treatment. Consultation/DraftGuidance
Prompted by the annual – but usually short-lived – fad for lifestyle changes as a new year begins, NICE has published guidance designed to help health professionals promote an enduring culture of health, using evidence-based activities and techniques which have been shown to help make the changes permanent. 
The guidance identifies fewatures of successful, cost-effective change interventions across several health- related behaviours. NICE has also published detailed guidance on how to change behaviour and improve health in specific areas, appropriate to where and how people live. This includes interventions that will help people to:  
  • improve their diet and become more physically active  
  • lose weight if they are overweight or obese (see New steps to tackle obesity)  
  • stop smoking
  • reduce their alcohol intake   
The guidance advises that resources should be appropriately concentrated, so that the most socially disadvantaged people are given the greatest support. 
In addition, the guidance recommends that policy-makers and commissioners should assess whether behaviour change interventions and programmes that are already in place are effective, cost-effective and apply evidence-based principles.
Newly updated NICE guidance on the diagnosis and management of prostate cancer have been published with the aim of ensuring that men are given information about the widening range of treatment options available and help in choosing the best option to suit them. 
Since the original recommendations were published in 2008, a number of novel and effective treatments have been licensed for the management of hormone-relapsed metastatic prostate cancer, with many more coming through the pipeline. There is also more information now available on the best way to diagnose and identify the different stages of the disease, as well as how best to manage the side effects of radical treatment. 
In the last few years, NICE has approved new treatments, including abiraterone (Zytiga), and has also recommended enzalutamide (Xtandi) and degarelix (Firmagon) in draft guidance as we go to press. 
The updated guideline includes a number of new recommendations on the swift diagnosis and treatment of different stages of the disease and a new protocol for men who choose active surveillance, which involves regular check-ups to see if and how the cancer is developing, rather than radical treatment. 
Dr John Graham, Consultant Lead Clinical Oncologist at Taunton and Somerset NHS Trust, commented: “It is important that information and support is available and easily accessible, to ensure patients can make the most appropriate decision in terms of their treatment. This guideline acknowledges that, and makes recommendations about supportive care.”
NICE has published new guidance calling on local authorities and health professionals to do more to help families address the impending obesity crisis in children and young people. 
The new guidance states that healthcare professionals and local commissioners need to better understand the challenges faced by families when seeking support to address obesity issues, and recommends the promotion of lifestyle weight management programmes designed to encourage long-term changes in behaviour. It also stresses the importance of helping parents and carers recognise that their child is overweight or obese and understand the benefits of addressing their condition. 
The new NICE guidance gives specific advice to commissioners on the lifestyle weight management services that should be available to children and young people. 
  • Such services, the guidelines state, should be designed by experts and should include:  
  • Behaviour-change techniques to increase motivation and confidence in the ability to change  
  • Positive parenting skills training  
  • A tailored, individual plan which is economically and culturally appropriate for the young person  
  • Help to identify ways of becoming less sedentary and to build activity into their daily life Ongoing support and follow-up