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Discussion Forum

 

Feel free to comment on anything that we have published recently or add to existing discussions. We won’t assume that you want us to consider comments posted here for publication in the Journal; please let us know if you want us to do so. Letters we are unable to print in the Journal may be posted here instead (see Writing for the BJGP for letter submission guidelines).

 

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Date: 22 Jan 2012
Topic: Response to ‘Is health eating for obese children necessarily more costly for families?’
Comments by: Susan Martin, Saddleworth Medical Practice, Uppermill, Oldham

The paper by Banks et al¹ was music to my ears. As someone who has been jousting with a tendency towards obesity since my teenage years I am not only well aware of the ‘healthy food costs too much’ argument so beloved by patients, but the counter arguments. The one that seems to confound people most of all is ‘why don’t you just eat less of what you can afford to buy?’ I have not yet had a sensible answer to this: generally there is a knotting of brows for a few seconds as though I were speaking in tongues, before moving on to some other issue.
 
It seems to me that there are two main problems to be overcome in quashing the ‘healthy is expensive’ argument. First the cheapness of less healthy options: the often quoted discount ready-made lasagne, for example. Second is the idea that a diet is not healthy unless it contains a liberal sprinkling of exotic fruit and veg. We are surrounded by images of blueberries with our breakfast cereal, pak choi in our ‘10 minute’ supper, and kiwi fruit at just about any time of day. These images are propagated by magazines and diet clubs alike. Is it any wonder people think they can’t afford it?
 
Last year one of Britain’s leading supermarkets introduced menus that cost around £50 per week for a family of four. In some quarters this came under fire for such mundanities as toast for breakfast. There is nothing wrong with toast for breakfast. In many Mediterranean countries (whose diet is seen as the gold standard) it is common to skip breakfast altogether in favour of elevenses, or to take little more than bread and coffee.    
 
By all means try and curb the purveyors of cheap, unhealthy options, but more importantly let us push a sensible, achievable alternative.
 
Reference
1. Banks J, Williams J, Cumberlidge T, et al. Is health eating for obese children necessarily more costly for families? Br J Gen Pract 2012; DOI: 10.3399/bjgp12X616300.

 

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Date: 5 Jan 2012

Topic: QOF should be more about disease and risk factors prevention

Comments by: Edoardo Cervoni, Tarleton Group Practice, The Health Centre, Tarleton

 

I urge a radical re-thinking of the obesity QOF system. QOF should be far more about disease and risk factors prevention. As there may be debate around the concept of obesity as a problem rather than a disease, there should be little doubt that obesity is a significant problem.¹ Obesity has been associated with cardiovascular disease, premature death, stroke, non-insulin-dependent diabetes mellitus, gout, gallbladder disease, GORD, asthma, joint problems, and several types of carcinomas. Abdominal obesity (increased waist-to-hip circumference ratio [WHR]) should be recorded as more closely correlated with metabolic disease and even malignancies.² Clinically I find it difficult to accept that patients may be diagnosed as obese without being first warned to be overweight and advised accordingly. Healthy lifestyle education should be a core activity of primary care workers and I am concerned that some non-profit organisations may be better at managing weight than GPs are.³ The paper from Phillips and colleagues told us that dietary counselling by clinicians in primary care is sub-optimal, and perhaps the same could be said about physical exercise advice.⁴ Bobbioni-Harsch and colleagues have shown how metabolically normal obese subjects could be at increased risk of cardio-metabolic diseases. Furthermore, their findings suggest that high BMI, alone or with fasting insulin, negatively affects the cardio-metabolic profile.⁵ Interestingly, patients may be more upset by being told that they are obese, or scared of having their weight checked, than being told about high cholesterol or abnormal glucose tolerance. GPs tend to avoid using the term ‘obese’ and often prefer to use a euphemism. They are aware that the term obese may upset the patient. It has been shown that the term obese makes patients believe that the problem has more serious consequences and makes them feel more anxious and upset than when the same symptoms are labelled using a euphemism. I strongly advocate for more regular use of the weight scale in primary care, as there is a continuum from normal body weight to obesity and the early identification of a trend of excessive weight gain may be both clinically more beneficial and less upsetting for the patient.

 

References
1. Heshka S, Allison DB. Is obesity a disease? Int J Obes Relat Metab Disord 2001; 25(10): 1401­–1404.
2. Björntorp P. The associations between obesity, adipose tissue distribution and disease. Acta Med Scand Suppl 1987; 723: 121–134.
3. Jebb SA , Ahern AL, Olson AD, et al. Primary care referral to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial. Lancet 2011; 378(9801): 1485–1492.
4. Phillips K, Wood F, Spanou C, et al. Counselling patients about behaviour change: the challenge of talking about diet. Br J Gen Pract 2012; DOI: 10.3399/bjgp12X616328.
5. Pataky Z, Makoundou V, Nilsson P, et al. Metabolic normality in overweight and obese subjects. Which parameters? Which risks? Int J Obes (Lond) 2011; 35(9): 1208–1215.

 

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Date: 2 Jan 2012
Topic: Response to ‘From the European Definition as an advocate not a steward/gatekeeper’
Comments by: Francesco Carelli, EURACT Director of Communications and Professor of Family Medicine, Milan, Italy

 

In her editorial, Clare Gerada describes, in this dismantling situation for family medicine, the progressive shift for GPs from an advocate to gatekeeper role.¹ This is true and dangerous.

 

The role of advocate in our situation has not legal but medical roots, opposite thinking from John Matthews.² It comes directly from the European Definition where GPs’ characteristics contain comprehensiveness, community orientation, and holism (a biopsychosocial approach).³ So, nothing to do with legal roots but the real medical roots.  Advocacy in this context is not separated from decision making, on the contrary, the GP must be the advocate in the sense to stay by their patients, making decisions together with their patients in a difficult bureaucratic and cutting system. Just recently in the WONCA European Definition the characteristic of patients’ empowerment was added in all its significance.

 

It does not make sense for GPs to spend their time negotiating contracts with managers and hospitals, and even less to bear financial risk for their expensively ill patients, turning GPs into rationers of care and away from their professional role as patient advocates.

 

So, I totally agree with Clare Gerada’s editorial. She understands how this dismantling situation in primary care (where innovation is going to destruction and cherry picking patients away from their normal primary care provider, limiting referrals and treatments on financial rather than clinical grounds, and creating opportunities to control medical care before it is delivered, and creating perverse incentives) is really the transformation from human and clinical advocate to a cold gatekeeper, in this case for other and upper providers.⁴

 

I think all these will turn in a worsening of our role and the final assimilation by John Matthew with a steward (a gatekeeper even) is indicative how the situation is going to disrupt the  advocacy  just against our most important clients, our patients!

 

References
1. Gerada C. From patient advocate to gatekeeper: understanding the effects of the NHS reforms. Br J Gen Pract. 2011: 61(592): 655–656.
2. Matthews J. From patient advocate to gatekeeper: understanding the effects of the NHS reforms. Br J Gen Pract 2012: 62(594): 12.
3. Allen J, Gay B, Crebolder H, et al. The European definition of general practice/family medicine. Wonca Europe, 2002 and 2011.
4. vanWeel C, Carelli F, Gerada C. Reforming  primary care: innovation or destruction? Br J Gen Pract 2012: 62(594): 43–44.

 

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Date: 13 Dec 2011
Topic: A systematic review:  the role of spirituality in reducing depression in men and women living with HIV/AIDS
Comments by: Dr Roxanna Amuzie, Urology F1 North Middlesex University Hospital Trust

Melvyn Jones (RA’s supervisor),Primary Care and Population health: UCL (Royal Free Campus), Rowland Hill Street, London

Vermandere et al’s¹ article highlighted end-of-life care as a particular area where spirituality can play an important role. In a link between spirituality and another chronic disease we looked at spirituality and HIV (R Amuzie, unpublished data, 2009). Vermandere’s literature review proposes that spirituality has a key position in the management of HIV sufferers. HIV infection is a major global problem and in 2007 was present in 33 million people around the world.² Antiretroviral therapy has been successful in slowing the progression of HIV infection and reducing AIDS-related mortality. But by doing so, HIV infection is now widely considered as a chronic illness and therefore HIV sufferers are beleaguered by similar challenges as those living with chronic illnesses like epilepsy and diabetes mellitus. Research suggests that people with HIV/AIDS are at greater risk of depression,³ and that depression in HIV sufferers is linked with more rapid loss of immune function, accelerated disease progression, and lower survival time.⁴

 

In clinical research, spirituality has been broadly defined as a belief in a higher power than oneself that is not thought to be God. Another definition is that spirituality is similar to an individuals’ experience of meaning and life purpose.⁵ It has been reported to reduce the risk of depression in people living with chronic illness. This review was conducted to examine the possible benefits and impact of spirituality on depressive symptoms in people with HIV/AIDS.

 

Systematic literature searches of PubMed, PsycInfo, and Embase were carried out, along with backwards and forwards citation tracking of key studies, identified 21 qualitative studies, of which five studies^6–10 met the predetermined criteria for eligibility and were included in the review. Formal meta-analysis was not possible due to the nature of the studies.

 

This review found that a large number of people with HIV/AIDS report experiencing depressive symptoms that are suggestive of mild-moderate depression. Studies provide statistical evidence that a greater level of spirituality in a person with HIV/AIDS is linked to fewer symptoms of depression. However, further research is required to examine the association between spirituality and clinically-diagnosed depression, as well as the impact of spirituality-focused interventions in reducing depression in people with HIV infection or AIDS.

 

References

1. Vermandere M, De Lepeleire J, Smeets L, et al. Spirituality in general practice: a qualitative evidence synthesis. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X606663.
2. Joint United Nations Programme on HIV/AIDS. AIDS epidemic update. Geneva: UNAIDS, 2001. (accessed 10 Jan 2011).
3. Ciesla J, Roberts J. Meta-analysis of the relationship between HIV infection and risk of depressive disorders. Am J Psychiatry 2001; 158(5): 725–730.
4. Leserman J. HIV disease progression: depression, stress and possible mechanisms. Biol Psychiatry 2003; 54(3): 295–306.
5. Ellison C. Spiritual well-being: Conceptualization and measurement. Journal of Psychology and Theology 1983; 11: 330–340.
6. Carrico AW, Ironson G, Antoni MH, et al. A path model of the effect of spirituality on depressive symptoms and 24-h urinary-free cortisol in HIV-positive persons. J Psychosom Res 2006; 61(1): 51–58.
7. Braxton ND, Lang DD,  M Sales J, et al. The role of spirituality in sustaining the psychological well-being of HIV-positive black women. Women Health 2007; 46(2–3): 1131–1129.
8. Yi MS, Mrus JM, Wade TJ, et al. Religion, spirituality and depressive symptoms in patients with HIV/AIDS. J Gen Intern Med 2006; 21(Suppl 5): 21–27.
9. Coleman CL, Holzemer WL. Spirituality, psychological well-being and HIV symptoms for African Americans living with HIV disease. J Assoc Nurses AIDS Care 1999; 10(1): 42–50.
10. Simoni JM, Ortiz Z. Mediational models of spirituality and depressive symptoms among HIV-Positive Puerto Rican women. Cultur Diver Ethnic Minor Psychol 2003; 9(1): 3–15.

 

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Date: 4 Dec 2011
Topic: Response to ‘What do we actually know about the referral process?’
Comments by: Peter Perkins, FRCGP, MRCS, Southbourne Surgery, Bournemouth
 
Whatever the true picture regarding GP autonomy and variation in referrals to secondary care, it seems likely that most of us have at least some interest in how our referrals compare with others.¹ Inevitably this has come under the current financial spot light. We are being told to make less referrals, find cheaper solutions, still practise safe, evidence-based medicine and, on the sharp end of NHS care delivery, explain all this and apologise to patients.

 

Our local PCT provided us with data related to our referrals to hospital outpatient clinics that resulted in patients being seen only once. Their interpretation of this crude data was that these referrals could therefore be seen as unnecessary. When I looked more closely at the cases involved it included One-Stop Clinics (for example, haematuria and DVT) and suspicious moles and breast lump referrals.

 

Ask any GP and there are often multifactorial reasons behind a referral. If some of these referrals are truly inappropriate then by all means provide us with feedback, but at least make certain the data is meaningful and accurate so that reasonable and valid conclusions can be drawn. And don’t make sweeping policy decisions based on erroneous conclusions.
 
Reference
1. Davies P, Pool R, Smelt G. What do we actually know about the referral process? Br J Gen Pract 2011; 61(593): 752–753.

 

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Date: 22 Dec 2011
Topic: A non-traditional method of teaching general practice to medical students: notes summarising
Comments by: Nigel Mabvuure, Brighton and Sussex Medical School, Audrey Emerton building, Brighton
 
For some medical students, it is necessary to undertake part-time work alongside their medical studies. Graduate students on 5-year courses, who do not receive NHS bursaries like their peers on graduate-entry courses, and students from low-income families may be in this group. The looming rise in tuition fees to £9000 per year may increase the number of students needing to work. While traditional student jobs such as bar and retail work are also open to medical students, healthcare-related jobs may be more beneficial. Healthcare assistant jobs are popular among medical students and a call has been made by Louden and Nickerson for GPs to employ students as phlebotomists.¹ Here I present another option: medical records summarising.

 

Locum GPs and trainees, especially, may not be familiar with a patient’s long history. It is helpful for a summary of the patient’s history to be presented in a readily accessible format, in other words, to be summarised. A summariser reads all the correspondence in a record and highlights the pertinent details. For medical students, this is an opportunity to learn how to write clinical letters and the GP approach to a wide range of presentations. I first learned of psoriatic arthritis by noticing that many patients with psoriasis also had arthritis, before my dermatology and rheumatology rotations, showing the educational value of summarising. Students also benefit from having a paid, usually flexible, position to increase their funds. The GP benefits by having employees who do not require costly medical terminology courses, and are possibly quicker and more accurate, as students already know what medical history is relevant.

 

Problems could arise if the practice is located at a university campus where the student might know some of the patients registered. However, such problems could be avoided by giving students clear guidance and education on their obligations in safeguarding patient data. Doctors should also ensure that students’ part-time duties do not interfere with their medical education and it may be helpful to have more than one student. To dissuade students spending too long ‘learning’ rather than summarising, my GP employer awards 10 pence per record summarised, above the basic wage.

 

Having assisted in the auditing of records for the QOF, I feel I have gained an insight into general practice above the level expected for a medical student. I therefore urge more GPs to consider advertising summariser jobs with their local medical schools in the first instance.
 
Reference
1. Loudon J, Nickerson S. Let us take blood. Br J Gen Pract 2011; [Epub ahead of print].

 

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Date: 7 Dec 2011
Topic: Buprenorphine versus Methadone use in opiate detoxification, are there other factors that should be considered?
Comments by: Hardeep K Bhupal, MRCGP, GP, Forensic Physician – Northamptonshire Police Force

The recent research on the ‘comparison of methadone and buprenorphine for opiate detoxification (LEEDS trial): a randomised control trial’ raises an important point with regards to utilising buprenorphine and methadone in opiate detoxification.¹

 

The authors quite rightly conclude equal clinical effectiveness between the two agents, a statement that is supported by previous studies.^2,3

 

However, there are additional factors that should be considered when determining which one of the two would be best suited for purpose. There is evidence to support the use of buprenorphine over methadone, especially when taking into account the risk of morbidity and mortality.

 

Nielsen et al identified an increased risk of overdose and adverse outcomes associated with methadone when compared to burprenorphine.⁴

 

In addition to the increased number of adverse incidents, they also concluded that presenting signs (respiratory rate and Glasgow Coma Scale score) were lower in methadone-related attendances hence indicating a heightened risk of complications and death.

 

This was further supported by Bell and colleagues who concluded that buprenorphine was associated with lower overdose risk and lower mortality when compared to methadone.⁵

 

Although the cost of buprenorphine is higher than methadone,⁶ and the clinical effectiveness of both agents is on a par, it is worth bearing in mind the increased risk of overdose, hospital admissions, morbidity, and mortality associated with methadone, that may negate the cost difference.

 

References
1. Wright NM, Sheard L, Adams CE, et al. Comparison of methadone and burprenorphine for opiate detoxification (LEEDS trial): a randomised control trial. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X613106.
2. Petitjean S, Stohler R, Déglon JJ, et al. Double blind randomized trial of buprenorphine and methadone in opiate dependence. Drug and Alcohol Depend 2001; 62(1): 91­–104.
3. Pinto H, Maskrey V, Swift L, et al. The SUMMIT Trial: A field comparison versus methadone maintenance treatment. J Subst Abuse Treat 2010; 39(4): 340–352.
4. Nielsen S, Dietze P, Cantwell K, et al. Methadone and buprenorphine related ambulance attendances: a population-based indicator of adverse events. J Subst Abuse Treat 2008; 35(4): 457–461.
5. Bell JR, Butler B, Lawrance A, et al. Comparing overdose mortality associated with methadone and buprenophine treatment. Drug Alcohol Depend 2009; 104(1–2): 73–77.
6. Jones ES, Moore BA, Sindelar JL, et al. Cost analysis of clinic and office-based treatment of opioid dependence: results with methadone and buprenorphine in clinically stable patients. Drug Alcohol Depend 2009; 99(1–3): 132–140.

 

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Date: 25 Nov 2011
Topic: Response to ‘From Patient advocate to Gatekeeper – understanding the effects of the NHS reforms’
Comments by: Peter Davies, FRCGP, GP, Member, Calderdale Clinical Commissioning Group, Keighley Road Surgery, Illingworth, Halifax

 

I read Clare Gerada’s article in BJGP November issue¹ with some surprise. I had to read to her last paragraph to find areas of agreement with her. I do believe that continuity, accessibility, caring, and the co-ordination of this matter to patients.

 

I do not believe the current NHS achieves this well. There are many breaks in continuity throughout the system; within GP surgeries, between GPs and other primary health care team members, between GPs and secondary care services, between health and social care. Access to care is reasonable, but it could be better. Co-ordination of care could be better at all levels across the NHS. Why are patients sent home from hospital wondering when their outpatient appointment or follow-up test is booked for? Why are they seeing GPs in the vain hope that we will have any better information than they have? Why are they spending time, and running up costs, in the wrong part of the system at the wrong time for the wrong reason? Why do we expect our fellow citizens to pay taxes for us to indulge such inefficiency? The current UK NHS is a moderately successful health service, but it is in need of improvement. The NHS has been described by Nigel Lawson as, ‘the closest thing the English have to a religion.’ Rabbi Julia Neuberger commented that she thought its priests had lost faith in their religion.² Practically the NHS needs to be justified by its works, not by faith.

 

As doctors we need to own the fact that care costs.³ Fragmentation is inefficient, and wastes time and money.⁴ Every decision we make is both clinical and financial. Every statement we make about the worth or value of any treatment is, in part, a financial evaluation. Every decision we make incurs a cost that the NHS is paying. Every pound can only be spent once, so every decision to do one thing is by default simultaneously a decision not to do another. To a large extent NHS doctors have been insulated from the financial consequences of their actions, and the NHS as a whole has borne them. As Tudor Hart describes, at one stage no one in the NHS had much or any idea about much anything cost.⁵ In the modern era we cannot get away with such laxity, and indeed in secondary care the accuracy of the coding for payment by results is improving meaning that we now have a far clearer idea about what they are doing and the levels of co-morbidity they are dealing with. Perhaps such techniques need to be extended to primary care so that we get more finely grained information about what and how much we actually do, and then we can stop regretting how much primary care works goes unmeasured, unappreciated, and unpaid.

 

In other industries workers at a similar level of seniority to GPs would be expected to be accountable for the simultaneous flows of activity and money. Commissioning challenges us to do this for the NHS. It is not a challenge we will all like, but I think it is one we cannot honourably decline.

 

As I see it commissioning is the chance our generation of doctors will have to make the NHS navigable.⁶ It is not about either ‘gatekeeping’ or ‘advocacy.’ It is not about anything American at all. It is about making the NHS in England work better for its patients.

 

Far from commissioning heralding the end of the NHS, I see it as the opportunity we have to get the NHS right for the generation to come.
 
References
1. Gerada C. From patient advocate to gatekeeper – understanding the effects of the NHS reforms. Br J Gen Pract 2011; 61(592): 655–656.
2. Neuberger J. The NHS as a theological institution. The ideal remains strong, but the practice too has to measure up. BMJ 1999; 319(7225): 1588–1589.
3. Garbutt G, Davies P. Should the practice of medicine be a deontological or utilitarian enterprise? J Med Ethics 2011; 37(5): 267–270.
4. Seddon J. Systems thinking in the public sector: The failure of the reform regime … and a manifesto for a better way. Devon: Triarchy Press, 2008.
5. Tudor Hart JT. A new kind of doctor. London: Merlin Press, 1988.
6. The King’s Fund. Improving the quality of care in general practice. Independent inquiry into the quality of care in general practice in England. London: The King’s Fund, 2011.

 

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Date: 21 Nov 2011

Topic: Response to 'Urgent suspected cancer referrals from general practice'

Comments by: Chris Smith, MRCGP, MRCP, NIHR In-Practice Fellow, Imperial College London

 

There has been some interesting debate around the reasons for the difference in UK cancer survival rates compared with other developed countries. Of concern, late diagnosis has been identified as the major contributor to the observed poor survival in England compared to other European countries, with the gatekeeper role of the GP raised as a possible explanation.¹ Clearly this is a complex area, but I think addressing the following two important issues will be critical.

First, an obvious solution to avoiding delayed diagnosis might be for GPs to adopt a lower threshold for referring patients with lower risk symptoms, rather than adopting a watch and wait strategy. However, at the same time, GPs are under greater pressure to reduce the costs associated with referrals to secondary care and subsequent unnecessary investigation. The challenge will be how to reconcile the conflicting issues of needing to diagnose cancer early while avoiding overwhelming secondary care services. The evidence presented from Australia where there are good cancer survival rates, and where GPs have better access to investigations such as computerised tomography suggests that better access to such investigations could be a solution for the UK. Increasing consultation times would allow more time to explore symptoms and signs. Clearly more research is needed here.

 

Second, fast track referrals are expected to comply with the 2-week wait referral criteria. However, the evidence for its effectiveness is limited and as Baughan et al have demonstrated, a significant proportion of patients whose referral did not comply with the urgent suspected cancer guidelines did have a diagnosis of cancer.² It provides a compelling case for clinical judgement in addition to using the guidelines. Moreover, it suggests that the guidelines need to be updated to reflect the increasing body of evidence on the positive predictive value of key symptoms and signs.³

 

References

1. Rubin G, Vedsted P, Emery J. Improving cancer outcomes: better access to diagnostics in primary care could be critical. Br J Gen Pract 2011; 61(586): 317–318.

2. Baughan P, Keatings J, Neill BO. Urgent suspected cancer referrals from general practice. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X606591 

3. Hamilton W, Astin M, Griffin T, et al. The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X572427

 

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Date: 21 Nov 2011

Topic: From patient advocate to gatekeeper
Comments by: John Matthews, GP, Park Road Medical Practice, Wallsend

Chair, CareFirst Pathfinder CCG, North Tyneside

 

In her editorial the Chair of the RCGP describes the role of GPs as gatekeepers in a negative light.¹ She asserts that this role has arisen in the past 20 years as a result of GPs being encouraged to take financial, as well as clinical, responsibility for their patients. In fact the role of the GP as a gatekeeper has been recognised for at least the past 100 years.² There should be nothing demeaning about GPs having a gatekeeper role it has been associated with the cost-effective delivery of healthcare services the world over.³

The role of advocate that she proposes has legal rather than medical roots. The advocate's only duty is to their client. It presupposes the separate and distinct role of a judge who is responsible for final arbitration. Such separation of advocacy from decision-making is a luxury that does not exist in medicine. In seeking to disengage GPs from the financial concerns of providing healthcare Dr Gerada is not helping us face reality. It may help us to see financial resources as we do any other finite resource, for example, a blood bank or a doctor's time. Clinical triage principles would direct a doctor to use the blood supplies on those patients in whom it would gain the greatest benefit and not those for whom its use would be marginal or futile. Similarly, a doctor does not decide how to allocate their time simply on the basis of one patient's need but has to spend it with regard to all their patients' needs. In both these cases the doctor does not behave as an advocate for an individual patient but as a steward (a gatekeeper even) of a finite resource who seeks to maximise its effectiveness. It is also important to be clear that the GP would be at fault for closing the gate unnecessarily as well as for opening it irresponsibly. Therein lies the complexity and value of general practice.

References

1. Gerada C. From patient advocate to gatekeeper: understanding the effects of the NHS reforms. Br J Gen Pract 2011; 61(592): 655–656.

2. Loudon I. The principle of referral: the gatekeeping role of the GP. Br J Gen Pract 2008; 58(547): 128–130.

3. The Commonealth Fund. International profiles of health care systems. Washington, DC: Commonwealth Fund, 2010.

 

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Date: 14 Nov 2011

Topic: Olympic absurdities

Comments by: Mike Fitzpatrick, Barton House Health Centre, London

 

My column on the promotion of exercise in the shadow of the Olympics has provoked an upsurge of moral indignation and a flurry of references from an international group of elite specialists and academics.^1,2 Their response suggests a remoteness from the realities of primary health care, indeed from the real world. I do not claim the authority of scientific evidence or that of prestigious medical institutions, but from the perspective of a jobbing GP point out three self-evidently absurd propositions in the arguments of the exercise zealots.

 

Inactivity is a major cause of ill-health. Over the thirty years in which I have been a GP, the most dramatic change in the health of my patients has been the increase in life-expectancy in old age, most spectacularly confirmed by the growing ranks of centenarians. This increase in longevity has taken place in a population in which only a tiny minority engage in any form of exercise (this is, of course, particularly true of women who make up the greater proportion of this thriving elderly cohort).

 

At least thirty minutes a day of at least moderate intensity activity on five or more days a week is necessary to achieve and maintain good health. I know club runners and committed footballers who fall short of the exercise standard now being promoted by the Department of Health and endorsed by the Chief Medical Officer. Indeed a brief survey of friends, relations, and colleagues reveals nobody who meets it. I do recall a patient with obsessive compulsive disorder and anorexia who met this target, but he was quite ill.

 

A brief intervention by a GP can transform a couch potato into an athlete. A belief in the magical powers of GPs to change established patterns of behaviour (including alcohol consumption as well as inactivity) in the course of a routine consultation (in 35 minutes in a popular Australian model) has become widely established in the world of health promotion. But it could not possibly be true that a chat with a doctor could achieve such transformations and solve at a stroke major social problems such as those associated with alcohol. This faith in the power of brief interventions reveals wishful thinking and professional hubris on a cosmic scale.

 

I am grateful to my GP colleague Rachel Pryke for drawing my attention to Lets Get Moving: A New Physical Activity Care Pathway for the NHS.³ It is true that this 86page document provides numerous assertions like that of our academic trio that the evidence is incontrovertible, but no actual evidence, for which the reader is referred to its 43 references. Skimming through these time is tight and like Pryke I have my QOF targets to consider, especially as these are now being monitored by the exercise police I find studies flawed by small scale, short duration, using diverse measures of exercise, and unreliable self-reporting, all showing modest effects, even after moving the outcome goal posts to guarantee success. Lets Get Moving is permeated with the jargon and dogma of motivational interviewing, reflecting the baleful influence of behavioural psychology in medical practice.^4,5

 

References

1. Weiler R, Stamatakis E, Blair SN. Physical inactivity is associated with earlier mortality the evidence is incontrovertible. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X613098

2. Fitzpatrick M. The Olympic legacy. Br J Gen Pract 2011; 61(592): 688.

3. Pryke R. The Olympic legacy. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X613052

4. Fitzpatrick M. The power of wishful thinking. Br J Gen Pract 2010; 60(573): 301.

5. Fitzpatrick M. Motivation in question. Br J Gen Pract 2011; 60(576): 543.

 

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Date: 08 Nov 2011
Topic: Physical inactivity is associated with earlier mortality – the evidence is incontrovertible
Comments by: Richard Weiler, GP, Honorary Consultant in Sport & Exercise Medicine, UCLH, Hertfordshire

Emmanuel Stamatakis, Senior Research Associate/NIHR Career Development Fellow, University College London, Research Department of Epidemiology and Public Health, London

Steven N Blair, Professor, Faculty Affiliate, Division of Health Aspects of Physical Activity/EPID, University of South Carolina, Department of Exercise Science, Columbia, South Carolina, US

We commend BJGP for publishing and bringing much needed attention to the opinions of Mike Fitzpatrick on the perceptions of physical activity promotion within the healthcare sector in this country.¹

 

There is, however, nothing virtuous, propagandist, patronising, and infantile about physical inactivity being the fourth leading risk factor for global mortality responsible for 6% of worldwide deaths and a major contributing factor to 60% of global non-communicable diseases.² There is a clear causal relationship between the amount of movement people do and all-cause mortality.³

 

Behaviour change psychology permeates all aspects of medicine and it is interesting to note that, despite widespread acceptance of pharmaceutical medications by doctors, enormous pharmaceutical advertising expenditure, and a large proportion of medical education being devoted to pharmacology, only 30–50% of patients change their behaviour sufficiently to consume prescribed medication at advised therapeutic doses.⁴ Changes to medical education are urgently needed to include greater emphasis on behaviour change techniques for they underpin much of what we do in clinical practice, and are effectively used to modify physical inactivity behaviour in primary care.^5,6

 

Dr Fitzpatrick insinuates that co-ordinated public health strategies involving health professionals and physical activity promotion have ‘no proven value in relation to health’. We congratulate Fitzpatrick on promoting lifestyle promotion at his clinic, according to the NHS Information Centre, last year his own surgery achieved 100% incentivised payments from QOF for lifestyle promotion indicators. Brief interventions in primary care achieve similar concordance with physical activity to prescribed medication,^7,8 so lifestyle recommendations are in fact of very great value in relation to health with far wider collateral benefits.^9,10,11

 

Physical activity promotion and lifestyle advice are included as the first treatment recommendation in 39 different sets of clinical guidelines in the UK because evidence supports that physical activity can be used to treat the same diseases that physical inactivity causes (and improve quality of life, mental health, productivity, and academic achievement).¹²
Medical ethics, medico-legal duties of care, and perhaps even moral responsibility also underpin the need for physical activity promotion, to the extent that General Medical Council Good medical practice obligations, state that ‘You should encourage patients and the public to take an interest in their health and to take action to improve and maintain it. This may include advising patients on the effects of their life choices on their health and well-being ...’.¹³

 

As a start, some simple tips assisting doctors with physical activity promotion in primary care was recently published in the BMJ.¹⁴

 

References
1. Fitzpatrick M. The Olympic legacy. Br J Gen Pract 2011; 61(592): 688.
2. World Health Organization. Global recommendations on physical activity for health. Geneva: WHO, 2010.

3. Department of Health. Start active, stay active. A report on physical activity for health from the four home countries’. London: DoH, 2011.
4. McDonald HP, Garg AX, Haynes RB. Interventions to enhance patient adherence to medication prescriptions: scientific review. JAMA 2002; 288(22): 2868–2879.
5. Writing Group for the Activity Counseling Trial Research Group. Effects of physical activity counseling in primary care: the Activity Counseling Trial: a randomized controlled trial. JAMA 2001; 286(6): 677–687.
6. Michie SM, Ashford S, Sniehotta FF, et al. A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: The CALO-RE taxonomy. Psychol Health, 2011. [Epub ahead of print].
7. Lawton BA, Rose SB, Raina Elley C, et al. Exercise on prescription for women aged 40–74 recruited through primary care: two year randomised controlled trial. Br J Sports Med 2009; 43(2): 120–123.
8. Weiler R, Stamatakis E. Physical activity in the UK: a unique crossroad? Br J Sports Med 2010; 44(13): 912–914.
9. Umpierre D, Ribeiro PA, Kramer CK, et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis. JAMA 2011; 305(17): 1790–1799.
10. Lindström J, Ilanne-Parikka P, Peltonen M, et al. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet 2006; 368(9548): 1673–1679.
11. Church TS, Blair SN, Cocreham S, et al. Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial. JAMA 2010; 304(20): 2253–2262.
12. Weiler R, Feldschreiber P, Stamatakis E. Medicolegal neglect? The case for physical activity promotion and exercise medicine. Br J Sports Med 2011. [Epub ahead of print].
13. General Medical Council. Good medical practice. GMC, 2006.

14. Khan KM, Weiler R, Blair SN. Prescribing exercise in primary care. BMJ 2011; 343: d4141.

 

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Date: 07 Nov 2011
Topic: Response to 'The Olympic legacy'

Comments by: Rachel Pryke, GP, Winyates Health Centre, Redditch, Worcestershire

 

It was with surprise that I read Mike’s Fitzpatrick’s assertion that exercise is ‘deemed virtuous but has no proven value in relation to health’.¹ Skimming through over forty references in the Department of Health Lets Get Moving commissioning guidance² made me feel that Mike needs to spell out the reasoning for his claim a little more robustly.

 

References

1. Fitzpatrick M. The Olympic legacy. Br J Gen Pract 2011; 61(592): 688.

2. Foster J, Thompson K, Harkin J. Let’s get moving — a new physical activity care pathway for the NHS. London: NHS, 2009.

 

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Date: 07 Nov 2011
Topic: Response to 'Tips fo GP trainees working in palliative care'

Comments by: Philip Hartropp, Mariners, Mill Lane, Alwalton, Peterborough

 

The tips offered to GP trainees is well balanced but with one significant omission.¹ No mention is made of the empowerment for the patient of an advanced directive (AD). GP trainees would do well to enquire if one is in place early on in the relationship so that the patient’s wishes will be respected. AD’s are part of the Gold Standards Framework checklist for palliative care but their use is still far from widespread.

 

Reference

1. Tunnicliffe K, MacKay K. Tips for GP trainees working in palliative care. Br J Gen Pract 2011; 61(592): 700.

 

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Date: 6 Nov 2011
Topic: From patient advocate to gatekeeper
Comments by: Dr Charles Heatley, GP, Birley Health Centre, Chair, Hallam and South Consortium, Sheffield

 

Clare Gerada offers no response to the problem of increasing spend on health at a time of diminishing funding whether due to political or economic circumstances. We have to face up to this before more and more of our GDP feeds an increasingly medicalised, secondary care-based system.

 

I am deeply involved in the CCG in Sheffield but that does not mean I agree with the reforms; we have no choice but to make the best of this and resist the pressure to marketise for the sake of it. We are developing deeper levels of joint working and understanding with our teaching hospital Trusts than we have for years, with a radical reform of urgent and non-urgent care in development.

 

Of course there is pressure on the soft target of elective referrals while we learn how to free up resources from cost effective alternatives to non-elective hospital admissions. Audits have shown a generic waste of resources through poor quality referrals; we have to address this directly, as reliance on professional behaviour is not going to work. We have been building an awareness of cost as a consequence of GP behaviour through practice-based commissioning. However, we can learn to look at cost as organisations, whether practices, federations, or CCGs; it is patronising to GPs if cost is only ever translated as something that enters the consultation.

 

We are reaching a point where GPs are starting to take part in the potential positive outcomes of joint work. I don't recognise much about the scenarios Clare uses as outcomes of this bill, and am concerned that this message will neither encourage engagement that gets the best out of bad legislation nor result in a mass protest; instead we will all have ourselves to blame for keeping our heads in the sand.

 

If on the other hand Lansley has played a magnificent sleight of hand, I have a substantial hat to eat.

 

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Date: 31 Oct 2011
Topic: Sputum induction: A solution to cope with challenges of classifying a pulmonary tuberculosis patient as ‘cured’
Comments by: Muhammad Atif, PhD candidate, Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Penang, Malaysia
Syed Azhar Syed Sullaiman, Dean, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Penang, Malaysia
Fahad Saleem, PhD candidate, Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Penang, Malaysia.

 

Treatment outcome of tuberculosis (TB) is reported on the basis of classification developed and recommended by the working group of World Health Organization (WHO) and International Union against Tuberculosis and Lung disease (IUATLD).¹ ‘Cure’, ‘treatment completed’, ‘treatment failure’, ‘died’, ‘default’, and ‘transferred out’ are six outcome measures. Directly Observed Treatment Outcome Short course (DOTS) implemented countries are required to report treatment outcome of tuberculosis on the basis of these outcome measures. Reporting ‘treatment completed’, ‘treatment failure’, ‘death’, ‘default’, and ‘transferred out’ is quite simple and easy but case is different for ‘cure’. To get highest cure rates is definitely aim of every National Tuberculosis Program (NTP). According to WHO outcome definitions, a pulmonary tuberculosis patient can be declared as ‘cured’ when his/her sputum smear or culture was positive at the beginning of the treatment but who was smear- or culture-negative in the last month of treatment and on at least one previous occasion. Truly speaking, meeting these criteria for achieving ‘cure’ is quite difficult.

 

Normally, after two to three months of anti TB treatment, that patient is unable to produce sputum. As a result, sputum specimen is not available for Acid Fast Bacilli (AFB) smear staining and culture. One possible solution can be sputum induction^2,3 at required time points during anti TB treatment. Sputum can be successfully induced by nebulising the patient with 5 to 10ml of 3% sterile saline for 10–20 minutes by using ultrasonic nebulizer.⁴ Other alternatives to sputum induction are gastric aspirates, bronchoalveolar lavage (BAL)⁵ and bronchoscopy. Gastric aspirates and BAL are often negative on direct smears and thus culture is required.⁶ Bronchoscopy is an invasive technique and patients often deny going through this process. Li et al³ reported that cost of induced sputum per patient is only 2.5% of that for bronchoscopy. Based on these evidences, we can say that sputum induction is safe and cost effective technique to cope the challenge of classifying a patient in ‘cure’ category.

 

Recent WHO guidlines¹ does not direct sputum induction in those patients who are unable to produce sputum. It is therefore suggested that, WHO guidelines should advice sputum induction as a routine procedure for non sputum producing patients. This would help in rational decision to declare a patient as ‘cured’, once AFB direct smear results are negative at the end of treatment and at least one previous occasion.

 

References

1. World Health Organization. Treatment of tuberculosis guidelines. Genevea: WHO, 2009.

2. Parry CM, Kamoto O, Harries AD, et al. The use of sputum induction for establishing a diagnosis in patients with suspected pulmonary tuberculosis in Malawi. Tuber Lung Dis 1995; 76(1): 72–76.
3. Li LM, Bai LQ, Yang HL, et al. Sputum induction to improve the diagnostic yield in patients with suspected pulmonary tuberculosis. Int J Tuberc Lung Dis 1999; 3(12): 1137–1139.
4. Leigh TR, Hume C, Gazzard B, et al. Sputum induction for diagnosis of Pneumocystis carinii pneumonia. Lancet 1989; 2(8656): 205–206.
5. Shata AM, Coulter JB, Parry CM, et al. Sputum induction for the diagnosis of tuberculosis. Arch Dis Child 1996; 74(6): 535–537.
6. Crofton J, Horne NW, Miller F. Clinical tuberculosis. London: The Macmillan Press Ltd, 1992.

 

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Date: 27 Oct 2011

Topic: GP CPD done and dusted?

Comments by: Gen Wong, Associate Clinical Director and GP Tutor, NHS, Salford/Northwest Deanery, Salford

 

The RCGP Conference, recently held in Liverpool, displayed an impressive 236 poster presentations divided into four categories. There were 35 posters in the education category. About 50% of the posters here were related to GP specialty training. Only two posters were on GP Continuing Professional Development (CPD). The research section had 65 poster presentations but only one on GP CPD.

 

Why is there such paucity in debate, analysis, and research into GP CPD? Are all pedagogical underpinnings of adult lifelong learning so firmly established as to make exploration in this area a fruitless venture? Have all avenues of critical enquiry into instructional strategies, learning quality, approach, methods, and evaluation been completely exhausted?

 

Current practice highlights the mechanics of the learning process. A learner will be considered fairly accomplished if they can independently decide on needs, goals, objectives, strategies, and reflection/evaluation of their learning. Even though this skill is laudable, in how many cases would a sequential mechanical process like this lead to higher critical thinking?

 

Critical thinking is vital because it facilitates a learner to think beyond that normal accepted knowledge framework, views, and biases.¹ One could argue a GP who is performing poorly and lacks insight could still be a highly accomplished mechanical learner but would not stray beyond what he considers as right. However, critical thinking skills do not come naturally and need to be taught, facilitated, and nurtured.

 

Current seismic changes going through the NHS necessitates a critical review of existing CPD practices. There is much to be said about Brookfields penetrating insight into hegemonic assumptions that ... seemed congenial but that actually work against our own best interests.²

 

References

1. Facione PA. Critical thinking: a statement of expert consensus for purposes of educational assessment and instruction. Millbrae (CA): The California Academic Press, 1990.

2. Brookfield SD. Becoming a critically reflective teacher. San Francisco, California: Jossey-Bass, 1995.

 

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Date: 27 Oct 2011

Topic: Alcohol and Pregnancy

Comments by: Gloria Jesuratnam, Medical Student, St George's, University of London

Dr Pippa Oakeshott, Reader in General Practice, St George's, University of London

Dr Raja Mukherjee, Consultant Psychiatrist for people with LD (Tandridge) Lead Clinician Specialist FASD Behaviour Clinic, St George's, University of London

 

In their national survey of post-pregnancy follow up of women with gestational diabetes mellitus, Pierce and colleagues found a lack of adherence to National Institute for Health and Clinical Excellence (NICE) guidelines.¹ NICE have recently updated their recommendations of safe alcohol limits in pregnancy, but it is unclear whether people are aware of the new guidelines. Having previously recommended no more than one unit of alcohol per day during pregnancy,² NICE now recommend no more than one or two units a week.³ NICE also advise avoiding alcohol completely in the first trimester of pregnancy.³ Although recommendations vary, all guidelines emphasise the danger of binge drinking.²

 

In September 2011, we carried out a questionnaire survey of women aged 16 to 40 years to investigate their knowledge of the new guidelines on safe consumption of alcohol during pregnancy. Women sitting in or walking through Leicester Square, London were given a patient information sheet and asked if they were willing to complete a brief, confidential questionnaire on alcohol in pregnancy. The questionnaire asked how many units of alcohol are recommended as safe during pregnancy and in which trimester of pregnancy it is safest to drink.

 

The response rate in 186 eligible women was 54% (100/186, and their mean age was 23 years, 97 correctly said the recommended level was no more than one or two units a week, of whom 79 thought no alcohol should be consumed during pregnancy. However, three women thought it was safe to drink one or two units daily. All 99 women who responded to the question agreed that it is unsafe to drink five units of alcohol (binge drinking) at one sitting during pregnancy. However, contrary to the guidelines, a third (32/98) of women thought that drinking was safest in the first trimester.

 

This survey showed the majority of participants knew the safe alcohol levels recommended during pregnancy in the new NICE guidelines. However, the study did reveal that a third of women incorrectly presumed that it was safer to drink in the first trimester of pregnancy. Perhaps, by increasing awareness, more women will avoid alcohol during this trimester. However, many pregnancies are unplanned, some may be associated with binge drinking, and women may unwittingly drink in the first three months of pregnancy before they know they are pregnant. Pierce and colleagues suggest education of women about the need for follow up after gestational diabetes mellitus is important.¹ We suggest another role for primary care may be to continue education about safe alcohol limits.

 

Acknowledgment: We thank all the participants and Dr Sedgwick.

 

References

1. Pierce M, Modder J, Mortagy I, et al. Missed opportunities for diabetes prevention: post-pregnancy follow up of women with gestational diabetes mellitus in England. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X6013116.

2. British Medical Association Board of Science. Foetal Alcohol Spectrum Disorders- a guide for healthcare professionals. London: British Medical Association Board of Science, 2007.

 

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Date: 13 Oct 2011
Topic: The QOF, NICE and depression
Comments by: David Jewell, MRCGP, Bristol

 

In his defence of the depression parts of the QOF, Alan Cohen also unwittingly illustrates some of the problems of the whole process.¹ For instance, when he states that patients like the use of questionnaires, it is because ‘they feel as though their symptoms are being taken seriously’, not because he can quote more substantive evidence that it makes a difference to harder outcomes. Too much concentration on process and not outcomes. Note that Dr Cohen is not claiming GPs are taking the symptoms more seriously; the implication is that the designers of the QOF would favour the quick, somewhat superficial, and very impersonal PHQ over serious engagement between GPs and their patients’ personal concerns. Not only de-professionalising, as Toop pointed out in his editorial,² but very destructively reducing all patients from individuals with their own contexts and concerns to units in a production line.

 

Then there is the encouragement to over-reliance on the PHQ. This has been consistently shown to overestimate severe depression when compared with other measures. The widespread and uncritical use of the PHQ may be leading to over-diagnosis of depression with excessive antidepressant prescribing. Those responsible for the workings of the QOF need to be reminded constantly that all medical interventions capable of doing good can also do harm.

 

However, it is the statement that ‘Not to have incentivised GPs to identify a group of people who were more at risk clinically . . . would have been negligent’ that is truly outrageous. Here there are QOF points for applying a universal method that also has substantial error rates, with the possibility again that this will lead to over and under identification. Dr Cohen here has subscribed to the suggestion both damaging and now proved to be erroneous, that GPs will only take action that is financially rewarded. If the lie were correct, then what is the implication for all those other patients with long-term disabling conditions, also at higher risk of depression? Or is he suggesting that this QOF provision should be extended to all patients? In which case it would become, effectively, a screening programme for which, again as Toop points out, there is no convincing evidence.

 

The QOF approach began as a limited set of targets to encourage more universal application of a number of measures that were backed by sound evidence and generally accepted as both achievable and beneficial. It has gradually expanded to incorporate more dubious measures that command less acceptance, and looks more and more like a set of hoops to make recalcitrant GPs work harder with little extra gain for patients. Meanwhile, the clamour from numerous lobby groups for inclusion of their pet measures in the QOF continues to grow. Not only de-professionalising, but very depressing and sadly, all too predictable.

 

References
1. Cohen A. The QOF, NICE, and depression. Br J Gen Pract 2011; 61(590): 549.

2. Toop L. The QOF, NICE and depression: a clumsy mechanism that undermines clinical judgement. Br J Gen Pract 2011; 61(588): 432–433.

 

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Date: 12 Oct 2011
Topic: Primary care electronic health records   who is in control?
Comments by: Nigel Masters, GP, Highfield Surgery, High Wycombe, Buckinghamshire

 

As a late adopter of electronic health records, apart from repeat prescribing, I was reluctant to leave my efficient paper practice notes that I controlled and wrote my patient’s narrative. It is now routine to record such contacts on the computer record but my eyes rarely lift from the keyboard. At the same time part of my mind is involved with the software set-tasks, often government driven, that need to be slavishly tackled in order to gain essential payment. I warned my past colleagues that this was the electronic hamster wheel of medical primary care workload and they have nearly all retired early. I am still at the primary care coalface but this is due in part in trying to wrest some personal control of this electronic record in order to aid my patient care.

 

Here I refer to the recommendation to use clinical indications on all repeat prescriptions which is a an excellent use of the repeat prescription electronic process described in detail on my website.1 The latest draft of the GMC guidelines on good prescribing recommends that all doctors should consider including such a process in their prescribing.2 Smoking recording is another area that has needed revisiting and my smoking pack year calculator3 provides a smoking exposure dose on those ‘ever smokers’ so that smoking is searchable and potentially predictive. In addition I have developed some paediatric drug dosage calculators to aid my busy everyday work. These self-created additions have given me the much needed personal ‘locus of control’ of the electronic health record but will scream in the face of industry standard setting and may make it impossible to transfer my detailed data reliably from GP system to system? Still I cherish my patient’s records in our small practice and a recent letter from a young consultant vascular surgeon unprompted said it all . . . ‘The computerised notes summary in your surgery is extremely impressive’.

 

References
1. Masters N. Learn about clinical indications. High Wycombe: Clinical Indications, 2008.
2. GMC. Good practice in prescribing and managing medicines and devices consultation document on prescribing for doctors June 2010. London: General Medical Council, 2010.
3. Masters N, Tutt C. Smoking pack years. High Wycombe: Smoking Pack years, 2007.

 

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Date: 11 Oct 2011
Topic: National undergraduate curricula for primary care
Comments by: Francesco Carelli, EURACT Council Basic Medical Education Committee, Chair, Professor FM University of Milan, Italy

 

Andrew Blythe and Julian Hancock consider the attraction, and challenge, of a career in general practice and family medicine is its diversity.¹ I would underline its specificity. Core competences for a GP are not ill defined, as might have been expressed by John Wayne ‘a GP’s got to do what a GP’s got to do.’ Since 2002, we had the European Definition of general practice/family medicine by WONCA/EURACT, with 11 fields of specific action, and six core competencies (primary care management, specific problem solving skills, person centered approach, comprehensive approach, community orientation, holistic approach), that define the role of family medicine and the family doctor in society.

 

Of course, GP-trainers need clear objectives to ensure they deliver high quality education, and specialty trainees require clarity about what they should learn. But here we have since 2005, the EURACT Educational Agenda, defining in depth what to teach and how, what to learn and how, according to the 11 fields and the six core competences in the European Definition.

 

Every country should build on the success of its postgraduate curriculum by creating a national undergraduate curriculum for primary care. Many GP trainees have spent no or very little time in primary care since they were at medical school. All future doctors will be in contact in some way with primary care and should study primary care as a core part of their undergraduate curriculum.

 

There are significant differences across the European Union in GP training and in family medicine (FM) teaching. GP training and the choice of general practice as a career probably depends, to a large extent, on the level of FM teaching at the undergraduate level. Only if we introduce students for a short clerkship in the practices will we get new doctors really willing to train as a GP. Also, all doctors, whatever their final speciality, will then understand the place of FM in the healthcare system.

 

The EURACT Basic Medical Education Committee, has carrier out a research study^2,3 on FM undergraduate teaching in Europe, using a Delphi study to determine a minimal curriculum. The length of the FM/GP clerkships/undergraduate programmes range from one to 12 weeks in different countries, and among different universities in a single country. Inter-country and intra-country variations are seen not only in the length of the programme but also in its content. Since there is no uniform curriculum for FM/GP across Europe  (and also nationally, the aim of this study was to create, or at least, suggest one.

 

The resulting document could be used in the future for the development of a uniform undergraduate curriculum for FM/GP across Europe to promote its development in countries at a lower academic level in FM and to achieve the uniformity required for high levels of teaching and better free inernational movement of future doctors in the labour market.⁴ Also, a nationally agreed curriculum will facilitate the exchange of good practice between schools sharing teaching resources and examination questions and would strengthen the core curriculum itself and get medical students prepared.

 

According to David Bird,⁵ the Foundation Programme is an excellent setting for improving communication skills within the doctor-patient consultation. Many patients choose to see a trainee rather than the regular GP because trainees can spend more time on each consultation and thus feel that their concerns can be expressed and addressed more thoroughly. A Foundation Programme so increasing patient satisfaction and also maintaining safe patient care should possibly be developed in many European countries.

 

References
1. Blythe A, Hancock J. Time for a national undergraduate curriculum for primary care. Br J Gen Pract 2011; 61(591): 628. 
2. EURACT BME Committee. Family medicine/general practice undergraduate teaching in Europe: a Delphi study to determine a minimal curriculum. Oral presentation 499. WONCA Europe Conference in Malaga. October 2010.
3. Tandeter H, Carelli F, Brekke M, et al. A 'minimal core curriculum' for Family Medicine in undergraduate medical education: A European Delphi survey among EURACT representatives. Eur J Gen Pract 2011; (1): 1–4.
4. Carelli F. Minimal undergraduate teaching curriculum in Europe. Br J Gen Pract 2011; 61(588): 440.

5. Bird D. General practice and The Foundation Programme. Br J Gen Pract 2011; 61(591): 633.

 

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Date: 9 Oct 2011

Topic: Ubi Scientica in the midst of the cosy cardigans of Caritas

Comments by: Dr Joanne Reeve, SAPC Communications Officer; NIHR Clinician Scientist in Primary Care, University of Liverpool, Liverpool

Professor Helen Lester, Chair of SAPC and 2012 Conference Chair; Professor of Primary Care, University of Birmingham, Primary Care Clinical Sciences Building, Birmingham

 

Checklands letter raises important concerns about barriers to engagement between academic and applied primary care settings.¹ Academic primary care is a distinct scientific discipline working within, and alongside primary care to support and challenge practice through scholarly activity. Issues related to scientific rigour and trustworthiness of scholarly activity, along with the evaluative validity/utility and coherence of ideas are of importance in both the academic and applied settings. Identifying how best to integrate these two perspectives highlights a key challenge to engagement: in thinking about how we communicate ideas about, and the results of, academic practice and scholarly activity. These are issues that the Society for Academic Primary Care (SAPC) is actively debating and addressing and are reflected in our revised position statement.²

 

The 2012 SAPC conference will be held jointly with the Royal College of General Practitioners bringing academic and applied practice together in one meeting. We are revising the abstract submission process to require an explicit description of the utility and significance of the submitted work for primary care practice and policy. We are programming workshops that address the utility of sociological scholarly activity in the consultation room and the latest evidence-base on commissioning. And we will be introducing a new festival of dangerous Ideas,³ the use of scholarly activity to challenge, spark news ideas, and identify and promote change.

 

We will be posting plans for 2012 on our website as they emerge. We welcome comments on these ideas. And invite everyone, including Dr Checkland, to join us at the 2012 meeting.

 

References

1. 1. Checkland K. Ubi Scientica in the midst of the cost cardigans of Caritas? Br J Gen Pract 2011; 61(591): 608. 2. SAPC. SAPC Position Statement. Oxford: Society for Academic Primary Care 2011.
2. 3. Reeve J, Abholz H, Bailey T, et al. A pause for thought: reflections on the 2011 SAPC conference. Prim Health Care Res Dev 2011; 12: 393–394.
3. 4. SAPC. Conference 2012. Oxford: Society for Academic Primary Care, 2011.
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Date: 7 Oct 2011
Topic: Time for a national curriculum for primary care  
Comments by: Professor Amanda Howe, Norwich Medical School: past Chair SAPC; Honorary Secretary RCGP

 

Blythe and Hancock pose an interesting question, but their article does not highlight three important issues.¹ First, that an undergraduate curriculum results in a generic ‘product’, whose nascent knowledge and competency must relate to patient care regardless of their subsequent specialisation. Second, that these competencies will be attained in different ways in different settings, and often are and should be practised in more than one undergraduate setting or speciality – both prescribing and consultation skills are exemplars. Third, the fact that a specific speciality does or does not lead on a specific component may not mean that the graduate fails to achieve that competency. So, let’s pretend that medical school (A) makes prescribing tasks a core learning activity of its final year GP placement, but medical school (B) signs off this competency at the end of year 4 in the medicine for the elderly placement, and uses its final year GP placement to focus on the applied skills of acute diagnosis of undifferentiated problems. From the primary care curriculum in each school this will look different, but both sets of graduates should be able to succeed in relevant work-based and Objective Structured Clinical Examination type assessments.

 

The idea in this article therefore needs further refinement to ensure it will provide useful information that will act as a driver for relevant change, as trying to map entry competencies for MRCGP onto GP departmental teaching alone would not reflect such legitimate variation. A national comparative mapping of current use of primary care placements,² and the learning objectives they prioritise, might well be more informative particularly because there are clear differences in long-term career impacts that may relate to the nature and status of GP teachers in different UK medical schools.³ Links between GP teaching leads at different medical schools are actually already established in the Society for Academic Primary Care’s ‘Heads of Teaching’ network, and the RCGP is and will remain a champion of exposing medical students and postgraduates to our discipline. Giving students the building blocks for MRCGP is only part of what we should seek to achieve, we need to show that all graduates leave medical school having learned to respect and aspire to the value of good generalist medical practice for patients, and seen its potential as an inspiring career choice.

 

References
1. Blythe A, Hancock J. Time for a national undergraduate curriculum for primary care. Br J Gen Pract 2011; 61(591): 628. 
2. Hopayian K, Howe A, Dagley V. A survey of UK medical schools' arrangements for early patient contact. Med Teach 2007; 29(8): 806–813.
3. Lambert T, Goldacre, M. Trends in doctors' early career choices for general practice in the UK: longitudinal questionnaire surveys. Br J Gen Pract 2011; 61(588): e397–e403.

 

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Date: 26 Sep 2011

Topic: Extent of cotton-bud use in ears

Comments by: Sidhartha Nagala, ENT Research Fellow, Addenbrookes Hospital, University of Cambridge
Pranay Singh, ENT Specialist Registrar, Ashford Hospital, Kent

Philippa Tostevin, ENT Consultant, St George’s Hospital Medical School, London

 

The use of cotton buds inside ears has widely been condemned worldwide by otolaryngologists. This is due to well documented complications including trauma, impacted ear wax, infection, and retention of the cotton bud.¹ The most common mode of accidental penetrating ear injury in children is cotton-bud induced.² Trends in cotton-bud usage have been studied previously, but have only focused on ear, nose, and throat (ENT) patients.³ In recent times, manufacturers have heeded the advice of the otolaryngologist and have consequently relayed warnings to the public. We conducted a survey to investigate the extent of ‘Q-tip’ cotton bud public use in ears and the awareness of associated complications.
Between January and August 2009, confidential questionnaires were given to patients at three primary care centres in the south east of England. The response rate was 80% (239/300). Ages ranged from 17 to 87 years, with a mean of 41.1 years. There were 144 (60%) female and 95 (40%) male responders. An alarming 68% admitted using cotton buds in their ears, with 76% of users using them at least weekly, if not more frequently. The primary reason (96%) given for using cotton buds was to remove earwax.

 

It is evident that there is a public perception that the ear requires regular cleaning. However, our knowledge dictates that earwax is produced in the outer part of the canal and migrates out with the epithelium towards the pinna. Other reasons included relieving an itch and drying the ear. Our survey showed that cotton-bud users were aware of 52% of the potential complications, whereas non cotton-bud users were aware of 59% of potential complications. There was no significant association between awareness of complications and cotton-bud use (X² = 2.23, df = 3, P = 0.53).

 

Despite manufacturers’ warnings, use of cotton buds inside ears seems to be common. Our survey was carried out in the south east of England, as a result there may be a population bias. Further research into both adult and paediatric populations country-wide is warranted. One previous study did attempt to evaluate cotton-bud use and awareness of complications.³ As responders were ENT-clinic attendees, the study was limited by a biased sample. However, similar levels of cotton-bud use and awareness of complications were found.

 

Awareness of cotton-bud related complications is an important public health issue. We recommend that public awareness of cotton-bud related complications and the notion of the ‘self-cleaning’ ear needs to be raised. A small proportion of patients do suffer from regular ear wax impaction. Safer methods of aural toileting that include syringing and microsuction may also need promoting. With the above information, the public can make an informed choice of whether or not to use cotton buds. One method of promoting awareness may be to distribute leaflets in primary care centres. This may reduce cotton-bud related complications in the community.

Acknowledgements

We would like to thank patients and staff in the three primary care centres in which the survey was carried out.

References
1. Raman R. Should cotton buds be banned? Trop Doct 1997; 27(4): 250.
2. Steele BD, Brennan PO. A prospective survey of patients with presumed accidental ear injury presenting to a paediatric accident and emergency department. Emerg Med J 2002; 19(3): 226–228.
3. Hobson JC, Lavy JA. Use and abuse of cotton buds. J R Soc Med 2005; 98(8): 360–361.

 

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Date: 21 Sep 2011

Topic: Response to 'The dying Keats a case for euthanasia?'

Comments: Brian Livesley, MD, FRCP, Emeritus Professor in the Care of the Elderly, Imperial College, University of London

 

Only recently has my attention been drawn to James Willis review¹ of my 20^th Memorial Keats Lecture entitled The dying Keats a case for euthanasia? This was presented and published in 2009. Willis asked, But what is the debate about? If he had been assiduous in his research as he appears to have been in purveying his own views on the topic, and by even minimal enquiry, he could have discovered that within 36 hours of the lecture being delivered an internal memo at the General Medical Council (GMC) asked Council to consider draft guidance on end-of-life care and to endorse proposals for a consultation.² Quite obviously, someone had very quickly grasped what the debate was about. The resulting GMC consultation began as a UK wide conference in London on 3 June 2009³ (also more than a year before Willis review) to provide an opportunity for individuals and organisations from all of our key interest groups to come together to consider the issues raised by the consultation draft. It also provided a focus midway through the consultation to raise awareness about the consultation. The 150 invited delegates included doctors and their representative bodies, patient and carer representatives, palliative care, and faith-based organisations, and other healthcare professionals and healthcare regulators. Subsequently the GMC published its booklet Treatment and care towards the end of life: good practice in decision making on 20 May 2010.⁴ This is still available free of charge, as it was several months before Willis review. But the debate needs to move on and now the question is, Has the Liverpool Care Pathway become a licence to kill?

 

References

1. Willis J. The dying Keats: a case for euthanasia? Br J Gen Pract 2010; 60(581): 942.

2. GMC. Council Minutes, 25 February 2009. 'To consider. End of Life Care: Consultation. Issue. 1. This paper invites Council to consider the draft guidance on end of life care and the plans for consultation. ...etc..' (This matter was listed as the only agenda item. Accessed on the GMC website on 1 June 2010).

3. GMC. End of life care - development of the guidance. London: General Medical Council, 2009.

4. GMC. Treatment and care towards the end of life: Good practice in decision making. London: General Medical Council, 2010.

 

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Date: 15 Sep 2011
Topic: Inequalities in general practice website provision
Comments by: Professor Ray Jones, Professor of Health Informatics, Faculty of Health, Education and Society, Plymouth University, Plymouth

Dr Lesley Goldsmith, Research Fellow, Faculty of Health, Education and Society, Plymouth University, Plymouth

Anita O’Connor, Research Assistant, Faculty of Health, Education and Society, Plymouth University, Plymouth

 

Beasley et al¹ in their editorial describe how the implementation of electronic health records (EHR) is a transformative change. Some practices have made that transformation. For example, Amir Hannan and colleagues at Harold Shipman’s previous practice at Haughton Thornton Medical Centre (http://www.htmc.co.uk), not only use EHR but offer their patients many e-health facilities, such as access to their own records, booking of appointments, repeat prescriptions, advice on preparing for the consultation, as well as links to numerous resources both locally and nationally. GP system suppliers provide patient directed web-based functions, such as repeat prescribing and patient access to records that, technically, just need to be ‘turned on’. However, practices using these functions are in the minority. A third of practices have yet to offer their patients use of a practice website.

 

We examined the geographical variation in practice website provision in August 2011. We used data from NHS Choices on 8399 practices in England. We chose a purposive sample of 1026 practices in 14 postcode areas across England that were likely to include areas with high, medium, and low provision of GP websites. We used practice name and address to search Google™ for a practice website. The accuracy of searching was checked by an observer variation study on a sub-sample of 50. There was agreement on 46/50 (Kappa = 0.81).

 

Two-thirds (676/1026) of practices had a website that could be found on Google. This varied from 94% (all but one practice) in Harrogate to 35% in Southend (Table 1). We did not assess the functionality of the websites but anecdotally know that many websites were just ‘electronic nameplates’ rather than functional sites for patient use.

 

Table 1. Website provision

	Postcode Area	No website n (%)	Website n (%)
Harrogate	HG	1 (6)	16 (94)
Taunton	TA	5 (10)	43 (90)
Southampton	SO	10 (13)	68 (87)
Bristol	BS	19 (16)	100 (84)
Halifax	HX	5 (22)	18 (78)
Plymouth	PL	18 (22)	64 (78)
Sunderland	SR	13 (26)	38 (74)
St Albans	AL	6 (26)	17 (74)
London SW	SW	48 (32)	101 (68)
Leeds	LS	47 (39)	73 (61)
Fylde	FY	23 (50)	23 (50)
Blackburn	BB	48 (51)	46 (49)
Wakefield	WF	39 (55)	32 (45)
Southend	SS	68 (65)	37 (35)
TOTAL		350 (34)	676 (66)

 

Discussion about digital health inequalities tends to focus on the access that patients may have to the internet or in their ability to use it,^2–4 but there are clearly inequalities in the provision of opportunity to use e-health. The online facilities that are offered at some practices should be offered to all and should be considered a mark of a quality practice. Primary care trusts or GP cooperatives or whoever is now responsible in areas such as Southend, Wakefield, Blackburn, and Fylde should examine why their patients should have such poor opportunity for e-health. We need to explore with all stakeholders in primary care — GPs, their staff, but also patients and carers — the opportunities and barriers to implementation of e-health methods.

 

References
1. Beasley JW, Holden RJ, Sullivan F. Electronic health records: research into design and implementation. Br J Gen Pract 2011; 61(591): 604–605.
2. The Royal Society. Digital healthcare: the impact of information and communication technologies on health and healthcare. London: The Royal Society, 2006.
3. Del Hoyo-Barbolla E, Kukafka R, Arredondo MT, Ortega M. A new perspective in the promotion of e-health. In: Hasman A, Haux R, van der Lei J, (eds.). Ubiquity: technologies for better health in aging societies. The Netherlands: IOS Press, 2006: 404–412.
4. Viswanath K, Kreuter MW. Health disparities, communication inequalities, and eHealth. Am J Prev Med 2007; 32(5 Suppl): S131–S133.

 

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Date: 13 Sep 2011

Topic: Are the serious problems in cancer survival partly rooted in gatekeeper principles?

Comments by: Peter Vedsted, Aarhus University, Research Unit for General Practice, Aarhus C, 8000, Denmark

Frede Olesen, University of Aarhus, Research Unit for General Practice, Aarhus C, 8000, Denmark

 

We are grateful for the debate about positive and negative aspects of gatekeeping raised in three responses to our paper,¹ and we agree with the important research questions raised in these. First, let us stress that we are strong advocates of the gate-adviser or gatekeeper system, meaning that if any decision-makers will use our paper as an argument for removing the gate-adviser they have simply misunderstood the paper.

 

We want research that contributes to improving a basically good system. All three letters strongly support the need for such research.

 

Our own primary hypothesis is that healthcare planners have used the easy access to the frontline doctor as an excuse for long waiting lists for complicated clinical trajectories. But we also raise the question whether we as GPs have found the correct balance between necessary investigations and the protection of patients against unnecessary investigations. This is an important, but yet not fully answered, research question that is also raised in the letter from Polak.² We sincerely support the call for more research in the net effect of better access to diagnostic procedures.

 

Polak also points to the crucial question whether people may have an increasing perception of GPs as being rationing ‘keepers’ only. That this may have an effect on the way patients seek help is in accordance with new research.³ People may think that the GP is some kind of ‘barrier’ to medical care access and thus postpone attending the GP. Or people experience their nice and friendly GP as very busy and do not want to disturb them, exactly the point also made by Davies.⁴

 

One of the challenges in comparing differences between countries is the possible difference in how diagnoses are registered. Treasure⁵ has a very important methodological point in asking whether the 1-year survival is higher in the non-gatekeeper systems simply due to lead time bias. Lead time bias is definitely a possible explanation for the outcome of these types of comparative studies. The question is, however, whether such lead time bias can explain differences between countries of 5–10% in relative survival. A recent simulation study⁶ found that the difference in registration of a breast cancer diagnosis should be unlikely large if it should explain the differences between UK and Sweden. However, the effect of lead time bias in comparisons needs much more rigorous research.

 

We strongly agree with Davies that our data should be replicated using newer data and also data on other serious diseases. New research should also address if different remuneration systems may have impact on the quality of gatekeeping.

 

We were happy to see three academically well argued responses to our paper. A fourth response by Manassiev seems to be very little in favour of discussing whether there could be side effects of gatekeeping. In many ways the response speaks for itself. In a proper way we point out that our study is an ecologic study. The use of quintiles in the paper by Møller et al⁷ does not change anything as we used this in our calculations. We do not think that use of the 1- and 5-year relative survival of lip cancer would improve the paper as suggested by Manassiev. Manassiev may have different memories about gatekeeping in some countries, but we prefer research published in the literature. We have written our arguments for the use of 1-year survival and we kindly ask our readers to check them and compare with Manassiev’s not quite academic approach. It is not correct that ‘the majority of sufferers of the top four cancers (lung, breast, prostate, and colon) would survive 1 year probably whatever the health system’. We do not agree with Manassiev about the incompetence of editors and reviewers and we trust that many readers are able to read papers without having passed Manassiev’s research school on the shape of the earth.

 

In conclusion, we must realise that general practice has several key roles. One important role is to be aware of new, rare, but serious diseases that, in a timely way, should be guided through the healthcare system without delay that may influence prognosis. We need much more research on the impact of different organisational models on this key role.⁸

 

References

1. Vedsted P, Olesen F. Are the serious problems in cancer survival partly rooted in gatekeeper principles? An ecologic study. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X588484.
2. Polak L. Are the serious problems in cancer survival partly rooted in gatekeeper principles?  [Letter] Br J Gen Pract 2011; 61(592): 661.
3.  Andersen RS, Vedsted P, Olesen F, et al. Does the organizational structure of health care systems influence care-seeking decisions? A qualitative analysis of Danish cancer patients' reflections on care-seeking. Scand J Prim Health Care 2011; 29(3): 144–149.
4. Davies P. Are the serious problems in cancer survival partly rooted in gatekeeper principles? [Letter] Br J Gen Pract 2011; 61(592): 661.
5. Treasure W. Are the serious problems in cancer survival partly rooted in gatekeeper principles? [Letter] Br J Gen Pract 2011; 61(592): 661.
6.  Woods LM, Coleman MP, Lawrence G, et al. Evidence against the proposition that ‘UK cancer survival statistics are misleading’: simulation study with National Cancer Registry data. BMJ 2011; 342: d3399.
7. Møller H, Linklater KM, Robinson D. A visual summary of the EUROCARE-4 results: a UK perspective. Br J Cancer 2009; 101(Suppl 2): S110–114.
8. Olesen F. Putting research into primary care practice. BMJ 2011; 343: d3922.

 

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Date: 13 Sep 2011

Topic: Response to Influence of patient payment on antibiotic prescribing in Irish general practice

Comments by: Garrett Igoe, Virginia Primary Care, Cavan, Ireland

 

In Murphy et al's article,¹ the authors make the statement 'patients should have the right to the same treatment regardless of how they pay for the service of their GP'. I think every right thinking GP would agree with this as an ethical principle on which to practice medicine.

 

However, although the authors acknowledge the weakness of their study in not matching cases for severity or duration of illness they go on to suggest that payment or non-payment is an influence on treatment decisions.

 

We know that non-paying patients consult more frequently.² Surely a more likely explanation of the findings is that patients who have to pay the cost of the consultation with their GP and the full cost of a prescription are likely to wait until they are sicker before they decide to consult their doctor and because they are sicker are more likely to be prescribed an antibiotic.

 

References

1. Murphy M, Byrne S, Bradley C. Influence of patient payment on antibiotic prescribing in Irish general practice: a cohort study. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X693820.

2. Lyons RA, O'Brien D, Flynn M, et al. An explanation for the difference in general practitioner consultation rates between GMS and non-GMS patients. Ir Med J 1992; 85(2): 52.

 

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Date: 11 Sep 2011

Topic: Response to 'Managing Self Limiting Respiratory Tract Infections'

Comments by: Suresh Pathak, (Retired GP), Romford, Essex

 

Please allow me to comment on the article Managing Self Limiting.

 

Respiratory Tract Infections by Sarah Peters et al.¹ I am a retired GP. When active in practice, I did a study of managing upper respiratory tract infections (URTI) in general practice. This study was related to one of the modules for the masters degree in general practice. For appropriate management of such conditions based on NICE guidelines, I recommended; 1) consistency of diagnosis; 2) explanation of the nature of viral illness to patient/parents; 3) identifying the reasons of patients attendance (identify who is the real patient); 4) encourage safe self care; 5) discourage dependence on the doctor; and 6) ensure the patient feels positive about the consultation and is not afraid to return if the clinical condition worsens.

 

Dr Ralph Gonzales, in the editorial published in The Lancet commented about prescribing antibiotic the combination of fixed patient expectations and pressures on physicians to limit appointment times has encouraged antibiotic prescribing as the path of least resistance.²

 

References

1. Peters S, Rowbotham S, Chisholm A, et al. Managing self-limiting respiratory tract infections: a qualitative study of the usefulness of the delayed prescribing strategy. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X593866.

2. Gonzales R, Sande M. What will it take to stop physicians from prescribing antibiotics in acute bronchitis? Lancet 1995; 345(8951): 665666.

 

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Date: 10 Sep 2011

Topic: Response to 'Are the serious problems in cancer survival partly rooted in gatekeeper principles'

Comments by: Nikolia Manassiev, GP, Yardley Wood, Birmingham

 

The paper trying to examine the role of GPs as gamekeepers and 1 year cancer survival¹ is meaningless. It would not do credit to a sixth former. Below follows a brief explanation why this is so.

 

The idea that a link between healthcare systems and cancer survival may exist is worth exploring but the paper does not do this. The paper is poorly designed, poorly executed, and factually incorrect. What is the reader to make of the fact that the paper uses statistics from 1995–1999, in other words, 1216 years old? The paper is based on EUROCARE dataset,² but the reader is not told that the information on which the dataset is based is not representative. The contribution of different counties to the cancer registry vary widely. Germany logs only 1% of its cancers with the registry, France 1015%, Italy 25%, Switzerland 2747%, and UK, Denmark, Sweden, Norway, Finland 100%. The reader is not even told which are the countries with gatekeeper's system and which are not. Dividing survival from individual cancer sites into quartiles and assigning an arbitrary value on each quartile in order to derive a meaningful measure of quality of cancer care is such a crude and fantastical method that it makes the Flat Earth Society looks like MENSA in comparison to the authors of this paper. While methodological and design flaws are understandable (we all make them from time to time) the failure of the authors to read their own references carefully, the failure to access the original data, and the failure to present the facts accurately is not. The whole paper¹ hinges not on original data, but on another paper.³ In that paper the authors divided the cancer survival in quintiles and not in quartiles as Vedstead and Olesen claim. The top and bottom 20% quintiles were then colour coded green and red and sorted out to give visual representation of where a country stands 'at a glance'. However, the data used by the authors of that paper³ has been extracted by the EUROCARE–4 study.² And here is the rub. Had Vedstead and Olesen read the original EUROCARE–4 study, they would have noticed on page 938 the following age-standardised 1-year and 5-year relative survival from all cancers:

 

Country	1–year cancer survival	5–year cancer survival
Denmark	99.9	91.8
England	99.1	93.5
Northern Ireland	100.5	89.9
Scotland	98	98.7
Wales	100.6	98.7
Belgium	94.1	87.8
France	98.9	95
Italy	98.5	90.6
Sweden	98.6	94.2
Switzerland	96.4	83.6
EUROPE	97.3	92.6

 

I rest my case here, as this piece of information invalidates their paper completely without needing to go into more details on methodology, statistics, and discussion. As far as I know, Belgium, France, Italy, and Switzerland do not have a gatekeepers system and their one-year appears equal or worse than that of the UK.

 

But still, for the sake of completeness let us ask a few more questions. For example it is not made clear by the authors why 1-year cancer survival rate is thought by them to be such an important a measure? Why not 5-year or 10-year? Is it because the results would be different if 5-year survival was chosen instead? 1-year cancer survival rate is generally considered meaningless, as the majority of sufferers of the top four cancers (lung, breast, prostate, and colon) would survive 1 year probably whatever the health system. Even if we for a moment imagine that the finding in the paper was true, might not lead-time bias be able to explain it? There is nothing in the discussion about and controlling for factors other than the healthcare system that may influence cancer mortality. For example countries such as Sudan, Central African Republic, Namibia, and Botswana have cancer survival that is better than any of the European countries.⁴ Is this because of the gatekeeper's system?

 

For the benefit of the interested reader it is worth mentioning that ecological studies have value well below cohort and case controlled studies, and for good reason. For if the data provided in the paper¹ were true, one may reasonably draw conclusion that the reason for the lower survival in the UK and Denmark is the genetic similarities that they have shared since the time of King Canute (Cnut).

 

While researchers seek to try and publish their work and their blind spots may be understandable, the failure of the peer-reviewers and the Editor(s) is deplorable and contemptible. People who do not read submitted papers carefully, who do not understand methodology and statistics, who do not make an effort to access the original data, who have not heard of lead-time-bias, who cannot think of any factors influencing cancer survival other than gatekeeper's role, should not be peer-reviewers or Editor(s).

 

References

1. Vedsted P. Olesen F. Are the serious problems in cancer survival partly rooted in gatekeeper principles? Br J Gen Pract 2011; DOI: 10.3399/bjgp11X588484.

2. Sant M, Allemani C, Santaquilani M, et al. Survival of cancer patients diagnosed in 1995–999. Results and commentary. Euro J Cancer 2009; 45(6): 931991.

3. Moler H, Linklater KM, Robinson D. A visual summary of EUROCARE-4 results: a UK perspective. Br J Cancer 2009; 101(Suppl 2): S110114.

4. Globocan. All Cancers (excluding non-melanoma skin cancer) Incidence and Mortality Worldwide in 2008. Summary. France: International agency for research on cancer, 2008.

 

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Date: 9 Sep 2011

Topic: Response to 'Measuring depression severity in general practice: discriminatory performance of the PHQ-9, HADS-D, and BDI-II'

Comments by: Nouman U Khan, Department of Psychiatry, Leigh Infirmary, Leigh

S Shah, GP Trainer, Elliott Street Surgery, Manchester

 

We read with interest the article by Cameron et al that raised an important observation regarding the objective assessment of the severity of depression in primary care patients.¹ The study was conducted to revalidate the tools for measuring the severity of depression in a cohort of primary care patients against the cut offs set by American Psychiatric Association and NICE. In this effort, the authors defined the optimal cut offs for moderate depression, but those did not achieve the likelihood ratios sufficient to inform the clinical practice.

 

The article emphasises that the GPs have to assess the severity of depression using one of the self-rating questionnaires only. However, the NHS evidence and the QOF payment methods state that depression questionnaires can be helpful in detecting depression and in assessing severity, but should not be used alone to determine the presence of depression that needs treatment.² This highlights the fact that clinical judgment should be used along with the depression scores.

We are also slightly concerned about the power of the study, as the article does not mention the predetermined sample size for optimal determination of the convergence. While 1134 patients were invited, the final analysis included data from only 20% of these. Hence, the study might be severely underpowered.

 

The study also started off with randomisation of the participants into two groups with pre- and post- interview questionnaires. The authors did not mention the purpose for randomisation. The two groups thus created were not considered when analysing the data and all the data was merged into one!

 

The study included all the adult patients from nine practices; however, the mean age was 49.8 years (standard deviation 14.1). This highlights the same concerns as were raised for a previous study by the same authors.^3,4 In addition, the older patients are likely to suffer from several chronic physical conditions, that have been completely overlooked.

 

Taking it all together, there are issues regarding the assessment of the severity of depression in the primary care. Further work to validate tools in a sufficient sample size inclusive of older patients from a wider ethnic background may help. In addition, regular training of the GPs to improve their clinical recognition of the problem may be beneficial.

 

References

1. Cameron IM, Cardy A, Crawford JR, et al. Measuring depression severity in general practice: discriminatory performance of the PHQ-9, HADS-D, and BDI-II. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X583209.

2. NHS Clinical Knowledge summaries. Depression - Goals and outcome measures. London: National Institute for Health and Clinical Excellence, 2011.

3. Bahri A, Hilton C. Antidepressant prescribing for older adults. Br J Gen Pract 2010; 60(570): 53.

4. Cameron IM, Lawton K, Reid IC. Appropriateness of antidepressant prescribing: an observational study in a Scottish primary-care setting. Br J Gen Pract 2009; 59(566): 644.

 

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Date: 9 Sep 2011

Topic: Methadone keeps people alive

Comments by: Stephen Willott, RCGP SDHIV Group, Clinical Lead for Drug Misuse & Alcohol for NHS Nottingham City, Nottingham

Euan Lawson, RCGP Substance Misuse Unit, Cumbria

We were surprised and disappointed to read Mike Fitzpatrick’s review column ‘Older addicts’, as we feel it is inaccurate and ill-judged.¹ We have no problem with The Review articles being controversial but we do expect some attempt to justify controversial views with evidence.

 

Fitzpatrick makes sweeping statements about one of the therapeutic mainstays of drug dependency. The evidence base for methadone as an opiate substitution therapy is strong and recognised by the national guidelines and the recently published RCGP guidance.^2,3 On an individual level a person on methadone is less likely to die, commit crimes, or get blood-borne viruses.⁴

 

In contrast, Fitzpatrick’s piece is largely rhetorical and it is flawed rhetoric at that. He argues that because there are people who have been on methadone for many years, this ‘confirms the spectacular ineffectiveness of the (methadone) treatment’. This is illogical, contrary, and is it not actually the reverse? The ageing demographic of those on methadone shows how well it has kept them alive, something that the RCGP’s 2010 Research Paper of the Year confirmed in a cohort of injecting drug users in Edinburgh.⁵ There is also little evidence that methadone maintenance increases the overall length of dependence.⁶

 

Fitzpatrick comments on ‘the substantial mortality arising from methadone overdose (among the children of users as well as their parents)’. There are risks, as with any medication, but deaths in users on scripts are rare and often related to polydrug use. Only 0.1% of drug deaths are under 15 years.⁷ Careful attention to prescribing guidelines has mitigated the risk and, ultimately, methadone clearly reduces drug-related deaths.

 

Finally, Fitzpatrick stands in moral judgement of those on methadone with the pejorative comments that users have been consigned to ‘lives of idleness and dependency’. He also suggests that medicalisation is ‘robbing drug users of their dignity as well as their health’. We fundamentally disagree with Fitzpatrick’s opinions, and it is utterly wrong and baseless to suggest methadone worsens health.

 

Many GPs have worked hard over many years to address the social exclusion and health inequalities of those with substance misuse health issues. It is perfectly reasonable to have a debate about medicalisation, and there is no reason why the prescribing of opiate substitution therapy shouldn't be included in that debate. However, we would prefer to see a debate that made some attempt to formulate opinions that go beyond a superficial kneejerk anti-methadone approach that has merely served to reinforce an ill-informed stereotype and deepen stigma.

 

References

1. Fitzpatrick M. Older addicts. Br J Gen Pract 2011; 61(589): 522.
2. Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive Drug misuse and dependence: UK guidelines on clinical management. London: Department of Health, 2007.
3. Ford C, Halliday K, Lawson E, Browne E. Guidance for the use of substitute prescribing in the treatment of opioid guidance in primary care. London: Royal College of General Practitioners 2011.
4. Gossop M, Marsden J, Stewart D, Treacy S. Outcomes after methadone maintenance and methadone reduction treatments: two-year follow up results from the National Treatment Outcomes Research Study. Drug Alcohol Depend 2001; 62(3): 255–264.
5. Kimber J, Copeland L, Hickman M, et al. Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment. BMJ 2010; 340: c3172.
6. Ward J, Hall W, Mattick R. Role of maintenance treatment in opioid dependence. Lancet 1999; 353(9148): 221–226.
7. Ghodse H, Corkery J, Ahmed K, Naidoo V, et al. Drug-related deaths in the UK: annual report 2010. London: St George's, University of London, 2010.

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Date: 8 Sep 2011

Topic: Response to 'Sleep apnoea: no laughing matter'

Comments by: Dr Ben Hudson, Senior Lecturer, Department of Public Health and General Practice, University of Otago, Christchurch, New Zealand

 

Hartley et al's editorial on sleep apnoea provides a useful review of the condition but overstates current knowledge about the effect of continuous positive airway pressure (CPAP) on cardiovascular disease.¹ They write that CPAP has since been shown to normalise cardiovascular mortality and morbidity in severe apnoeics both in secondary and primary care and support this assertion by citing a Cochrane review and a recent paper in the BJGP.^2,3 However, neither reference demonstrated a reduction in cardiovascular morbidity or mortality with CPAP, although both found that CPAP was associated with a reduction in blood pressure.

 

There are already good reasons to use CPAP, but it is not yet known whether reduction in cardiovascular risk is one of them. This is currently being investigated by a multi-centre randomised control trial, the Sleep Apnoea Cardiovascular Endpoints Study. Until the results of this trial are known, claims for the effect of CPAP on cardiovascular outcomes should be made with caution.

 

References

1. Hartley S, Vachon J, Benainous O. Sleep apnoea: no laughing matter. Br J Gen Pract 2011; 61(588): 434–435.

2. Giles TL, Lasserson TJ, Smith B, et al. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database of Systematic Reviews, 2006; (3): CD001106.

3. Di Guardo A, Profeta G, Crisafulli, et al. Obstructive sleep apnoea in patients with obesity and hypertension. Br J Gen Pract 2010; 60(574): 325–328.

 

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Date: 6 Sep 2011
Topic: Methotrexate prescribing in primary care
Comments by: Laura Durber, Medical Student, St George’s, University of London

Lucy Scrannage, GP

Marc Duffield, GP

Pippa Oakeshott, Reader in General Practice, St George’s, University of London

 

The September editorial ‘Prescribing safety: the case of inappropriate medicines’ highlights the importance of safer prescribing by GPs. Methotrexate prescribing in primary care was not mentioned although GPs often participate in shared care of patients treated with this immunosuppressive. Methotrexate is used to treat rheumatoid arthritis, psoriasis, and cancer, but can potentially cause fatal blood dyscrasias and liver cirrhosis.¹ Prescription cost analyses show a 7.4% increase in the prescription of oral methotrexate in primary care between 2009 and 2010.^1,2
The role of the GP in shared care of patients on methotrexate typically involves prescribing the dose advised by the specialist, ensuring compatibility with concomitant medication such as antibiotics and NSAIDs, checking that the patient understands weekly dosing, and monitoring full blood count and renal and liver function every 4–12 weeks.¹ Patients should be warned of the need to report a sore throat, mouth ulcers, bruising, or signs of liver toxicity.⁴ Between 2004 and 2006 there were 165 patient safety alerts for methotrexate.¹ Furthermore, a national patient safety agency (NPSA) report found that the most common reason for methotrexate related litigation was prescribing error by GPs.²

 

In September 2011 we carried out an audit on the use of oral methotrexate in a multiethnic inner London practice with 9700 patients. Our findings highlighted the potential for prescribing error. A search identified 11 patients currently prescribed oral methotrexate, four of whom had prescription errors. These comprised a pregnant patient with methotrexate in current repeat prescriptions (although it was not being issued), a three month prescription of methotrexate despite a rheumatology request for 6 weekly blood testing, and two prescriptions with unclear dose instructions. In addition two patients did not book their monitoring bloods on time, one patient had no monitoring at all, and two patients had been discharged from the rheumatology clinic for not attending.

 

The audit also showed that secondary care often failed to provide copies of the shared care guidelines for prescription of methotrexate in primary care. Two recent hospital letters did not provide clear instructions for ongoing monitoring or dosing. The audit was on a small scale in one practice and cannot be used to draw any conclusions about current levels of prescribing error with oral methotrexate. However, when combined with evidence that this drug has been associated with a large number of patient safety incidents, it serves to act as a reminder that we should continue to work toward the standard set out in the NPSA methotrexate safe prescribing checklist.⁶

 

References
1. BMJ Group and Pharmaceutical Press. British national formulary.

2. The Health and Social Care Information Centre. Prescription cost analysis 2010.
3. The Health and Social Care Information Centre. Prescription cost analysis 2009.

4. Guy’s St Thomas’ Foundation Trust Drug and Therapeutics Committe. Shared care prescribing guideline Methotrxate (oral and subcutaneous) in adult patients with rheumatoid arthritis.
5. National Patient Safety Agency. Patient safety alert: Improving compliance with oral methotrexate. London: National Patient Safety Agency, 2006.
6. National Patient Safety Agency. Towards the safer use of oral methotrexate. London: National Patient Safety Agency, 2006.

 

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Date: 4 Sep 2011
Topic: Response to ‘Performance management, appraisals, and revalidation: quantity analysis and quality control for UK GPs’
Comments by: Andrew Eastaugh, Southwold Surgery, Southwold, Suffolk

 

Davies et al make some important points about the need for GPs to access data on how they work, both as individuals and as members of team, for the purpose of appraisal and revalidation.¹ However, they appear to fall into the increasingly common habit of treating the two processes as identical and equating them with performance management. This is both dangerous and destructive, particularly in those responsible for running these processes. While the questions the authors pose are important and contributory, the primary questions to be addressed are as follows:

 

1. Is this doctor good enough? This is a summative question for revalidation asked by the GMC on behalf of society, that will, we hope, ensure all practicing doctors are above a minimum level of competence.
2. What are the current issues for the way this doctor practices, and what will help this doctor’s practice grow and flourish? This is a formative question asked by the doctor themselves through reflective practice and as part of the appraisal process.  It flows into the PDP. The appraiser is merely a facilitator of that process.  
3. How well is this doctor contributing to the goals of the organisation for which he/she works? Whether this question is summative or formative is dependent on how educationally enlightened the organisation is. My suspicion is that it is usually summative.

 

Naturally the three questions need to be asked of similar data, but that by no means makes them synonymous questions. I might consult a railway timetable to know the time of a train I intend to catch? Whether it has a restaurant car? Or whether there is a train at all to where I am going and I might be better on a bus?

 

Unfortunately, not only have the authors confused these three processes, so have the GMC (question one), RCGP (question  two), and the Department of Health (question three), with the result that the GMC who should be asking question one independently, is using the process of question two that should be independent education, supervised by those who have a vested interest in delivering a politically (rather than scientifically) determined health care policy, who are longing to use question three to get us all to do as we are told.

 

Reference

1. Davies P, Walsh M, Pollock C. Performance management, appraisals, and revalidation: quantity analysis and quality control for UK GPs. Br J Gen Pract 2011; 61(589): 526.

 

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Date: 3 Sep 2011

Topic: Response  to ‘One for all’ concerns regarding NICE antibiotic guidelines on suspected bacterial meningitis!

Comments by: Andrew J Pollard, Chair of the NICE Bacterial Meningitis and Meningococcal Septicaemia Guideline Development Group, Professor of Paediatric Infection and Immunity, University of Oxford

Matthew Thompson, GP and Senior Clinical Scientist, University of Oxford

Tim Stokes, Consultant Clinical Adviser, Centre for Clinical Practice, National Institute for Health and Clinical Excellence (NICE), Manchester and GP Leicester

We are grateful for the opportunity to provide some comment following the letter by Saeed et al¹ that points out an apparent discrepancy between NICE recommendations2 for primary care antibiotic therapy (penicillin) and secondary care management (ceftriaxone) and makes a case for availability of a third generation cephalosporin in the GPs ‘black bag’.

Unfortunately, the authors’ arguments are based on a fundamental misunderstanding of the guidance as the population they discuss should not have been given antibiotic therapy in the first place. The only population for whom there is a recommendation for universal pre-hospital antibiotic therapy in this setting are those with suspected meningococcal disease (both meningococcal meningitis and septicaemia), that means patients who are ill with a non-blanching rash. The previous chief medical officer’s (CMO’s)³ advice and the NICE guideline² only refers to these patients. The arguments about Haemophilus influenzae type B meningitis and pneumococcal meningitis put forward by the authors, although microbiologically correct, are irrelevant as such patients with suspected meningitis and no rash should not receive pre-hospital antibiotics.

 

The reason for avoiding antibiotics in non-meningococcal meningitis is that such patients should have investigations in hospital (for example, lumbar puncture) and important therapeutic interventions (for example, steroids) before or at the same time as they receive antibiotic therapy. At present such interventions are not available in most community settings. So for these individuals the priority is to provide rapid access to hospital and minimise the time from presentation to appropriate management. This is discussed in the full version of the NICE guideline where GPs are advised to send such cases to hospital urgently.²

 

The NICE guideline development group searched the evidence for the use of pre-hospital antibiotic use in meningococcal disease and concluded that there was insufficient high quality evidence to recommend antibiotic therapy in this setting (some studies indicated a worse outcome when antibiotics were used pre-hospital, and others implied improved outcomes but all were inadequate to draw firm conclusions) and, therefore, the NICE guideline has emphasised urgent transfer to hospital for children with a non-blanching rash. Despite the lack of supportive evidence, the recommendation to administer parenteral penicillin as previously recommended by the CMO³ was not rescinded as it was also considered that there was insufficient evidence to change the current practice. The NICE guideline therefore changes the emphasis for GPs seeing cases of suspected meningococcal disease. Where previously all such cases should have received penicillin prior to transfer to hospital, the emphasis is now on urgent transfer to hospital with opportunistic use of penicillin where this can be done without incurring any delay.

 

The appearance of antibiotic resistant bacteria in the community is a concern but is best managed by limiting antibiotic use rather than wider use of broad spectrum agents. With regard to the moderate penicillin resistance that the authors note was documented by Kyaw et al⁴ (and elsewhere), it is important to monitor through good surveillance (best achieved by obtaining blood and cerebrospinal fluid cultures in hospital) but, as Kyaw et al say in their paper, the clinical significance of moderate resistance among meningococci remains unknown.⁴

 

Meeting a case of meningococcal disease is thankfully a once in a lifetime experience for most GPs and, carriage of ceftriaxone over a GPs' career is unnecessary and wasteful, especially as we are still uncertain whether antibiotic therapy outside a hospital environment even helps. We recommend that GPs continue to carry benzylpenicillin, at minimal cost, and to administer it if its use will not delay hospital admission.

 

References

1. Saeed K, Stannard T, Dryden M, Lambert H. ‘One for all’ concerns regarding NICE antibiotic guideline on suspected bacterial meningitis! Br J Gen Pract 2011; 61(591): 606.
2. National Institute for Health and Clinical Excellence. Bacterial meningitis and meningococcal septicaemia (CG102). London: NICE, 2010. (accessed 5 Sep 2011).
3. Department of Health. Professional letter — chief medical officer: meningococcal infection. London: Department of Health, 1999. (accessed 5 Sep 2011).
4. Kyaw MH, Bramley JC, Clarke S, et al. Prevalence of moderate penicillin resistant invasive Neisseria meningitidis infection in Scotland, 1994–9. Epidemiol Infect 2002; 128(2): 149–156.

 

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Date: 2 Sep 2011
Topic: Nursing care in hospitals
Comments by: David Brooks, FRCGP, Hutton, Preston

 

The inadequacies and failings of nursing care in our hospitals have been in the news recently and seem to have triggered much public comment, and even discontent. I was somewhat surprised to see Dr Clare Gerada’s name linked in agreement with the views of Dr Peter Carter, general secretary of the Royal College of Nursing. It seems that Dr Carter wants relatives to free up nursing time by feeding and caring for relatives in hospital. There are very real problems delivering good quality nursing care these days that must be addressed, and soon, but this suggestion cannot provide much of an answer. Most relatives will be happy to do what they can when they can. However, so many relatives need to work, and others live a significant distance from hospitalised family members. A majority, one feels, will be uneasy and ill prepared when carrying out intimate nursing tasks. None can provide 24-hour professional care. Dr Gerada may well have been misreported but surely this is not RCGP policy.

 

Conflict of Interest: Septuagenarian

 

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Date: 31 Aug 2011
Topic: An alarming symptom
Comments by: Geryl Rees, Heaton Mersey Medical Practice, Stockport, Cheshire

John Whitaker, Heaton Mersey Medical Practice, Stockport, Cheshire

 

I was asked to visit an 80 year old lady complaining of unilateral tinnitus. She suffered with cardiac failure and had been receiving home visits for a while on account of her reduced mobility. She also had a past history of contralateral mastoid surgery and subsequent hearing loss. New auditory symptoms in her one good ear were understandably of particular concern for her.
 
Upon letting me in to her three bedroom semi-detached house she described her symptoms. She had been experiencing an intermittent high-pitched beeping sound over the past 24 hours. Intrigued I unpacked my auroscope to examine further. As I peered towards a healthy looking tympanic membrane I was surprised to hear a beep for myself. Looking directly above the patient’s sofa there was a smoke alarm flashing; a second beep a minute later clinched the diagnosis.

 

The role of home visits has been a subject of on-going debate.¹ However, this case served as a reminder of the possible role of home visits not only in serving our less mobile patients, but also in securing an unusual diagnosis that otherwise might have led to unnecessary further investigation. It also enabled the important public health preventative measure of ensuring a functioning battery in the smoke alarm, even though it required the patient’s son to come round and fit it.

 

Reference
1. Theili G, Kruschinski C, Buck M, et al. Home visits – central to primary care, tradition or an obligation? A qualitative study. BMC Fam Pract 2011; 12: 24.

 

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Date: 27 Aug 2011
Topic: Does better disease related knowledge improve Health Related Quality of Life (HRQoL)?
Comments by: Fahad Saleem, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia

Mohamed A Hassali, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia

Asrul A Shafie, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia

Muhammad Atif, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia

 

The concept of HRQoL is being used to measure factors other than illness affecting human health and its status. This result in predicting different dimensions within the patient's life and helps healthcare professionals to understand patient perceptions of illness.¹ HRQoL in patients suffering from chronic illnesses is heavily disrupted resulting in decreased satisfaction with daily life activities. Therefore, HRQoL is an important tool in the assessment of treatment outcomes.

In recent years, a growing demand to educate patients with chronic disorders is reported in literature. Several methods have been utilised to improve patient knowledge including patient groups, published literature, specialist clinics, and information technology. Although the provision of disease-related information to patients has been considered a good practice, it is not clear whether disease related knowledge has any impact on their HRQoL. For example, in a cohort of patients with ulcerative colitis, Mayberry and Rhodes reported that anxiety levels among the patients increased up to 50% as they came to knew more about their condition.² Martin et al also reported similar results while discussing patients with inflammatory bowel disease.³ In an ongoing study by the authors themselves, patients reported lower HRQoL even after they received an educational intervention. Therefore, it can be predicted that HRQoL is negatively affected once patients are made aware of their disease.

 

There is a reason for this prediction. In practice, HRQoL recapitulates a wide range of physical, communal, and emotional behaviors, that are vital in the management of diseases. HRQoL is extremely difficult to measure impartially, as it depends on many preexisting and irreversible factors such as economic status, intelligence, personality, socio-political conditions, nature and duration of disease etc.⁴ Patients with low socio-economic status and having chronic diseases are reported with lower HRQoL. When these audiences attend an intervention or educational programme, they may have an increase in disease related knowledge resulting in an increase concern towards health status. This disturbs the psychological and mental domain that decreases the overall HRQoL as other factors are not modified by the interventional or educational programme.

 

For that reason, healthcare providers have to target the resources appropriately to those patients who are likely to get benefit. A blanket distribution policy is not always successful. This strengthens the fact that information that is provided to the patients needs to be tailored as per individual’s needs. In clinical setting, this can be achieved by a one-to-one discussion. Another option is that information should be reduced, leaving an open choice for patients to make contact for further details on specific points if needed. Studies focusing in depth psychosocial profile are also recommended to get a clearer view of HRQoL. These steps could be useful in clinical practice, particularly at point where improving HRQoL is still possible.

 

References
1. Bredow T, Peterson S, Sandau K. Health-related quality of life. In: Peterson S (ed.). Middle-range theory: application to nursing research. 2nd edn. Philadelphia, US: Lippincott Williams & Wilkins, 2008.
2. Mayberry JF, Rose J, Rhodes J. Assessment of patient information booklet on ulcerative colitis. Ital J Gastroenterology 1989; 21: 193–195.
3. Martin A, Lucia  L, Castagliuolo I, et al. What do patients want to know about their inflammatory bowel disease. Ital J Gastroenterology 1992; 24(9): 477–480.
4. Verma S, Tsai H, Giaffer M. Does better disease-related education improve quality of life? A survey of IBD patients. Dig Dis Sci 2001; 46(4): 865–869.

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Date: 24 Aug 2011
Topic: Management of an Imported Case of Shigella Dysentery in Primary Care.
Comments by: Jamshid Nikkhah, Henley Cross Medical Practice, London

Dariush Nikkhah, Henley Cross Medical Practice, London

 

Shigella bacillus still remains an important cause of diarrhoea in the UK. Up to 51% of cases are associated with foreign travel.¹ The majority of domestic strains are Shigella sonnie but S.flexneri, S.boydii, and S.dysenteriae are often imported and associated with foreign travel.¹ Data from the Health Protection Agency shows that the number of cases has fallen from 1992 to 2010 but still 1747 cases were reported in 2010.² The main imported sources of infections are from travel to India, Egypt, and Pakistan.¹

 

We describe the case of an 8 month old boy returning to the UK from Nepal with his family. He presented to primary care with diarrhoea and pyrexia. His GP advised his parents to give him oral rehydration fluids (Dioralyte) on top of maintenance fluids. Unfortunately, he represented to the GP out-of-hours service with continuing diarrhoea and a specimen was taken for stool culture. Shigella sonnie was grown from the culture and his GP was promptly informed. The species identified was sensitive to amoxicillin and ciprofloxacin.

 

The child was started on Amoxicillin syrup 250mg/5ml tds for a week by his GP.  Within 2 to 3 days of starting antibiotics he recovered and has remained well with no further symptoms. The only other member of the family to also have diarrhoea was a young cousin who had joined them from Australia, from Nepal, and had recovered within 5 days without treatment.

 

Travellers diarrhoea can be due to a host of conditions and can be encountered by the primary care physician. Shigella is a frequent possibility and it does not always present with bloody diarrhoea. It is often self limiting and does not need antibiotics except in cases of S. dysenteriae, and in young children or the elderly who present with a severe toxic febrile illness.^3,4 Rehydration fluids and bed rest are the mainstay of treatment. Antibiotic resistance is high and up to 60% resistance to Amoxicillin has been documented² but this case was surprisingly sensitive to Amoxicillin.^4,5

 

References
1. Health Protection Agency Centre for Infections. Travel and migrant health section - Feb 2011 Shigella spp – 2008 update. London: Health Protection Agency, 2008.

2. Health Protection Agency. Epidemiological data Shigella spp 1999–2010. London: Health Protection Agency, 2011.

3. Morgan E, Cooke F, Torok E. Oxford handbook of infectious diseases and Microbiology. 1st edn. Oxford: Oxford University Press, 2009.

4. Nikkah J, Mehr-Movahead A. Antibiotic resistance among Shigella species isolated in Tehran Iran. Ann Trop Med Parasitol 1988; 82(5): 481–483.
5. Cheasty T, Skinner JA, Rowe B, Threfall EJ. Increasing Incidence of antibiotic resistance in shigellas from humans in England and Wales: recommendation for therapy. Microb Drug Resis 1998; 4(1): 57–60.

 

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Date: 19 Aug 2011
Topic: Response to ‘Tips for GP trainees working in trauma and orthopaedics’
Comments by: Jane Searle, Mosborough Health Centre, Sheffield

 

The article 'Tips for GP trainees working in trauma and orthopaedics'¹ would have benefited from a GP-educators perspective.

 

Tips on how to maximise the potential usefulness of an orthpaedic post for a budding GP would have been helpful. Orthopaedics posts are often viewed as having little relevance to a GP trainee when in fact it does abound with very useful learning opportunities. The rare but serious conditions; CES, septic joint, and pathological #, similarly the easily missed conditions, for example, slipped femoral epiphysis, are very valuable conditions to see and would stand any registrar in good stead for their future career.

 

Learning who needs referral for joint replacement, and then post-operative complications like loosening and joint infections, is similarly valuable. Orthopaedic surgery is often non-essential in contrast to many other surgical procedures. Patients are weighing up the risks versus benefits and in my experience greatly value an opportunity to discuss these issues with a knowledgeable GP.

 

Perhaps more emphasis on the links with the curriculum and the competencies that are demonstrated doing this post would be more helpful to many registrars.

 

Reference
1. Dawe E, Reeve W, Burkes M. Tips for GP trainees working in trauma and orthopaedics. Br J Gen Pract 2011; 61(589): 532–533.

 

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Date: 16 Aug 2011
Topic: Development of prescribing-safety indicators for GPs using the RAND Appropriateness Method.
Comments by: Pawan Randev, GP Cancer Lead North West London Cancer Network

Shirlene Ho, Pharmacy student

Pauline McCalla, Principal Pharmacist Ealing Hospital NHS Trust / Cancer Network Lead

 

Avery and colleagues have developed prescribing safety indicators that focus on individual prescribing decisions.¹ Most GPs work in practices that have systems of prescribing. The common factor is the clinical computer system prescribing module. This allows the prescriber to view detailed BNF data about medication (F2 and chosen drug in EMIS).

 

Practices have administrative systems that highlight new medication and enter data into the clinical system. Unfortunately, there is significant variability in the recording of medication as we have found in an audit of recording the of biologic therapy in primary care.

 

All patients being prescribed etanercept or adalimumab for a variety of indications at Ealing Hospital NHS Trust, a district general hospital, were included in the audit. It was confirmed that letters were routinely sent to their GP informing them of initiation of or change to anti-TNF agent (+/- methotrexate).

 

For each patient the following information was requested from their GP practice:

          • a list of their current and repeat medication
          • any medication history recorded.

 

Subsequently, those practices that failed to reply were contacted by phone and asked how/where they had recorded information provided in letters from the rheumatology or dermatology consultant about the anti-TNF treatment initiated at the hospital.
 
Out of 164 patients only 12(7.3%) had the anti-TNF agent listed as an ongoing (repeat) medication in the GP records.

For a further 3(1.8%) patients it was listed under past medication, for 11(6.7%) it was recorded under 'significant/ medical history' and for 2(1.2%) under 'active problems'. In addition concomitant methotrexate therapy was only recorded for 3 of the 84 patients on etanercept.

 

For the remaining 136 patients the only record would have been the original (scanned) letter from the consultant.

As a result there would be no record of this medication in a structured format in the prescribing record. Prescribing would be undertaken in ignorance of the true range of prescribed medications.

 

We propose that this is considered as an indicator of practice prescribing safety –primary care recording of roaccutane and biologics could be the marker medications.

 

Reference
1. Avery AJ, Dex GM, Mulvaney C, et al. Development of prescribing-safety indicators for GPs using the RAND Appropriateness Method. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X588501.

 

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Date: 15 Aug 2011

Topic: Are the serious problems in cancer survival partly rooted in gatekeeper principles?

Comments by: Wilfred Treasure, Muirhouse Medical Group, Edinburgh

Thank you for this important and interesting paper.¹ Can I ask at what point in the course of the illness and by what criteria cancer was diagnosed? In my practice in Edinburgh, the diagnosis of cancer is based on histological examination of tissue obtained by a specialist. Imagine two patients: one patient in a system without a gatekeeper presents directly to a specialist who takes a biopsy that shows cancer; the patient dies 53 weeks after presentation and is therefore alive at 1 year. The other patient, in my practice, sees me initially and is referred and, 2 weeks later, sees a hospital specialist who takes a biopsy; this second patient dies 53 weeks after presentation to me, that is 51 weeks after seeing the specialist and having cancer diagnosed. Apparently the first patient survives 53 weeks and the second patient 51 weeks. I'd be grateful for a comment on this.

 

Reference
1. Vedsted P, Olesen F. Are the serious problems in cancer survival partly rooted in gatekeeper principles? An ecologic study. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X588484.

 

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Date: 13 Aug 2011
Topic: ‘Heartsink’ patients in general practice
Comments by: Andrew Moscrop, University of Oxford

 

In the summer of 1986, in response to a doctor describing heartsink, Jospeh Saperia advocated ‘attendance at a Balint-type GP seminar’.¹ 25 years later, again in response to a doctor describing heartsink, Saperia has repeated that counsel on the BJGP discussion forum.²

 

Tom O’Dowd recently wrote to the BJGP, reflecting on the study of heartsink patients that he conducted in 1988.³ He admitted to still experiencing heartsink today ‘albeit much less frequently’, and encouraged clinicians to ‘reflect upon their clinical experience in a systematic way’.⁴

 

Here then is something circular and something linear:  a quarter-century-old call for Balint work reoccurring; and a senior GP recommending reflective work while reflecting upon his own personal development. O’Dowd, in his recent correspondence, suggests that the recognition and acknowledgement of heartsink patients is part of the growth of a young GP; meanwhile Saperia’s repeating comments imply the profession overall has been slower to mature.

 

Many GP practices now have in-house counsellors who, despite perhaps years of experience, are still encouraged to discuss difficulties and challenging clients with a designated supervisor. GPs may have no less need for this sort of ‘professional support’, by which I mean support for ourselves as professionals: it would seem a mature response to our work, but one too-easily squeezed from our working lives. In my own recent work on heartsink I echoed the suggestions of psychodynamic approaches and Balint groups. To that I might add peer support or mentoring. For, as a young GP myself, reading Tom O’Dowd’s reflections after his several decades in general practice, I could not but think how he might have been able to help the young O’Dowd with his heartsink problem of 23 years ago.

 

References

1. Saperia J. Making dysphoria a happy experience. Br Med J (Clin Res Ed) 1986; 293(6542): 317–318.
2. Saperia J. Heart sink – cause and cure. 2011 19 Jul. On: BJGP Discussion Forum.

3. O’Dowd T. Five years of heartsink patients in general practice. BMJ 1988; 297(6647): 528–530.
4. O'Dowd T. 'Heartsink' patients in general practice. Br J Gen Pract. 2011; 61(588):437–438.

 

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Date: 12 Aug 2011
Topic: Managing osteoarthritis in primary are: the GP as public health physician and surgical gatekeeper
Comments by: John Havard, Saxmundham Health, Suffolk

Karen Blades, GP

Mr Phillip Dale, Physio

Prof. Brendon Noble, University College, Suffolk

Kimi Prosser Suffolk PCT

 

Managing osteoarthritis in primary care¹ is an increasing problem for GPs with the ageing demographic. As the authors point out, physiotherapy and exercise are frequently ignored and 10% of patients referred for a joint replacement decline the procedure. It is apparent that GPs consistency as treatment planning gatekeepers is too variable and so, as commissioners in Suffolk, we have developed a new modus operandi with the help of our PCT and physiotherapist colleagues.

 

Essentially we plan to use a physiotherapy assessment and treatment team to ensure exercise and weight loss are tackled. We will insist on expert patient contact so patients who are desperate for surgery at least go in with their eyes and expectations sharply focused. We have introduced an objective Suffolk Hip Score that comprises a patient questionnaire (Yoxford Hip Score - named after a local village), a radiological score, and a physiotherapy assessment score. Our consultant colleagues felt they almost always listed the referrals that came in from senior physiotherapists and so this is why they did not contribute to the scoring. This new, thorough, objective assessment system should remove any patient and/or relative derived pressure on GPs and consultants to move patients up the list since it fairly assesses patient need in relation to others. Furthermore we will hold the surgery list in primary care and refer patients to the consultant according to need and there will be a contractual obligation to undertake the hip replacement within four weeks.

 

We are about to launch this THR project and the TKR version is next down the line in both time and anatomy. PROMS data suggests that we have greater potential to achieve better patient outcomes with knees than hips.

 

We believe that this type of innovative treatment gating protocol will provide important benefits to our healthcare system in terms of both system efficiency and patient experience. We look forward to assessing our methods to find out.

 

Reference
1. Croft P, Porcheret M, Peat G. Managing osteoarthritis in primary are: the GP as public health physician and surgical gatekeeper. Br J Gen Pract 2011; 61(589): 485–486.

 

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Date: 11 Aug 2011

Topic: Are the serious problems in cancer survival partly rooted in gatekeeper principles?

Comments by: Louisa Polak, GP, Nayland Surgery, CO6 4LA

As an experienced GP, I disagree with two aspects of this interesting paper.¹

First, rather than being an ‘unexpected ... side effect’ of gatekeeping, more numerous delayed diagnoses are the inevitable price of fewer unnecessary investigations, that is one of the goals of gatekeeping. We need a study comparing the harm done by investigations (though this could never include patients' unnecessary worry and waste of time) in countries with and without gatekeepers, before deciding which system is superior.

 

Second, I do not believe that the authors' suggested explanations for delayed investigation and referral, such as financial constraints and fear of being ‘negatively judged by doctors in the secondary sector as referring unnecessarily’, are likely to be supported by the future research they wisely recommend. Instead, I think it will show that most of us try to work with individual patients to weigh up the chance of benefit from an investigation against its possible harms. Thus we already act as advisers who counsel the patients on what to do, as the authors recommend, with cost-effectiveness a very secondary consideration.

 

The public perception of our role as ‘“keepers” simply rationing care’ is already growing more prevalent in anticipation of GP commissioning. I hope this paper will not be cited in support of this unhelpful and ill-founded view.

 

Reference
1. Vedsted P, Olesen F. Are the serious problems in cancer survival partly rooted in gatekeeper principles? An ecologic study. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X588484.

 

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Date: 11 Aug 2011
Topic: Improving the detection and management of anxiety disorders in primary care
Name: Jim Hardy

 

The editorial by Buszewicz and Chew-Graham¹ make a number of good points about the detection and management of anxiety disorders in primary care. My view is that anxiety management is the greatest challenge we face as primary care physicians, but I would question whether the medical model approach encompassed within the GAD-7 and accompanying NICE guidelines is enough. As professionals we can sense anxiety in our bones and the way we need to improve upon managing it is to acknowledge not just the patient in front of us, but our response to the patient. It is much more about the relationship and the way we deal with it.

 

In these times of vanishing resources we need to focus on the benefits of strong therapeutic relationships rather than becoming too encumbered by guidelines and questionnaires.

 

Reference
1. Buszewicz MJ, Chew-Graham C. Improving the detection and management of anxiety disorders in primary care.  Br J Gen Pract 2011; 61(589): 489–490.

 

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Date: 10 Aug 2011

Topic: Ubi Scientia in the midst of the cosy cardigans of Caritas?

Comments by: Kath Checkland, University of Manchester, Manchester

Daniel Edgcumbe makes an eloquent plea for GPs to engage with the body of knowledge relating to health services, systems, and policy making,¹ As a GP engaged in research in this area I can only wholeheartedly agree with his analysis. However, I believe there are significant problems within the world of general practice research that militate against this occurring.

First, established disciplinary boundaries render much of the work that my colleagues and I do invisible. Journals such as the BMJ and, on occasion, the BJGP, are often unsympathetic to research that is qualitative, emergent, and theory generating. Much of the work in this field is cross-disciplinary, and finds a home in journals such as Sociology of Health and Illness, Social Policy and Administration, and the excellent Journal of Health Services Research and Policy. However, such journals have lower impact factors than biomedical journals (typical social science journal impact factors are less than 2, compared with a figure of 13 for the BMJ), and this means that our work is undervalued within university medical faculties. Furthermore, it has been my experience (as a reviewer and as an applicant) that the scoring systems used to decide which abstracts are worthy of a presentation slot at academic conferences, such as the Society for Academic Primary Care, are biased in favour of clinical and quantitative research, making it difficult to find an audience for the work that we do.

Second, and leading on from this, even academic medics appear to be unaware of the wide ranging and excellent body of research that exists in the field of social sciences. As an illustration of this, my colleagues and I undertook a large and detailed study of practice-based commissioning; work that is clearly relevant in the current political context. This work was extensively published in journals that appear on PubMed and Medline, and a simple search for 'practice-based commissioning' on Google Scholar™ retrieves many of these papers and the project reports within the first few pages of results. Indeed, we (along with colleagues from the London School of Hygiene and Tropical Medicine) are so well recognised as experts in the field of commissioning research that we were recently awarded a contract to set up a Policy Research Unit on Commissioning and the Healthcare System, funded by the Department of Health. In spite of this, when the RCGP decided to set up a Centre for Commissioning not only were we not contacted, but an email offering support went unanswered for nearly 6 months.

I straddle two worlds, being a practising GP and an active researcher in the field of social science and health policy. As such I both know the literature and know the reality of life on the ground. While I am only too aware that busy GPs do not have time to wade through long papers in sociology journals, those journals with a mass GP audience such as the BJGP and the BMJ owe it to us to at least attempt to signpost and summarise the relevant research. In addition, I would encourage our academic institutions such as the RCGP and the SAPC to engage more fully with the wider world of research, acknowledging our junior place in a well-established academic field and signalling our openness to learn and engage with research paradigms beyond the randomised controlled trial.

 

Conflict of interest: I am a member of the Editorial Board of the BJGP.

 

Reference
1. Edgcumbe D. Ubi Scientia in the midst of the cosy cardigans of Caritas? Br J Gen Pract 2011; 61(586): 345.

 

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Date: 9 Aug 2011

Topic: Are the serious problems in cancer survival partly rooted in gatekeeper principles?

Comments by: Peter Davies,
FRCGP, GP, Keighley Road Surgery, Illingworth, Halifax, GP Appraisal Lead, Calderdale PCT, Calderdale Commissioning Consortium, Provost, Yorkshire Faculty, RCGP

 

The paper by Vedsted and Olesen¹ raises serious questions about GPs and their gatekeeper role. Clearly, if the gatekeeper function is acting simply as a delaying tactic then it is difficult to justify its presence. If the delay leads to harm, such as delayed diagnosis and increased mortality, then it is an example of a medical system causing harm, and that would need to be reviewed, and maybe removed.

 

The data that Vedsted and Olesen use are from some time ago, reflecting practice conditions and outcomes in the 1990s. Is no more recent data available to see what is happening currently?

 

In the UK, GPs now have access to the 2-week rule system for urgent referrals and growing access to detailed diagnostic scans and tests. Our means to diagnosis are improving, but we do not yet know if we use them well.

 

Perhaps the key need now for primary care in the UK, and the world, is to focus its effort more clearly on the diagnostic activity, and its accuracy of problem definition. The current short, crowded primary care consultation in the UK is an obstacle to allowing doctors sufficient thinking time to assess symptoms and their significance, both to the patient and in terms of likely pathology.^2,3 The problem of delayed diagnoses may not be gatekeeping, but rushing, and thereby failing to define the problem properly. Perversely, we seem to have built a UK medical system based on rushing rather than thinking and in doing so achieved a reduction in both our sensitivity for and specificity of diagnosis. This may appear cheap, but it may actually be costing more to run, as referrals may become a displacement mechanism for time stressed doctors, rather than a carefully formulated question to ask a specialist.

Have we overvalued speed and quantity in medicine thereby actually reducing our quality and effectiveness?

 

References
1. Vedsted P, Olesen F. Are the serious problems in cancer survival partly rooted in gatekeeper principles? Br J Gen Pract 2011; DOI 10.3399/bjgp11x588484.
2. Esmail A. Longer appointments for all. J R Soc Med 2006; 99(12): 644–645.
3. Davies P. The beleaguered consultation. Br J Gen Pract 2006; 56(524): 226–229.

 

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Date: 9 Aug 2011
Topic: Response to Acupunture in the August issue
Comments by: Steve McCabe, Portree Medical Centre, Isle of Skye

 

The failure of your brief editorial response¹ and the response of Paterson and colleagues² to address any of the concerns raised by the multitude of critical letters^3–12 published in the August edition of the BJGP relating June's acupuncture paper and editorial is, in my view, wholly unacceptable.

 

You say that ‘the Board...did not consider that there was a case for retraction of the paper or for releasing the peer reviews’ - why not? Surely releasing the peer reviews would, at the very least, facilitate the concept of openness. Refusing to do so merely creates a suspicion of something to hide.

 

Likewise the author's response fails to adequately address the numerous concerns raised by the letter writers. Again I regard this as unacceptable. They make vague statements that are, at their heart, actually meaningless. For example, they state that ‘acupuncture is a safe and potentially effective intervention’ but ‘potentially’ is a vague and nebulous term. Ultimately anything can be claimed to have ‘potential’ benefits and that's why we have an established and robust system for clinical trials to test such hypotheses. In this trial it was absolutely essential to exclude any bias from ‘spending more time with physicians’ before any claims about needling per se could be made but this is just washed over.

 

Like others I believe the Journal should retract its supporting editorial, at the very least, because the claims contained there in cannot be substantiated. That alone is enough to justify retraction.

 

I have been a College member and BJGP reader for nearly 20 years. Throughout that time the BJGP has struggled to achieve recognition and credibility in the world of quality medical journals. I therefore find it astonishing that it is quite prepared to score such an obvious own-goal. It does the reputation of the Journal and, indeed, the College, no good at all.

 

References

1. Jones R. Editor’s response. Br J Gen Pract 2011: 61(589): 495.

2. Paterson C, Taylor R, Griffiths P, et al. Authors’ response. Br J Gen Pract 2011: 61(589): 495.

3. Colquhoun D. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract 2011: 61(589): 491.
4. Cockram L. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract 2011: 61(589): 491.

5. Lawson E. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract 2011: 61(589): 492.

6. Devroey D, Van de Vijver E. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract 2011: 61(589): 492.
7. Power M, Hopayian K. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract 2011: 61(589): 493.
8. Rose L. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract 2011: 61(589): 493.
9. Wallace M. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract 2011: 61(589): 494.

10. McCartney M. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract 2011: 61(589): 494.

11. Farrimond S. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract 2011: 61(589): 494.
12. Meijer M, Verwoerd A. Acupuncture for ‘frequent attenders’ with medically unexplained symptoms. Br J Gen Pract 2011: 61(589): 495. 

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Date: 5 Aug 2011

Topic: ‘One for all’ concerns regarding NICE antibiotic guidelines on suspected bacterial meningitis!

Comments by: Kordo Saeed, Consultant Microbiologist, Royal Hampshire County Hospital, Winchester
Timothy Stannard, Friarsgate Practice, Winchester

Matthew Dryden, Royal Hampshire County Hospital, Winchester

Helen Lambert, Friarsgate Practice, Winchester

The most common bacteria causing meningitis include Streptococcus pneumoniae, Neisseria meningitides, and Haemophillus influenzae. Guidelines issued by the National Institute for Health and Clinical Excellence (NICE) in regards to bacterial meningitis recommend administration of benzylpenicillin for children and young patients with suspected meningococcal disease in the pre-hospital setting. This is in accordance with existing advice issued by the chief medical officer.^1,2 However, when the same patient comes in to hospital, the advice on the empirical antibiotic choice changes to third generation cephalosporins (with or without high dose amoxicillin depending on risk factors for Listeria monocytogenes infections) this means that, essentially, the same patient can be prescribed different antibiotics depending on where he or she is first seen!

At present there is convincing evidence suggesting an independent incremental association between ‘delays’ in administering ‘the correct’ antibiotics and mortality from acute bacterial meningitis.⁵ In addition, we know that delay in commencing adequate antibiotic therapy in septic shock cases is associated with higher mortality, and the use of inappropriate antibiotics is associated with higher mortality in blood stream infections.^6–8 Penicillin resistant rates among UK Haemophillus species isolates is 17.7% and penicillin intermediate S. pneumoniae is 10.8%. In a Scottish study the prevalence of moderate penicillin resistant meningococci was 8.3%, the majority of isolates (52.2%) belonged to serogroup B,^3,4 and according to the same NICE guidelines the prevalence of Haemophillus resistance to third generation cephalosporins is almost zero. There is currently a low prevalence of pneumococcal cefotaxime/ceftriaxone resistance in the UK, with only 1.7% of strains reported to have intermediate or high resistance to cefotaxime between 2004 and 2007. Given these numbers it is unclear as to why NICE is still recommending benzylpenicillin.

Paul Erlich’s ‘Frapper fort et frapper vite’ statement is correct, however, in addition to ‘hit hard and hit fast’ we believe that in these cases we need to ‘hit right’ to achieve a more favourable outcome. Therefore, the choice of empirical antibiotic should be the same both in pre- and post-hospital settings, and benzylpenicillin in the doctors bag should be replaced with a third generation cephalosporin, for example, cefotaxime, to be administered to patients in a timely manner, unless of course there is history of true beta-lactam allergy or other contraindications.

 

References
1. National Institute for Health and Clinical Excellence. Bacterial meningitis and meningococcal septicaemia (CG102). London: NICE, 2010. (accessed 5 Sep 2011).
2. Department of Health. Professional letter — chief medical officer: meningococcal infection. London: Department of Health, 1999. (accessed 5 Sep 2011).
3. Sahm DF, Jones ME, Hickey ML, et al. Resistance surveillance of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis isolated in Asia and Europe, 1997–1998. J Antimicrob Chemother 2000; 45(4): 457–466.
4. Kyaw MH, Bramley JC, Clarke S, et al. Prevalence of moderate penicillin resistant invasive Neisseria meningitidis infection in Scotland, 1994–9. Epidemiol Infect 2002; 128(2): 149–156.
5. Proulx N, Fréchette D, Toye B, et al. Delays in the administration of antibiotics are associated with mortality from adult acute bacterial meningitis. QJM 2005; 98(4): 291–298.
6. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34(6): 1589–1596.
7. Ibrahim EH, Sherman G, Ward S, et al. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest 2000; 118(1): 146–155.
8. Leibovici L, Shraga I, Drucker M, et al. The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection. J Intern Med 1998; 244(5): 379–386.

 

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Date: 31 July
Topic: Five year training: an example from the First Master Second Level of Family Medicine in Italy
Comments by: Francesco Carelli, EURACT Council, BME Committee, Chair, Professor FM University of Milan

 

The review Five years training: a radical rational approach to delivery, by Nigel de-Kare-Silver¹ discusses how long the postgraduate specialty training should be.

 

For the Secretary of State for Health (Tooke Report)² one of  its key points is that general practice training should be extended to 5 years. However, since then, adverse national economic factors have arisen and discussion on this change appears very low-key.³

 

The proposed changes in medical contacts would put additional responsibility with the ongoing development of an ever-growing body of health knowledge, the development and implementation of complex systems of delivery of health care, increasing expectations in the consultation style to undertake specialist outpatient level services and deliver many differing services at multiple layers to their patients.

 

More is expected in terms of requirements of the position but nothing has been taken away. Other specialties have longer training programmes to prepare their trainees for work in clinical fields that are narrower in breath than primary care.

 

There is little evidence of opposition to the idea of 5-year training programmes but, equally, little evidence that this will be developed in the foreseeable future. With the increasing expectations of the range and styles of services a GP should provide there is a need to make sure professionals have the right skills to request, manage and interpret   what is needed to care for their patients.

 

New fields of responsibility are rapidly emerging, including leadership, strategy, and policy development and implementation, commissioning, public health, teaching at all levels and all disciplines, management, and research.

 

In the current situation, an alternative route is suggested: the 3 years training programme remains in its current position and GPs should be invited to undertake a new higher level qualification as a Master, where all GPs would have the right to choose whether to embark by competition. This would be a part time programme followed over a period of 2 years with a range of specialist qualifications and accreditations. There would be generic entry-level modules in topics like such as organisation leadership, team skills, and negotiation skills prior to the more detailed studies in the higher-level trainee’s chosen field.

 

There are uncertainties that the infrastructure of current training is able to deliver such a model and a risk, that if accepted, the time needed to develop the modules may stall the initiative.

 

To help ideas and initiatives, I can report on a first advanced Master’s Degree in Family Medicine was officially opened this winter in Italy. Organised by University Campus Bio-Medico of   Rome in collaboration with the Italian Society of General Medicine (SIMG). The course runs alongside, but does not replace, the three years of training administered by the regions. Classes are structured in 15 modules plus a specialised form of addresses. The structure is similar to that proposed in the article. This initiative indicates the way ahead: start from small universities or specific professional groups, that are linked and economically self-sufficient.

 

The Master’s course can and must also be the hurdle for the jump in quality, the way into academia (EURACT).⁴

The Master stresses issues that closely affect citizens and their families’ lives and not just place the organizational structures of general medicine at the center of social-health of an entire urban context (neighborhood, etc.) but also make the ‘antennae’ to recognise sources and monitor any aspects of social danger and violence. As in a valuable discipline, therefore, between ‘humanities’ and technical evidence-based. Of course, I agree with Nigel de Kare-Silver that GPs completing this programme may rightfully expect a higher level of remuneration to reflect their higher level of training

References

1. De Kare-Silver N. Five-year training: a radical rational approach to delivery. Br J Gen Pract 2011; 61(588): 464–465.
2. Tooke J. Aspiring to excellence. Findings and final recommendations of the independent inquiry into modernising medical careers. London: Aldridge Press, 2008.

3. Allen P. Britain’s economy – the highs and lows. The Guardian 2011; 23 Apr.

4. EURACT. http://www.euract.org

 

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Date: 19 Jul 2011
Topic: Heart sink – cause and cure
Comments by: Joseph Saperia, London
 
The ‘which came first, the chicken or the egg?’ question applies similarly to the heartsink patient or the heartsink doctor. The doctor’s well meaning but inadequate attempt to deal with the patient causes heartsink in the doctor because the problem defeats him. The patient is aware of the doctor’s feelings of despair and rejection and his heart sinks too!¹

 

Dr O’Dowd² initiated a regular discussion group about his heartsink patients with four GPs, a health visitor, and occasionally a psychologist. I have no doubt that it was the psychologist’s help that provided the source of improvement in the patients. It would have been more useful if the heartsink patients themselves had been formed into a regular discussion group with a psychologist as the group leader.

 

The patients’ views of their doctors’ attempts to treat them would have been very illuminating. O’Dowd writes that these patients’ only common thread seems to be the distress they cause their doctor and the practice. I suggest another common thread, their doctor’s inability to cope with their problems.

 

Allow me to describe the way forward. The patient was a 49-year old woman who presented with recurrent headaches of a 2-year duration. They occurred at monthly intervals, lasted three days, often with nausea but no vomiting, were eased by paracetamol, didn’t disturb sleep, and were followed by a feeling of well being. Over the past two months, the pattern had changed and the headaches occurred each week for three days. Clinical examination was unrewarding.

 

She had been my patient for some 20 years and we discussed various key situations in her life – her early childhood in a troubled family with an alcoholic father, her first marriage of eight years, and her present long happy one, her 21 year old daughter who has left home and was living with a man, her hysterectomy five years ago, and her feeling that she was still a complete woman who continued to enjoy the sexual side of her marriage. Her full time job as a solicitor’s clerk was satisfactory.

 

We were quiet for a minute or two then she said that during her hysterectomy five years ago she had received a blood transfusion and ‘knew’ that it took five years for the symptoms of disease from the transfusion to develop. It was a breath-taking revelation and I gently discussed and explained the true facts; I shared and enjoyed her almost palpable visible relaxation and relief. She could easily have become a, O’Dowd heartsink patient and he, in turn, would have been her heartsink doctor. I had no heartsink patients but mea culpa, for some of my patients I was surely a heartsink doctor.

 

Attendance at a Balint-type GP seminar provides the opportunity to gain the knowledge, experience, and technique necessary to prevent the development of heartsink in the doctor and thus in the patient. Also, if one accepts a new patient in whom heartsink is well established one must show a willingness to accept the patient in the way that one accepts a patient with a difficult unstable angina or severe emphysema.
 
References
1. Saperia J. Making dysphoria a happy experience. Br Med J (Clin Res Ed) 1986; 293(6542): 317–318.
2. O’Dowd TC. Five years of heartsink patients in general practice. BMJ 1988; 297(6647): 528–530.

 

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Date: 15 Jul 2011
Topic: Response to ‘letter on non-medical prescribers’
Comments by: David Church, GP, (past SHO and MOSS to Crown Health Enterprise, New Zealand), Machynlleth

 

In response to Dr Pancholi's letter,¹ I would add that it is not only non-medical prescribers whom GPs are asked (nay, forced, as Pancholi describes) to take responsibility for, but it includes hospital doctors and consultants too. It is nigh impossible to refuse to sign the forms, as the patient/relative 'needs' the medication and has been told that the GP must issue it. Indeed, the NHS regulations require us to provide the 'required form' so that the patient can obtain the medicine 'on the NHS'.

 

I have written elsewhere before along these lines, but the green bit of paper that is often called a 'prescription', and for which GMC and MPS/MDU advisers always indicate the signatory of is taking responsibility for the 'prescription', this FP10 is not really a 'prescription' in the original sense, it is just a financial instrument, being a reimbursement claim form for the patient to obtain the item 'on the NHS'. The signatory should only be expected to take responsibility for little more than confirming that the patient needs the item 'on the NHS'.

 

The actual 'prescription', it can be argued, is the original instruction to make up the item and issue the medication to the patient, written in a clinical letter from OPD, or scrawled on an 'urgent medication request' form from hospital, or some scrap from elsewhere, or a verbal communication, direct or indirect from somewhere or other. This instruction, including the original request for the 'recipe' (a term older doctors may recognise from when they had to actually list ingredients!), actually constitutes the real 'prescription' as issued by the real, and I would argue, 'responsible' prescriber. The subsequent issue of FP10s are just financial instruments. Take perhaps the giving of an FP10 for a tetanus immunisation, or a personally administered stat dose of diamorphine at home visit for an MI.

 

The FP10 issued for these can in no way be called a 'PREscription' because it is not written beforehand, it is only a financial reclaim form made out after the event - ie possibly a 'POST-scription', but not a 'PREscription'.

The actual prescription would be the typed computer entry -'send to nurse: needs Tetanus jab stat', or similar. Can we entice the GMC and whatever legal authority is necessary to make changes to the system and the guidance, to recognise the changes that have happened in the NHS financial systems and recording and medicine in general of the last 60 years to give us a more robust and safer system for 'prescribing' for patients and 'recording' for NHS finances, taking into account the actual responsibilities of the actual 'prescribers'?
 
Reference
1. Pancholi K. Working with non-medical prescribers. Br J Gen Pract 2011; 61(584): 223.

 

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Date: 13 Jul 2011
Topic: Ensuring patient safety
Comments by: David Church, GP, (past SHO and MOSS to Crown Health Enterprise, New Zealand), Machynlleth

 

In regard to the dilemma of how the GMC can ensure patient safety in the face of European requirement for mutual recognition of qualifications in doctors, I would like to pose a question:

 

While it appears the GMC must recognise the basic medical qualification of aliens, and allow qualified doctors to work in Britain, a position with which I have no argument, what is there to stop the GMC from preventing them from working at higher-grade posts in specialties for which they do NOT have a qualification?

 

I am not allowed to work in any specialty (including general practice) in Britain for which I do not have a suitable higher qualification, excepting at a basic supervised level. The same applies to me in New Zealand. I can work here as an unsupervised GP only if I am on the GP Register at Cwmbran. I can work in a hospital specialty, say gynaecology, but only as a junior SHO, not as a registrar. Same in New Zealand. I could set up in private practice, but only if the MPS or MDU were willing to accept myself, my qualifications, and my experience. I would note that to work in general practice in Britain requires skills in certain functions that are not required in some other countries (and the same applies to all hospital specialties too), for example our social services/national insurance system.

 

It would not be unfair to test foreign doctors in such country-unique skills before allowing them to work here, as indeed seems to be the case in certain foreign countries anyway. I cannot just go to France and set up as a neurosurgeon, even though they may recognise my MB, ChB.

 

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Date: 11 Jul 2011

Topic: Response to letter ‘How to protect general practice from child protection’

Comments by: Steve Ford, Haydon Bridge

Michael Fitzpatrick’s letter is ominously illuminating.¹

In vain I searched for irony but found none. In its place I found the authentic voice of the Borg (Star Trek), ‘We are Borg. Resistance is futile. You will be assimilated!’ Remorseless reductionist logic will have dominion and soft squishy humans, with their manifold flaws and weaknesses, like feelings and social context, will be eliminated.

Taking his words at face value, it is hard to avoid the conclusion that Dr Fitzpatrick has fatally misconstrued the nature of health care, particularly in general and primary care. It may be possible to sustain an illusion of care provision for a period without engaging the higher cerebral functions to fully embrace and synthesise the patient’s physical, psychological, and social dimensions into a diagnostic formulation that may guide subsequent advice or action, but the performance will be a miserably cold, shrivelled, deformed, and dangerously incomplete thing.

The confusion of which he writes is wholly his own. The central skill of the GP is to, more or less, successfully wrangle all of the factors that Dr Fitzpatrick affects to scorn with all of the features to which he ascribes virtue into a whole functioning mechanism that more completely answers the patient’s needs.

It would be instructive to know the candid views of the full range of his PHCT colleagues as expressed in his annual appraisal. Has Dr Fitzpatrick painted a true picture of his daily practice?

Patients are not petridish specimens in isolation. Attempts to enforce ‘in vitro’ practice must be resisted. ‘In vivo’ is the only approach for fully formed GPs.

Reference
1. Fitzpatrick M. How to protect general practice from child protection [letter]. Br J Gen Pract 2011; 61(588): 436.

 

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Date: 11 Jul 2011

Response to ‘Is patient-centred care a tautology?’

Comments by: Ken Menon, The Ongar Surgery, Essex

There are often many interpretations of patient-centred care. The plethora of information at a patients disposal coupled with current financial strictures, highlights the importance of the concept of patient-centred care and its place in providing evidence based medicine that is cost-effective.

Many PCTs and hospitals have and continue to place increasing restrictions in various aspects of health care; screening tests, for example, cervical smear, pathological and radiological investigations, not to mention the proliferation of referral management schemes. All these are directed, it seems, towards improving care, containing costs, and hopefully enriching the patient experience. Whether these various attributes are ever reconcilable is a matter of dispute and interest. However, it would seem prudent to consider patient-centred care as a consideration of a patient’s likes/dislikes and views in the light of the available facilities. This places upon the doctors the need to describe and discuss the restrictions in place, and the options available within those restrictions, with as full a disclosure of relevant information as possible. This would then enable the patient to make an informed choice. The doctor serves as the source of information and the director in encouraging, without coercion, the patient towards the most appropriate choice.

Too often patient-centred care is also confused with the exercise of autonomy by the patient. Respect for autonomy is often taken to mean acceding to the request of a patient. On the contrary, autonomy is best viewed as an expression of choice by an informed patient. Choice in this case would be one from the available options at the time, currently this would entail a discussion of cost and clinical effectiveness within the parameters of availability.

Now, one could argue that this is what doctors should always have been doing. One benefit of the current restrictions is to return doctors to their professional roots and to encourage evaluation of the scope of care with patients.

In both these scenarios doctors would be required to address the perennial issue of needs versus wants and their own professionalism.

 

Reference
1. Verheij T. Is patient-centred care a tautology?: View from the Netherlands. Br J Gen Pract 2011: 61(588): 472.

 

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Date: 11 Jul 2011

Topic: Medical professionalism and pay-for-performance

Comments by: JPM Chambers, MRCGP, Dublin 11

William Tormey, FRCPI, The Surgery, Dublin 11

In his Editor’s Briefing, Roger Jones opines that the Quality and Outcomes Framework may lead to maladaptive behaviours and deprofessionalisation.¹ This begs the question, what exactly constitutes medical professionalism? In 1977, Dr CF Donovan defined clinical competence as the first key responsibility of the doctor.² A continuing commitment to excellence through the application of current knowledge, and the continuing acquisition of new knowledge are key attributes of medical professionalism.³ However, the population mortality reduction of 11 lives per 100 000 people as a consequence of the pay-for-performance contract in England, and the implication that a similar payment system improved blood pressure control in Scotland, suggests that the ethos of professionalism may not be centre stage in medical education.^4,5 Success for the profession will arrive when there is no difference between measured patient outcomes, irrespective of the means of doctor remuneration.

 

References
1. Jones R. Editor’s briefing. Br J Gen Pract 2011; 61(588): 427.
2. Donovan CF. A doctor’s responsibility to his patients. Proc R Soc Med 1977; 70(1): 21–23.
3. Swick HM. Toward a normative definition of medical professionalism. Acad Med 2000; 75(6): 612–616.
4. Fleetcroft R, Parekh-Bhurke S, Howe A, et al. The UK pay-for-performance programme in primary care: estimation of population mortality reduction. Br J Gen Pract 2010; DOI: 10.3399/bjgp10X515359.
5. Simpson CR, Hannaford PC, Ritchie LD, et al. Impact of the pay-for-performance contract and the management of hypertension in Scottish primary care: a 6-year population based repeated cross-sectional study. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X583407.

 

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Date: 7 Jul 2011

Topic: Response to ‘HIV: low prevalence is no excuse for not testing’

Comments by: Pip Fisher, GP, Whitehouse Centre, Huddersfield

Caroline Kane, FY1 Doctor, London

Our practice, the Whitehouse Centre in Huddersfield, serves asylum seekers, drug users, and the homeless; therefore, a high proportion of our patients come from populations with a high prevalence of HIV. We routinely offer blood-borne virus testing when patients register with us and find uptake is high. In 2010 we audited the rates of testing for the sub-saharan African population registered with us. Of 274 black Africans registered, 29 (11%) were known to be HIV positive, 11 (38%) of whom had been diagnosed on routine testing at our practice; 16% of black Africans registered with the practice remained of unknown status at the time of the audit.

Looking at those who had not been tested, it was clear that higher rates of uptake were achieved if the blood was taken at the same consultation as the test was offered rather than asking the patient to return at a later date. This will be familiar to all those working with patients who have chaotic and difficult lives, and is not unique to HIV testing.

In his response to your editorial on HIV testing in general practice,¹ Smith is concerned that contacting patients to offer HIV testing will increase stigma.² However, we do not shy away from contacting at risk populations for breast screening or cervical smear screening for fear of stigmatising either the disease or the population involved. A simple offer of an appointment for a health check for those patients who have not been seen for sometime should not offend, and may save lives.

 

References
1. Arkell P, Stewart E, Williams I. HIV: low prevalence is no excuse for not testing. Br J Gen Pract 2011; 61(585): 244–245.
2. Smith C. HIV: low prevalence is no excuse for not testing [letter]. Br J Gen Pract 2011; 61(588): 436–437.

 

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Date: 5 Jul 2011

Topic: Respnse to 'Future-proofing primary health care: GP recruitment and retention in the new NHS'

Comments by: David Corbett, PD, Trainer and GP, Bexley, Kent

 

I am increasingly bemused by the narrowing and blinkered view of training to becoming a GP. Rosenthal and Chana¹ comment ‘many trainees still spend part of this time in posts that offer traditional hospital-based experience that may not reflect the context of new community based service models.’

Cautiously I would like to add the comment ‘so what?’ We do want ‘well rounded’ GPs, people open to new ideas, and who are open to ‘lifelong learning.’ Many who qualified at a similar time to me will have done hospital jobs as ‘part of the team.’ Six months at the end of which we were hopefully competent but also confident. Confident. Now that’s a word we haven’t been using too much recently but, as long as not false, important.

Doing six months and making a good job of a delivery or episiotomy repair, doing pleural taps or biopsies, covering the paediatric clinic when the consultant had to rush off. Not perhaps relevant to my job now but it did instill a confidence and satisfaction to my work. There is now much less ‘hands on’.

Interestingly a local gastroenterologist recently told me he used to teach his GP trainees to do endoscopies, no longer, as 4 months is ‘not enough.’ We now have tasters that might encourage some degree of competence (‘please sign me up’) but are we creating doctors with no confidence in their own abilities?

I like the idea of First5, encouraging doctors as they start their careers as GPs, dealing with issues, and educating around the GP mantle. It is a long career and may become longer so we need to generically give new GPs the tools to handle the future. Are we narrowing so much and trying too hard with training that we’re taking the enjoyment out of the process, when perhaps some of this could be done later? It is now rare to have colleagues, who had done several years as gynaecologists/surgeons, join our ranks and I think we have lost something here.

In my GP career I have been very grateful for sabbaticals to try working in different places/environments. This also seems to becoming more difficult and not encouraged generally while trying to achieve CCT. That great idea of learner-led education, particularly for trainees, seems to have gone out of the window.

I suppose I am saying, can we be a bit more generic in our training years, widen our horizons again, and use First5 to help settle doctors into the rewarding job we do?

 

Reference

1. Rosenthal J, Chana N. Future-proofing primary health care: GP recruitment and retention in the new NHS. Br J Gen Pract 2011; 61(588): 430–431.

 

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Date: 4 Jul 2011

Topic: Response to ‘How to protect general practice from child protection’

Comments by: Danny Lang, Cornwall and Isles of Scilly PCT, Cornwall

The bad news is that the BJGP published under such a negative and provocative title without balanced debate, in contrast to the recent BMJ head-to-head debate ‘Has child protection become a form of madness’.^1,2 One interesting comparison made in that debate is that Sweden and Finland spend 50% more of their gross domestic product on children and families than we do in the UK, we spend 200% more than they do on social problems. In my view these figures help us understand societal attitudes that have knock-on effects through all services for children and families including general practice. The current UK GP contract is certainly not child and family friendly and it is unlikely that current NHS changes will improve matters.

Mike Fitzpatrick’s latest letter over-emphasises the personal while flagging up the real difficulties for general practice.³ My work as a frontline GP and my statutory role as a named doctor for safeguarding children allows me to understand these difficulties, and indeed the importance of making vulnerable adults safe that he highlights in the same Journal.⁴
The good news is that the great majority of children grow up well and happy in their families and GP practices support them in this. I emphasise this when delivering safeguarding training to GPs. In doing this work GPs can develop a sense of why something is going wrong. With appropriate use of their knowledge, skills, and information, GPs can address the needs of children and their families across the spectrum of vulnerability and need through to abuse and neglect. There is no question that this is challenging, but in the UK all professionals are obliged by statute to fulfil our professional roles and responsibilities. Those specific to general practice are on pages 60–63 of Working Together to Safeguard Children 2010.⁵

GP colleagues in Cornwall show appreciation of the importance of safeguarding, but many feel there is too much guidance and insufficient resources. The majority of the practices value the RCGP/NSPCC Toolkit for Safeguarding Adults and Young People, that being written for GPs by GPs helps practices establish policies and procedures on safeguarding which work.⁶

I commend the RCGP for grasping the safeguarding nettle, collaborating with the NSPCC to produce this toolkit, and including safeguarding as one of the ten priorities of the RCGP Child Health Strategy for 2010–15.⁷ Can the BJGP help the College bring this strategy forward? Up to 25% of our patients are children. They are the future of the UK.

 

References
1. Fitzpatrick M. How to protect general practice from child protection. Br J Gen Pract 2011; 61(585): 299.
2. Spinelli M, Howard L. Has child protection become a form of madness? No. BMJ 2011; 324: d3063.
3. Fitzpatrick M. How to protect general practice from child protection [letter]. Br J Gen Pract 2011; 61(588): 436.

4. Fitzpatrick M. Warehousing. Br J Gen Pract 2011; 61(588): 466.
5. Department for Children, Schools, and Families. Working together to safeguard children. A guide to inter-agency working to safeguard and promote the welfare of children. London: HM Government, 2010.

6. RCGP and NSPCC. Safeguarding children and young people. A toolkit for general practice, 2009 revision. London: The Royal College of General Practitioners, 2009.

7. Harnden A, Boardman C, Lambe M; on behalf of the RCGP Steering Group. RCGP Child Health Strategy 2010–2015. London: Royal College of General Practitioners, 2010.

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Date: 1 Jul 2011
Topic: Response to ‘Impact of the pay for performance contract and the management of hypertension in Scottish primary care’           
Comments by: Dr Chris Mimnagh, Medical Director, NHS Knowsley
 
Simpson et al highlight a key issue in contract design for primary care.¹ Extrinsic motivation in the form of performance related contracts has a long term adverse consequence in the form of removing or negating intrinsic drive inherent in every professional. The work of Edward Deci in 1971, and Harry Harlow in 1950 is familiar to the world of psychology and predicts that in tasks that involve higher cognitive function rewards on a ‘do this and that will happen’ basis result in a diminution of intrinsic professional strive to do the best regardless of reward.
 
This should clearly be kept in mind when our new contract is negotiated. GPs should be rewarded for being the best GP they can be, not a target driven process manager.
 
Reference
1. Simpson CR, Hannaford PC, Ritchie LD, et al. Impact of the pay-for-performance contract and the management of hypertension in Scottish primary care: a 6-year population-based repeated cross-sectional study. Br J Gen Pract 2011; 61(588): 443–451.

 

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Date: 1 Jul 2011
Topic: The changing landscape of health and the NHS; are GP educators up for the challenge?
Comments by: Avril Danczak, Primary Care Medical Educator, North West Deanery

Alison Lea, Primary Care Medical Educator, North West Deanery
 
What impact are the changes proposed in the White Paper Equity & Excellence¹ having on GP training? How are GP Educators responding educationally to the changes ahead?

 

We asked our cohort of south & central Manchester GP ST3s completing training in August 2011, to describe the impact of the reform debate on their education, on the Study Release Course and in their training practices over the past year.

Potentially, learning could have occurred at additional formal sessions on the Study Release Course.  We added sessions covering finance, commissioning, data analysis of referrals and prescribing, and ethical issues in commissioning. Sessions on leadership and practice management were already scheduled. 

 

For many, learning was enriched by exposure to these issues but the subject was not welcomed by all learners. Comments about the Study Release Course included:

 

'More confidence around commissioning',
'More acknowledgement of GP in the bigger picture'
'Thinking about our position as commissioners and the ethic'
'Appreciating the importance of negotiation and leadership skills'
'Thinking about supply versus demand, and impact on the Doctor -Patient relationship'.
However, several remarked, 'took a lot of time, didn’t need to feature so much'.

 

GPST3 were also asked to reflect on their experiences within training practices and responses included:

 

'Encouraged to attend PBC meetings',
'Now have referral meetings which are useful',
'Now think about referrals more',
'In-house teaching of GPs working in clusters'.
Disappointingly perhaps, some GP ST3s remarked:
'not noticed a difference',
Or were 'unsure as not able to attend meetings in the practice'. 

 

Noticing that 'things have become more stressful in the practice' emphasised that GP ST3s were learning about how changes may affect the cultural climate of general practice.

 

Educators can and should recognise and exploit 'naturally occurring' learning opportunities, arising during times of change and evolution. If we seize such opportunities, we can both model, and help our learners develop the skills of responding to a changing environment. These are skills that they will certainly need for their whole careers in a health service where 'the only constant is change'.

 

What has been the experience of other educators? 

 

Reference
1. DoH. Equity and excellence. Liberating the NHS. Department of Health, 2010.

Reference for the evaluation methods
1. Lashbrook D. Educational speed dating. Educ Prim Care 2010; 21(6): 392.

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Date: 25 Jun 2011

Topic: Let us take blood

Comments by: Joanna Loudon, Medical Student, Edinburgh
Susie Nickerson, Murrayfield Medical Centre, Edinburgh

Medical students nowadays often report difficulty in gaining experience in performing routine venepuncture. In the past, students were regularly expected to take blood from hospital patients, allowing them to become very competent in the procedure before qualification. However, phlebotomists now do the majority of in-patient venepuncture, leaving few opportunities for students to learn and improve their confidence with this procedure.

 

One excellent way to overcome this problem is for GP practices to take on students as phlebotomists. This benefits both the student and the practice staff. Not only is the student given extensive opportunities to practice blood-taking, but he or she also gains experience of working efficiently in a clinical setting and putting knowledge from medical school into practice. In addition, if the post is paid, this can help fund student life (although many students will still be prepared to undertake this work on a voluntary basis).

 

Having a medical student phlebotomist allows the practice to offer more appointments for venepuncture and allows practice nurses to carry out more specific nursing tasks. The university holidays are times when practice staff will want to take holiday, so the student can be employed on a regular basis during the vacation periods. Staff can delegate simple patients to the medical student for venepuncture and blood pressure monitoring, in order to focus their own time on more complex patients or on management tasks.

 

As a medical student, I was extremely keen to work as a phlebotomist when the opportunity arose and have now worked at the same GP practice for three vacation periods. Due to my relative inexperience with venepuncture initially, I was given 4 days of training by the practice nurse.  Learning to use the computer system was also an important skill that I had to get to grips with early on. There is no doubt that my ability to communicate and relate to patients has really been enhanced by this experience.

 

It appears that taking on medical students as phlebotomists is uncommon in general practice, even on a voluntary basis. This seems a shame as employing a student to take blood can be highly advantageous to everyone involved. We would really urge GPs to consider this option in the future when approached by medical students.

 

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Date: 24 Jun 2011
Topic: Undescended testes: there is no role for imaging 
Comments by: Gillian Duthie, Specialist Registrar Paediatric Surgery, Birmingham
Anthony Lander, Consultant Surgeon, Birmingham
 
Paediatric surgical clinics receive large numbers of referrals for boys with suspected undescended testes. In over 60% of these referrals the testis is easily palpable in the scrotum. Many of these referrals are thus unnecessary. Good clinical examination is all that is required in the majority and there is no role for ultrasound imaging or MRI scans to locate impalpable testes.

 

We have found an increasing tendency for GPs to request either an ultrasound or magnetic resonance imaging to locate the position of the testis. This is expensive and unnecessary and the parents are unimpressed when the surgeon swiftly demonstrates two normal testes in the scrotum.

 

Several studies confirm that there is no role for the use if imaging in the surgical work up for undescended testis. Tasian et al found that that over a third of paediatricians routinely used imaging prior to referral.¹ They also carried out a systematic review and meta-analysis of the performance of ultrasound (USS) in impalpable testes.² Sensitivity and specificity were 45% and 78% respectively. They concluded that USS did not reliably localise impalpable testes.  A study by Desireddi et al in 2008 looked at the role of MRI in impalpable testes³ and found an accuracy of just 62%.

 

If the testis is undescended, the scrotum is usually hypoplastic on that side. If the scrotum looks normal but the testis is not immediately obvious the examiner should gently stroke a hand along the line of the inguinal canal and a normal testis will usually emerge from the canal or be found at the external ring. Once found the testis is delivered into the scrotum. A normal testis sits comfortably at the base of the scrotum with a good length of cord above it.

 

If the testis remains at the external ring or does not enter the scrotum the child needs an orchidopexy. If the testis is truly impalpable it may be absent, intra-abdominal, or in the proximal inguinal canal. If this is the case a laparoscopy is required but there is no role for imaging. Undescended testes should be diagnosed in infancy and the testes brought down shortly thereafter.
 
References
1. Tasian GE, Yiee JH, Copp HL. Imaging use and cryptorchidism: determinants of practice patterns. J Urol 2011; 185(5): 1882–1887.
2. Tasian GE, Copp HL. Diagnostic performance of ultrasound in nonpalpable cryptorchidism: a systematic review and meta-analysis. Pediatrics 2011; 127(1): 119–128.
3. Desireddi NV, Lui DB, Maizels M et al. Magnetic resonance arteriography/venography is not accurate to structure management of the impalpable testis. J Urol 2008; 180(4 Suppl): 1805–1808.
 
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Date: 13 Jun 2011
Topic: GP Appraisers and Nanotechonolgy
Comments by: Ruth Taylor, FRCGP, London

Recently I attended a support group meeting for GP appraisers. Upon arrival it became apparent that the event was sponsored by the ‘Institute of Nanotechnology’ that funded the cold buffet. A representative of the Institute started to give a presentation about nanotechnology. The audience’s photos were taken without prior notice or permission, and we were told that all GPs details had been entered onto the Institute’s database as interested parties. We were informed that it was up to individual GPs to ask for removal if they wished. At this point a heated protest ensued, and the photography and presentation were stopped. There had been no consultation about the inclusion of the subject of nanotechnology in the meeting and many of us saw no relevance to our learning needs as appraisers. The GP-organiser of the meeting admitted the mistake and apologised. However, this episode highlights ethical issues that will increasingly present dilemmas under proposed NHS changes. With greater involvement of private, commercial, and other companies in the NHS, and with GP consortia holding the purse-strings, it will be a matter of discernment and probity, which products or organisations doctors are seen to endorse. Some companies will not share the same values as doctors and many will protect their interests and information by the ‘commercial confidentiality’ principle. Photographs are not only a breach of privacy but can be used for publicity and commercial gain, giving an impression of endorsement. Doctors must be consulted and agree what a company’s involvement will be, and retain the right of veto, if we wish to safeguard ethical decision-making and impartiality. The cold buffet may not be worth it.

 

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Date: 18 May 2011
Topic: Must I?
Comments by: Dr David Carvel, Biggar Health Centre, Biggar

 

I naturally felt honoured and privileged to be formally invited to the RCGP annual conference in Liverpool this October. The glossy brochure displayed the smiling faces of the eminent speakers beaming out at me, and the programme indeed made interesting reading. I was a little taken aback, however, to read, both on page two and in the President's accompanying letter, that attendance at this 3-day event is not optional. It unequivocally states that this is 'the MUST ATTEND event for GPs and practice team colleagues.'

 

If this really were the case, surgeries the length and breadth of the land (including Merseyside) would be devoid of staff, and I suspect the combined capacities of Anfield and Goodison Park would struggle to accommodate us all.

 

There are few absolutes in medicine. I respect recommendations, gentle persuasion, and important advice but weary of pharmaceutical companies, medical educators, and others muscling in and telling me what is supposedly 'essential', 'crucial', or 'unmissable'.

 

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Date: 16 May 2011
Topic: Response to ‘The future of national health systems’
Comments by: Dr Mick Leach, Harrogate

 

As I read the editorial written by Iona Heath and colleagues¹ I found myself agreeing entirely with what was written. It seems to me that the fundamental mistake we are making, as a society, is briefly described at the end of the second introductory paragraph, where patients are described as consumers ‘no longer citizens bound by ties of mutual responsibility’. The current political mantra, that as doctors we appear to be embracing, is to ask what patients want and then seek to provide it. This is not sustainable, and I see the fall out every day in my general practice and out-of-hours work. We need medical leaders (in all the Royal Colleges and other positions of influence), more every day doctors (like me), the PCTs, and politicians, working together with patients as real partners, to have the courage and honesty to determine limits on what will be available, and what should be expected from all participants in health care.

 

Reference
1. Heath I, Mangin D, Toop L, Brodersen J. The future of the National Health System. Br J Gen Pract 2011; 61(586): 319­–320.

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Date: 5 May 2011
Topic: Response to ‘letter on GPs at the Deep End’
Comments by: Dr Edin Lakasing, Hertfordshire

 

I read the letter by Karen Steven and Catherine Jackson¹ in response to Graham Watt’s article ‘GPs at the deep end’.² I agree wholeheartedly with their assertion that factors apart from deprivation impact significantly on workload. By coincidence, I am a graduate of the University of Dundee, and familiar with the communities in north east Fife and rural Angus to which Steven and Jackson refer. I wish to reiterate some of their points, and additionally raise other related matters.

 

The Hertfordshire village in which I practice forms parts of the large swathe of commuter land surrounding London. Economically affluent, it nevertheless has around 40% more residents aged over 75 than is average for our PCT – itself well above the national average. Our nursing and care home residents account for 2.5% of the practice population, yet generate 25% of all the terminal care workload and over 50% of all other home visits.³ Our practice list size is actually 6300 but when ‘weighted’ for deprivation we are only paid for 5650, effectively punishing GPs financially for working in affluent areas, with no evidence that this has reduced health inequalities nationally.

 

Meanwhile, if one scratches below the ‘best of both worlds’ rhetoric used by estate agents to hype up this area, a quite different picture emerges. This, and similar communities are the apotheosis of Margaret Thatcher’s dictum that ‘there is no such thing as society’, a place where people opt to lead atomised lives with few social threads binding residents. Given the cost of living, entertainment facilities, particularly for younger people, are poor as are civic amenities, not least public transport. Competitive materialism, that carries the dubious honour of leaving its protagonists looking much the same as each other, is rife. Presentations with stress-related illness and somatisation disorder are alarmingly frequent. As a local GP, I could make a case for issuing Londoners contemplating the well-trodden path into the Home Counties with a health warning: for a few extra feet of living space, they may well find themselves in a cultural vacuum with poor social support, spending up several hours a day on ever more crowded and inefficient trains. 

 

I have previously argued that deprivation, however significant, should not be the sole driver of healthcare needs assessment,⁴ and each passing year strengthens this belief. Despite much political promises about reducing wealth, and with it health inequalities, these have continued to rise inexorably, and unequal societies extract a significant toll on happiness across the socio-economic spectrum. Doctors and other healthcare professionals cannot correct this alone, but given that we live and work with the consequences, we should engage in rational debate about how best to fund what is expected of us.
 
References
1. Steven K, Jackson C. GPs at the deep end (letter). Br J Gen Pract 2011; 61(585): 293–294.

2. Watt G. GPs at the deep end. Br J Gen Pract 2011; 61(582): 66–67.
3. Lakasing E, Sparkes C. A practice-based mortality survey revisited – what trends are emerging? Br J Community Nurs 2010; 15(5): 236–240. 
4. Lakasing E. Health inequalities in the UK: remedy requires action beyond redistribution of wealth. Br J Gen Pract 2009; 59(567): 782–784.

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Date: 5 May 2011
Topic: Response to ‘The uber-GP: an exploration of clinical excellence, leadership, and patient centred care in general practice.’
Comments by: Dr Mark Houghton, Sheffield

 

Professor Lakhani’s vision for the ‘uber GP’ is inspiring at first sight.¹ But he ignores a fatal tangle in the golden thread caused by the GPs handling of abortion. The three strands of the golden thread were Sir James McKenzie’s meticulous clinical work, compassionate care, and leadership. Lakhani links these to the  ‘high levels of trust in GPs’ today.

 

I’m not sure we have been trustworthy with abortion. Here, society has trusted us to be meticulous in clinical decision making, compassionate and showing justice in our leadership. Were we and are we?

 

The problem is that, in my 37 years in the profession, I did not notice meticulous clinical reasons to be commonly guiding abortion decisions. In any discussion among GPs I have never heard a majority say abortions are decided for meticulous clinical reasons. I have never heard clinical evidence quoted ‘at the coalface’. The reasons were usually autonomous patient choice and crisis ‘help’. ‘Of course it’s not legal,’ is a common private admission. All these years 95% of the thousands of abortions done were authorised under ground C of the 1967 Abortion Act. This requires the risk to a mother's mental or physical health from abortion to be less than that from delivering the baby. How many could quote and weigh up any research on that?

 

Concerning the relative risks, I will touch on some of the research evidence in large follow up studies from Europe and North America. Maternal deaths from suicide, murder, accidents and complications are higher following abortion than normal childbirth by a factor of between 2 and 3.5.^2,3 (British confidential figures on maternal deaths are of insufficient quality to capture all deaths related to abortion. This is because many abortions were not recorded or the deaths happened more than 28 days after the abortion.)

 

Robust and widely accepted scientific evidence points to abortion raising the risk of premature birth in subsequent pregnancies.  The increased risk of a preterm delivery is between 1.3 and 2.0 and rises with the number of abortions.⁴ The high fees charged for medical insurance of GPs who do abortions is another warning that all is not well. If we want general practice to survive, then perhaps we should tidy up our act with respect to the Abortion Act. First, McKenzie's example could inspire more compassionate care and wider trust through a meticulous examination of each abortion case under the law. We could relate this more precisely to the evidence about risk from abortion. Second, we could lead by admitting we were not always meticulous in the past. This might earn the right to remind communities that the Abortion Act exists for the common good. It is to guide doctors, mothers, fathers, born children, and unborn children in compassionate discharge of painful decisions. We will show that we meticulously consider before aborting the far fewer cases where legal abortion is a medical necessity.

 

Mackenzie’s tangled thread could be unravelled by leadership on abortion, then the vision so eloquently laid out in Lakhani’s article might be justified.¹ Otherwise, as Tony Blair knows, investigators may not be kind to establishment GPs who they will judge by the law and the evidence available.
 
References
1. Lakhani M. The über-GP: an exploration of clinical excellence, leadership, and patient-centred care in general practice. Br J Gen Pract 2011; 61(584): 218-220.
2. Gissler M, Kauppila R, Meriläinen J, et al. Pregnancy associated deaths in Finland 1987- 1994. Acta Obstet Gynecol Scand 1997; 76(7): 651-657.
3. Reardon DC, Ney PG, Scheuren F, et al. Deaths associated with pregnancy outcome: a record linkage study of low income women. South Med J 2002; 95(8): 834-841.
4. Shah PS, Zao J; Knowledge Synthesis Group of Determinants of preterm/LBW births.  Induced termination of pregnancy and low birth weight and preterm birth: a systematic review and meta-analyses.  BJOG 2009; 116(11): 1425–1442.

 

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Date: 27 Apr 2011
Topic: Response to ‘Reforming the NHS: necessary and achievable?’
Comments by: Francesco Carelli, EURACT Council, Director of Communications, Professor FM University of Milan
 
Roger Jones’ editorial¹ is totally in line with similar events in Italy, where government is trying, using health, finances, and public administration ministries, to force changes based on diktat, managerialism, bureaucracy, on avoiding doctors’ opinion, and discussion (the last one being specific for Italy).

 

So, we are facing efforts on untested reforms proceeding much too quickly, contributing to GPs’ burn-out. An iterative approach would enable such ‘ideas’ to be learned from the early adopters and pathfinders instead of obliging all to do soon and all unwilling and conflicting day by day.

 

Competition based on prices rather than quality is on the horizon also in Italy with a system named CReG (Chronic Related Group) just similar to DRG (Disease Related Group) in hospital setting, care for chronic patients based on low price offers by different providers (“any willing provider” as Clare Gerada underlines in her letter to RCGP members) already not only GPs but mainly coming from the market, groups outside primary care and NHS itself.

 

This opening up of healthcare boundaries destroys opportunities for collaboration between primary and secondary care, and the new system will exacerbate inequalities because more developed practices will be the only ones, as primary care, and if they succeed on any other willing provider, to work the system in this financial way.
 
I’m worrying about future quality of education and training funding and management when family medicine will be so under-professionalised as a specialty and seen as managerialism to be just supported for this aim by new providers of NHS services, diverting educational resources into services funding. Family doctors in UK and in Italy should work together in this dangerous situation for family medicine itself. We have to fight against compelling all GPs, also by diktat with fixed dates, to be just clerks, administrative and so on, we must slow down, get discussion and collaboration, and allow every agreed system to develop iteratively and based on evidence and learning.
 
GPs know best the matter and they must not be turned from talented clinicians into medical managers. We both in UK and in Italy must use the WONCA, EURACT, RCGP Definitions and Statements on Family Medicine, ask for professionalism, for using our core competences, discourage fragmentation of primary care and perverse incentives driving patient flows where costs are lower but quality not the same, and personal care not at all, ask for extending the duration and scope of vocational training so to be real specialists in a really good for patients NHS.
 
References
1. Jones R. Reforming the NHS: necessary and achievable? Br J Gen Pract 2011: 61(584): 163-164. 
2. http//www.euract.org 
3. Department of Health. Liberating the NH: developing the healthcare workforce. London: HMSO, 2011.
 
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Date: 25 Apr 2011
Topic: Response to letter on ‘Working with non-medical prescribers’
Comments by: Molly Courtenay, Professor, University of Surrey 
 
Rushforth argues that ‘claims about the benefits and safety of non-medical prescribing (NMP), based on some of the evidence referenced in the editorial, should be treated as probable rather than proven’.¹

 

The reference used to support statements relating to such matters as GPs confidence in nurse prescribing, the ‘freeing up’ of GPs’ time by nurse prescribing, and non-medical prescribers (NMP) staying within their area of competence, is a paper that reports on a subset of data that formed part of a national study. Although the study did involve interviews with 12 doctors, it also comprised data from interviews with an additional 32 healthcare professionals, 165/200 patient questionnaires, and 40 videotaped observations of nurse prescriber consultations.² The triangulation of methods and data sources therefore strengthens this evidence with regards to the benefits of NMP in dermatology. More recent research examining patient views of nurse prescribing adds further support for these benefits.³  The supporting reference for the assertion that nurse prescribing is safe was based on a review of 25 nurse and midwife prescribers. However, importantly, these researchers⁴ audited the records of 142 patients for which over 200 items were prescribed.

 

Anxieties held by doctors about NMP surround nurses’ clinical skills and the fear that they will prescribe outside of their area of competence. Unlike doctors, who are able to prescribe once they have completed their undergraduate medical education, nurses must have at least 3 years’ experience as a qualified nurse and must also have successfully completed a rigorous 6 month training programme enabling them to prescribe. This is an important difference. Most nurse prescribers have 10 years’ qualified experience and nearly all have gained specialist qualifications at degree or masters level during this period. Prescribing would, therefore, seem to be an appropriate use of this wealth of knowledge and experience. Indeed, doctors and nurses in general practice report⁵ nurse prescribing to be a ‘superior and safer’ arrangement than for a nurse to be ‘prescribing by proxy’ (i.e. obtaining a doctors signature for a prescription initiated by a nurse), thus reducing the potential for error and improving lines of responsibility.
 
References
1. Rushforth B. Working with non-medical prescribers. Br J Gen Pract 2011; 61(587): 380.
2. Courtenay M, Carey N, Stenner K. Nurse prescriber-patient consultations: A case study in dermatology. J Adv Nurs 2009; 65(6): 1207–1217.
3. Courtenay, M, Carey N, Stenner K, et al. Patients’ views of nurse prescribing: effects on care, concordance and medicine taking. Br J Dermatol 2011; 164(2): 396–401.
4. Drennan J, Naughton C, Allen D, et al. National Independent Evaluation of the Nurse and Midwife Prescribing Initiative. Dublin: University College Dublin, 2009.
5. Courtenay M, Stenner K, Carey N. An exploration of the practices of nurse prescribers who care for people with diabetes: a case study. J Health and Chronic Illness 2009; 1: 311–320.

 

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Date: 25 Apr 2011
Topic: Response to 'Placebo interventions in practice'
Comments by: David Church, GP, Powys

 

This article and the decision to publish it suffers from a severe error in translation.¹ I do not know what the Swiss word for 'placebo' is, but I do know the meaning of 'placebo' when used in an English-language context, and the meaning the authors attempt to attribute in their article is completely wrong.

 

A placebo is a completely inactive treatment, be it pill or procedure, believed by doctors and patients alike to have no beneficial effects whatsoever, and hopefully no harmful ones either. It is used to introduce blinding to studies as to whether participants have received the potentially active treatment under investigation or none. Examples of relatively pure placebos are 'sugar pills' and 'sham acupuncture', though both are agreed to have some possible effects: sugar is known to have some sort of reassuring and calming effect if placed on babies' tongues, and sham acupuncture involves time with practitioner which interaction may affect the illness. This use of placebos involves no 'deceit' at all, and both participants and observers are blinded, but know that there is a chance (usually 50:50) they will receive either active treatment or 'fake'. It is used to be able to compare the real effect of drug versus no drug without introducing bias in those who know they have, or have not, received the potentially better treatment.

 

This is the understanding of 'placebo' that prevails among a sample of my colleagues in Britain, and also among the majority of local patients.

 

What the article seems to want to talk about are 'alternative' treatments and drugs with no proven or provable efficacy. Unfortunately, there is some tendency to lump together drugs of vegetable origin and known efficacy, of various strengths of efficacy, with 'herbal' drugs (meaning uncertain), 'non-specific' drugs with undisclosable mode of action, homoeopathic drugs, and a vague group of other things.

 

For a doctor to give a patient something they believe has no value, but to say, in any way (and I found the consideration of how it might be said interesting), that it is of value, is a deceit, from which we should shy away quite honestly.
I have a feeling there might be some useful discussion hidden in this paper somewhere, but sadly the translation problems between language and culture are currently hiding it from view.

Reference
1. Fässler M, Gnädinger M, Rosemann T, Biller-Andorno N. Placebo interventions in practice: a questionnaire survey on the attitudes of patients and physicians. Br J Gen Pract 2011; 61(583): 101­–107.  

 

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Date: 13 Apr 2011
Topic: Response to ‘Primary excision of cutaneous melanoma: does the location of excision matter’
Comments by: Kavit Amin, Sheffield

 

We read with interest the article on primary excision of melanoma by GP’s.¹ There is conflicting evidence between different studies assessing the adequacy of biopsies and recognition of malignant skin lesions in primary and secondary care. However, most of these studies often have differing time spans, population numbers, with groups of patients cared for within local populations. If a national study were to be conducted, it would be of interest to include, not only the specialty performing biopsies, but also the seniority of clinician and the amount of training received.

 

Speaking from personal experience as a surgical trainee, most junior trainees perform ‘one stop’ excisions of suspicious lesions in secondary care once identified by a clinician of seniority. Initially, trainees are observed until they are deemed competent to perform excisions independently. At a large tertiary hospital I have recently worked at, histopathologists not content with biopsies feed back to the multidisciplinary team of dermatologists and surgeons. This is then relayed to the GP practice, in the form of a written letter. This real time feedback has proved beneficial for GPs and they have frequently remarked on the benefits of such feedback.

 

The most important factor to consider at present is recognition of abnormal skin lesions. Training could take the form of skin cancer workshops implemented at GP practices by skin cancer specialists from secondary care. Goulart et al identify that GPs and dermatologists should work together. Some have already eluded to the notion that there is limited training in dermatology at medical school. Furthermore, GPs are eager to develop these skills. Standardised quality training sessions are required that are examined.  Areas that need more emphasis include dermoscopy, the use of feedback, interactive components, and web-based strategies on a national level. The potential increase in the incidence of melanoma and non-melanoma skin cancers signifies that GPs will have an imperative role in the recognition of melanoma in the future.² If GPs are willing to learn and wish to undertake the workload, dermatologists may not be able to uphold independently in years to come, we should help develop these skill beginning with recognition, followed by training in removal of skin lesions at a later date.
 
References
1. Murchie P, Sinclair E, Lee AJ. Primary excision of cutaneous melanoma: does the location of excision matter. Br J Gen Pract 2011; 61(583): 131-134.
2. Goulart JM, Quigley EA, Dusza S, et al. Skin cancer education for primary care physicians: a systematic review of published evaluated interventions. J Gen Intern Med 2011; [Epub ahead of print]

 

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Date: 7 Apr 2011
Topic: Subdermal contraceptive implant loss
Comments by: Sheila Pennington, GP, Hall Green Health, Birmingham, UK;
Kerry Walsh, GP Registrar, Hall Green Health, Birmingham, UK
 
The numbers of prescriptions for contraceptive implants are steadily increasing. The upward trend is in line with the shift to LARC methods anticipated in the NICE guidance.¹ A contraceptive subdermal implant can be fitted in general practice, but the cost of supplying the implant is not re-claimable from the Prescription Pricing Authority. Each patient requesting an implant has to be given an advance prescription of an implant, obtain it from a pharmacy, and bring it to be fitted.
        
Our general practice has 24,000 patients. We had fitted 187 implants in 11 years: 21 before 2007, 25 in 2007, 30 in 2008, 42 in 2009, and 68 in 2010. However, 232 patients had been prescribed an implant. There were 48 prescriptions for implants with no record of fitting in the practice.
 
Inspection of the notes revealed evidence that three patients had taken their implants to Family Planning Clinics to be fitted and three patients had handed in unwanted implant. One patient had stated that she has collected an implant but could not find it at home.
 
Letters were sent to the remaining current patients who had received a prescription but not had a fitting (31 letters sent): 10 patients had left the practice; 21 patients did not respond to this letter. Nine patients responded as follows. Four patients had their implant fitted by a GP or elsewhere; two patients returned their prescriptions to the surgery; one patient said that no prescription had been issued; one patient informed us that she has not cashed her prescription; and one patient returned an implant. Therefore 30 prescriptions were unaccounted for and one known to be lost.
 
An implant currently costs £79.42. The potential loss of 31 implants has been £2462.02 plus dispensing fees.
 
The potential loss to the NHS is considerable and could be addressed by making it possible to re-claim the cost of supplying implants from the Prescription Pricing Authority.
 
Reference
1. NICE implementation uptake report: long acting reversible contraception. NICE clinical guideline 30.
 

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Date: 20 Mar 2011
Topic: Response to ‘The UK's dysfunctional relationship with medical migrants’
Comments by: Nonyelum Agomo
 
I just wanted to congratulate Drs Simpson and Esmail on their excellent article on the UK's dysfunctional relationship with medical migrants.¹ As a British-born Nigerian, who trained abroad and has sometimes been at the receiving end of being looked down on as inferior to local graduates, I could not agree more with the many points they raised in their article. I hope that this will prompt a healthy debate on the role of overseas graduates and appreciate the role they play.
 
My only disappointment is that, with the article being buried in the middle of the journal, I may have missed a great read had it not been for me being at the end of a long queue.
 
Reference
1. Simpson J, Esmail A. The UK's dysfunctional relationship with medical migrants: the Daniel Ubani case and reform of out-of-hours services. Br J Gen Pract 2011; 61(584): 208-211.

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Date: 16 Mar 2011
Topic: Response to “Which early ‘red flag' symptoms identify children with meningococcal disease in primary care”
Comments by: Gavin Young
 
I think this is a superb paper¹ - an excellent example of really helpful primary care research. I have one query: I recognise the importance of confusion, but wonder how useful this is. We know that by the time the purpuric rash appears often irreparable harm has also occurred. Do we know whether the same applies to confusion?
 
Reference
1. Haj-Hassan TA, Thompson M, Mayon-White R, et al. Which early ‘red flag' symptoms identify children with meningococcal disease in primary care? Br J Gen Pract 2011; 61(584): e97-e104. DOI: 10.3399/bjgp11X561131.
 

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Date: 3 Mar 2011

Topic: Sustainable medicine and radiologic risk 
Comments by: Francesco Carelli, EURACT Council Director of Communications, International Ambassador of Association Health Care Professionals, University of Milan

At the Annual Conference by RCGP run under the banner of  'Sustainable Primary Care', Trevor Thompson and Tim Ballard underlined that family doctors can push for virtuous cycles.¹ By walking and cycling instead of driving or by eating mainly plant-based food, we do as family doctors our duties for medical education as EURACT core competence towards community² and we increase chances for health and sustainability.

 

As GPs we are valued and trusted as focal points in the community and as advocates for our patients, so we could and should be effective in every side for health. For example, we know that medical diagnostic radiation with x and gamma rays in radiology and nuclear medicine is a proven class I carcinogen, even at the lowest doses; that the level of this exposure is continuously rising and totals the dose equivalent to at least 100 chest x-rays per person per year in industrialized countries; we know that this level of exposure corresponds to an attributable extra-risk of cancer of at least 2% in the general population.³

 

Also, we face with the increasing availability and increasingly inappropriate rate of use (in at least 30% all cases) of imaging tests, also appreciating use of those test modalities with highest radiological dose exposure (such as scintigraphy, TC-PET, or Multislice Computed Tomography).

 

The European Commission⁴ suggests a minimization of the use of ionizing radiation technologies, whenever the information can be obtained by careful clinical evaluation and/or by alternative non-ionizing techniques.

 

On the other side, defensive medicine, demand from patients, and marketing messages encourage increased use of diagnostic methods with high biological risk (chest MSCT, CT-PET, virtual colonoscopy, etc) particularly for mass screening, in the absence.^5,6

 

As family doctors we have to call on Governments and all relevant authorities, for health as well as for sound social, economic and scientific reasons, to:

• Reinforce in medical practice the guidelines on medical imaging of the European Commission;
• Introduce stringent quality control of imaging prescription, starting in clinical areas (such as pediatrics and obstetrics) with higher biological impact (and downstream costs) of radiation-induced damage;
• Promote adequate information campaigns to the public, warning of the risks and damage of inappropriately requested examinations: this could be managed at the best in the primary care setting as a community context (core competence in EURACT European Definition and Educational Agenda and Performance Agenda⁷) most oriented for patients' relationships and health campaigns and local political game;
• Audit for inappropriate and unjustified use of imaging testing, including for research purposes.

 

References
1. Thompson T, Ballard T. Sustainable medicine: good for the environment, good for people. Br J Gen Pract 2011; 61(582): 3-4.
2. WONCA European Definition http://www.euract.org/ ( accessed 22 Jan 2011)
3. Picano E. Sustainability of medical imaging. BMJ. 2004; 328:578-80.
4. European Commission Referral Guidelines for imaging. Rad Protect 2001; 118: 1-125. Available at: http://europa.eu.int/comm/environment/radprot/118/rp-118-en.pdf (accessed 22 Jan 2011)
5. FDA Warning. Center for Devices and Radiological Health. Public health notification: reducing radiation risk from computed tomography for pediatric and small adult patients (2 Nov 2001). Available at: www.fda.gov/cdrh/safety.html (accessed 02 Jan 2011).
6. International Commission on Radiological Protection 2007. Recommendations on the protection of man and the environment against ionising radiation. http://www.icrp.org/ (accessed 22 Jan 2011 )
7. EURACT Educational Agenda. http://www.euract.org/ (accessed 22 Jan .2011 )

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Date: 23 Feb 2011
Topic: Response to: ‘The primary care electronic health record: who's righting the software?’
Comments by: Dr Paul Rasdale
        
I am extremely grateful to Wilfrid Treasure for his article.¹ My practice has only changed to Vision in the last few weeks and it has been one of the most stressful events of my professional career. The need to adapt to a new system gives the opportunity to question why things are designed as they are. Unfortunately, pointing out deficiencies tends to be met with fairly standard responses like ‘it's a steep learning curve’ or ‘you will soon get used it’. While both of these statements are undoubtedly true, they are not usually accompanied by any great willingness to admit to deficiencies in the software design or any offer to explore IT fixes. The assumption is the doctors, nurses, and staff will just adapt to the new systems no matter how labour intensive or divorced from clinical benefit. I wholeheartedly agree with Dr Treasure's sentiment that EHRs need to be designed with more regard to clinical utility at the coal face as opposed to data collection and retrieval. 
        
Reference
1. Treasure W. The primary care electronic health record: who's righting the software? Br J Gen Pract 2011; 61(583): 152–154.

 

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Date: 19 Feb 2011
Topic: Response to “‘They won't do any harm and might do some good': time to think again on the use of antidepressants?”
Comments by: Dr Royse Murphy
        
The article ‘They won't do any harm and might do some good…'¹ raises a number of challenging points. Are antidepressants used for community depression no better than placebo? Do GPs over-prescribe? Are there alternative or better treatments?
 
I believe that a balanced use of anti-depressants, referral for counselling, and GP support works. I use psychiatric services for resistant depression and where my assessment indicates a significant self-harm risk. I use the PHQ-9 but also a checklist of depression symptoms; and it is interesting that symptoms vary considerably from published list to list and that men typically present differently (impulsive, angry or irritable, self esteem defended, increased sexuality) to women (tearful, withdrawn, expressing low self esteem, reduced sexuality), with due regard to an overlapping gender spectrum.
 
The first consultation is inevitably longer than the appointment time allows but subsequent GP support, explanation, and shared 'social' and work planning is essential and doesn't need to be time-consuming. Patients' health models often guide me on likelihood of compliance with medication, but I have two tests which should answer positive before prescribing: 'Does the patient have a clinical depression?' (A sustained low mood impacting significantly on their life, and low self esteem which severely affects their perceptions of this) and 'Are they stuck or about to get stuck?' (Most patients understand exactly what is meant by this question). If one of these answers is negative then they may need support or counselling but antidepressants may not make a difference and could cause harm.
 
Placebo is fascinating and under-researched. I strongly believe (and there is strong evidence) that if a GP can work well with a patient within their health model both natural healing and the positive outcomes of interventions are maximised. Therefore I continue to see patients with depression at monthly intervals for a limited period of time for review and encouragement; and disengagement is part of building patient self-reliance. Improvement is always indicated by the patient spontaneously referring to the depression in past terms. I occasionally use some limited brief counselling techniques and psychological models such as Transactional Analysis.
 
Is it a good use of GP time? Perhaps patients perceive us to be their best option in a crisis, and we can make an essential difference at a critical time in their lives. Having a clear strategy helps to make this more efficient and more effective.
 
Reference
1. Middleton H, Moncrieff J. ‘They won't do any harm and might do some good': time to think again on the use of antidepressants? Br J Gen Pract 2011; 61(582): 47-49.
 

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Date: 9 Feb 2011
Topic: Skin malignancy in primary care
Comments by: Mark Shapley
        
Family doctors need to adopt a problem-based approach rather than a disease-based approach to consultations¹ and while this does not differentiate between generalists and specialists it does indicate the point at which each starts from.
 
The NICE guidance on cancer services to improve outcomes for patients with skin cancer takes a disease-based approach.² Those clinicians that sat on the guideline development group tended to have a secondary care background. Controversy has surrounded the guidelines since publication. The update on basal cell carcinoma (BCC)³ readdressed the balance and admitted that ‘there was no high-quality evidence comparing the management of BCC by GPs working in the community with specialists in secondary care’. If this is true for BCCs it is true for malignant melanomas.
 
The difficulty with cancer research in primary care is that the disease is rare and therefore studies suffer from using secondary outcomes and old data. Selection bias is always a serious issue. 

Talking to primary care colleagues now reveals a fear of minor surgery in case a malignant melanoma (or other cancer) is removed. There is also disinclination to full disclosure of differential diagnosis on pathology request cards in case it is interpreted that the GP ‘suspected’ a cancer. Recently, the structured correspondence from multidisciplinary meetings in the West Midlands on patients with malignant melanoma or squamous cell carcinoma who have had the primary excision in general practice have had a standard message appended that the GP should not have removed the lesion. This is without full knowledge of what took place during the primary care consultation.
 
Primary care needs a problem-based approach and an estimate of the likelihood of malignancy. All lesions have a possibility of malignancy and if this was not so then there would be no insistence that all excised lesions are sent for histological analysis. A dermatologist is not equivalent to histological analysis as the research that does exist shows that even specialists get it wrong.
 
The excision of lesions should be about an assessment of the probability of malignancy and an admission that there is always diagnostic doubt. If suspicion is high then referral to specialist care is indicated, if it is low then primary care excision is appropriate, if it is negligible then no further action should be invoked. These lines of management should be taken with the informed consent of the patient and appropriate safety netting. A difficulty comes in defining the numerical probabilities of high, low, and negligible but these may vary with the ideas, concerns, expectation, beliefs and values of the patient.
 
Why didn’t NICE just stick to the phrase ‘a GP should not knowingly remove a malignant melanoma’?
 
The paper by Murchie⁴ is reassuring to those of us in general practice who still do minor surgery. The conclusion of Purdy and de Berker⁵ is also true in that there is insufficient evidence to justify changing National guidelines. If only it was only strong evidence that built guidelines. The base of guidance is evidence but the super-structure opinion.

 

References
1. http://www.rcgp-curriculum.org.uk/PDF/curr_1_Curriculum_Statement_Being_a_GP.pdf
2. http://www.nice.org.uk/nicemedia/live/10901/28906/28906.pdf
3. http://www.nice.org.uk/nicemedia/live/10901/48878/48878.pdf
4. Murchie P, Sinclair E, Lee AJ. Primary excision of cutaneous melanoma: does the location of excision matter. Br J Gen Pract 2011; 61(583): 131-134.
5. Purdy S, de Berker D. To excise or not to excise? Should GPs remove possible melanomas? Br J Gen Pract 2011; 61(583): 87-88.

 

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Date: 31 Jan 2011

Topic: Response to ‘GPs at the deep end'

Comments by: Roderick Shaw, Stockbridge Health Centre, Edinburgh

 

As a GP undoubtedly working in the ‘paddling pool’ with regard to deprivation, I was intrigued by Graham Watt’s articles^1,2 and would agree with much that he says. Nonetheless, I would question his statement that affluent patients ‘present less complex burdens of need’. Indeed, we are often told by various different health professionals how difficult and complex our patients are to manage compared to those from less privileged backgrounds. Unfortunately, a reduction in the ‘prevalence of health problems’ is not necessarily associated with a reduction in the complexity of the patients’ perception of need. That ‘explanations may take longer due to problems in health literacy’ is also debatable. I wonder how many of his patients present having studied the minutiae of the PIL from their latest prescription?

　

References

1. Watt G. GPs at the deep end. Br J Gen Pract 2011; 61(582): 66–67.

2. Watt G. Patient encounters in very deprived areas. Br J Gen Pract 2011; 61(583): 146.

 

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Date: 31 Jan 2011

Topic: David Cameron’s letter on ‘myth busting’

Comments by: Tom Kirk

 

David Cameron’s "Myth Busting" letter to the UK medical profession was patronising and clumsy. Instead of acknowledging the issues and problems with his rushed plan on a level basis, he seeks to instruct us where we are wrong. Andrew Lansley had been doing a reasonable job of appearing to engage with the constructive criticism of the proposed changes in the government white paper. However, David Cameron’s letter exposes the arrogance of the current Government, and a deep rooted inability to accept criticism and adjust accordingly.

 

The medical profession and its representative bodies have so far used a policy of constructive engagement, seeking to ameliorate the worst in the coming changes. This policy has now been shown to be unproductive. It is clear from this letter than the Government is pressing ahead with the changes regardless of the problems highlighted. The Government has made a show of consulting with the profession, but has not listened to the results. If it had, it would be rethinking the changes.

 

As the 2010 Commonwealth Fund update recently stated, the system David Cameron labels as "unsustainable" is currently the most cost effective and efficient health system of the all the countries reviewed. By putting incentives for GPs to delay referrals, and deny high cost drugs, he will worsen patient care, and tarnish that doctor patient relationship with mistrust over motives. We must not let the Government’s ideologically driven changes divide patients from doctors, and GPs from consultants.

 

Myth 1 – NHS is fine as it is

David Cameron says Change is necessary.

This is a statement of fact, but not an indication of the needed direction of change. To state that change is necessary in health care is stating the blinding obvious – it is probably one of the fastest changing industries around. However, this is not an excuse to rush through untried ideologically based ideas. The phrase "despite spending the European average on health, some of the outcomes are poor in comparison" is deliberately misleading. Yes, levels reached in spending do hit the enlarged EU average, and yes we are not top of the league table for all outcome data (though we are top, or near top for a fair few). But here is a list of countries which spend more than the UK (8.7) as a percentage of GDP on health.¹

• France 11.2
• Switzerland, Austria Germany -c 10.2
• Belgium Portugal Denmark Greece -c 9.7
• Iceland, Netherlands, Spain, Sweden - c 9.1

 

Myth 2 – Plans out of blue

David Cameron says Plans not out of the blue.

All David offers here is "I disagree", followed by comparisons to failed fundholding, and commissioning under the labour government, glossing over the largest ever change to the structure of the NHS, and abolition of most of the management structure. He states "our plans simple build on these advances" – yes in the same that Marxism simple builds on the idea that sharing is good.

 

Myth 3 – That the plans are untested and implemented too fast

David says that things aren’t untested and too fast.

David’s argument here is that the changes will happen two years in the future– on the assumption that two years is clearly enough time completely reorganise the entire. He glosses over the fact that there are no significant trials of this system that show its works, no evidence to back up the changes. In the process he making a mockery of the carefully built evidence base that has been assembled, and is completely giving up on the noble ideas of evidenced based policy – returning the NHS to a political football.

 

Myth 4 – GPs will spend all their time on paperwork

David says – not true.

GPs will be apparently given extra resources to cover this part of the job. The idea here is that the money saved by axing PCTs and SHAs will be used to pay for this extra resource. A recent analysis that stated that it will actually cost money to axe the PCTs. The response by Walsh published suggested that the cost of reorganisation will cost 2-3 billion, and that even if the savings come in as planned, which is unlikely, we will still be spending more money than saving this parliament.²

 

Myth 5 – that GPs will be forced to work with Private health sector companies to help them with commissioning

David says – nothing could be further from the truth

I believe him on this. GPs won’t be forced to work with private companies. They won’t have to be forced. With PCT’s and SHA’s gone, there won’t be anyone else but private companies. Thus, no forcing from government is required, as the practicalities and the situation they have created will do it for them.

 

Of interest are a number of things NOT mentioned in the letter.

What happens when GP consortia fail? This is bound to happen as whichever formulas they use to work out budgets, some area will have a natural deficit. On top of this some areas will inherit deficits that may make budgets unworkable.

Answer is – they will taken over as failing consortia by Private health companies

What happens to training, when all easy and profitable routine work is contracted out to private companies?

Training will worsen, doctors will become under skilled and patients will lose out.

What happens to NHS hospitals and departments if they are out bid by private providers?

Answer is – They will close, and give a nearly complete local monopoly to the private provider.

 

References

1. OECD http://www.oecdilibrary.org/docserver/download/fulltext/8110161ec043.pdf?expires=1296126278&id=0000&accname=guest&checksum=BFD1EFB7BFF32D290EA1499234004E74

2. BMJ 2010; 341:c3843 Reorganisation of the NHS in England http://www.bmj.com/content/341/bmj.c3843.full <http://webapp.doctors.org.uk/Redirect/www.bmj.com/content/341/bmj.c3843.full>

 

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Date: 13 Jan 2011

Topic: Response to 'Our first experience of an ethics committee'
Comments by: Dr John O'Malley
 
I was saddned to read this encounter with a local ethics committee. Having been a member of one, I would like to add some observations. First of all, these committees are not 'rubber stampers' and they exist to protect patients. If this is the first time the student concerned has been at a meeting that is overrunning, welcome to my world! Waiting 40 minutes is wrong but often such meetings raise issues that have been noted before and they must be attended to.

 

The 'eleven grim faces' may well have endured 3 hours of a meeting and I must admit to being shocked when I encountered my first 4 hour meeting. I am astounded to read that the student felt his academic career should be commented on. Does that mean we should just forget the meeting and take the proposer at their word? Such meetings have often have world authorities in front of them and we do not go about flattering them on their works but deal with their proposals with even-handed rigour.

 

A factual point; ethics committes do not put a proposer under a barrage of questions from committee members and most direct them through the chairman who collates them before the meeting with the proposer.

Research is a serious business and can often have harmful consequences. Such ethics committees are there to raise the standard of proposals not to stifle them, and I see no reduction in submissions since their inception. 

 

Reference

1. Sandhu J, Khan N. Our first experience of an ethics committee: entering the Dragon's Den. Br J Gen Pract 2011;  61(582): 70.

 

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Date: 12 Jan 2011

Topic: Response to ‘Deprived areas: deprived of training?’

Comments by: Wesley Martin, Riverside Medical Practice, Patna

 

Many thanks to Mark Russell and Murray Lough for their article.¹ Geographical issues are also important as is trainee ranking at selection. I have been involved in training for 23 years. I work in Ayrshire and live about a mile outside my practice area. Most Ayrshire trainees live in Glasgow, 37 miles away, travelling every day despite having a four-year placement in Ayrshire practices and local hospitals. In ST3, maternity leave is increasingly difficult to arrange placements for, especially where trainees who return less than full time find that their travelling time is approaching their time in the practice and not unreasonably want a post nearer home, meaning that we lose those trainees permanently from early in ST3. Not unreasonable but why is this unpredictable?

 

Post selection ranking means effectively that rural and deprived areas are selected against, the practice they are placed with being effectively a record of their ranking. I accept there are notable exceptions. Deprived and especially more rural deprived training practices will not get, or will ‘lose’ trainees thereby sustaining a loss of income and experience in a very rapidly changing environment. I predict in 5–10 years time a considerably larger inverse correlation than now between being a training practice and deprivation score, when our endangered status approaches extinction.

 

I see my role as equipping trainees to be able to work anywhere, in or out of hours, and have a high production capacity which I hope they never need to or want to reach. Is it unreasonable after a four-year attachment to a practice to expect that a trainee may know more about the people and the area than the fastest way home?

　

Reference

1. Russell M, Lough M. Deprived areas: deprived of training? Br J Gen Pract 2010; 60(580): 846-848.

 

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Date: 12 Jan 2011

Topic: Response to '"They won't do any harm and might do some good": time to think again on the use of antidepressants?'

Comments by: John Nichols

Middleton and Moncrieff¹ make a good case for being cautious about prescribing antidepressants in primary care.  The discussion is, however, somewhat one sided. The responsible GP will be aware that there is always a suicide risk if a severely depressed patient is sent away without an antidepressant. Being on the waiting list for CBT will not necessarily prevent suicide. Patients who commit suicide have a low concentration of serotonin in the brain.² An experienced GP will also know of patients who have been symptom free on  antidepressants who experience breakthrough symptoms when they try to wean themselves off the drug.

 

The old RCGP dictum that every diagnosis should have a physical, social, and psychological component is especially relevant to treatment of depression. The physical component must surely be serotonin deficiency in many cases but it would be wrong to treat this deficiency and ignore the psychological and social components which might be more important.

 

Recent evidence suggests a link between the physical component of depression and nutritional deficiencies.^3-5 The evidence for omega-3 and antidepressants working synergistically is especially convincing.⁶ Recently, when a patient reported breakthrough depression symptoms, I doubled her SRRI dose and added an OTC high dose omega-3. At follow up, she told me: 'I feel normal for the first time in over 3 years'. Could this be just a placebo effect?

 

References

1. Middleton H, Moncrieff J. `They won't do any harm and might do some good': time to think again on the use of antidepressants? Br J Gen Pract 2011;  61(582): 47-49.

2. Gross-Isseroff R, Israeli M. Biegon A (1989). Autoradiographic analysis of tritiated imipramine binding in the human brain post mortem: effects of suicide. Archives of General Psychiatry;46(3):237-41.
3. A Report from The Mental Health Foundation (2006). Feeding Minds - the impact of food on mental health.
4. Polivy J. Herman CP (2005). Mental health and eating behaviours: a bi-directional relation [Review]. Canadian Journal of Public Health. Revue Canadienne de Sante Publique;96(S3):S43-6, S49-53.
5. Hallahan B. Hibbeln JR. Davis JM. Garland MR (2007). Omega-3 fatty acid supplementation in patients with recurrent self-harm. Single-centre double-blind randomised controlled trial. British Journal of Psychiatry;190:118-22.
6. Jazayeri S, Tehrani-Doost M, Keshavarz SA, Hosseini M, Djazayery A, Amini H, Jalali M, Peet M (2008). Comparison of therapeutic effects of omega-3 fatty acid eicosapentaenoic acid and fluoxetine, separately and in combination, in major depressive disorder. Australian & New Zealand Journal of Psychiatry;42 (3): 192-8.  

 

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Date: 6 Jan 2011
Topic: Response to ‘Selecting GP specialty trainees: squaring the circle?’¹
Comments by: Terry Kemple

 

The main concerns of a speciality training programme must be to ensure it selects and trains GPs who are competent and motivated to care for their patients, produce enough of these GPs to meet the needs of the country, and to be economic with its use of state funding. Other concerns about the needs of doctors who are ‘weaker candidates’, ‘trainees with greatest need’, and ‘lost tribes’ of doctors who are outside training programmes are real but less important. The 2005 reforms (Modernising Medical Careers) were intended to ‘improve patient care by improving medical education with a transparent and efficient career path for doctors’.²

 

We need to continue to improve our speciality-training programme using quality improvement principles. These suggest that we should ask and answer the following five questions before we embark on any change:

1. What are we trying to achieve?
2. What do we know about this subject already?
3. How will we measure our success?
4. What can we actually achieve with the available resources?
5. How and when will we review this process?

 

Andrew Perrin sums up the reality of improvement when he was recently quoted in the New York Times talking about how his university plans to reverse grade inflation and make grades more meaningful: ‘It’s going to be modest and nowhere near enough to correct the problems … But it’s our judgment that it’s the best we can do now’.³

 

References
1. Kemple T. Selecting GP specialty trainees: squaring the circle? Br J Gen Pract 2011; 61(582): 61-62.
2. Modernising Medical Careers. http://web.archive.org/web/20080616044743/http://www.mmc.nhs.uk/default.aspx?page=310
3. Perrin A. A quest to explain what grades really mean. The New York Times 2010; A18. http://www.nytimes.com/2010/12/26/education/26grades.html (accessed 18 Jan 2011).

 

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Date: 4 Jan 2011
Topic: How commissioning may further deprive the deprived
Comments by: Mark Freeman, GP, Churchwood Medical Practice, St Leonards-on-sea, East Sussex

 

I read with interest the letter by Dr John Glasspool ‘Future recruitment of GPs to deprived areas’ in January’s issue of the BJGP.¹ As another GP serving a deprived community on the south coast, the inequalities in remuneration plus attitudes towards us from surrounding, more prosperous, areas really can grate. However, it is worth exploring what the future may hold for practices such as ours.

 

With the advent and advancement of practice-based commissioning, our performance is already being judged against our budgets. The density of disease and social burden we carry in our practice is no where near reflected in the budget setting formulae which use population data from the 1990s. Since then there has been a further polarisation in our society with those who have dropped through the net into poverty, whether by chronic disease or other social ills, being ever further concentrated into geographic areas. To meet the needs of these populations requires extra resources. This is just not being addressed by those who set the budgets. It is far easier to label those practices as over-prescribers and over-referrers when in fact they are working hard to do an extremely good job for their patients in adverse circumstances.

 

This has the potential to be a crisis in practices serving deprived areas in otherwise prosperous commissioning areas. They stand to be picked out as failing practices because they appear overspent when in fact they are doing a good job for their patients. They either will have to compromise their duties to their patients or lose the ‘budget achieving’ remuneration, which it is suggested may be as much as 20% of income. This, compounded with income figures already diverging from those luckily positioned in rural areas to receive dispensing payments, will affect morale and further increase the difficulty of recruiting and retaining GPs to work in challenging areas.

 

The level playing field of GP income devised decades ago is acquiring an ever-increasing gradient. Those accelerating downhill towards the swamp-end deserve respect for working in difficult circumstances and should not be dismissed as ‘failing practices’. There needs to be urgent action to restore that level playing field again before it is too late.

Reference
1. Glasspool J. Future recruitment of GPs to deprived areas. Br J Gen Pract 2011; 61(582): 61.

 

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Date: 2 Jan 2011
Topic: Response to ‘Selecting GP specialty trainees’
Comments by: Deborah White, GP Registrar, Stockton on Tees

 

Kemple’s analysis¹ of potential outcome measures for assessing selection into GP specialty training is apposite; however, his suggested improvement to this process is fatally flawed. Selection must be based on aptitude, not on success in aspects of the existing MRCGP examinations, which should reflect the acquisition of knowledge, skills, and attitudes during structured GP training – not before it.

 

Furthermore, offering the best of weaker candidates who did not qualify for entry into GP-training any unfilled training posts, suggests pairing the trainees with greatest need with the posts potentially least able to support them. It also risks the recreation of ‘the lost tribe’, which the recent reforms of postgraduate medical specialty training have sought to remove.

 

Irish and Patterson rightly note the lingering disquiet within the profession over the current ultra-objective selection process;² they will need to work hard to keep the profession on board in taking this selection process forward.

References
1. Kemple T. Selecting GP specialty trainees: squaring the circle? Br J Gen Pract 2011; 61(582): 61-62.
2. Irish B, Patterson F. Selecting general practice specialty trainees: where next? Br J Gen Pract 2010; 60(580): 849-852.
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