Examples of mini-clinics which are conducted in primarycare
- Well-woman/well-man clinic
- Elderly nonattending patients
- Giving-up-smoking clinic
- Joint outreach clinics with a consultant who shares care (egorthopaedics)
- Antenatal clinic
- Cardiac1 & hypertensionclinic
- Citizen's advice clinic
- Diabetes clinicMET40
- Asthma clinic
- Easy to keep to management protocol
- Check-lists prevent omissions
- Co-operation cards allow shared care
- Flow-charts to identify trends
- Help from specialist practice nurse
- Fewer outpatients referrals (by 20%)
- Better co-operation with hospitals
- GPs can improve clinical skills
- Improved dialogue with specialists
Disadvantages
- Extra time needed
- Extra training needed
- Not holistic
- Not flexible
- Value often unproven
- Access to hospital technology
- Travelling time by consultants to outreach clinics iswasteful
Activities in well-woman clinics
- Cervical smear and breast examination
- Breast examination/mammography
- Pre-conception counselling
- Antenatal and postnatal care
- Rubella and tetanus* vaccination
- Smoking and alcohol advice*
- Safer sex advice for HIV*
- Family planning/sterilization*
- Diet and weight*
- Blood pressure*
- Discussion of HRT issues
Breast examination/teaching breast self-examination in nurseclinics
There is disagreement about whether this is desirable, and, if so,whether we can delegate this to nurses. Some (but not all) studies report thatcancers in those having this protocol are detected earlier, with improvedsurvival, compared with mammography alone. But UK DoH advice is against breastpalpation in asymptomatic women, even if on the Pill/HRT. The DoH advisesagainst delegation to nurses, but in some practices it may only be nurses whomwomen find acceptable so validating nurse training is a key issue.
Well-men
Women live longer, so why should they get all the prevention? (itmight be argued). Nurses can do all the well-woman activities *starred above inwell-man clinics. One such clinic yielded 25% obese; 14% with diastolic BP100mmHg; 66% needing tetanus vaccination; and 29% needing smoking advice. Seethe OXCHECK study, p 495 and the NHS National ServiceFramework for ischaemic heart disease (OHCM p91).RCT43 [N=874]
Diabetic clinic
Education and encouragement are the mostimportant activities. This is best conducted in group sessions wherepassive-dependency is minimized and people (patients) help and motivate eachother. Traditional one-to-one care even whenoptimized, is associated with progressive deterioration of knowledge,problem solving ability, and quality of life. Better cognitive and psychosocialresults are associated with more favourable clinical outcomes includingfalling BMI and HbA1c.RCT44 [N=120]
Advantages over hospital clinics: patients see the same person eachtime; weekly appointments are possible during periods of difficult control;telephone advice is easily available. Mini-clinics are cheaper than outpatientclinics and outcome studies have provedeffectiveness.
Even young insulin-dependent diabetics can be managed wholly inprimary care from presentation provided there is no overt ketoacidosis. Thereare dangers in adhering too closely to protocols.However, the vital test is retinal photography or dilating the pupil forfundoscopy.Other vital areas are diet, exercise & smoking advice, BP & lipidcontrol, and round-the-clock blood glucose monitoring, with checks on U&Eand HbA1c.
Liaison with community consultant-services
May prevent hospital admission.
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