Registrar feedback on 'Formative assessments in medical education'.

We agree with A’Court and colleagues that the consequence of diagnosing greater numbers of people with other chronic conditions in addition to hypertension may be associated with increasing difficulties in providing access.1 The argument is that as more patients with chronic disease require regular management, the demand for appointments with GPs and practice nurses increases. This is important since some other chronic conditions are under recorded, including for example chronic obstructive pulmonary disease, chronic kidney disease, and obesity. The implications are that tackling chronic disease in this country is going to be challenging unless the capacity of primary care is increased. We also agree, however, that changing methods of diagnosis may help to reduce the numbers of people with false positive diagnoses, as may be the case in hypertension. The suggestion that structured equation modelling offers an alternative analytic approach is interesting. However, although structured equation modelling would be possible, the fact that the associations are at the population level would mean that inferences about causality could only be supported at the population level. Perhaps this is an approach that could be used in future studies that include additional data.