First5®--a UK initiative relevant to the global general practice community.

In 2009, the Royal College of General Practitioners (RCGP) in the UK created the First5® initiative to support new GPs through the first years of independent practice. For new GPs, finishing training and taking the first steps into a career in family medicine is an exciting but also challenging time. The RCGP and fellow Wonca organizations are well placed to support young colleagues through this transition period. The First5® initiative is based around five key pillars, which help to support new GPs by ensuring they are well represented, supported and encouraged by their member organization. Peer support, mentoring, career guidance, revalidation and tailored continuing professional development are just some aspects of the programme. This article describes the origins and key components of the concept then explores the progress which has been made to date. The challenges faced by new practitioners are not unique to the UK, or indeed to general practice, and we hope that the First5® initiative will inspire colleagues across Europe and around the world.

The first5 concept.

The concept of First5 recognises the challenges faced by GPs at the end of training and comprises five pillars, which could help to support new GPs through the first 5 years of independent practice. The world of general practice is constantly changing and it is important that new GPs can be supported to develop the confidence and skills required to meet the demands of the new healthcare world.

Establishing the continuing professional development needs of general practitioners in their first five years after training.

AIMS: To identify existing and preferred methods of accessing CPD for GPs in the first five years of independent practice. To establish areas of CPD need for this group. To quantify how many First5 GPs are currently part of a small group and if they undertake CPD in this format. To investigate how First5 currently fund CPD and how much they would be willing to invest in CPD per year. METHODS: Online survey of RCGP members who have been on the GP register for less than five years. RESULTS: First5 GPs access CPD in a variety of formats. CPD provision around practice management and leadership aimed at GPs in their first five years is currently lacking. Many First5 GPs already belong to a small group but more than half find undertaking CPD in the small group is challenging. Most First5 GPs self fund their educational activity and would like to spend £500 or less per year on CPD. CONCLUSION: Cost-effective CPD tailored to the needs of GPs in their first five years of independent practice and delivered in a variety of formats is lacking in some educational areas. First5 GPs require formal written guidance on delivering CPD in small groups.

Continuing professional development and revalidation: an analysis of general practitioners' recorded learning.

Revalidation will be introduced in 2010; it will require general practitioners (GPs) to demonstrate they are fit to practise according to standards set by the Royal College of General Practitioners (RCGP). This will include the requirement to achieve 50 continuing professional development (CPD) credits per year. There has been no published analysis of GPs' current CPD. This paper describes a retrospective analysis of the learning logs kept by 71 practising GPs undertaking the interim Membership by Assessment of Performance (iMAP) programme, considering quantity of recorded learning, evidence of reflection on outcome and spread of content across the domains of the General Medical Council's Good Medical Practice (GMP). The average GP iMAP candidate undertook 87 hours of CPD over the year (range 21.5 hours to 293.5 hours); 16 (22.5%) undertook less than 50 hours while 22 recorded more than 100 hours. The GPs averaged five different types of CPD and 31 recorded outcomes across the year. Most GPs recorded outcomes in each domain of GMP. Those who logged more activities were also those more likely to record a wider spread of learning across the RCGP's curriculum. These results suggest that the RCGP's proposed managed CPD scheme is feasible based on the current CPD activity of this self-selected group.

Using BNP to develop a risk score for heart failure in primary care.

AIMS: Chronic heart failure is a common condition with high mortality. Accurate diagnosis in primary care is difficult. Elevated B-type natriuretic peptide (BNP) is associated with left ventricular systolic dysfunction and increased mortality. Prognostic scoring systems using BNP may help to stratify risk in primary care patients. The aim of this research was to establish the independent variables which predict mortality in a primary care population-prescribed loop diuretics and to generate and validate a scoring system for heart failure in general practice. METHODS AND RESULTS: Five hundred and thirty-two patients were followed up for a mean of 6.4 years after attending a research clinic for clinical assessment, electrocardiogram (ECG), echocardiography, and BNP. Multivariate analysis was used to establish independent prognostic variables and to generate a prognostic scoring system. The score generated was [0.50 x BNP+5 x age+50 x (CVA+sex+diabetes+ECG)]. The cut-off scores for risk groups were; 25th percentile, 411; 50th percentile, 475; 75th percentile, 524; Harrell's c=0.75. CONCLUSION: Developing prognostic scoring systems provides a means of risk stratifying patients without relying on a single cut-off diagnostic value for BNP. Further validation of such scoring systems may improve future management of community heart failure patients.

The diagnosis of heart failure in general practice: implications for the UK National Service Framework.

BACKGROUND: The UK National Service Framework recommends patients with suspected heart failure undergo echocardiography. Selection of patients for this investigation in primary care is difficult. It is not clear which clinical features best identify patients with left ventricular systolic dysfunction. AIM: Using echocardiography, to establish the accuracy of primary care diagnosis of left ventricular systolic dysfunction. To investigate the sensitivity, specificity and predictive values of clinical features in the diagnosis of left ventricular systolic dysfunction. STUDY: A cross-sectional study of 621 patients from a population prescribed loop diuretics in 7 general practices. METHOD: Clinical diagnoses were extracted from general practice records. Symptoms, clinical signs, ECG features, brain natriuretic peptide levels and echocardiographic findings were studied in a research clinic. RESULTS: Left ventricular systolic dysfunction (ejection fraction <40%) was present in 50% of 621 patients prescribed loop diuretics in primary care. General practice diagnoses showed high false positive rates. Individual or combinations of clinical features did not accurately predict left ventricular systolic dysfunction. CONCLUSION: These results suggest the clinical diagnosis of left ventricular systolic dysfunction is inaccurate in this population. General practitioners should have a low threshold for referring patients prescribed loop diuretics for echocardiography. Increased open access echocardiography facilities will be needed.

Difficulties of introducing the National Service Framework for heart failure into general practice in the UK.

BACKGROUND: The National Service Framework (NSF) sets standards for the management of heart failure in the UK. Loop diuretics are commonly first prescribed in primary care. Some patients taking these drugs have heart failure and may benefit from other treatments including ACE inhibitors. Accurate diagnosis in primary care is essential for the aims of the NSF to be realised. AIMS: To investigate loop diuretic prescribing in general practice, to analyse recorded clinical features, patient investigations and ACE inhibitor use in this population. METHOD: One thousand three hundred and one patients taking loop diuretics were identified from prescription records of seven general practices. Demographic details, clinical features, investigations and drug treatments were extracted from patient records. RESULTS: The prevalence of loop diuretic prescribing increased with age. Twenty percent of patients were attributed a diagnosis of heart failure but relevant clinical features were recorded in less than 50% of patient records. Open access echocardiography was used in 8.9% of patients. ACE inhibitors were prescribed in 39.8% of patients considered to have heart failure. 18.2% of these were taking the recommended target dose. CONCLUSION: Loop diuretics are prescribed commonly, particularly in the elderly. There is no clear pattern of documented clinical features that leads to prescription of these drugs. Open access echocardiography is rarely used to aid diagnosis. ACE inhibitors are under-prescribed and under-dosed in patients diagnosed with heart failure in this study population.