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 Enhanced
DIGITAL
VERSION
Indudcd.

ADAM STATEN AUL STATEN

PRACTICAL
GENERAL
PRACTICE

Guidelines for Effective

Clinical Management
SEVENTH EDITION

F
ELSEV1ER
Practical General Practice
Practical General Practice
Guidelines for Effective Clinical Management

SEVENTH EDITION

Adam Staten, MA (Cantab), MBBS, MRCP (UK),

DRCOG, DMCC, PGCertCE, MRCGP
General Practitioner
Milton Keynes, UK

Paul Staten, MBBS, MA (Cantab), DRCOG, MRCGP

General Practitioner
Milton Keynes, UK

For additional online content visit

ExpertConsult.com

Edinburgh London New York Oxford Philadelphia St Louis Sydney 2019

© 2020, Elsevier Limited. All rights reserved.

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Third edition 1999
Fourth edition 2003
Fifth edition 2006
Sixth edition 2011
Seventh edition 2020

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This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds or experiments described herein. Because of rapid advances in the
medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the
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Contents

Preface, vii 16 Contraception, Sexual Problems, and Sexually

The Structure of the Book, ix Transmitted Infections, 246
Acknowledgements, xi Lindsey Pope
List of Contributors, xiii
17 Infectious Diseases and Vaccination, 278
Neil Ritchie
Section 1: Principles and Practice of 18 Psychiatric Problems, 313
Primary Care Dominique Thompson

1 Principles and Practice of Primary Care, 1 19 Urinary and Renal Problems, 340
Adam Staten Lindsey Pope

2 Long-Term Conditions, 7 20 Ear, Nose, and Throat Problems, 354

Stewart W. Mercer, Harry Hao-Xiang Wang Adam Staten

3 Communication Skills, 11 21 Eye Problems, 371

Annemieke Bikker, Lynsay Crawford Suzannah Drummond

4 Ethics, 19 22 Skin Problems, 381

Al Dowie Kieran Dinwoodie, Anchal Goyal, Catriona Nisbett,
Jane Colgan
5 Disability, 26
Lynn Legg, Jane Tracy 23 Allergic Problems, 403
Aziz Sheikh

Section 2: Manual of Clinical Practice 24 Diabetes and Endocrinology, 409

6 Children’s Health, 37
Ruth Margaret Bland, Hilary Lockhart Pearce
25
7 Cardiovascular Problems, 65
David Nicholas Blane
Russell Drummond, Frances McManus, Kate Hughes,
Sharon Mackin, David Carty
Persistent Physical Symptoms and Symptoms
Without Apparent Disease, 426
Christopher Burton

8 Respiratory Problems, 93 26 Palliative Care and Care of the

Hilary Pinnock Dying Patient, 431
Ben Dietsch
9 Gastroenterologic Problems, 109
John Paul Seenan, Heather Lafferty

10 Surgical Problems, 134 Section 3: Appendices

Iain Wilson
Appendix 1 Routine Schedule of
11 Musculoskeletal Problems, 142
Immunizations, 471
John MacLean
Appendix 2 Incubation Period and Infectivity of
12 Neurological Problems, 170
Common Diseases, 472
Declan Nugent
Appendix 3 A Suggested Table of
13 Women’s Health, 191
Immunizations for Travel, 474
Lindsey Pope
Appendix 4 Notification of Infectious
14 Obstetric Problems, 209
Diseases, 475
Lindsey Pope
Appendix 5 Child Health Promotion, 476
15 Older People’s Health, 229
Ian Reeves Appendix 6 Stages of Child Development, 478

v
vi Contents

Appendix 7 Stages of Puberty, 481 Appendix 19 Immunizations in Pregnancy, 503

Appendix 8 Predicted Normal Peak Flow Appendix 20 Edinburgh Postnatal Depression
Values in Children (Under 15 Years Scale, 504
of Age), 483
Appendix 21 Admission Procedures for Patients
Appendix 9 Peak Expiratory Flow in Normal With Mental Health Problems, 506
Subjects, 484
Appendix 22 The Early Warning Form for Use in
Appendix 10 FEV1/FVC Charts, 485 Psychotic Illness, 508
Appendix 11A Summary of Management of Appendix 23 AUDIT, 509
Asthma in Adults, 487
Appendix 24 International Prostate Symptom
Appendix 11B Summary of Management of Score (IPSS), 511
Asthma in Children, 488
Appendix 25 Body Mass Index, 513
Appendix 11C Management of Acute Severe
Appendix 26 Reference Ranges for Young
Asthma in Adults in General
Adults, 514
Practice, 489
Appendix 27 Anaphylaxis Algorithm, 516
Appendix 11D Management of Acute Severe
Asthma in Children in General Appendix 28 Problems Associated With Specific
Practice, 491 Causes of Disability, 517
Appendix 12 Care Pathway for Respiratory Tract Appendix 29 The Community Dependency
Infections, 493 Index, 521
Appendix 13 Guidance for DMARD Appendix 30 Nottingham Extended Activities
Prescribing, 495 of Daily Living Questionnaire
(EADL), 523
Appendix 14 Dermatomes and Myotomes, 497
Appendix 31 Drug Stabilities in Syringe
Appendix 15 Testing Peripheral Nerves, 498
Drivers, 524
Appendix 16 Drug Levels, 500
Appendix 32 Guidelines for the Urgent
Appendix 17 Checklist to Guide the Review Referral of Patients With Suspected
of a Patient With Multiple Cancer, 526
Sclerosis, 501
Appendix 33 Opioid Dose Conversion Chart, 531
Appendix 18 Medical Management of
Obesity, 502 Index, 532
Preface
It is 30 years since the publication of the first edition of this
textbook and since then, a time during which five further
editions of the book have been published, a wealth of research
and numerous guidelines have been produced as part of the
worldwide crusade to practise the evidence-based medicine,
for which this book was in some ways a forerunner.
This is the first edition not to be edited by Alex Khot
and Andrew Polmear, whose vision and passion for produc-
ing straightforward, evidence-based, and above all practical
guidelines for general practitioners working at the coal face
of primary care originally brought this textbook into being.
We hope this edition follows those principles and remains
a reliable desktop companion for GPs.
Producing a guidelines-based book like this is much like
the endless work of Sisyphus pushing his boulder up a hill
in Tartarus for all eternity, only to watch it roll back down
before reaching the summit. The pace of change in medicine,
the rate at which guidelines are produced, and at which
consensus opinion changes, makes it almost inevitable that
a book such as this is at risk of being out of date before the
ink is dry on the page. However, guidelines tend to change
by evolution rather than revolution and the content of this
book, produced by experts working in the real world of daily
practice, is likely to differ only by nuance in the coming
years from the guidance produced by the various esteemed
medical institutions.
As ever, this book should be seen as a guide and a template
from which general practitioners can derive their own ways
of working based on a logical, structured approach. The
chapters of this book are designed to mirror the mental
processes of the doctor during the general practice consulta-
tion and so help that doctor to synthesise rational and safe
treatment plans for his or her patients.
Whilst keeping pace with the changes in guidance has
made the production of this book a challenge, the wealth
and breadth of research and guidance currently available has
also enabled our contributors to produce more robust guid-
ance than has ever previously been possible.
In recognition of the fact that previous editions of this book
have attracted a readership outside of the United Kingdom, this
edition has deliberately been designed to be less UK focused
with guidance based on guidelines and opinion from around
the globe. Where possible the details of patient support groups,
relevant to specific diseases in different countries, have also
been included to reflect the more global outlook of this edition.
Adam Staten
Paul Staten
vii
The Structure of the Book

Bullets Where the order is important we number the list:

1. Sit the patient up.
Different coloured bullet points have been used to provide 2. Give oxygen.
emphasis for different types of comment: 3. Give diamorphine …
• Black bullets are for general information or explanation
e.g. ‘Treatment can be expected to….’ Boxes
• Pink bullets are instructions for questions that should be
asked, examinations that should be performed, or inves- These are used to highlight information that might otherwise
tigations and treatments that should be undertaken e.g. get lost in the text: guidelines, a list of tests as a ‘work-up’
‘Ask the patient x, y and z’, ‘Examine for a, b and c’. for a patient with a particular condition, or patient organisa-
• Grey bullets are used where there is a subdivision of another tions for example.
heading.
References
Lists
Our aim is to reference every statement of fact. Where such
Where we present a list in no particular order we use: a statement is not accompanied by a reference, the reader
(a) chest pain; or can assume it is taken from the reference in a box at the
(b) hypotension; or start of that section.
(c) heart failure.

ix
Acknowledgements
Firstly we would like to thank Alex Khot and Andrew Polmear
whose vision led to the production of the first six editions
of this text book; we hope that this current edition lives up
to the high standards they have set. We would, of course,
like to thank all our contributors who have worked to ever
tightening deadlines, to produce a set of great chapters, fre-
quently swimming against the tide of new guidance and
research to keep this edition up to date as we have moved
through production. We would particularly like to thank
Mr Iain Wilson, Mr Robert Hone, and Dr Naema Alam
who all stepped in at the last moment with invaluable advice
and contributions to help get this book to press.
An enormous thank you must go to the team at Elsevier,
in particular, Carole McMurray, Pauline Graham, and Radjan
Lourde Selvanadin for whom the last few months and years
must have felt like something of a cat herding exercise.
Adam would like to thank his wife Shiva and his daughters
Rose and Grace who have had to tolerate a husband and
father who has spent many vacant hours tapping slowly at
his laptop. Paul would like to thank his partner Erica for
her help and support.
xi
List of Contributors
The editor(s) would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without
whom this new edition would not have been possible.

Annemieke Bikker, MSc Lynsay Crawford, MBChB

Teaching Fellow Clinical University Teacher
University of Edinburgh School of Medicine, University of Glasgow
Usher Institute of Population Health Sciences and Deputy Director of Vocational Studies
Informatics School of Medicine, University of Glasgow
College of Medicine and Veterinary Medicine GP Partner
Edinburgh, Scotland Balmore Surgery
Possilpark Health and Care Centre
Ruth Margaret Bland, BSc, MBChB, MD, FRCPCH Glasgow
Consultant General Paediatrics
Royal Hospital for Children and Honorary Associate Ben Dietsch, MBChB
Clinical Professor Lead Specialty Doctor
Institute of Health and Wellbeing Willen Hospice
University of Glasgow Milton Keynes
Glasgow
Kieran Dinwoodie, MBChB, MRCGP, DRCOG, DTM&H,
David Nicholas Blane, BSc, MBChB, MPH Dip Derm
Clinical Academic Fellow General Practitioner Principal
General Practice and Primary Care Calderside Medical Practice
University of Glasgow Blantyre
Glasgow
Al Dowie, PhD
Christopher Burton, MD, FRCGP General Practice and Primary Care
Professor of Primary Medical Care University of Sheffield University of Glasgow
Sheffield Glasgow

David Carty, MBChB, PhD, FRCP Russell Drummond, MBChB

Consultant Endocrinologist Honorary Clinical Associate Professor
Department of Diabetes, Endocrinology and Clinical School of Medicine, Dentistry and Nursing
Pharmacology University of Glasgow
Glasgow Royal Infirmary Glasgow
Glasgow
Suzannah Drummond, MBBS, FRCOphth
Jane Colgan, MBChB, DTH&H, MRCP Consultant in Ophthalmic Surgery
Specialty Doctor Ophthalmology
Monklands Hosptial Tennent Institute of Ophthalmology
Lanarkshire Glasgow
Airdrie, Scotland

xiii
xiv List of Contributors

Anchal Goyal, MBBS, nMRCGP, DRCOG, DPD, GPwSI Catriona Nisbett, MBChB, MRCGP, MRCP, DRCOG, Dip
Dermatology Dermatology
NHS Lanarkshire General Practitioner
Monklands District General Hospital, Airdrie The Murray Surgery, East Kilbride

Kate Hughes, MBChB PhD MRCP (Diabetes and Declan Nugent, MB BCh, BAO, MRCGP
Endocrinology) General Practitioner
Consultant Physician and Diabetologist and Glasgow
Endocrinologist
Honorary Senior Lecturer Hilary Pinnock, MBChB, MD, MRCGP
School of Medicine, Dentistry and Nursing Reader
University of Glasgow Allergy and Respiratory Research Group, Centre for
Glasgow Population Health Sciences
University of Edinburgh
Heather Lafferty, MBChB, MRCP Edinburgh, Scotland
Consultant Physician and Gastroenterologist General Practitioner
Queen Elizabeth University Hospital Whitstable Medical Practice
Glasgow Whitstable

Lynn A. Legg, PhD, MPH Hilary Lockhart Pearce, MBChB, MRCPCH

Research Fellow Consultant General Paediatrics
Scottish Centre for Excellence in Rehabilitation Research Royal Hospital for Children
University of Strathclyde Glasgow
Glasgow
Lindsey Pope, MBChB, MRCGP, PGCertMedEd, FHEA
Sharon Mackin, MBChB (Hons), MRCP Clinical Senior University Teacher
Specialty Registrar Diabetes and Endocrinology General Practice and Primary Care
Department of Diabetes and Endocrinology University of Glasgow
Glasgow Royal Infirmary Glasgow
Glasgow
Ian Reeves, BSc, BM
John MacLean, MBChB, MRCGP, FRCPS (Glas), FFSEM, Department of Medicine for the Elderly
DRCOG Southern General Hospital
General Practitioner Glasgow
Maryhill Health and Care Centre and
Sport and Exercise Medicine Doctor Neil Ritchie, MBChB, PhD, MRCP(UK) (Infectious
Hampden Sports Clinic and Scottish FA and Diseases)
Honorary Clinical Associate Professor Clinical Lecturer in Infectious Diseases
University of Glasgow Institute of Infection, Immunity and Inflammation
Glasgow University of Glasgow
Glasgow
Frances McManus, MBChB, BMedSci, PhD, MRCP
(Diabetes and Endocrinology) John Paul Seenan, MBChB, MD, MRCP
Consultant Physician Consultant
Department of Diabetes Department of Gastroenterology
Endocrinology and Clinical Pharmacology Queen Elizabeth University Hospital
Glasgow Royal Infirmary Glasgow
Glasgow

Stewart W. Mercer, MD, PhD, FRCGP, FFPHM, FRCPE

Professor of Primary Care Research
University of Glasgow
Director of the Scottish School of Primary Care
Glasgow
 List of Contributors xv

Aziz Sheikh, BSc, MBBS, MSc, MD Harry Hao-Xiang Wang, PhD

Chair of Primary Care Research and Development Associate Professor
University of Edinburgh School of Public Health
Usher Institute of Population Health Sciences and Sun Yat-Sen University
Informatics PR China
College of Medicine and Veterinary Medicine Honorary Senior Lecturer
Edinburgh General Practice and Primary Care
University of Glasgow
Dominique Thompson, MBChB, MRCGP (Dist) Glasgow
GP and Director
Buzz Consulting Iain Wilson, MBBS, BSc, MRCS
Bristol Surgical Trainee
Queen Alexandra Hospital
Jane Tracy, MBBS, DRACOG, GCHE Portsmouth
Director
Centre for Developmental Disability Health Victoria
Monash University
Melbourne, Victoria, Australia
 S E C T I ON 1   Principles and Practice of Primary Care

1
Principles and Practice of
Primary Care
ADAM STATEN

C H A P T E R CO N T E N T S
Challenges of Primary Care Telemedicine
Population Challenges Communications Technology
The Challenge of External Factors Models of Care
The Evolving Primary Care Team Telephone Triage
Nurse Practitioners Shared Medical Appointments
Physiotherapists The General Practitioner Consultant
Clinical Pharmacists The Virtual Ward
Physician Assistants/Associates Caring for the Doctor
Mental Health Professionals The Burnout Syndrome
Medical Assistants Finding Help and Treatment
Use of Technology
Electronic Medical Records

OBJECTIVES
• Primary care can be defined as any care that is delivered in
the community as opposed to the inpatient setting. In
wealthier countries primary care is usually considered to be
the first level of care provision, whereas in poorer countries
it may be seen as a systemwide strategy to providing access
to healthcare (World Health Organization [WHO], 2003).
• It is widely recognised that building health services around
high-quality primary care results in better public health,
fewer inequalities in healthcare by socioeconomic class, and
lower rates of unnecessary hospital admissions (Kringos,
Boerma, van der Zee, & Groenewegen, 2013).
• The structure of primary care varies widely from country to
country but there are key similarities to treating patients in
the community that are true in all countries, and all
healthcare systems, including the interaction between
healthcare, social care, and third sector organisations, a
holistic approach to patient care, and an approach to
patient care that is proactive rather than reactive.
• The WHO (2003) recognises the core principles of primary
care to be:
1. universal access to care and coverage based on need;
2. commitment to health equity as part of development
oriented to social justice;
3. community participation in defining and implementing
health agenda;
4. intersectoral approaches to health.
• These principles are underpinned by the declaration of
Alma-Ata, made in 1978 (WHO 1978) in which primary care
was defined as “essential health care based on practical,
scientifically sound and socially acceptable methods and
technology made universally accessible.”

1
2 se c t i o n 1 Principles and Practice of Primary Care
Challenges of Primary Care
Population Challenges
• The provision of holistic care is at the heart of primary
care and providing this care is increasingly challenging
with a global population that is increasing in size, age,
and multimorbidity.
• The increasing capability to diagnose and treat disease leads
to increasing patient demand and increasing resource cost
both in terms of time and finance.
• Particularly in developed nations, the rise of illnesses
related to lifestyle factors such as smoking, alcohol con-
sumption, and obesity create a burden to the healthcare
system and are a complicating factor to many other ill-
nesses. Globally, infectious diseases such human immu-
nodeficiency virus/acquired immunodeficiency syndrome
(HIV/AIDS) contribute to the increasing burden on
primary healthcare (and the wider healthcare system).
• An increasing emphasis in maintaining wellness rather
than simply treating ill health has put primary care at
the forefront of screening programmes, education pro-
grammes, and primary preventative treatment.
• The increasing capabilities of modern medicine, the
emphasis on keeping people well, and wider public
access to healthcare information (via the internet, for
example) all contribute to rising patient expectations and
managing these expectations in a resource limited envi-
ronment can prove very challenging. In the United
Kingdom the General Medical Council (GMC) found
that this rise in expectations was a key contributing
factor to the 100% increase in complaints made against
doctors between 2007 and 2012 (GMC, 2014). Rising
patient expectations is also frequently cited as a reason
for doctors leaving their role in primary care (Leese,
Young, & Sibbald, 2002).
The Challenge of External Factors
• Healthcare is expensive and funding for primary care is
not always adequate to meet the needs of the population
it serves. For example, in many developing countries
funding is diverted away from the provision of compre-
hensive primary care in favour of providing vertical care
programmes targeting specific issues such as HIV/AIDS
or childhood immunisations (Maeseneer et al., 2008).
• The provision of healthcare can become highly politicised
and interference in healthcare from politicians for politi-
cal purposes, rather than to improve patient care, can be a
source of real frustration and dissatisfaction for doctors.
• Doctors now practice in the full glare of the media (and
social media) spotlight. Not only can this be intimidat-
ing and exposing, but doctors working in general prac-
tice are often left to undo the damage done by inaccurate
messages promulgated by the media.
• A worldwide tendency to increasing litigation and, in
some circumstances, the criminalisation of medical error
add to the pressures of working within primary care and
medicine in general.
The Evolving Primary Care Team
• Whilst general practitioners (GPs) are usually considered
to be central to the provision of primary care services,
the primary care team includes all those professionals
who contribute to the health and well-being of patients
in the community.
• With the increasing complexity of healthcare provision,
and the increasing complexity of the patients who receive
treatment in the community, any attempt for GPs to
practice in isolation without recourse to the wider
primary healthcare team is likely to result in frustration
for the GP and poor-quality, possibly dangerous care for
patients.
• The roles and responsibilities of the primary care team are
to some extent limitless. It is characteristic of primary care
that practitioners working in the community are expected
to deal to a greater or lesser extent with every problem that
a patient may present. Often these problems are not simply
medical and they may be complicated by, or indeed may
primarily be, psychological or social problems.
• Many tasks in primary care are as well, and often better,
performed by members of the primary care team other
than GPs.
• The structure of primary care teams varies from country
to country—for example, in the United Kingdom den-
tists usually work separately from GPs, but in other
European countries it is common for doctors and den-
tists to be colocated. Similarly, professionals such as
social workers and mental health nurses are located
alongside GPs in many countries.
• As coordinating patient care becomes ever more complex
it is vital that the extended primary care team works
coherently to avoid patient neglect or duplication of
effort to deliver effective, rational care to patients.
• Workforce problems in primary care in many countries
have led to the innovation of new roles for established
healthcare professionals within primary care and the cre-
ation of entirely new types of healthcare professionals.
• The primary care team in any community should be
tailored to suit the healthcare needs of the local popula-
tion and it is therefore essential for anyone involved with
workforce planning to be familiar with the variety of
professionals that can contribute to providing primary
healthcare.
• To deal with the demands of modern healthcare, doctors
should see themselves as having a key role in driving
healthcare policy toward establishing the most effective
primary care teams for their particular populations.
Nurse Practitioners
• Nurse practitioners, or advanced nurse practitioners, are
trained beyond the usual competences of registered

nurses so that they are able to practice autonomously and
assess and diagnose undifferentiated problems, to synthe-
sise treatment plans (Royal College of Nursing, 2012).
Key to this is their ability to prescribe independently.
• Nurse practitioners work in many different areas of
healthcare but within primary care they provide care
both for acute illness (usually by providing consultations
for minor illness) and chronic disease (such as perform-
ing routine reviews in respiratory illness or diabetes).
• They are well established in Anglophone countries where
they are seen as a key resource in helping to manage
patient demand, but they are less well recognised in other
parts of the world.
• Training to become an advanced nurse practitioner varies
from country to country and depends on the area of
healthcare in which the nurse is working, but in the
United Kingdom the Royal College of Nursing provides
accredited training courses to upskill nurses and prepare
them for an advanced role.
• Evidence suggests that nurse practitioners provide good
levels of patient satisfaction and good patient outcomes,
but the evidence of cost effectiveness remains equivocal
(Martin-Misener et al., 2015).
Physiotherapists
• Up to 30% of primary care consultations relate to
musculoskeletal problems, many of which are best dealt
with by physiotherapists. However, direct access to phys-
iotherapists for patients is not necessarily the norm
within primary care.
• Direct access is usually available to patients in Australia,
absent in the United States, and patchy throughout the
European Union. This variability in access is despite the
fact that the majority of countries, particularly within
Europe, have the requisite legislation and train their
physiotherapists to have the requisite competencies to
practice independently. Often the barriers to enabling
direct access come from within the medical profession
itself, despite the potential reduction in workload that
physiotherapists can provide (Chartered Society of Phys-
iotherapists, 2013). Where direct access is not available
patients must usually come via their primary care physi-
cian to get access to physiotherapy.
• The provision of direct access physiotherapy has been
shown to be both clinically and cost effective (Mallet
et al., 2014).
Clinical Pharmacists
• Clinical pharmacists have an extended role that involves
direct patient-facing activity with particular respect to
medicine management. Their key roles are in optimising
medication and dosage regimes, de-conflicting medica-
tions that may interact, and ensuring the cost effective-
ness of medications. Many are also involved in the
management of minor ailments and chronic disease.
CHAPTER 1 Principles and Practice of Primary Care 3
• As polypharmacy in an ageing population becomes
more common, expertise in medicine management will
be increasingly important and an increasing workload
burden for general practitioners.
• The role is perhaps best established in the United States
where clinical pharmacists have been working and evolv-
ing their role over a period of decades. In 1997 the
WHO published policy statements that envisaged an
expanded future role for pharmacists that would benefit
patients in healthcare systems globally. Since then the
role has become increasingly recognised in the Anglo-
sphere and across Europe. Clinical pharmacists are also
invaluable in bolstering the primary care teams in coun-
tries where doctor numbers are low.
Physician Assistants/Associates
• To train as a physician assistant (also known as a physi-
cian associate) the trainee must already have a degree in
a life or healthcare science subject. Physician assistants
then undergo an intense period of training in the medical
model to enable them to interview, examine, and diag-
nose patients; order and interpret tests; and perform
procedures according to competency. They may work in
a variety of settings from surgery to emergency medicine,
but many work in primary care.
• The physician assistant is a dependent medical practitio-
ner who works under the supervision of a physician. The
ability to prescribe is variable depending on the country
(or US state) in which the individual works.
• The physician assistant is a US invention; the role was
established there over 50 years ago. Currently there are
around 100,000 physician assistants practicing. They
have been shown to be cost effective and acceptable to
patients, and in recent years several countries have shown
interest in developing training programmes to produce
physician assistants to alleviate pressure on primary care
doctors (Legler, Cawley, & Fenn, 2007).
Mental Health Professionals
• Mental health problems are an enormous part of primary
care, either as the presenting problem or as a complicat-
ing factor for other problems. Up to one third of all
general practice appointments are thought to involve a
mental health component.
• Given this workload and the economic burden of mental
health in primary care, the WHO has produced policy
emphasising the importance of providing good-quality
primary mental healthcare. However, it remains unusual
for mental health nurses, or other mental health profes-
sionals who are capable of delivering psychologic treat-
ments, to be embedded within the primary care team.
• Since 2014 in the Netherlands there has been a deliberate
shift in the provision of mental healthcare from second-
ary to primary care. This has been largely facilitated by
increasing the number of mental health nurses working
4 se c t i o n 1 Principles and Practice of Primary Care
alongside GPs such that between 2010 and 2014 the
proportion of practices in the Netherlands with a mental
health nurse increased from 20% to over 80%. This has
not reduced GP workload but has increased the number
of long appointments available in the community to
patients with mental health problems (Magnée et al.,
2016).
• A Cochrane review of the effectiveness of counselling
provided within primary care found that it was clinically
more effective in the short term than usual care (although
not in the long term) and associated with similar costs
to usual care (Bower et al., 2011).
Medical Assistants
• Medical assistants primarily work within primary care
teams in the United States. They are allied health profes-
sionals who work in both administrative and clinical
roles. Their duties may include scheduling appointments,
handling correspondence, updating patient notes, as well
as performing clinical procedures such as ECGs and
blood draws, assisting the physician during procedures,
or preparing patients for examination.
• It is suggested that they are a key means by which doctors
can relieve themselves of their administrative workload
and so enable themselves to focus more on direct patient
care (Sinsky et al., 2013).
Use of Technology
The use of technology within medicine has the potential to
improve patient care and make the working life of primary
healthcare professionals easier and less stressful. As tech-
nologies develop it is important that those working within
primary care stay alert to new ways in which this technology
can be applied to their own working environments.
Electronic Medical Records
(Davies et al., 2016)
• The use of electronic medical records (EMRs) is common
but not ubiquitous. In New Zealand, Scandinavia, and
the United Kingdom the use of medical records is almost
universal, but this is not the case in other developed
nations; for example, in Canada rates are below 80% and
in Switzerland they are below 60%.
• Even where EMRs are used the capabilities of different
systems vary enormously with the most advanced allow-
ing the review of results, correspondence, production of
patient summaries, transfer of electronic prescriptions to
pharmacies, and prompts and alerts for patient review.
This allows for more seamless care, reduction in duplica-
tion of work, and the setting up of efficient and reliable
patient recall systems for patient review and monitoring.
• Higher levels of doctor satisfaction with their EMRs
have been shown to correlate with overall higher job
satisfaction.
Telemedicine
• Telemedicine (or telehealth) relates to the remote moni-
toring of patients and the transfer of biometric data
from the patients’ home to their doctor. It has perhaps
been most utilised when dealing with cardiovascular or
respiratory disease to enable early detection of decom-
pensation of the monitored illness and proactive, early
management.
• As technology advances and equipment such as blood
pressure monitors and oxygen saturation probes become
cheaper it is likely that this will be seen as a convenient
and cost-effective means of managing patients. It has the
added advantage of engaging patients with their own
care and empowering them to take responsibility for
managing their illness.
• The cost effectiveness of telemedicine remains uncertain
(Henderson, 2013), but it is likely that increasing
amounts of remote monitoring will become part and
parcel of future general practice; and as its use becomes
more common its cost effectiveness will improve.
Communications Technology
• We have more ways to communicate with one another
than ever before—via telephone, email, text message, or
video phone. These technologies present the possibility
of interacting with our patients and our colleagues more
efficiently and more flexibly.
• Younger patients in particular are comfortable with com-
municating electronically. For example, the use of virtual
clinics that employ email and text messaging to com-
municate with young diabetic patients has dramatically
improved attendance rates (Mayor, 2016).
• Video phone applications (such as Skype) have been
used in a variety of settings: providing remote care
for refugees, orthopaedic follow-up, and psychiatric
consultation. GPs in the United Kingdom have
experimented with using SkypeTM to review patients
in nursing homes.
• There are numerous email or phone-based systems that
can be employed to enable GPs to access specialist advice
rapidly, which may obviate the need for an acute admis-
sion or a referral for specialist advice.
Models of Care
• As the burden of caring for enlarging and ageing popula-
tions increases, the way in which patients are seen in
primary care will need to be adapted to increase capacity
within the system.
• GPs need to adapt the ways in which they see their
patients to suit their particular patient populations.
Some of these varied models of seeing patients will
be reliant on the technologies discussed earlier in the
chapter; others require a fresh approach to the traditional
medical consultation.

Telephone Triage
• Telephone triage is a means by which patient demand and
flow can be managed. It has become popular, particularly
in the United Kingdom, as a way to reduce the number of
patients that need to be seen face to face and involves
patients speaking to a health professional (usually a doctor
or a nurse) by phone to assess the need for a face-to-face
review before the patient is offered an appointment.
• Some who advocate the system estimate that up to 60%
of primary care problems can be resolved over the phone
and there is evidence suggesting that patients find this
means of interacting with their GP satisfactory.
• However, the ESTEEM trial was a large-scale trial of
telephone triage which found that, although clinician
contact time on the day of the appointment request was
reduced, overall clinician contact time was no different
to usual care, which to some extent undermines its
purpose (Holt et al., 2016).
Shared Medical Appointments
• Shared medical appointments are part medical consulta-
tion, part education session. Groups of patients with
the same condition are seen together for an extended
appointment and educated about their condition and
how it can be managed. This saves overall clinician time
whilst increasing the contact time the patient has with
the clinician. Other benefits include empowering patients
to self-manage and the creation of a peer support network
for patients.
• They have been used in a range of settings including
diabetes, maternity, physiotherapy, and liver disease.
Patients report higher levels of satisfaction with shared
medical appointment care than with usual care (Hey-
worth et al., 2014).
The General Practitioner Consultant
• This is a model of care that relies on the GP having a
team of varied allied health professionals at hand.
• This model of care relies on central triage which directs
patients toward the relevant professional (e.g., physio-
therapist, mental health nurse, physician associate). The
GP is not directly involved in the initial patient contact
but is called in to consult on cases that are beyond the
capability of the allied health professional.
• Theoretically this frees up the GP to dedicate time to
those most complex patients who require the most skilled
input albeit at the expense of the regular and recurrent
patient contacts that many would argue provide job sat-
isfaction in primary care.
The Virtual Ward
• The virtual ward is a concept designed to manage
patients, often housebound patients, who require intense,
CHAPTER 1 Principles and Practice of Primary Care 5
proactive, and multidisciplinary input. It is an elabora-
tion on the concept of the multidisciplinary team and
may or may not make use of telehealth data.
• Versions of the virtual ward that have been trialled usually
involve a team consisting of community nurses, GPs, ger-
iatricians, and possibly representatives from social ser-
vices. This team meets at regular intervals to discuss a case
load of complex patients.
• By meeting regularly and having input from a
number of disciplines this approach aims to improve
proactive care and so reduce the risk of an acute
decompensation in illness requiring hospital admis-
sion. It should also reduce duplication of effort by
improving communication between all those involved
in the patient’s care.
Caring for the Doctor
The Burnout Syndrome
• The world of general practice is without doubt stressful
and continues to become more so as a result of the chal-
lenges detailed already in this chapter. A 2015 Com-
monwealth Fund survey of primary care in 10 developed
nations found that significant proportions of doctors
in all 10 countries found their work in general practice
either very stressful or extremely stressful (Davies et al.,
2016).
• The phenomenon of physician burnout is well recog-
nised but often not well handled. The three key features
of burnout are usually described as:
1. emotional exhaustion;
2. depersonalisation;
3. an absent sense of personal accomplishment.
• The burnout syndrome overlaps with, and is compli-
cated by, anxiety and depression and shares key features
with those issues such as social withdrawal, absentee-
ism from work, and problems with drug and alcohol
abuse.
• Doctors are at high risk of burnout as they are selected
based on personality traits such as perfectionism, high
achievement, a sense of responsibility, and competitive-
ness, which all put them at higher risk of burning out.
• Work within medicine exposes people to extended
periods of extreme emotional stress (both their own and
that of other people), which contributes to burnout.
• A perceived stigma to mental illness amongst doctors
also means that doctors tend to seek help late by which
point the damage may well be significant, including
suicidality.
Finding Help and Treatment
• It is important that those working within general prac-
tice recognise the signs of stress and burnout both in
themselves and in their colleagues and feel able to seek
help or suggest that their colleagues seek help.
6 se c t i o n 1 Principles and Practice of Primary Care
• Treatment for the burnout syndrome, or for depression or
substance misuse problems in general, is along standard
lines and includes cognitive behavioural therapy (CBT),
medication, and counselling. These can be sought via the
doctors’ own GP although many are reluctant to seek help
in this way for themselves. Alternatively, many countries
have mental health programmes specifically for medical
professionals that can operate on an anonymous basis.
• Self-help techniques such as mindfulness also have a
good evidence base amongst doctors working in primary
care and many simple mindfulness techniques can be
learnt via online apps.
• GPs also have the opportunity to tackle the source of
their distress either by changing the way in which they
work or by changing the type of work that they do
within the varied world of primary care.
Further Reading
Staten, A., & Lawson, E. (2017). GP wellbeing: Combatting burnout
in general practice. London: CRC Press.
References
Bower, P., Knowles, S., Coventry, P. A., et al. (2011). Counselling for
mental health and psychosocial problems in primary care. Cochrane
Database of Systematic Reviews, (9), CD001025.
Chartered Society of Physiotherapists. (2013). Direct access and
patient/client self-referral to physiotherapy: A review of contem-
porary practice within the European Union. Physiotherapy, 99,
285–291.
Davies, E., et al. (2016). Under pressure: What the Commonwealth
Fund’s 2015 international survey of general practitioners means for
the UK. Retrieved from http://www.health.org.uk/publication/
under-pressure#sthash.3qqLghqH.dpuf.
General Medical Council. (2014). What’s behind the rise in complaints
about doctors from members of the public. Retrieved from https://
gmcuk.wordpress.com/2014/07/21/whats-behind-the-rise-in
-complaints-about-doctors-from-members-of-the-public/.
Henderson, C. (2013). Cost effectiveness of telehealth for patients with
long term conditions (Whole Systems Demonstrator telehealth ques-
tionnaire study): Nested economic evaluation in a pragmatic, cluster
randomised controlled trial. British Medical Journal (Clinical Research
Ed.), 346. doi:https://doi.org/10.1136/bmj.f1035.
Heyworth, L., et al. (2014). Influence of shared medical appoint-
ments on patient satisfaction: A retrospective 3-year study. Annals
of Family Medicine, 12, 324–330.
Holt, T., et al. (2016). Telephone triage systems in UK general
practice: Analysis of consultation duration during the index day
in a pragmatic randomised controlled trial. The British Journal of
General Practice, 66, e214–e218.
Kringos, D. S., Boerma, W., van der Zee, J., & Groenewegen, P.
(2013). Europe’s strong primary care systems are linked to better
population health but also to higher health spending. Health
Affairs, 32, 686–694. doi:10.1377/hlthaff.2012.1242.
Leese, B., Young, R., & Sibbald, B. (2002). GP principals leaving
practice in the UK. The European Journal of General Practice, 8,
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Legler, C. F., Cawley, J. F., & Fenn, W. H. (2007). Physician assis-
tants: Education, practice and global interest. Medical Teacher, 29,
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Maeseneer, J., van Weel, C., Egilman, D., et al. (2008). Funding for
primary health care in developing countries. BMJ (Clinical
Research Ed.), 336, 518–519.
Magnée, T., de Beurs, D. P., de Bakker, D. H., et al. (2016). Consulta-
tions in general practices with and without mental health nurses: An
observational study from 2010 to 2014. BMJ Open, 6, e011579.
Mallett, R., et al. (2014). Is physiotherapy self-referral with telephone
triage viable, cost-effective and beneficial to musculoskeletal
outpatients in a primary care setting? Musculoskeletal Care, 12,
251–260.
Martin-Misener, R., et al. (2015). Cost effectiveness of nurse practi-
tioners. British Medical Journal Open, 5, e007167.
Mayor, S. (2016). Use texts, apps, and Skype to keep young people
with diabetes engaged with services, says guidance. British Medical
Journal (Clinical Research Ed.), 352, i394.
Royal College of Nursing. (2012). Advanced Nurse Practitioners: An
RCN Guide to advanced nursing practice, advanced nurse practition-
ers and programme accreditation.
Sinsky, C., et al. (2013). In search of joy in practice: A report of
23 high-functioning primary care practices. Annals of Family
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2
Long-Term Conditions
STEWART W. MERCER, HARRY HAO-XIANG WANG
C H A P T E R CO N T E N T S
Prevalence of Long-Term Conditions
Comorbidity and Multimorbidity
Prevalence of MM
Global Burden
Deprivation Effects
Effects of MM
Healthcare Utilisation
Mental and Physical
OBJECTIVES
• A long-term condition (LTC) is commonly defined as
a condition that requires ongoing medical care,
limits what one can do, and is likely to last for a year
or more.
• Common long-term conditions include diseases such as
coronary heart disease, diabetes, asthma, and stroke.
Patients with such conditions are commonly seen and
managed in primary care in the long term. Less common
Prevalence of Long-Term Conditions
• Prevalence rates of individual long-term conditions vary
considerably between different countries and populations,
though in most countries, including developing countries,
long-term conditions are increasing rapidly in the popula-
tion. This is true in all age groups, although certain condi-
tions affect certain age groups more than others.
• It should be borne in mind that all prevalence estimates of
long-term conditions are based on data collection methods
that have some flaws. Thus prevalence estimates will vary
according to how the condition is defined and measured.
Comorbidity and Multimorbidity
• International studies have demonstrated that many people
living with chronic disorders have multiple chronic health
problems simultaneously. The co-occurrence of one or
more additional long-term conditions to a person with an
Polypharmacy
Clinical Guidelines
Evidence-Based General Practice
Management
Organisational
Inverse Care Law
What Do Patients With LTCs Need From General Practice?
chronic conditions seen in general practice include multiple
sclerosis, Parkinson disease, and muscular dystrophy.
• Conditions once considered terminal are now commonly
seen, and regarded as long-term conditions, due to
improved survival rates from treatments, and this includes
many cancers and infectious diseases such as human
immunodeficiency virus (HIV) and acquired
immunodeficiency syndrome (AIDS).
index condition (a condition of primary concern) is
termed comorbidity. For example, a patient with diabetes
and asthma, being cared for by a diabetologist, may be
considered by the specialist physician as a diabetic with
comorbidity. It is a term mainly used by specialists reflect-
ing their own area of expertise.
• In general practice, patients commonly have two or more
long-term conditions without one being clearly an index
condition, and indeed the extent to which different con-
ditions affect patients often varies over time. Thus in
primary care the term multimorbidity (MM) is preferred
to comorbidity.
Prevalence of MM
• Multimorbidity is common and has been rising in preva-
lence over recent years. For example, a Canadian study of 21
family practices in Quebec reported a multimorbidity
7
8 se c t i o n 1 Principles and Practice of Primary Care
prevalence of 69% in 18- to 44-year-olds, 93% in 45- to
64-year-olds, and 98% in those over age 65, with the
number of chronic conditions varying from 2.8 in the
youngest to 6.4 in the oldest (Fortin et al., 2005). In the
United Kingdom, a large, nationally representative study in
Scotland found that over 40% of the whole population (all
ages included) had at least one long-term condition, and
almost 25% of the entire population had multimorbidity
(Barnett et al., 2012).
• The prevalence of multimorbidity increases substantially
with age and is present in most people aged 65 years or
older. However, the Scottish study also found that the
absolute number of people with multimorbidity was
higher in those younger than 65 years than those over
65 years, thus long-term conditions and multimorbidity
should not be considered simply a problem of old age.
Global Burden
• Over recent decades, life expectancy has improved dra-
matically and currently exceeds the age of 75 on average,
in nearly 60 countries. This is due to improved living
circumstances, greater access to universal education, and
rapid advances in clinical medicine and public health.
• The ageing of the global population is regarded as the
most crucial driver of increases in the burden of chronic
diseases. It is particularly evident in wealthier countries
where many people are living much longer now than
ever, though not necessarily healthier in their extra years.
It is estimated that by 2020, the incidence of long-term
conditions will increase by approximately 30% to 40%
as the population ages.
Deprivation Effects
• Health is seldom distributed evenly across populations
and in most (if not all) countries of the world, the
poorest health is found in those living in situations of
poverty. This is also true of multimorbidity, which
tends to be worse in those of the lowest socioeconomic
status. The study in Scotland (discussed earlier) revealed
an astonishingly precise relationship between multimor-
bidity and deprivation. Multimorbidity in those living
in the most deprived areas also develops some 10 to 15
years younger than in the least deprived decile of the
population.
• Many (though not all) studies have found that multi-
morbidity is more common in women than in men.
Effects of MM
• Many LTCs are associated with increased mortality and/
or morbidity, and this is exacerbated by increasing levels
of multimorbidity. There is a clear linear relationship
between levels of multimorbidity and death rate.
• Multimorbidity also increases hospital admission rates,
even for potentially avoidable admissions and has a
major negative impact on quality of life.
Healthcare Utilisation
• Patients with LTCs and multimorbidity may have higher
overall vulnerability to diseases and less resistance to acute
health threats (e.g., higher susceptibility to influenza).
These interacting influences lead to a complex pattern in
the demand and utilisation of health services.
• Multimorbidity leads to an increased likelihood of referrals
between different providers of healthcare (often in a vertical
manner—i.e., general practitioner [GP] to several special-
ists, but also between specialists, especially in centres of
excellence). Excessive use of specialist care leads to a rapid
rise in healthcare expenditure. Multimorbidity has become
one of the most salient influences on cost of healthcare due
to the heavy burden on the healthcare utilisation.
Mental and Physical
• LTCs span both mental and physical conditions, and com-
monly patients have both. This relationship is bidirectional
in that patients with mental health problems commonly go
on to develop physical health problems, and patients with
a wide range of LTCs are more likely to go on to develop
mental health problems than the general population.
Polypharmacy
• A common problem in patients with LTCs is polyphar-
macy, which is usually defined as being on five or more
regular medications. In patients with multimorbidity, poly-
pharmacy is even more common. This has serious implica-
tions for iatrogenesis. Indeed, a common reason for hospital
admission, especially in the elderly, is medication side effects
and interactions. Not only is this harmful to patients, but
it also infers a huge financial drain on healthcare systems.
• A second problem with polypharmacy is adherence to med-
ication regimens. Research has shown that once patients get
to five or more medications per day their adherence begins
to decline. That’s not to say that patients stop taking all their
tablets, but they do tend to be creative in developing their
own regimens, especially skipping tablets that have effects
that they don’t like such as loop diuretics.
• Patients often have strong perceptions of which tablets may
be giving them side effects (even if this is unlikely to be the
case), which can be influenced by a whole host of things
such as pill size, colour, and taste. It has been suggested that
polypills (combination pills with several ingredients—e.g.,
for cardiovascular disease) may enhance adherence by
reducing the number of tablets required each day, though
at present there is little evidence to support this.
Clinical Guidelines
• A likely major driver of polypharmacy is guidelines. The
development of clinical guidelines based on evidence
collated from randomised controlled trials has been one
of the major advances in the delivery of evidence-based
medicine over the last 20 years. However, guidelines are
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Northampton, Ralf of Chester seized at, i. 336;
Henry II. at, ii. 23, 143;
priory of S. Andrew at, 37;
meeting of justiciars and barons at, 391;
Assize of, 172, 173;
councils at, i. 136; ii. 32–40, 172, 427.
See David, Simon
Northmen, their work in Frankland and in England, i. 100;
enter the Loire, 101;
sack Nantes, ib.;
attack Toulouse, Paris, Bordeaux, 102;
defeated at Aclea, ib.;
sack Tours, ib.;
seize Angers, 103;
driven out, 104;
besiege Paris, ib.;
defeated by Rudolf, 115;
attacks on Tours, 181, 182.
See Ostmen
Northumberland, Scottish claims upon, i. 286
Norwich, i. 40, 41;
sacked, ii. 155, 156;
massacre of Jews at, 289;
castle, i. 284, 430.
See Herbert, John
Nostell priory, i. 68
Nottingham, i. 320;
council at, ii. 329

O’Briens, their rivalry with the O’Neills, ii. 86.

See Donell, Murtogh, Terence
O’Conor, see Roderic, Terence
Octavian, cardinal, see Victor IV.
Odelin de Umfraville, ii. 145, 153, 160
Odo, count of Paris, duke of the French and king of West-
Frankland, i. 104
Odo, count of Anjou, i. 109, 133
Odo I., count of Blois, Chartres and Tours, i. 145
Odo II., count of Blois etc., seizes Melun, i. 149, 189;
character, 150;
defeated at Pontlevoy, 157, 158;
count of Champagne, 160;
besieges Montboyau, 161;
Saumur, 163;
attacks Amboise, ib.;
seizes Sens, 164;
aims at the Empire, 166;
death, 167
Odo, count of Gascony and duke of Aquitaine, i. 174, 175
Odo, son of Robert II. of France, i. 177, 178
Odo of Britanny, i. 211, 212
Oilly, see Robert
O’Lochlainn, see Donell, Murtogh
O’Neills, their rivalry with the O’Briens, ii. 86
Orderic, i. 24
Orkneys, see Ralf
Orléans, viscounts of, i. 249, 250
O’Ruark, see Tighernan
Osbern Huitdeniers, i. 353
Oseney priory, i. 43
Ossory, ii. 102
Ostia, see Alberic
Ostmen, their settlements in Ireland, ii. 82–84;
relations with England, 83, 86, 87;
struggle with Malachi and Brian, 85;
ecclesiastical relations, 87–89;
share in Irish politics, 89, 90
Otto I., Emperor, i. 119
Otto II., Emperor, i. 119, 120
Otto of Saxony, son of Henry the Lion, his proposed marriage, ii.
341;
chosen Emperor, 372, 373;
quarrel with John, 407
Otto, cardinal, ii. 69
Oundle, i. 60
Owen, prince of North Wales, i. 435, 436, 437; ii. 179
Oxford, i. 41–44;
Robert Pulein at, 43;
Henry I. at, 44;
bishops seized at, 303, 304;
Matilda at, 322, 331–333;
military advantages, 331;
taken by Stephen, 332;
Vacarius at, 379;
Richard I. born at, 445;
Henry and Thomas meet at, ii. 24;
Gerald de Barri at, 460;
councils at, i. 283, 402; ii. 349–350, 427;
castle, i. 41, 331–334;
gilds, 30, 43, 52;
S. Frideswide’s priory, 42;
Port-meadow, 43;
schools, ib.; ii. 462.
See John

Paganel, see Ralf

Pageham, ii. 32
Palestine, see Jerusalem
Paparo, see John
Paris attacked by northmen, i. 102, 104;
capital of the duchy of France, 105;
university of, ii. 461.
See Odo
Paschal III., antipope, ii. 55
Patrick, bishop of Dublin, ii. 88, 89
Patrick, earl of Salisbury, governor of Aquitaine, ii. 58, 59
Paula of Maine, i. 222, 254
Pavia, council at, i. 498, 499.
See William
Peace, edict for preservation of, ii. 339, 340;
conservators of, their origin, 340
Pembroke, Flemings in, i. 52.
See Gilbert, Richard, William
Pencarn, ii. 179
Périgueux, ii. 223
Périgord, see Adalbert
Peter, duke of Aquitaine, see William VI.
Peter “Bogis,” ii. 421, 422
Peter of Capua, cardinal-legate, ii. 375, 395
Peter of Celle, i. 482, 483
Peter of Colechurch, ii. 486
Peter de Leia, bishop of S. David’s, ii. 455, 456
Peter Lombard, ii. 461, 467
Peter of Saintes, tutor to Henry Fitz-Empress, i. 375
Peterborough, “Black Book” of, i. 58;
chronicle, 81
Petronilla, queen of Aragon, wife of Raymond-Berengar IV. of
Barcelona, i. 463
Petronilla, wife of Tertullus, i. 128
Petronilla of Grandmesnil, countess of Leicester, ii. 138, 150
Pevensey, i. 430
Peverel, see William
Philip I., king of France, i. 220, 221, 224
Philip Augustus, son of Louis VII. of France, born, ii. 56;
receives young Henry’s homage, 62;
crowned, 216;
quarrels with Blois, 217;
marries Elizabeth, ib.;
crowned again, 218;
succeeds Louis, 219;
demands Margaret’s dowry, 232, 236;
quarrel with Flanders, 234;
plots with Geoffrey, 243;
claims wardship of Eleanor of Britanny, ib.;
of Arthur, 245;
attacks Berry, ib.;
truce, 246;
takes the cross, 249;
takes Châteauroux, 251;
attacks Auvergne, 252;
negotiates with Richard, 253, 254;
receives his homage, 255;
takes Le Mans, 259;
Tours, 264;
treaty with Richard, 275;
policy in Palestine, 320;
returns to France, 313;
demands the Vexin etc., ib., 314;
alliance with John, 314, 323, 363;
attacks Normandy, 363, 364;
routed at Fréteval, 366, 367;
secures Arthur, 370;
war with Flanders, 374;
truce with Richard, 375;
takes Evreux, 389;
receives homage of Arthur, 390;
of Eleanor, ib.;
razes Ballon, 394;
divorces Ingebiorg, 395;
treaty with John, 395–397;
takes Ingebiorg back, 401;
cites John to his court, 402, 408;
conquers eastern Normandy, 403;
besieges Arques, 405, 406;
burns Tours, 407;
takes Saumur and enters Poitou, 410;
successes in Normandy, ib.;
takes Isle of Andely, 411–416;
Petit-Andely, 416;
Radepont, ib.;
Château-Gaillard, 416–423;
Normandy submits to, 424–425;
conquers Poitou, 426;
takes Loches and Chinon, ib.;
marches against John, 428
Philip, count of Flanders, joins young Henry, ii. 141;
threatens to invade England, 155, 158;
his policy in France, 216;
quarrels with France, 234, 235;
pilgrimage to Canterbury, 235
Philip de Broi, ii. 21
Philip Gay, i. 297
Philip of Gloucester, i. 335, 336
Philip de Thaun, i. 94
Pierre-Pécoulée, treaty of, i. 234
Pipe Rolls, i. 26, 431–432
Pipewell, council at, ii. 277
Pisa, see Henry
Poitiers stormed by Adalbert of Périgord, i. 145;
Henry and Eleanor married at, 393;
council at, 458;
Richard enthroned at, ii. 130;
taken by Philip, 426.
See John
Poitou granted to Hugh the Great, i. 123;
barons of, appeal to Philip against John, ii. 402;
conquered by Philip, 426.
See Aquitaine
Polycraticus, i. 486–491
Pontaudemer, siege of, i. 241
Pontigny, abbey of, i. 70;
S. Thomas at, ii. 42, 54
Pont-l’Evêque, see Roger
Pontlevoy, battle of, i. 157, 158
Popes, see Adrian, Alexander, Calixtus, Celestine, Eugene,
Innocent, Lucius, Paschal, Urban
Porhoët, see Eudo
Port, see Adam
Portmannimot of Oxford, i. 43
Port-meadow at Oxford, i. 43
Port-reeve, i. 29;
of London, 45.
 See Gilbert Becket
Portsmouth, ii. 400, 427
Premonstratensians, i. 357, 358
Prendergast, see Maurice
Provence, i. 454, 463.
See William
Provins, i. 482
Pucelle, see Gerard
Puiset, see Hugh
Pulein, see Robert
Pullus, see Robert

Quévilly, i. 471; ii. 198

Radepont, ii. 403, 416

Rahere, founder of S. Bartholomew’s hospital, i. 67
Rainald, bishop of Angers, i. 193
Raino, bishop of Angers, i. 131, 132
Ralf, bishop of the Orkneys, i. 289, 355
Ralf, bishop of Rochester, made archbishop of Canterbury, i. 68
Ralf, earl of Chester, his marriage, i. 314;
claims Carlisle, ib.;
seizes Lincoln castle, 315;
brings Robert to relieve it, 316;
at battle of Lincoln, 317, 320;
again seizes the castle, 334;
joins Stephen, 336;
imprisoned, ib.;
gives up Lincoln, ib.;
revolts again, 377, 395;
dies, 399
Ralf, earl of Chester, second husband of Constance of Britanny,
ii. 369, 370
Ralf of Bayeux, i. 241
Ralf de Broc, ii. 39, 76, 79, 149
Ralf de Diceto, dean of S. Paul’s, ii. 439;
his Angevin History, i. 127
Ralf of Faye, ii. 129
Ralf Flambard, justiciar, i. 8, 9, 21, 32, 432;
bishop of Durham, 80
Ralf of Fougères, ii. 137, 147, 148, 258
Ralf de Glanville, ii. 145, 160;
justiciar, 177;
takes the cross, 248;
resigns and dies, 279
Ralf of Issoudun, ii. 401, 405
Ralf Paganel, i. 295, 298
Ralf of Varneville, chancellor to Henry II., ii. 142, 297
Ralf of Vermandois, i. 307
Ramirez the Monk, king of Aragon, i. 463
Ramsbury, see Matilda
Rancogne, see Geoffrey
Rathbreasil, synod of, ii. 93
Raymond-Berengar III., count of Barcelona, i. 463
Raymond-Berengar IV., count of Barcelona, i. 463, 466
Raymond of St. Gilles, count of Toulouse, i. 454, 455
Raymond V., count of Toulouse, his marriage, i. 458;
war with Henry II., 464–467;
meets Henry at Grandmont, ii. 58;
does him homage, 133;
struggle with Aragon, 211;
quarrel with Richard, 244, 250, 251;
death, 371
Raymond VI., count of Toulouse, marriage, ii. 371;
homage to John, 397
Raymond Trencavel, viscount of Béziers and Carcassonne, i.
462, 464, 466
Raymond the Fat, ii. 104, 108, 183
Reading, i. 282, 322; ii. 61, 240, 308
Redvers, see Baldwin
Rees Ap-Griffith, prince of South Wales, his dealings with Henry
II., ii. 164, 179–181, 237;
with John and Richard, 280;
death, 351
Reginald, earl of Cornwall, i. 391; ii. 144, 146
Reginald, chancellor to Frederic Barbarossa, and archbishop of
Cöln, ii. 55
Reginald Fitz-Urse, ii. 78
Reims, councils at, i. 206, 237, 367, 368.
See Gervase, William
Remigius, bishop of Dorchester, moves his see to Lincoln, i. 39
Rennes united with Nantes, i. 449.
See Conan, Hoel, Juhel
Richard, third son of Henry II. and Eleanor, born, i. 445;
first betrothal, 463;
invested with Aquitaine and betrothed to Adela, ii. 62;
enthroned at Poitiers, 130;
revolts, 135;
submits, 165;
his character, 206–208;
fights the barons in Aquitaine, 209, 210, 214, 215, 220, 223;
refuses homage to his brother, 224;
takes Hautefort, 231;
refuses to give up Aquitaine, 233;
war with Geoffrey and John, ib.;
reconciled, 234;
gives up Aquitaine to Eleanor, 235;
wars with Toulouse, 244, 250, 251;
negotiates a truce, 246;
seizes the Angevin treasure, ib.;
reinstated in Aquitaine, 247;
takes the cross, 248;
tries to regain Châteauroux, 252;
negotiates with Philip, 253, 254;
meets Henry and Philip at Bonmoulins, 254;
homage to Philip, 255;
encounter with William the Marshal, 261;
scene with Henry at Colombières, 266;
comes to Fontevraud, 271;
reconciled with the Marshal, 272;
recognized as Henry’s successor, 273;
duke of Normandy, 274;
treaty with Philip, 275;
goes to England, ib.;
crowned, 276;
fills vacant sees, 277, 278;
his policy, 278;
appoints justiciars, 279, 283;
sells sheriffdoms etc., 280;
dealings with Wales, ib.;
with Scotland, 281;
with John, 281–282;
goes to Normandy, 287;
holds council there, 288;
possible successors, 295;
treaty with Tancred, ib.;
marriage, 296;
names William of Monreale for the primacy, 297;
sends Walter of Rouen to England, 297, 298;
his voyage, 317;
conquers Cyprus, ib.;
alliance with Guy of Lusignan, 318, 320;
reaches Acre, 319;
quarrel with Leopold of Austria, ib.;
relations with other crusaders, 319–321;
truce with Saladin, 321;
homeward voyage, 322;
wrecked and captured, ib.;
given up to the Emperor, 324;
his ransom, 325, 326;
negotiates with Philip and John, 327;
returns to England, 328;
imposes taxes, ib., 329;
negotiates with Scotland, 330;
crowned at Winchester, ib., 331;
king of Burgundy, 331;
leaves England, ib.;
forgives John, 334;
 gives license for tournaments, 342;
annuls his charters, 343, 356;
sends the abbot of Caen to England, 343;
quarrel with S. Hugh, 350;
edict against the clergy, 355;
cessions to Philip, 361;
difficulties in Gaul, 361, 362;
treaty with Philip, 364;
goes to Normandy, 365;
to Tours, 365, 366;
regains Loches, 366;
routs Philip at Fréteval, ib., 367;
claims wardship of Arthur, 370;
alliance with Toulouse, 371;
with Henry VI., 372;
called to elect an emperor, ib.;
league against Philip, 374;
truce, 375;
builds Château-Gaillard, 375–380;
quarrel with Abp. Walter, 380, 381;
lays siege to Châlus, 382;
wounded, 384;
dies, 385, 386;
burial, 386, 387;
his encouragement of municipal life, 470;
grant to merchants of Cöln, 485
Richard, archbishop of Canterbury, ii. 170, 434
Richard I., bishop of London, i. 45
Richard II., bishop of London, i. 502, 503
Richard Fitz-Nigel, treasurer and bishop of London, ii. 277;
his Gesta Henrici, 439
Richard of Ilchester, ii. 66;
bishop of Winchester, 158, 176;
work in the Exchequer, 193, 194;
seneschal of Normandy, 193;
death, 277
Richard de Clare, earl of Pembroke or Striguil, ii. 99, 100;
 goes to Ireland, 103;
takes Waterford, 104;
marriage, ib.;
blockaded in Dublin, 109, 110;
summoned by Henry, 112;
does homage for Leinster, 113;
in Normandy with Henry, 145, 182;
governor of Ireland, 182;
death, 183
Richard le Breton, ii. 78
Richard Fitz-Count, son of Robert of Gloucester, i. 386, 405; ii.
146
Richard Fitz-Godoberd, ii. 100
Richard of La Haye, i. 340, 341
Richard of Hommet, constable of Normandy, ii. 146
Richard de Lucy, justiciar, his character, i. 417;
his share in election of Thomas, ii. 1–3;
excommunicated, 66;
takes Leicester, 146;
marches against the Scots, 149;
besieges Huntingdon, 154, 156;
protests against the forest visitation, 171;
retires to a monastery, 176
Richard de Morville, ii. 139, 161
Richenda de Clères, sister of William of Longchamp, ii. 305
Richer de l’Aigle, i. 51, 395
Richmond, see Alan
Ridel, see Geoffrey
Rievaux abbey, i. 71
Robert I., king of France, i. 149, 164
Robert the Brave, count of Anjou, i. 102;
duke of the French, 103
Robert the Magnificent, or the Devil, duke of Normandy, i. 166
Robert, son of William the Conqueror, betrothed to Margaret of
Maine, i. 216;
homage to Geoffrey the Bearded, 217;
to Fulk Rechin, 223;
 seeks Fulk’s help in Maine, ib.;
sells the Cotentin to Henry, 4;
wars with his brothers, 5, 6;
pledges Normandy to Rufus, 3;
crusade, ib.;
invades England, 9;
war with Henry, 11;
taken prisoner, 13;
dies, 271
Robert Bloet, chancellor, justiciar and bishop of Lincoln, i. 22
Robert II., bishop of Lincoln, ii. 24
Robert I., bishop of Hereford, i. 370, 495
Robert of Melun, i. 481;
bishop of Hereford, ii. 24
Robert of Bellême, count of Alençon etc., i. 6;
banished, 10;
sues for peace, 11;
flies at Tinchebray, 13;
captures Elias, 225;
imprisoned, 233
Robert, count of Burgundy, i. 178
Robert, count of Dreux, i. 394
Robert, earl of Ferrers, ii. 139, 163
Robert, earl of Gloucester, son of Henry I., friend of William of
Malmesbury, i. 92, 94;
escorts Matilda over sea, 243;
at Henry’s death, 270;
dispute for precedence with Stephen, 274;
joins Stephen, 283;
defies him, 294;
comes to England, 309;
marches to Lincoln, 316, 317;
receives Stephen’s surrender, 320;
made prisoner, 327;
exchanged, 329;
goes to fetch Geoffrey, 330;
returns, 332;
 besieges Wareham, ib.;
takes Portland and Lulworth, 333;
meets his sister at Wallingford, 334;
routs Stephen at Wilton, ib.;
builds a castle at Farringdon, 335;
helps Geoffrey in Normandy, 338, 339;
dies, 343, 344
Robert I., earl of Leicester and count of Meulan, i. 16, 54, 56
Robert II., earl of Leicester, joins Henry, i. 400;
justiciar, 417;
at council of Northampton, ii. 39;
refuses the kiss of peace to Reginald of Cöln, 55, 56;
dies, 61
Robert III., earl of Leicester, rebels, ii. 138, 142;
goes to England, 148;
made prisoner, 150;
restored, 167;
repulses Philip from Normandy, 363
Robert II., count of Meulan, ii. 138
Robert de Barri, ii. 101
Robert de Bruce, ii. 145
Robert, abbot of Caen, ii. 343, 344
Robert Fitz-Stephen, ii. 100;
goes to Ireland, 101;
blockaded in Carrick, 109;
made prisoner, 111;
released, 113
Robert of Marmion, i. 335
Robert de Montfort defeats Henry of Essex in ordeal, ii. 60;
rebels, 138
Robert of Mowbray, ii. 155
Robert I. of Oilly, i. 41, 42, 331
Robert II. of Oilly founds Oseney priory, i. 43;
gives up Oxford to the Empress, 322;
death, 332
Robert Pulein, i. 43, 44
Robert Pullus, i. 483
Robert of Sablé, i. 343
Robert of Selby, chancellor of Sicily, i. 365
Robert of Sillé, ii. 137
Robert de Stuteville, ii. 145, 153, 160
Robert of Torigny or de Monte, ii. 194
Robert of Turnham, seneschal of Anjou, ii. 388, 389;
of Poitou, 426;
prisoner, 427
Rocamadour, ii. 74, 226, 227
Rochelle, La, ii. 428
Roches, see William
Rochester, see Ralf, Walter
Roderic O’Conor, king of Connaught, ii. 97;
of Ireland, 98;
treaty with Dermot,102;
gathers a host against him, 104;
blockades Dublin, 109, 110;
routed, 110, 111;
promises tribute to Henry II., 116;
treaty, 182
Roger, king of Sicily, i. 365
Roger of Pont-l’Evêque, i. 354, 368;
archbishop of York, 477;
earlier career, 478, 479;
accepts the royal customs, ii. 24;
dispute with S. Thomas, 30;
crowns young Henry, 72;
appeals to the king, 78;
dies, 285
Roger, chaplain to Henry I., chancellor, bishop of Salisbury and
justiciar, i. 22;
his administration, 25, 26;
called the “Sword of Righteousness,” 26;
his Church policy, 63;
joins Stephen, 278;
his family, 302;
relations with Stephen and with the Empress, ib., 303;
 seized at Oxford, 303, 304;
death, 310
Roger, earl of Clare, ii. 12, 16, 180
Roger, earl of Hereford, i. 429
Roger of Howden, i. 82; ii. 439
Roger de Lacy, ii. 400, 401;
at Château-Gaillard, 411, 417, 418, 423
Roger of Montrésor, i. 151
Roger de Mortemer, ii. 299
Roger de Mowbray, ii. 139, 152, 160, 162, 163
Roger “the Poor,” chancellor, i. 302, 303
Rohesia, wife of Gilbert Becket, i. 50, 352
Roland, count of Maine, i. 203
Roland of Siena, cardinal, see Alexander III.
Rome, relations of William and Lanfranc with, i. 15;
trial of Stephen’s and Matilda’s claims at, 370;
schism at, 498
Ronceray, i. 165 note 3{363}, 166; ii. 200
Roscilla of Loches, wife of Fulk the Red, i. 110
Rotrou, archbishop of Rouen, ii. 72, 81
Rouen surrenders to Geoffrey Plantagenet, i. 341, 342;
besieged by Louis VII., ii. 164;
palace, 196;
young Henry buried at, 232;
Richard’s heart buried at, 387;
Arthur imprisoned at, 407;
submits to Philip, 425.
See Rotrou, Walter
Rouergue, i. 454
Roumare, see William
Roxburgh, i. 287
Rudolf of Burgundy, king of West-Frankland, i. 111, 115
Rufus, S., priory of, i. 476

Saher de Arcelles, i. 363

Sainfred, bishop of Le Mans, i. 204
Saintes granted to Fulk Nerra, i. 159, 173;
 taken by William VII. of Aquitaine, 215;
regained and lost again, 216.
See Peter
Saintonge ceded to Geoffrey Martel, i. 174;
granted to Fulk Rechin, 214;
war of, 215, 216, 252, 253
Saint-Saëns, see Elias
Saints, Old-English, revived veneration for, i. 33, 80
Saladin tithe, ii. 249
Salisbury, i. 32–33.
See Herbert, Hubert, Jocelyn, John, Patrick, William
Saltwood, ii. 79
Sancho VI., king of Navarre, submits to Henry II.’s arbitration, ii.
190
Sancho VII., king of Navarre, suppresses revolt in Gascony and
attacks Toulouse, ii. 316;
helps Richard, 366, 367
Saumur, i. 161;
taken by Fulk Nerra, 162;
blockaded by William of Poitou, 213;
betrayed to Fulk Rechin, 220;
burnt, ib.;
Henry II. at, ii. 256;
taken by Philip, 410;
abbey of S. Florence, i. 162, 163.
See Gelduin
Savaric of Mauléon, ii. 405, 426
Saxony, see Henry, Matilda, Otto
Scarborough, i. 428
Schools, Augustinian, i. 43;
at Oxford, ib., ii. 462;
London, i. 47;
Malmesbury, 84, 85.
See Universities
Scotland, its relations with Henry I., i. 96.
See David, Henry, Matilda, William
Scutage, i. 432, 433;
 the Great, 459–461;
of 1195, ii. 343;
1196, 348
Sees, removal of, i. 40
Selby, see Robert
Sempringham, order of, i. 359, 360;
helps S. Thomas, ii. 41
Seneschal of France, office of, i. 450
Sens, i. 164; ii. 42, 68
Serfdom in twelfth century, i. 61, 62
Serlo the Mercer, mayor of London, ii. 472
Severn, valley of, i. 35
Sherborne castle, i. 304
“Sheriff’s Aid,” ii. 15
Sheriffs of London, i. 45; ii. 471;
Middlesex, i. 46;
inquest on (1170), ii. 126, 127
Shrewsbury, i. 295, 298, 299
Sibyl, queen of Jerusalem, ii. 247, 320
Sibyl of Anjou, daughter of Fulk V., i. 240, 241
Sicily conquered by Henry VI., ii. 371, 372.
See Constance, Jane, Roger, Tancred, William
Sillé, see Hugh, Robert
Simeon of Durham, i. 81, 82
Simon, count of Montfort, i. 467
Simon de Montfort, count of Evreux, ii. 138
Simon, earl of Northampton, ii. 144;
claim to Huntingdon, 154
Simon of Dover, i. 363
Simon Fitz-Peter, ii. 21
Sleaford, i. 304
Smithfield, i. 47;
S. Bartholomew’s priory and hospital, 67
Soissons, ii. 42, 65.
See Guy, William
Solomon, king of Britanny, i. 103
Spain, proposed crusade in, i. 453, 497
Standard, battle of the, i. 289–291
Stephen Harding, S., i. 69, 70
Stephen of Blois, son of Stephen-Henry and Adela, i. 235, 236;
his “Lombard grandmother,” 256;
brought up by Henry I., 273;
count of Mortain, ib.;
marriage, ib.;
relations with Henry, 274;
oath to Matilda, ib.;
goes to England, 276;
gains the treasury, 277;
crowned, 279;
first charter, ib.;
character, 280, 281;
treaty with Scotland, 282;
early successes, 283;
second charter, 284;
revolt against him, ib.;
holds forest assize, 285;
goes to Normandy, 286;
invades Scotland, 287;
relations with the barons, 292, 293;
with Earl Robert, 294;
revolt in the west, 295–299;
grants Northumberland to Henry of Scotland, 300;
besieges Ludlow, 301, 302;
takes Leeds, 302;
seizes Roger of Salisbury and his nephew, 303, 304;
summoned before a council at Winchester, 305;
penance, 306;
truce with Geoffrey, 307;
besieges Arundel, 309;
sends Matilda to Bristol, 310;
keeps Whitsuntide in the Tower, 311;
besieges Lincoln castle, 315;
exploits at battle of Lincoln, 319, 320;
prisoner, 320;
 exchanged, 329;
takes Wareham and Cirencester, 330;
Oxford, 332;
besieges the castle, 332, 333;
routed at Wilton, 334;
takes Farringdon, 335;
builds Crowmarsh, 336;
imprisons Ralf of Chester, ib.;
wears his crown at Lincoln, 337;
banishes Abp. Theobald, 368;
trial of his claims at Rome, 370;
reconciled to Theobald, 371;
knights Eustace, 377;
drives Vacarius from Oxford, 379;
refuses a safe-conduct to John Paparo, 380;
proposes to crown Eustace, 381, 390;
imprisons the bishops, 391;
meets Henry, 397;
treaty, 400;
last days, 403;
death, 404
Stephen I., count of Champagne, i. 160
Stephen II., count of Champagne, i. 177;
rebels, 177, 178;
defeated, 178, 186;
dies, 271
Stephen-Henry, count of Blois, Chartres and Champagne,
receives Fulk Rechin’s homage, i. 221;
his parents, 255, 256;
marriage, 271, 272;
crusade and death, 272
Stephen of Turnham, seneschal of Anjou, ii. 273, 279
Stockbridge, i. 327
Striguil, see Richard, William
Strongbow, ii. 99 note 7{445}
Stuteville, see Robert, William