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International Primary Care Association

Clinical Focus Primary Care

Hypertension is the persistence of elevated blood pressure - one of the most familiar medical conditions encountered in family practice. Hypertension is asymptomatic, and its management can be arduous, which is unfortunate given that its presence represents a dangerously potent herald of significant morbidity and mortality.

‘Legal highs’ are more properly known as Novel Psychoactive Substances (NPS): in the UK, following legislative changes in 2016, all current and future such compounds are proscribed. There are over 560 NPS, and their consumption is common. Most individuals who take NPS, or any other recreational drugs, do not develop significant physical or mental health problems, but a considerable number will do so, and many will first present to primary care.

Despite their large number, NPS can be broken down and considered under four main classes: ‘stimulants’, which are drugs like cocaine, ecstasy, and amphetamine; ‘cannabinoids’, which are drugs like cannabis; ‘depressants’ that are opioids and benzodiazepines; and ‘hallucinogens’ like ketamine and LSD. However, the wide range of NPS means that sometimes the novel drugs are more dangerous, and NPS must not be considered as ‘safer’ alternatives to more established compounds. Furthermore, NPS are available in a wider range of formulations, and GPs must enquire as to how the drug is consumed: whether swallowed, snorted, smoked, or injected, with the risk profile changing accordingly.

Good assessment requires a non-judgmental and empathic approach, and should aim to classify the drug type and method of consumption, acute and chronic physical and mental health harms, and any need and patient desire to have further care from specialist services. Acutely, benzodiazepines and antipsychotics may be prescribed for very agitated patients. Autonomic instability, hyperthermia, and altered or loss of consciousness warrant urgent transfer to the Emergency Department.

Within the last year of life many patients are likely to need an integrated palliative approach involving primary care, community nursing and when complex, specialist palliative care. Others may also need palliative care for symptom control and Advance Care Planning (ACP) alongside ongoing interventions for their underlying disease prior to the last year (especially in non-malignant disease when prognostication can be difficult). In these cases, patient need rather than prognosis should ultimately guide your approach.

Following an overview of the public health need for palliative care, trajectories of illness and ACP we present three case studies, identifying key learning points and providing relevant overviews of basic management approaches to common symptoms in palliative care.

A 51 year old man had direct trauma to the left shoulder whilst playing rugby. He had swelling and tenderness around the clavicle. Breath sounds and percussion sounds were normal on both sides. There was no evidence of direct injury of the chest wall. The patient was haemodynamically stable and neurovascular examination was normal. Examine his shoulder X ray (Figure 1)

A 37 year old young lady attends the Emergency Department with cough, breathlessness and green phlegm of 3 days duration. She has never smoked and there was no significant past medical history. Her observations were as follows:

The deed is done. Brexit is happening. We shall see what it brings to the NHS, a worsening of frontline medical and non-medical staff by all accounts. A trickle of exits of EU citizens may turn to a deluge if the issue of retaining citizenship is not resolved, early on in the negotiations. The worry is that the UK government may be relying on recruiting from outside the EU, such traditional heartlands as India, Nigeria and other Commonwealth of Nations. I am not sure if this will be easy as the laws on immigration and rights have so parred the advantages that there is unlikely to be a rush of healthcare staff wishing to come to the UK. The double whammy for politicians is that increasing numbers of staff, particularly in primary care, are choosing to retire early, work part time or simply have a career change. Plugging this gap, with the decision for additional places in medical school, will take over a decade for the effect to show. Indeed, the last round of undergraduate medical school places were unfilled and had to be offered in clearing. I cannot remember this happening in my working lifetime, 39 years. Jam tomorrow then!  

Colorectal cancer is the third most common cancer in men and the second most common cancer in women worldwide. Incidence strongly increases with age, with the median age at diagnosis being 70 years in developed regions. Although 5-year relative survival exceeds 90% in stage I disease, it only marginally exceeds 10% in stage IV disease. This review aims to guide generalists through the early diagnosis, referral, and treatment of colorectal cancer, and highlight current preventive strategies.

Primary care professionals are amongst the most frequent users of the National Poisons Information Service in the United Kingdom. This paper provides an up-to-date review on the management of acute poisoning in this setting.


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