A recent BMJ article looked at this interesting issue.

The early detection of cancer by either screening or the prompt recognition of potentially important symptoms is already the province of primary care. In the United Kingdom’s breast and cervical cancer screening programmes primary health care team members have both developed and been delegated important roles in providing information and advice to women at all stages of the screening process.

The attitudes of general practitioners and practice nurses to breast screening are critical in influencing women to attend, and practice administrative staff are key in maintaining accurate patient notification lists. Roetzheim et al have shown that the supply of primary care physicians is significantly correlated with the stage at diagnosis of patients with colorectal cancer: as the supply of primary care physicians increased, the odds of late-stage diagnosis decreased.

Diagnosing cancer in primary care is often difficult. Many cancers present with common symptoms such as persistent cough or non-specific abdominal pain yet few patients with such symptoms turn out to have cancer. Apart from the traditional features in the clinical history – such as change in bowel habit, rectal bleeding, abdominal pain, and unexplained weight loss in colorectal cancer – there is evidence that other information available to general practitioners might help in identifying malignancy. For example, over 30 years ago Pereira-Gray noted the importance of behaviour change – such as a recent decision to stop smoking – in indicating a likelihood of malignancy. Moreover, dynamic evidence, such as the addition of new symptoms, the persistence of a symptom, or changes in the characteristics of a problem, is particularly relevant in general practice, where patients are assessed over time.

The traditional focus on symptom control in palliative terminal care is being extended to incorporate, for example, the administration of hormonal and chemo-therapeutic agents for both palliation and cure. General practice based follow up of patients with breast cancer has been shown to be acceptable to patients and does not delay the detection of recurrences.

Primary care oncology has come of age. Policymakers, planners, and researchers need now more formally to recognise the roles and responsibilities of the primary care team in important aspects of oncology. This must be supported by high quality and generalisable research that addresses fundamental clinical issues at the heart of primary care. In addition primary care professionals must themselves become more involved in the development of the cancer screening programmes and new therapeutic initiatives which they will eventually play a part in managing.

The National Service Framework for Coronary Heart Disease has been published in England. The Welsh approach is likely to be similar.

As part of this quality framework, standards of service for the NHS will be provided by the National Institute for Clinical Excellence (NICE) and by the National Service Frameworks (NSFs).

The NSF for Coronary Heart Disease aims to improve the quality of care, and reduce inequalities in health and undesirable variations in the service provided by the NHS. The NSF establishes 12 standards for the prevention, diagnosis and treatment of coronary heart disease. The standards are intended to remain relevant for 10 years or more.

The standards encompass all aspects of care, including population strategies, the management of acute coronary syndromes and cardiac rehabilitation.

Primary care is expected to achieve the prevention of cardiovascular events in the highest risk patients, the appropriate management of stable angina and the detection and treatment of heart failure. It is likely that PCGs will have to develop new models of care to enable GPs to achieve their targets. An example of this would be a secondary prevention clinic run by the PCG, to which various practices will refer.

All doctors working within primary care will have to participate in clinical audit and use the results to improve the quality of care. Practice-based registers of patients at risk are expected to be up and running by April 2001.

The NSF offers the patient a co-ordinated "pathway of care" which will ensure quality improvement and will make us all accountable for our performance. It provides the opportunity for primary care to demonstrate that it can provide high standards of care to the population it serves.

GPs must also ensure that patients with suspected angina or heart failure are offered appropriate investigations and treatment. Fast-track chest pain clinics are to be set up so that patients with suspected angina can be seen by a specialist within 2 weeks of urgent referral by their GP.

Health authorities will be required to set up smoking cessation clinics in the community.

Other standards include reducing call to needle time for thrombolysis in heart attack patients, and increasing the number of re-vascularisation procedures carried out. Consultant cardiologist Dr Roger Boyle has been appointed National Heart Director to oversee the Government’s programme to modernise cardiac services.

This is a new search engine which searches on a wide range of different databases.

http://SUMSearch.uthscsa.edu

is free. Trish Greenhaugh, ex assistant editor of the Lancet, looked at evaluations of NHS Direct. She put in the text 'NHS Direct evaluation' and rejected SUMSearch's offer to focus it down or map to MESH headings. She was offered (in a logical order) a non-systematic editorial/overview (with a warning that it may be non-systematic in approach!). Two 'possibly relevant' systematic reviews (one of which was useful, and with a link to 'why systematic reviews are helpful') and 15 original articles, about 5 of which were relevant.

Her own previous search had missed the first editorial because she had asked for 'evaulatION' and the article talked about 'evaluatING' the service. SUMSearch got round that. There was a prominent offer of material from the Merck Manual - perhaps reflecting the sponsor, but this was easy to ignore.

The aim of a number of new web searchers has been to try to search many databases with one original phrase. SUMSearch is not the only one to do this but is clearly getting there. One worry is that it does not appear to link to the Cochrane database though it does reach it through DARE.