Discussion Forum

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Clinical/general

Date: 3 Jul 2008
Topic: Response to ‘Top Tips in 2 minutes: Consulting with children’
Comments by: Dr Chris Godwin, Blaina Medical Practice, Blaenau Gwent

Tim Caroe¹ in a piece on communication with children refers to a child’s mother as ‘mum’ as in “That’s fine” said mum’. Many paediatricians do the same (for example, ‘Mum says the child is better’). The immediate impression is of Dr Caroe’s or the paediatrician’s mother sitting sweetly in the corner of the consulting room giving advice to her nearly grown-up son. The second impression is of a presumptive doctor arrogantly giving a pet name to the child’s mother, who may never be referred to as ‘mum’ at home. The third is of a curmudgeonly son-of-a-camel allowing himself to be needled by trivia and writing to journals about it in metaphorical green ink.

Reference
1. Caroe T. Top Tips in 2 minutes. Br J Gen Pract 2008; 58(552): 520-521. View abstract online

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Date: 11 Jun 2008
Topic: A cautionary tale highlighting problems that can occur when prescribing analgesic patches in older people
Comments by: Mr JW Hobman, Senior House Officer Elderly Medicine, GP; Dr Ian R Craig, Consultant in Elderly Medicine, Department of Medicine for the Elderly Dewsbury District Hospital, Dewsbury

We report the case of a 79 year old lady which highlights the care required in the prescribing of analgesic patches in older people. Our patient was known to have osteoporosis and presented to her GP with increasing back pain that was unresponsive to co-codamol. In conjunction with the patient’s family a trial of buprenorphine patches was commenced. Her past history included long-term warfarin for atrial fibrillation. Because of difficulty establishing stable anticoagulation over the preceding months a 1mg/day warfarin dose with a view to achieving benefit without risk was instituted. This is an appealing theory which is however unlikely to be efficacious.¹

When her family arrived to change the patch after 3 days our patient was found non- specifically unwell. An out of hours (OOH) GP diagnosed a urinary tract infection and prescribed cephalexin. No patches were seen on the patient at the visit. When the clinical condition worsened the OOH doctor was recalled. He found an empty patch box in the bin. An ambulance was called.

In the emergency department five patches were found on the patient’s flank. These were only obvious with the patient completely undressed. The patches were removed and naloxone given. Initial progress was good. However the patient later developed new and unrelated cardiac problems from which she died 8 days after admission.

Patches are now an established method of prescribing. Without careful examination patches have the potential to remain hidden from carers and health care professionals. This is particularly important when visiting unfamiliar patients out of hours when the complete medication history may not be immediately available.

The case highlights the risks of prescribing patches particularly in patients with impaired cognition. Our patient’s cognitive impairment was relatively recent and only apparent on direct questioning. The previous problem with warfarin compliance was perhaps a subtle early sign of cognitive decline.

Analgesic patches can be useful in patients when poor compliance is an issue. Carers must be made aware that external heat sources such as heat pads and hot water bottles will increase absorption of the active ingredient. Carers must also be advised to keep the medicine out of reach of their confused dependant.

Reference
1. Stroke Prevention in Atrial Fibrillation Investigators. Adjusted-dose warfarin versus low-intensity fixed dose warfarin plus aspirin for high risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet. 1996;348: 633–638

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Date: 5 May 2008 11:56

Topic: Triage of febrile children

Comments by: Ben Essex

I think it is essential to ask if the child has been to a malaria area in the previous few weeks. There is no mention of this critical question in the paper by Monteny et al.¹ This is an important omission.

Reference
Monteny M, Berger MY, van der Wouden JC, Broekman BJ, Koes BW. Triage of febrile children at a GP cooperative: determinants of a consultation. Br J Gen Pract 2008; 58(549):242–247. View abstract online

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Date: 17 Mar 2008

Topic: Headache classification

Comments by: DP Kernick

Ninety-five per cent of headaches that we see are classified as primary, i.e. an underlying pathology cannot be demonstrated. In the April issue of the journal, Dr Jackson¹ highlights a number of important points in describing her approach to primary headache that are equally relevant to many other areas of medicine. The fundamental starting point is that when presented with the unknown, we need to make sense of the situation and act. With headache we construct a taxonomy based on clinical description and response to treatment, an exercise undertaken by committee.² As our knowledge increases, classifications change accordingly.

However, the maps we construct are only an approximation of the terrain we seek to navigate. As Dr Jackson says, there are benefits of a clear diagnosis and explanation even if the pathophysiology is inaccurate. Her important observation with which I concur is the importance of creating a story that makes sense to both physician and patient helping them to ‘go on together’.

My own perspective is that far greater insights into the pathogenesis of headache can be obtained by studying the non-linear dynamics of the underlying neural processes rather than a reductionist approach which focuses on an artificial static.³ But that’s just an alternative map that seems to make sense for me.

References

1. Jackson A. Management of headache. Br J Gen Pract 2008; 58(549): 282–283. View title page online.

2. The International Classification of Headache Disorders. 2^nd edition. Cephalalgia 2004; 24:(Suppl 1).

3. Kernick D. Migraine – new perspectives from chaos theory. Cephalalgia 2005;25: 561-566.

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Date: 14 Feb 2008 14:58
Topic: Yogurt and antibiotic-associated diarrhoea
Comments by: Jeremy Hamilton-Miller

The conclusion drawn by Conway et a¹ as a result of their recent study is: ‘Overall, this study failed to demonstrate that yogurt has any effect on antibiotic-associated diarrhoea’. I am concerned that this gives the wrong message, as readers will take this to mean that this conclusion applies to all brands of bioyoghurt, when only one brand (Yeo Valley) had been tested. It is highly likely that each different brand of yoghurt will vary, in that the precise strains of the so-called ‘probiotic’ organisms used in their manufacture are separate, distinct biological entities, each with differing properties.

Conway et al state that ‘Yoghurt is a probiotic’, citing a paper by Guarner et al²; however, the latter paper refers specifically to ordinary yoghurt (made using Lactobacillus delbrueckii subsp. bulgaricus and Streptococcus thermophilus) and not bioyoghurt, in respect to its ability to relieve lactose intolerance. A product cannot be assumed to be a probiotic unless and until the specific strains therein have been shown to exert a health benefit in humans, in order to fulfil the generally accepted definition. Some bioyoghurts do fulfil these criteria.

Conway et al do not tell readers the precise strains present in the Yeo Valley product tested here, merely that they belong to the species Lactobacillus acidophilus and Bifidobacterium animalis subsp lactis. There are thousands of different strains within these two species, each of which is different; only a very few strains will have been shown to possess probiotic properties. I have been informed by Neil Lewis of Yeo Valley that these strains are, respectively, LA5 and BB12, both of which are well-known. Unfortunately, most suppliers of probiotics, whether in the form of yoghurts or supplements, give no information on the label as to either the precise strains present or any indication of numbers of viable bacteria present in their marketed products. These two factors – lack of precise strain identification and no information as to bacterial numbers – thus make it impossible for the consumer or the practitioner to make an informed choice.

The question also arises as to which antibiotics were taken in the three groups. Different antibiotics vary in their propensity to cause diarrhoea – for example, trimethoprim is rarely responsible for this, while the incidence for cefixime may be as high as 30%.

References
1. Conway S, Hart A, Clark A, Harvey I. Does eating yogurt prevent antibiotic-associated diarrhoea? A placebo-controlled randomised controlled trial in general practice. Br J Gen Pract 2007; 57(545): 953-959. View abstract online

2. Guarner F, Perdigon G, Corthier G et al. Should yoghurt cultures be considered probiotic? Br J Nutr 2005; 93: 783-786.

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Date: 2 Feb 2008
Topic: Easing the pain: challenges and opportunities in headache management
Comments by: Ian K Campbell

What a missed opportunity! In his otherwise balanced editorial, Dr David Watson¹ fails to mention several of the most common causes of headache seen in general practice: (1) chronic mild unrecognised dehydration, (how any of us drink enough?); (2) caffeine excess in one form or another; and (3) referred pain from musculo-skeletal trigger points over one or both occipital processes (acupuncture points GB 20-ALWAYS examine these areas!)

As Dr Watson suggests, tension headaches form a significant percentage of generalised headaches; in my experience also, sinus pain is over-diagnosed, as is headache due to refractive error!

Reference
1. Watson DPB. Easing the pain: challenges and opportunities in headache management. Br J Gen Pract 2008; 58 (547): 77-78. View title page online

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Date: 26 Jan 2008
Topic: Management of ear wax in primary care
Comments by: Matthew Weller, SpR ENT, Heart of England Foundation Trust, Birmingham

As a specialist registrar in ENT surgery, I read with interest the recent article by Coppin et al on the management of earwax in primary care.¹ It would certainly seem from this randomised controlled trial that the use of a bulb syringe as a first line treatment for patients at home would be a suitable alternative to formal ear syringing. If problems were to persist, then syringing could be considered as a second line of treatment. It should be noted as well that the most important endpoint would be the alleviation of symptoms, rather than complete clearance of wax from the ear canal. Wax in the ear canal is a normal occurrence, and does not need removing unless the patient is symptomatic, or examination of the tympanic membrane is required.

I do have a couple of points to raise. Firstly, the paper states that it is not known which wax softening drops are most effective, and references a systematic review published in the BJGP in 2004. In these days of evidence-based medicine, systematic reviews are the gold standard in assessing the available literature on a subject. The Cochrane database provides rigorous assessment of the current literature, and the Cochrane review of cerumen softening agents published in 2003 concluded that use of wax softening agents was more effective than no treatment, but that there was no significant difference in the different types of over-the-counter softening agents.² Based on current evidence the use of water as a softening agent would be as effective, but cheaper, than sodium bicarbonate.

Secondly, the study concludes that patient satisfaction was slightly lower in the group using the bulb compared with the irrigation group. I would suggest that the satisfaction of the bulb group would increase if this treatment were available as an over-the-counter option at the pharmacy, thus removing the need for a visit to the GP. This could bring the level of patient satisfaction in line with the satisfaction of those undergoing formal irrigation.

References

1. Coppin R, Wicke D, Little P. Managing earwax in primary care: efficacy of self-treatment using a bulb syringe. Br J Gen Pract 2008; 58 (546): 44-49. View abstract online

2. Burton MJ, Doree CJ. Ear drops for the removal of ear wax. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD004326. DOI: 10.1002/14651858.CD004326

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Date: Jan 2008
Topic: Forge water, folklore, and warts
Comments by: D Deeny

I note, from reading both local and international medical journals, that there is no evidence that current treatment of cutaneous warts is effective^{1, 2} This is particularly true for the use of liquid nitrogen.

I have been in general practice for 15 years. I can only concur with the evidence. I have spent money buying liquid nitrogen equipment and getting supplies of it delivered. I have not found it of much use when treating cutaneous warts.

Forge water, the water the blacksmith uses to cool hot irons, has being used by the Irish as a ‘wart cure’ for centuries.^3-5 As a boy, I remember dipping my hands in forge water; my warts went without trace, within weeks. I had multiple hand warts for 3 years, several treatments had been tried, to no avail, from surgery to salicylic acid pastes.

There is a Farrier School in Kildare Town. The organiser of this school allowed me access to their forge water. Recently, five patients used the forge water. In four out of five patients, all their warts disappeared with 3 months, including a 4-year-old with 15 hand warts! Needless to say they were pleased with the results, as some had many warts for years. Forge water treatment was painless and a non destructive treatment for their warts. It worked for both plantar and hand warts.

It may be that water, high in iron concentration, is effective. Who knows?, there maybe science in the myth. If forge water is truly effective, GPs can use their expensive liquid nitrogen containers to store blacksmiths’ ‘Wart Cure’!

References
1. Gibbs S, Harvey I. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2006, 3: CD001781.

2. Bourke J. Treatment of cutaneous warts. Modern Medicine Ireland, Oct 2006.

3. O Hogan D. Irish Superstitions, page 88.

4. Vaughan P. The Last Blacksmith of Lissmore, page 74.
5. O Farrell P. Superstitions of the Irish country people, page 41.

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Date: 2 Jan 2008, 13:56:49
Topic: Bulb syringing for earwax

Comments by: Dr Judith A Langfield

I was fascinated to read this article. My parents used to syringe their own ears using a rubber bulb syringe. They did so because before 1948 they had to pay to see the doctor. This obviously encouraged self-treatment. It would be intriguing to see this come back into general use again.

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Date: 4 Oct 2007
Topic: 'Connected care in a fragmented world'

Comments by: Dr Jane Wilcock, GP, The Lowry Medical Practice

Pendlebury Health Centre, Swinton, Manchester

I would like to hug Jane Farmer for a wonderful clear, bold article¹ stating the real values of general practice both to patients and GPs!

After years of feeling that I am out of date and old fashioned in my GP values and unfashionably remaining in the same practice for 20 years I have read a supportive article. The political society we read about subscribes to portfolio careers and valuing fame, choice and change but here’s to all those GPs who are quietly going about their careers trying to offer consistency and high quality health care across the UK.

Reference
1. Farmer J. Connected care in a fragmented world: lessons from rural health care. Br J Gen Pract 2007; 57(536): 225-230. View abstract online.

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Date: 16 Aug 2007
Topic: NICE fever advice

Comments by: Wouter Havinga

The NICE guidelines for ‘Feverish illness in young children’ is a document that contains useful practical advice on fever care. It illustrates that when dealing with a child with fever, the issue is to exclude an underlying dangerous infection rather than treating the fever with antipyretic interventions. This gives the opportunity for every clinician to give the same confidence-building message to the public.

Antipyretic agents (paracetamol and ibuprofen) should not be used routinely with the sole aim of reducing body temperature in children with fever who are otherwise well.
Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose.
Paracetamol and ibuprofen should not routinely be given alternately to children with fever.
Tepid sponging is not recommended for the treatment of fever.
Children with fever should not be under dressed or over wrapped.
The use of antipyretic agents should be considered in children with fever who appear distressed or unwell. Either paracetamol or ibuprofen can be used to reduce temperature in children with fever. Paracetamol and ibuprofen should not be administered at the same time to children with fever.¹

To build confidence in parents who are caring for feverish children, it is essential that health professionals stop maintaining two medical myths, the first that fevers can get too high and death ensues; and second, that febrile convulsions happen when the temperature gets too high. These two myths are the cause for the widespread anxiety about fever. Furthermore, doctors believe that reducing the temperature makes the child feel more comfortable.

The result of the advice ‘to manage the fever’ gives parents the impression that the temperature should be reduced and is often advised as such by clinicians. However, the above bullet points illustrate otherwise. This is important because every practicing doctor in the out-of-hours service is aware of phone calls from parents who ring in a panic because they realise that they ‘cannot control the temperature’.

This iatrogenic fever phobia is a frequent cause for distress in parents, which has its effects on the child, and the health professionals who deal with the caller.

Due to the frequency of these type of calls, it puts pressure on the out-of-hours service. The outdated advice ‘to manage the fever’ or ‘to control the fever’ is potentially resulting in a second call during the same shift when the temperature is not responding, and this again is the cause for attendances to the primary care centres and subsequent contacts with the paediatric departments and admissions.

Rather than advising to fear and fight a fever, doctors can give advice that supports the fever process and, as such, build confidence in parents caring for their feverish child. Implementing this NICE advice and organising a public awareness campaign to support the fever process has the potential to create health gains for all involved and financial gains for the PCTs due to less pressure on the services.

Reference

1. http://guidance.nice.org.uk/CG47/quickrefguide/pdf/English (page 14)

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Date: 16 Aug 2007
Topic: Defined daily dose for topical NSAID use – clinical update

Comments by: D Carnes, PL Cross, and M Underwood

For the purposes of a randomised controlled trial (RCT) comparing the effectiveness of topical versus oral ibuprofen for chronic knee pain in primary care, we needed a defined daily dose of topical ibuprofen required to treat one knee (TOIB study ISRCTN 7935305).

With the exception of diclofenac in dimethyl sulfoxide cutaneous solution, the dosage regimens for topical non-steroidal anti-inflammatory drugs (NSAIDs) given in the BNF and patient information sheets are vague. A maximum daily amount of 15g is suggested for ketoprofen gel, and 25g for one preparation of felbinac gel, but these are total daily doses, not per joint. No specific amount is given for ibuprofen gel. Nor were the manufacturers able to give advice on a normal dose for one knee.

Some ex vivo studies of the penetration of ibuprofen into the knee joint and peri-articular structures have specified a daily dose of topical ibuprofen. However, the amount used in these studies was substantially larger than the dose one might expect to use in routine practice: 7.5g of 5% ibuprofen gel three times daily, which provides 1125 mg of ibuprofen per day from 22.5g of gel. This dosage regimen would mean that a 100g tube of gel would last just 4.4 days, which would be unrealistic for routine use. To establish a realistic defined daily dose for topical NSAID use for knee pain we used two approaches:

1. A typical loading dose for topical preparations is 2mg vehicle/cm2 of skin (personal communication Marie Miller, Dermal Laboratories.) We were unable to identify any previous estimates for the surface area of the skin over the knee or those parts of the knee to which patients typically apply topical preparations. Therefore we estimated the knee surface by considering the knee as a cylinder. One of our research team (DC) measured the knees of 15 members of the public, all over 35 years of age. Measurements were taken of the circumference of the extended knee at three levels: the superior aspect of the lateral and medial condyles of the femur, the joint line, and the tibial tuberosity. The mean of these values was taken to be the circumference.

We also measured the vertical height of the extended knee from the superior border of the patella to the insertion of the patella tendon at the tibial tuberosity. Mean circumference was 39.4cm and height 13.9cm giving a surface area of 548cm2. We then halved this figure because in our clinical experience topical NSAIDs are generally applied to the anterior aspect of the knee only, giving an area of 274 cm2, which was multiplied by 2mg to provide an estimate of a single application (0.55g). Although the surface area of the knees measured may not be completely representative of the population with chronic knee pain, and the surface area of the knee varies slightly according to the degree of flexion;4 these results are likely to be sufficiently accurate for our purpose.

2. The fingertip unit of creams and ointments was developed as a guide for the use of topical steroid preparations for dermatological practice. It is used to help patients assess how much topical steroid to use. The unit equates to approximately 2.5 cm of cream or ointment, the length of the distal phalanx of the index finger; it weighs approximately 0.5g and covers approximately 312cm2, an area similar to that of the anterior aspect of the knee. This approach suggests that a single application of ointment is 0.5 gram.

Both approaches came up with a similar value. We therefore defined a single application as 0.5g. Manufacturers typically recommend topical ibuprofen application three or four times per day. We standardised a three times daily regimen for all preparations. This made a defined daily application of a topical NSAID cream, gel, or ointment for one knee 1.5 g, which for ibuprofen 5% equates to 75mg ibuprofen per day (a 10% preparation concentration would equate to 150mg).

These doses of ibuprofen are substantially less than the 1125mg/day used in ex vivo penetration studies: 7% of that used by Dominkus.3 Few prescriptions for oral NSAIDs are for more than 200g;6 and, according to the pharmaceutical company estimate of 2mg/cm2, to rub in the 7.5g of vehicle used for one dose by Dominkus a skin area of 3750cm2 would be required. We recognise that the amount of active ingredient absorbed will vary, depending on the concentration of the preparation. However, the actual amount of vehicle applied is likely to be unaffected by the concentration of any active ingredients. We feel confident that 1.5g is a realistic defined daily dose of topical NSAID for one knee.

This calculation will serve to inform clinicians and researchers on the appropriate dosage for topical NSAIDs.

References
1. Cross PL, Ashby D, Harding G, et al; TOIB Study Team. TOIB Study. Are topical or oral ibuprofen equally effective for the treatment of chronic knee pain presenting in primary care: a randomised controlled trial with patient preference study. BMC Musculoskeletal Disord. 2005; 6: 55.
2. British Medical Association and Royal Pharmaceutical Society, London. British National Formulary 51. London; March 2006. p 531.
3. Dominkus M, Nicolakis M, Kotz R, et al. Comparison if tissue and plasma levels of ibuprofen after oral and topical administration. Artzneim-Forsch/Drug Res: 46(11):1138–1143.
4. Finlay AY, Edwards PH, Harding KG. ‘Fingertip unit’ in dermatology. Lancet 1989; 2(8655): 155.
5. Long CC, Finlay AY, Averill RW. The rule of hand: 4 hand areas=2FTU=1g. Arch Dermatol 1992; 128(8): 1129–1130.
6. http://www.ic.nhs.uk/pubs/prescostanalysis2005/pcaexcel/file (accessed 18 Sept 2006).

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Physical health

Date: 7 Jul 2008
Topic: Response to ‘Magic bullets for insomnia?’
Comments by: John S Dowden, Medical Editor, Australian Prescriber

The article ‘Magic bullets for insomnia?’¹ was of interest because of recent concerns in Australia about the adverse effects of z drugs, particularly zolpidem. Adverse reactions such as hallucinations and amnesia appeared soon after zolpidem was marketed in Australia,² but there have been increasing reports of bizarre behaviour in patients taking the drug.

These bizarre adverse events include painting while sleeping, eating while asleep, and sleepwalking.^2,3 Approximately 10% of all reports mention sleep driving. This can be considered with the 1.4% of the English patients who associated z drugs with road traffic accidents.¹

The concerns about patient safety prompted Australian drug regulatory authorities to consider rescheduling zolpidem as a controlled drug. That option was not pursued, but a black box warning has been added to the product information. This includes the recommendation to limit the use of zolpidem to a maximum of 4 weeks.³ A similar warning has been included in the information for patients.

References

1. Siriwardena AN, Quershi MZ, Dyas JV, Middleton H, Orner R. Magic bullets for insomnia? Patients’ use and experiences of newer (Z drugs) versus older (benzodiazepine) hypnotics for sleep problems in primary care. Br J Gen Pract 2008; 58(551): 417-422. View abstract online
2. Adverse Drug Reactions Advisory Committee (ADRAC). Seeing things with zolpidem. Australian Adverse Drug Reactions Bulletin 2002; 21 (1). http://www.tga.gov.au/adr/aadrb/aadr0202.htm#zolpi

3. Zolpidem ("Stilnox") - updated information – February 2008. Department of Health and Ageing 2008 http://www.tga.gov.au/alerts/stilnox2.htm

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Date: 25 Nov 2007 21:56
Topic: Primary Care Spirometry: Coordinated efforts needed to enhance spirometry quality and interpretation in primary care
Comments by: Poels PJP MD, Schermer TRJ PhD, I Smeele PhD

In the September issue of this journal, White et al.¹ reported on the feasibility and usefulness of remote electronic reporting (by e-mail) of primary care based spirometry. They conclude that the quality of spirometry tests was low and the agreement between specialists and GPs on acceptability was slight, and on diagnosis was fair. The authors’ advice to investigate next if quality of spirometry testing and interpretation in primary care can be improved by remote electronic reporting.

Although the paper provides some interesting new information, there is also much that the authors do not report. For instance, the paper only reports on the acceptability of spirometry tests in terms of agreement between the GP and the respiratory specialist. More details about the actual quality of the submitted spirometry tests would be required to be able to verify the authors’ conclusion that the ‘quality of the spirometry done in primary care was unsatisfactory’.

Despite these shortcomings in the study methods used, we agree with the authors that some kind of continuous support for GPs is necessary to improve test quality as well as interpretation of the test results.² We recently reported that the use of a computerized expert system for the interpretation of the spirometry test results had no benefit for the acuity of GPs’ diagnosis and subsequent management changes.³ From another study we know that chest physicians can give valid interpretations of lung function when they just receive written information without actually seeing the patient.⁴

So what need to happen next? There is an increased awareness by government authorities, insurance companies, and healthcare professionals that primary care spirometry testing needs to be accredited in some way.⁵ Therefore, in the Netherlands the COPD and asthma general practice advisory group (www.cahag.nl) and all other disciplines involved in primary care spirometry (i.e. lung function technicians, chest physicians, GPs, practice nurses) will soon start unfolding a nationwide programme to enhance the quality of primary care spirometry.

This programme consist of three elements: (1) improving training (e.g. clarifying the minimum requirements of a spirometry training like has previously been done in New Zealand,⁶ use of standardised educational materials like CD-ROM Spirometry Fundamentals⁷); (2) improving organisation (e.g. describing standards for minimum practice organisation and protocols for cooperation with secondary care); and (3) improving quality assurance (e.g. periodic outreach visit by lung function technicians,⁸ incorporation of spirometry quality indicators in practice accreditation, and a system of registration of the spirometry driver license).

We believe that only with such coordinated efforts spirometry performance and interpretation in primary care can be enhanced structurally.

References
1. White P, Wong W, Fleming T, Gray B. Primary care spirometry: test quality and the feasibility and usefulness of specialist reporting.
Br J Gen Pract, 2007; 57 (542): 701-705. View abstract online.

2. Poels PJ, Schermer TR, van Weel C, Calverley PM. Spirometry in chronic obstructive pulmonary disease. BMJ 2006; 333(7574):870-871.
3. Poels PJP, Schermer TRJ, Schellekens DPA, Akkermans RP, de Vries Robbe PF, Kaplan A et al. Impact of a spirometry expert system on general practitioners' decision-making. Eur Respir J 2007; Published ahead of print June 27, 2007, 10.1183/09031936.00012007.
4. Lucas A, Smeenk F, Smeele I. Interpretation of the results of spirometry and anamnesis into a diagnose and advice for treatment: validity and reliability. Eur Resp J 2004; 24(48):87s.
5. Gruffydd-Jones K, Stephenson P, Levy M, GPIAG Working party. What standards and terms of employment should respiratory practitioners with a special interest expect from an employing organisation? Prim Care Respir J. 2007 Jun;16(3):182-7.
6. Spirometry training courses. A Position Paper of The Australian and New Zealand Society of Respiratory Science & The Thoracic Society of Australia and New Zealand. http://www.anzsrs.org.au/spirotrainingposition.pdf February 2004.
7. Spirometry Fundamentals. http://www.spirofun.org/.
8. Thuyns V, Schermer J, Jacobs E, Folgering M, Bottema M, van Weel C. Effect of periodic outreach visits by lung function technicians on the validity of general practice spirometry. Eur Respir J 2003; 22(45):439s.

Date: 4 Oct 2007
Topic: Primary care spirometry
Comments by: Paul J Nicholson OBE FRCP FFOM MRCGP, London

Guidelines for the care of patients with chronic obstructive pulmonary disease (COPD)¹ and those for asthma² encourage the objective assessment of lung function at all levels of health care. However, limited data are available on the quality of spirometry performed in primary care. Since spirometry is incentivised by the Quality Outcomes Framework, the study by White et al³ in this journal (Sept 07 issue) is important, as is a coincidental study in the US that shows that of 368 tests completed in primary care over 6 months, 71% were technically adequate for interpretation and that family physician and pulmonary expert interpretations were concordant in 76% of tests.⁴

White et al challenge an ‘unstated assumption’ that the professionalism of primary care clinicians will ensure that spirometry is performed to an acceptable standard.³ Wherever this assumption might exist, it must be purged actively. Spirometry is among the most useful and accurate measures of respiratory health, however, when not performed correctly, it can lead to misdiagnosis and mismanagement. Like many health measurements, spirometry is subject to measurement error. Measurements of the same quantity can vary in the same individual, from one day to another, in different hands, with different equipment, at different centres. Error may arise in the subject, the observer and/or the measurement process. In spirometry, the most common cause of erroneous results is sub-optimal patient coaching.⁵ Thus spirometry requires specific training over and above basic professional training. NICE guidelines emphasise the need for appropriate training and for competence in the interpretation of spirometry results.¹

White et al state that there is currently no standard for the training and conduct of primary care spirometry. As an occupational physician responsible for spirometry programmes in a non-hospital setting, I argue that the competence of clinicians performing spirometry and interpreting results are identical, irrespective of the clinical setting. Of note, the Association for Respiratory Technology and Physiology (ARTP) with the British Thoracic Society (BTS) provide a competence qualification in spirometry. The certificate in spirometry incorporates competence assessment via a training course run at over 20 centres nationwide, a written assignment, a portfolio of examples and a short practical exam and viva. The certificate is noted to be useful for nurses in both primary and secondary care.⁶

The authors methodology required practices to perform spirometry according to the 1994 update of the American Thoracic Society (ATS) guidelines.⁷ However, these were superseded in 2005 by joint ATS and European Respiratory Society (ERS) guidelines that are available for free online.⁸

The authors point out that the quality of spirometry is likely to be determined by several factors including the quality and length of spirometry training, the aptitude of the spirometry technician, supervision after completion of training, and the quality of test interpretation. The ATS and ERS also published guidelines on interpretative strategies for lung function tests in 2005.⁹ These too are available for free online.

Eaton et al’s study of spirometry in primary care practice demonstrated that non-acceptability of results was largely ascribable to failure to satisfy end-of-test criteria.¹⁰ Failure to use appropriately calibrated/prepared equipment is another concern.¹¹ These issues emphasise the importance not only of effective training but also of effective quality assurance programmes. The ARTP, BTS, and British Lung Foundation want the mandatory implementation of quality assurance measures for all NHS personnel performing spirometry within by 2010.¹⁰ Given that standards do exist, spirometry in primary care is instantly amenable to clinical audit, peer review and therefore quality improvement. Specialist reporting of spirometry conducted in primary care, as studied by White et al, could prove to be a useful quality improvement tool, but adequate training of those performing spirometry must to be the primary corrective measure to correct this quality non-conformance.

References
1. Chronic Obstructive Pulmonary Disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care. NICE. London. 2004. http://www.nice.org.uk/pdf/CG012_niceguideline.pdf

2. British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN, Edinburgh 2007; 2007.
http://www.sign.ac.uk/guidelines/published/support/guideline63/download.html

3. White P, Wong W, Fleming T, Gray B. Primary care spirometry: test quality and the feasibility and usefulness of specialist reporting.
Br J Gen Pract, 2007; 57 (542): 701-705. View abstract online.

4. Yawn BP, Enright PL, Lemanske RF, et al. Spirometry can be done in family physicians' offices and alters clinical decisions in management of asthma and COPD. Chest, 2007 Jun 5 [Epub ahead of print].

5. Enright PL. How to make sure your spirometry tests are of good quality.
Respir Care, 2003;48:773-776.

6. http://www.artp.org.uk/

7. American Thoracic Society. Standardization of spirometry: 1994 update. Am J Respir Crit Care Med, 1995; 152: 1107-1136.

8. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J, 2005;26:319-338.
http://erj.ersjournals.com/cgi/content/full/26/2/319

9. Interpretative strategies for lung function tests.
Eur Respir J, 2005;26:948-968.
http://erj.ersjournals.com/cgi/content/full/26/5/948

10. Eaton T, Withy S, Garrett JE, et al. Spirometry in primary care practice: the importance of quality assurance and the impact of spirometry workshops. Chest, 1999;116:276-277.

11. Joint Statement from the Association for Respiratory Technology & Physiology (ARTP), the British Thoracic Society (BTS) and the British Lung Foundation (BLF) for World COPD Day 2005. http://www.brit-thoracic.org.uk/article9.html

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Date: 16 Aug 2007
Topic: Are pneumococci also the most frequent germs in exacerbations of chronic bronchitis?
Comments by: Carl Llor, Primary Healthcare Centre Jaume I, Tarragona; Josep Maria Cots, Primary Healthcare Centre La Marina, Barcelona, Spain

We read the article recently published by Holm et al¹ on the aetiology of lower respiratory tract infections with interest. In this article, the authors only reported 16.8% of bacterial aetiology among the patients with non-pneumonic infections of the lower respiratory tract. In this study Streptococcus pneumoniae was the most frequent among the bacterial agents observed, being isolated in one third of the bacterial infections followed by Haemophilus influenzae in 21.7% of the total number of bacterial infections.

The authors comment that expectoration was more frequent among the patients without pneumonia than among those with radiologically confirmed pneumonia. Among the 316 patients with non-pneumonic infections, many were probably exacerbations of chronic bronchitis or even with spirometric diagnosis of COPD. It would therefore be interesting to know the aetiology of these patients since hospital series indicate H. influenzae as the most frequent aetiological agent.

However, in a study carried out by our group in primary care patients (n = 1947) with exacerbations of chronic bronchitis, the most frequently isolated agent was pneumococcus with almost 35% of all the bacterial causes.² On the other hand, in this study H. influenzae, was only responsible for 12.6% of all the exacerbations, being third by order of frequency. If the results obtained by Holm et al were similar in patients with chronic bronchitis, this would further support the different aetiology of the patients within the community setting compared with that of the hospital, which would be explained by the lesser severity of the patients attending our consultation offices.

Since a microbiologic study was performed, it would also be interesting to know, if possible, what diagnoses the respiratory infections by H. influenzae corresponded to and whether there was a correlation between the different aetiological agents and the concentrations of C-reactive protein and procalcitonin, taking into account that in other studies the highest values of these inflammatory markers seemed to be more associated with pneumococcal infection.³

References
1. Holm A, Nexoe J, Bistrup LA, et al. Aetiology and prediction of pneumonia in lower respiratory tract infection in primary care. Br J Gen Pract 2007; 57(540): 547–554. View abstract online.
2. Llor C, Cots JM, Herreras A. Bacterial etiology of chronic bronchitis exacerbations treated by primary care physicians. Arch Bronconeumol 2006; 42: 388–393.
3. Almirall J, Bolíbar I, Torán P, et al. Community-acquired pneumonia Maresme study group. Contribution of C-reactive protein to the diagnosis and assessment of severity of community-acquired pneumonia. Chest 2004; 125: 1335–1342.

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Date: 16 Aug 2007
Topic: Chronic musculoskeletal pain
Comment by: Dr Anna Alexander, FY2 Department of Medicine, Hammersmith Hospital, London

It was interesting to read the systematic review on prognostic factors for musculoskeletal pain in primary care by Mallen et al and the editorial by Carnes and Underwood (BJGP August 2007).

It is very clear that we need more research on chronic musculoskeletal pain before we could come to any definite conclusion. Cervicogenic headache is a highly controversial issue and had been through much debate. Research has shown that interleukin beta (IL-β) and Tumour Necorosis Factor alpha (TNF-α) have a role in cervicogenic headache. It is possible that a similar mechanism may exist in low back pain and in other musculoskeletal pains. Until we find the biomolecular markers of this condition, it will be misunderstood and treatment will continue to be contaminated by non-scientific practice.

Reference
1. Martelletti P. Proonflammaotry pathways in cervicogenic headache. Clin Exp Rheumatology 2000, 18(Suppl 19): S33–S38.

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Service organisation

Date: 7 Jul 2008
Topic: Response to ‘Death certification post Shipman’
Comments by: David Church, GP, Machynlleth

I do not agree with Messrs Holden and Cox that the current system for death certification is seriously flawed.¹ After all, I understand that Dr Shipman’s case was detected by the current system not less than twice! The failure was not in the death certification system, but in lack of action by those to whom the discrepancies were reported. The problem is that the tone of the inquiry was directed towards finding someone to blame ‘outside’ of the official authorities. It therefore fell to blaming GPs, despite a complete opposite truth in the evidence, which just happened to be convenient to the government anyway, who were in the midst of trying to discredit GPs in any way possible so that various other changes in the NHS could be forced through.

It is no surprise that there have been no concrete actions to change the existing system of certification of cause of death: no failings were detected within the system, and consequently no-one has come up with any way of doing any part of it better. Plus, the aims of the inquiry were achieved without improving the system criticized – the Government’s aims were not to improve death certification, but to lay a smear on GPs, which was achieved quite readily due to lack of effective counterspin by the profession’s representatives.

Reference
1. Holden J, Cox S. Death certification post Shipman. Br J Gen Pract 2008; 58(552): 510. View title page online

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Date: 6 Jul 2008
Topic: Response to ‘The NHS at 60’
Comments by: Alan Keith, GP, Rotherham, South Yorkshire

I was interested and not a little surprised to read in Prof. Graham Watt's leading article¹ that the QOF has ‘largely ironed out social gradients in incentivised quality markers’. If Prof. Watt cared to look down from his ivory tower for a moment he would realize that it has done nothing of the sort. It certainly could have been used to this end and it is a tragedy that it has not.

The reason of course is that in calculating quality payments it is the square root of the prevalence of a chronic disease rather than the prevalence, which can be safely assumed to correlate with the actual workload involved, that is used to calculate the payments. The effect of this is to take money out of practices in which there are a great proportion of deprived, elderly or ethnic minority patients (We have all three) and put in the pockets of GPs in some of the most prosperous and desirable parts of the country.

The GPC who negotiated this egregious deal have proved extraordinarily resistant to any attempt to change, or even discuss it, in spite of the fact that it was roundly condemned at this year's LMC conference.

Furthermore, it was not discussed at last year's ARM of the BMA; the reason being that although I had proposed the motion and it had been quite properly put forward by the Rotherham division of the BMA, it was unaccountably omitted from the agenda by the staff at BMA house. This year however I was luckier, the motion actually made it onto the agenda but unfortunately in a position in which it is most unlikely to be debated.

It is not as if this would be difficult to rectify. It could be done by a stroke of the pen and would be entirely revenue neutral. Indeed, one wonders what on earth inspired the civil servants from the Department of Health to allow it in the first place. If the government are to be believed they are whole hearted in favour of supporting general practice in deprived areas. Unless of course this is part of the softening up process for the advent of APMS practices.

It could of course be claimed that, in spite of all thi,s QOF does deliver extra funding where there was none before and perhaps we should be grateful for these crumbs from the rich man's table.

Reference
1. Watt G. The NHS at 60: time to end the fairy tale. Br J Gen Pract 2008; 58(552): 459-460. View title page online

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Date: 6 Jul 2008
Topic: Response to ‘Alsfords’s theoretical political framework’
Comments by: Dr Mark Freeman, Churchwood Medical Practice, St Leonards-on-sea, East Sussex

Charlotte Williamson’s piece on Alsford’s theoretical political model¹ provides a seductive analysis which she is applying to the flux happening now within health service organisation in the UK. However it should be acknowledged that this is a political theory. By describing clinician’s interests as ‘dominant’, the use of language alone implies that their interest should be moderated or brought down.

Alsford developed his theory to effect change in 1970s US health care, when many could agree clinicians’ interests may be entrenched for financial reasons. However I would argue that what motivates clinicians who have grown up in, been trained in, and who work in the NHS of the UK is quite different. Williamson alludes to professional monopolists believing altruism as a motivator. I would argue this is a truth rather than a belief. Going the extra mile for the patient, or staying on the extra hour to sort out a problem, demonstrates the beneficence of the clinician and nurtures the relationship for the patient. This is a marker of quality that I have yet to see quantified or put into the equation when it comes to advocating change. It is integral with a sense of ownership of the system by the clinician. Clinicians know it is in the best interests of the patient (and indeed a silent majority of patients know this also).

When clinicians are seen as resistant to change it needs to be borne in mind they are so when they can see a system that works being eroded. The type of personality that is attracted to medicine is not the same as the businessman. When describing our interest as ‘dominant’, it is not the money that it is making us resist change, it is the preservation of a system whereby we can feel good about doing good. Individual patients see the benefit of this every day. Politicians need to understand how fundamental this is to the whole business of doctors treating patients to the satisfaction of all concerned. And when doctors are seen as resisting change, we need to shout loudly that it is not because of conservatism (with which so may find convenient to label us), but because we are and always have been radical advocates of out patients’ interests.

Reference

Williamson C. Alford's theoretical political framework and its application to interests in health care now. Br J Gen Pract 2008; 58(552): 512-516. View abstract online

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Date: 4 Mar 2008 11:36:43
Topic: Complementary medicine
Comments by: Dr Andrew Sikorski

Ernst is a left brain analyst.¹ We GPs have to make sense of convoluted individual histories in snapshot opportunities and assist these individuals to the best of our ability while ticking QoF boxes and attempting to stick to 'Primo non Nocere'. Unsurprisingly not all the answers were presented during the education we received at medical school nor are they all contained within the BNF. Anyone trying to stick to the rigid guidelines is calling down the known ills of our vocation on their shoulders – burn out, depression, drink, drugs, divorce and suicide.

Fortunately we have a corpus callosum linking between our right and left brains.

Hence doing our best with our patients can lead to some amazing stories of recovery or coping in the face of unanswerable adversity. We all realize Ernst hasn't the answers for us – let’ s ensure he leaves us some hope. Dismissing complementary therapeutic techniques is like throwing the baby out with the bath water and by now I would be mad, bad or dead without them.

Reference

Edzard E. Complementary and alternative medicine: what the NHS should be funding? Br J Gen Pract 2008; 58(548): 208-209. View title page online

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Date: Jan 2008
Topic: GP burnout
Comments by: Francesco Carelli, Professor F.M. University of Milan, EURACT Council Director of Communications

Anders Brondt with Frede Olesen and Danish colleagues¹ demonstrate that burnout is affecting many GPs. The paper reports a study of Italian GPs which found higher levels of emotional exhaustion and depersonalisation, but lower values on personal accomplishment compared with the Danish research.²

In Italy I co-ordinated the European Research on Burn Out in General Practice sponsored by EGORN. The results were presented at EGPRN meetings and WONCA Congresses in Amsterdam, Kos, Florence, and Paris.³ The study confirmed that burnout syndrome among GPs is becoming an international and widespread problem. Apart from high workload and lack of a portfolio career, one of the most important reasons is the high (and intolerable) pressure from governments, mainly in terms of budget rationing. Furthermore, in Italy there is the emergence of groups in the public who are more demanding and less deferential, and there is the feeling that the media has become more hostile towards the medical profession.⁴

The public has begun to have higher (and sometimes unrealistic) expectations of public services. Politicians have responded by opening up a debate about the size of public spending, but often they appear to be too hasty in blaming the medical profession when things go wrong.⁴ Guidelines, protocols, regulations, and inspections are perceived by many doctors as eroding their control over their own professional lives.

In Italy, as in other 12 European countries, we used the Maslach questionnaire and a modified questionnaire to investigate some aspects of GPs’ working lives. Over 30% declared they were thinking of changing jobs. This was mainly regarding 47-55 years olds who were working in urban settings. GPs expressed feeling: (a) emotionally drained from work; (b) used at the end of the workday; and c) frustrated with the job. A relevant number of GPs, regardless of whether they live in urban, rural, or mixed settings, are having marriage problems.

This situation about job satisfaction and burnout is clearly increasing because of bureaucracy, progressive loss of role, and uncertainty regarding the future for the National Health System and contrasting interests in the political field.

References
1. Brøndt A, Sokolowski I, Olesen F, Vedsted P. Continuing medical education and burnout among Danish GPs. Br J Gen Pract. 2008; 58(546): 15-19. View abstract online
2. Grassi I, Magnani K. Psychiatric morbidity and burnout in the medical profession: an Italian study of general practitioners and hospital physicians. Psychother Psychosom 2000; 69(6): 329-334.
3. Carelli F, Petrazzuoli F, Lionis C, Soler K. A particular aspect of GPs’ burn-out syndrome: the intolerable bureaucratic pressure felt as an institutional mobbing, WONCA Europe Conference, Florence, August 2006.
4. Carelli F. Where job satisfaction is dying. BMJ, 2003; 326: 22.

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Date: 19 Nov 2007
Topic: Personal and public health care
Comments by: David Church, GP, Machynlleth, Powys

I would tend to disagree with Prof. Abholz’s¹ view that it is only within the last few years that GPs have seen a shift from personal to public health roles. And as a result or implemented by QOF or EBM.

It may be true of GPs in other countries, but British GPs have had a strong duty and role in public health as well as personal care for centuries, possibly longer, depending on one’s view of the origin date of general practice.

At medical schools in the 1980s there was good grounding in public health for all of us, not just GPs, from departments as diverse as ‘Man in Society’, ‘Infection Control’, and Microbiology, for a start. Indeed, the Leeds School (and no doubt others) was set up partly around and involving the staff of the Public Dispensary. However, going back further, there were huge contributions to social medicine by local authorities under the Poor Laws (when properly discharged), and their predecessors, the Parish Wardens, using general medical manpower when needed.

Certain instances of historical public medicine are rightly famous in Britain – the Broad Street Pump, for example, and William Pickles. Going back even further, there is evidence that roman military forces in Britain were served by attached medical staff who, being part of the military establishment would have had loyalties to the Legion as well as the individual, and so were taking public health into consideration.

I think it is an integral part of medical tradition in Britain to be aware of the public health effects of individual illness and treatment, and one of which we can and should be proud.

Reference
1. Abholz H-H. Conflicts between personal and public health care: can one GP serve two masters? Br J Gen Pract 2007; 57(542): 693-694. View abstract online.

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Date: 19 Nov 2007
Topic: Death certification
Comments by: Dr M G Bamber and Dr A McKechnie, The Surgery, Back Lane, Colsterworth, Grantham, Lincs

I read your paper in the Back Pages of the BJGP¹ with increasing sadness. The purpose of a death certificate is primarily to state the cause of death, while the other two functions you cite are soft accompaniments.

Your example where you state that there was ‘… no doubt at all that death was from natural causes’ depressed me in a journal designed to educate its readers. My increasingly unfashionable view is that the doctor should try to find the cause of every death. How can you expect the state of the nation’s health to be assessed from guesses and kind words on death certificates designed to be ‘acceptable to both the registrar and the family’?

The reluctance to both variously request and finance autopsies has now produced the situation that a doctor can train as a histopathologist in the UK without ever having done an autopsy. Many young doctors have not seen, let alone performed, an autopsy.

Some conditions identified after death may have real relevance to surviving relatives and medical and nursing attendants. My anecdotal favourites in my career to date have been aortic aneurysms and tuberculosis.

Peter Davies elsewhere in the same edition of the Journal² quotes Raymond Tallis referring to ‘sessional functionaries robotically following guidelines’.

Please be more inspiring and reactionary, if only for the sake of younger colleagues alone, so that Tallis’ observation can be reversed.

References
1. Jewell D. Viewpoint - Death certification. Br J Gen Pract 2007; 57(540): 583. View article in full.
2. Davies P. Mangin on QOF. Br J Gen Pract 2007; 57(540): 580–581. View abstract online.

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Date: 4 Oct 2007
Topic: Advanced Access
Comments by: Terry Kemple, Horfield Health Centre, Horfield, Bristol

Is it difficult to get a fast, convenient or personalized appointment with a GP?

Chris Salisbury et al's two papers^1,2 in the August BJGP investigated the effects of the introduction of the ‘Advance Access’ scheme. The scheme was meant to fix the perceived problem that patients couldn’t get to consult a GP quickly. The studies showed that in reality Advance Access was not needed, fixed nothing, and produced only marginal changes.

The Department of Health’s national access survey³ investigated but did not confirm the perception that getting an appointment with a GP was difficult. In some areas there may be problems. In my own practice the survey reported that 18% of patients felt they couldn't get an appointment within 48 hours, but we think we have plenty of unbooked appointments at the start of each day and if there is no additional unbooked appointment available we will always see patients the same day if they want. These gaps between perception and reality need acknowledging and addressing.

Primary health care services are being compared with services like supermarkets that seem to be open to sell all things, to all people, all of the time, almost everywhere. GPs feel under pressure to copy the supermarket example but if GPs do provide enough appointment then the problem might be the public’s perception of what‘s on offer.

Patients want a choice of appointments² that includes a fast service (that is, same day), a convenient service (at a day and time of the patient’s choice), and a personalized service (with a doctor of their choice within a few working days). GPs can never guarantee that an appointment is fast, convenient, and personalized but they can make the choice between these services (and their consequences) clearer for patients. If GPs do under provide, poorly describe, or badly explain their services, it’s like supermarkets failing to stock their shelves with plainly labeled products and with no instructions on how to use the products.

The stock of appointments needs to be relabeled in terms that the patients understand like fast, convenient or personalized appointments. Clear instructions on how to use the fast ‘same day’, convenient appointment with any GP and the personalized appointment with a named GP can help patients choose what they want, and know what they can expect in that appointment.
Unlike supermarkets, primary health care in the UK really is accessible for all people, all of the time, almost everywhere. Patients will soon enjoy even more choice about who, when, where, and how they access and use primary health care as the patient’s NHS summary care record becomes widely available.

If it is easy to get a fast, convenient or personalized appointment with a GP then the gap between perception and reality is a marketing failure that the NHS needs to fix with better advertising of its GP services.

References

1. Salisbury C, Montgomery AA, Simons L, et al. Impact of Advanced Access on access, workload, and continuity: controlled before-and-after and simulated-patient study. Br J Gen Pract 2007; 57(541): 608-614. View abstract online.

2. Salisbury C, Goodall S, Montgomery AA, et al. Does Advanced Access improve access to primary health care? Questionnaire survey of patients. Br J Gen Pract 2007; 57(541): 615-621. View abstract online.

3. National GP Patient Surveys on Access and Choice

Summary Report 2006/2007 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_075455

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Date: 9 Aug 2007 21:36
Topic : 10 Downing Street Petition Against 0844 NEG Surgery Line Doctors Numbers

Comments by: a concerned patient

As many GPs will be aware, as the results of the activities of a company called Network Europe Group (NEG) and their activities in marketing a telephone switchboard service solution for doctors’ practices (Surgery Line), many GPs have ditched their conventional local priced 01/02 numbers in favour of 0844 numbers provided by NEG along with the so called ‘free’ new switchboard and call queuing equipment.

However, there is a growing movement against the use of these numbers by patients who are wholly opposed to their adoption by their local doctors’ surgeries.

Some of these discontented patients have now started a petition against the use of the 0844 NEG numbers by doctors surgeries on the 10 Downing Street petitions website at:

http://petitions.pm.gov.uk/NGN-use-by-GPs/

Many patients oppose the use of these 0844 NEG Surgery Line numbers for the following reasons:

They are excluded from flat-rate landline calling plans like BT Option 3 where customers pay a fixed price such as £7.99 per month for unlimited 01/02 calls. Instead, 0844 numbers are charged at £3 per hour and are not even the same price as a local rate call (£1.80 per hour) for callers who do not subscribe to a fixed price calling plan.
They are excluded from bundled minutes on practically all mobile phone contract bundled minutes plans and also cost extra on pay as you go phones too. Some mobile phone providers charge up to 40p per minute to call an 0844 NEG number.
The 0844 numbers are charged at 13p per minute from BT Payphones compared to 1p per minute for 01/02 numbers from the same BT Payphone.
Calls to 0844 numbers from overseas are usually barred as are calls to the 0870 number which is the only one NEG allows doctors using their service to quote as a replacement number. Where the numbers can be called from overseas the cost is often 10 times higher, or more, than calling a UK 01/02 number.

The overall view of patients is that, by getting these numbers doctors are putting their own commercial interests first in cutting the budget their practice has to spend on advanced telephone equipment by getting it subsidised through the calls, whereas patients believe doctors should pay for the equipment out of their own budgets and continue to charge their patients for normal priced 01/02 calls.

I would be interested to hear the views of GPs on this matter.

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Date: 2 Aug 2007 15:17
Topic: Interpersonal continuity article
Comments by: Kerr L. White M.D.

The BJGP is the best GP/FP by all measures! The piece in the RJGP (July 2007) by Barbara Starfield (the first colleague I appointed when I started the new Department of Health Care Organization at Johns Hopkins in 1965) and John Horder (a long-time friend who I first met in 1959) is a classic! They have boiled down in two-and a half pages the essential contribution of primary care to compassionate and scientifically-informed medical responses to the population's diverse health problems, but also its fundamental role in underpinning any balanced, safe, and cost-effective health care 'system'. The list of references is superb. It is a true classic and copies should be sent to all U.K. MPs and all U.S. Congress Members.

Reference
1. Starfield B, Horder J. Interpersonal continuity: old and new perspectives. Br J Gen Pract 2007; 57(540): 527-529. View abstract online.

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Patient groups

Date: 24 Dec 2007
Topic: Denial of primary care to vulnerable migrants
Comments by: Tom Yates, 5th year Medical Student, Cambridge; Virginia Leggatt, Physician, Medical Foundation for the Care of Victims of Torture, London

The Department of Health and Home Office are reviewing access to NHS services for foreign nationals and are due to report shortly. If, as expected,^{1, 2} rules governing access to primary care are aligned with those governing hospital care, victims of trafficking, undocumented migrants, and refused asylum seekers will lose the right to access freely many NHS primary care services. This group includes those unable to return to their country of origin because this is deemed unsafe, either on medical grounds or for reasons of security. As these individuals are entitled to claim National Asylum Support Service assistance, it seems inconsistent to deny them access to primary care.

Clearly, the majority of this group are unable to pay private healthcare costs³ so if these proposals are implemented, they will be denied access to almost all health care. Evidence is growing⁴ that the 2004 hospital charging regulations have led to care being denied not only to refused asylum seekers, but also to other vulnerable individuals with every right to free NHS care. It seems likely that, if the rules governing access to primary care are changed, similar errors will occur.

Migrant children denied primary care would be unlikely to receive childhood vaccinations, reducing herd immunity and endangering their peers. In addition, many migrants with worrying symptoms who are denied investigation in primary care will appear in accident and emergency departments, where care is significantly more expensive. Delayed diagnosis of communicable diseases could have implications not only for the individuals concerned but also for the whole community. Managing advanced illness once treatment has been deemed ‘immediate and necessary’ will be much more costly.

Without increased funding for administration, charging in primary care is unlikely to be workable.⁵ The only health impact assessment of such charging suggested that, even in areas accepting large numbers of migrants, foreign nationals are unlikely to place significant burdens upon primary care services and that the costs of administering any charging regime are unlikely to be recouped.⁵ There are other practical considerations, including liability when harm accrues to patients.

We consider it unethical to use the deliberate denial of health care to enforce immigration policy. We do not believe that it is the role of GPs to police such policies and urge those who agree to make submissions to the Department of Health consultation that will follow the publication of the review.

Reference
1. Medact. Proposals to exclude overseas visitors from eligibility to free NHS Primary Medical
Services: impact on vulnerable migrant groups. London: Medact, 2007. Available from
www.medact.org/content/refugees/Briefing%20V1%20agreed.pdf (accessed 23 Dec
2007).

2. Yates T, Crane RJ, Rushby M. Charging vulnerable migrants for health care. Student BMJ 2007; 15: 433.

3. Refugee Action. The destitution trap: research into destitution among refused asylum
seekers in the UK. London: Refugee Action, 2006. www.refugee-action.org.uk/campaigns/documents/RA_DestReport_Final_LR.pdf (accessed 23 Dec 2007).

4. Kelley N, Stevenson J. First do no harm: denying healthcare to people whose asylum
claims have failed. London: Refugee Council, 2006. www.refugeecouncil.org.uk/policy/position/2006/healthcare.htm (accessed 23 Dec 2007).

5. Hargreaves S, Friedland JS, Holmes A. The Identification and charging of Overseas Visitors at the NHS Services in Newham: a Consultation. London: Newham Primary Care Trust, 2006. www.newhampct.nhs.uk/docs/publications/IHUEntitlementReport06.pdf (accessed 23 Dec 2007).

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The James Mackenzie Lecture 2006

The following comments refer to this article: Haslam DA. Who cares?The James Mackenzie Lecture 2006. Br J Gen Pract. 2007; 57(545): 987–993. View title page online

Date: 25 Feb 2008 14:56:38
Topic: The James Mackenzie Lecture 2006
Comments by: Dougal Jeffries

I too was delighted by the tone and content of David Haslam's James McKenzie lecture, but like the previous commentator I am baffled as to why the personal convictions of such College stalwarts as Professor Haslam seem not to be reflected in any official College policies. It seems as though every thoughtful GP is railing against the imposed rigidity of QOF and its unintended harmful side-effects (medicalisation, excessive prescribing, creation of anxiety, detraction from non-targeted clinical areas, reduction in personal and individualised care etc.), while the College proclaims what a wonderful job we are all doing.

I attended the Annual Conference in Edinburgh last year, and far from perceiving it as the triumph that the College establishment proclaimed it to be, I thought it was a depressing spectacle of self-congratulation and complacency in the face of the most aggressive assault on our professional independence and integrity for the past 30 years. I would love to think that David's wisdom and his suspicions that something is seriously amiss might be reflected in some serious self-questioning among the senior ranks of the College.

Date: 19 Dec 2007 17:22:11
Topic: The James Mackenzie Lecture 2006
Comments by: Dr Nicholas Shah MBChB MRCGP MSO MSc, Whetstone Medical Centre, Birkenhead

Thank you very much for article ‘Who Cares?’. I found it thought-provoking and I can strongly identify with your thoughts. I have been an inner city GP for 15 years and have pursued the medical model with postgraduate exams, diplomas, and degrees etc. but wonder what it all means in these evidence-based, target-driven days. Your suggestion that making people feel better might be important reason that we exist as GP’s has caught my imagination!

Date: 14 Dec 2007 14:37
Topic: The James Mackenzie Lecture 2006
Comments by: John McGough

I have just read David Haslam's lecture. It is rare to feel such tremendous empathy with a writer as I did on reading it. He so well encapsulates many of the faults of our current medical model, especially as it is applied to general practice.

I frequently feel confusion as to my patients' problems, so, as he suggests, I just listen and reassure. They appear to go away happy, and they return, so something beneficial must have passed between us. I also feel a strong sense of guilt and uncertainty when I treat problems such as hypertension and hypercholesterolaemia, knowing that only a small proportion of those treated will benefit from the treatment. I often tell people the figures for the benefit to help them decide on whether to start treatment, which frequently elicits ‘What do you think, Doctor?’.

I do not see any easy answer to this in a population whose fears are fed by a media that appears to base its stories on the sales they will generate, and not on any perception of public good. Perhaps there is no answer but to continue to listen and to reassure.

Date: 13 Dec 2007 19:48
Topic: The James Mackenzie Lecture 2006
Comments by: Ian Stevens

Just a note to say how much I enjoyed and valued your paper. I am an NHS physiotherapist and work with GPs and in a pain clinic. I have the time to listen, and find that biomedicine and measurement are often blind to narratives and suffering. I recommend the following paper to other clinicians interested in the area of meaning and placebo: www.annals.org/cgi/content/full/136/6/471
All the best and I loved the Neil Young quote!

Date: 12 Dec 2007 15:04:16
Topic: The James Mackenzie Lecture 2006
Comments by: Kenny

I have just finished reading your excellent James Mackenzie lecture in December's BJGP. Thought-provoking, relevant, and to the point. Thanks in particular for introducing me to the McNamara Fallacy, a useful and expanded alternative to the rather overused ‘drunken search’.

Date: 4 Dec 2007 09:17
Topic: The James Mackenzie Lecture 2006
Comments by: Michael Jameson

An original, valid portrait of ‘The Complete Doctor’ which is relevant to today and to medicine worldwide. Medicine led other self-registering and self-regulating professions in portraying ‘The Doctor’ of both sexes, and then did the same in portraying ‘The Good Doctor’. This lecture leads the rest of our profession in portraying ‘My Doctor’ as recognised by the patient without deference but with an understanding of the link between rights and responsibilities of consulting one. Well done. Now for family solicitors and parish priests to adopt these tested principles by improving the quality of care they provide for the people who trust them.

Date: 3 Dec 2007 4:49
Topic: The James Mackenzie Lecture 2006
Comments by: Jonathan Heatley, GP, Horsham, West Sussex

I loved your Mackenzie lecture in this weeks' BJGP. I entirely agree that boosting patients' confidence and self-esteem is one of the things we should do well if we are to be effective GPs. However, there is the subsequent problem of making patients dependent on us and this has been a constant conflict in my experience. Every now and again one has to remind patients that although we are free and sympathetic, they need to stop using us as a sounding board. If we have been too kind they take this very badly and this is the typical trap that catches doctors who are keen to be liked. It seems to be a more reliable practice to be a mixture of strict and kind and this really is a difficult balancing act that is hard to teach and must be learnt through experience. I have sometimes gone out of my way to be helpful/kind to someone I feel I have been too strict with, and its astounding the positive effect it has. They should not by rights be so thankful but by some quirk of human nature they are. On the other hand when a colleague who is kinder and more indulgent has to get stricter there occasionally follows a complaint.

Date: 2 Dec 2007 15:56
Topic: The James Mackenzie Lecture 2006
Comment by: John Sharvill

Thank you David Haslam for writing this. It should be compulsory reading for all NHS reformers, QOF points designers, GP registrars, and probably evidence-based gurus and lawyers. I particularly liked the illness/disease comparison and the digital/analogue contrast.

My muddle is though how can we have got into the current state with you at the rudder of the College? The little yellow boxes that pop up invading every consultation almost demand that patients now need to book a double slot. Firstly, to get the new contract bits sorted so that the practice can survive financially, then to see the doctor to discuss their problems. Please could you write a follow up with the solution?

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