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Discussion Forum

Welcome to the BJGP Discussion Forum. Feel free to comment on anything that we have published recently, or to add to existing discussions. This is an open site, so please avoid abuse. Also we won’t automatically 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. 

 

 

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Clinical/general

 

Date: 29 Dec 2009
Topic: Response to 'Practitioners’ views on managing childhood obesity in primary care: a qualitative study’
Comments by: Professor Peter Schwarz, TU University, Dresden, Germany; Anne-Marie Felton, President, Federation of European Nurses in Diabetes; Dr Michael Hall, International Diabetes Federation – Europe

Turner et al showed that primary care practitioners are unaware of guidance provided by the department of health and NICE on the management of childhood obesity.¹ Even if GPs and practice nurses believed primary care was an appropriate treatment setting for childhood obesity, they questioned the extent, to which they could effectively intervene. Furthermore they felt unprepared to manage childhood obesity and perceived their efforts as ineffective.

 

The study raises important issues shared by other non-communicable disease (NCD) prevention/management initiatives. As a part of the European funded IMAGE project (Development and Implementation of a European Guideline and Training Standards for Diabetes Prevention - IMAGE), a European evidence-based and practice guideline for the prevention of type 2 diabetes including obesity will be prepared and will be freely available online and printed. Parallel to this, a curriculum for the training of prevention managers will be released in April next year. The IMAGE concept is that appropriately trained personnel can deliver efficient and effective prevention strategies to those at risk of diabetes. A similar approach may be effective for other NCDs, including obesity.

 

We are involved with IMAGE, a major EU sponsored multidisciplinary multinational project, which aims to address the prevention of diabetes through evidence-based guidelines which recommend interventions implemented by trained prevention managers. The project is reaching completion, courses for prevention managers are currently being piloted in several European centres, and a full report on the whole IMAGE project will be given at the World Diabetes Prevention Conference in Dresden in April 2010. Details can be found at http://www.image-project.eu/

Reference
1. Turner KM, Shield JPH, Salisbury C. Practitioners’ views on managing childhood obesity in primary care: a qualitative study. Br J Gen Pract 2009; 59(568): 856-862. View abstract online

 

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Date: 29 Dec 2009

Topic: Response to ‘The present state and future direction of primary care: a qualitative study of GPs’ views’

Comments by: Jim Newmark

 

As a former senior partner of twenty years and a salaried doctor of four, the conclusions of this rather interesting piece of research¹ are no surprise. We are left with the impression of smug partners and embittered salaried GPs. My sympathies are with the latter.

 

My plea is for those partners who are perhaps half a decade, or even a decade, away from retirement, to make the brave step of changing directions. Perhaps it is time to voluntarily step down to a salaried position? Why not act as a grandparent to our younger colleagues? To be happy to hold the baby while your sons/daughters are out shopping, but to be even happier handing him/her back at the end of the day for them to go through those sleepless nights. We are still there for advice, and are still going to be paid more than the vast majority of people in this country. We still have our savings, our paid-for house, our comfortable living. And now perhaps a chance to expand to do what we always wanted to do – hobbies or another field of medicine. What are you waiting for?

 

I know this because I did it. I have never regretted a second of leaving my well-established and increasingly successful practice. I love watching it expand and I think I actually would have held it back if I remained. We remain on friendly terms, and perhaps there is a bit of a feeling that it was my child, but it now needs to grow up. Meanwhile, I am learning and working in other areas of medicine that I never really knew existed.

 

Reference

1. Lester H, Campbell S, McDonald R. The present state and future direction of primary care: a qualitative study of GPs’ views. Br J Gen Pract 2009; 59(569): 908-915. View abstract online

 

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Date: 19 Nov 2009
Topic: Response to ‘Genes, gender, sport, and justice’
Comments by: Edoardo Cervoni
 
I totally share Peter Toon’s question on how should we judge athletes. Should this be based on the effort or performance? In fact, he quite correctly adds: ‘It’s not just genes carried on the XY chromosomes that affect performance; people with particular body types as a result of their genetic inheritance perform very differently in many sports ... Why should we accept these differences but not chromosomal anomalies?’.

 

We may argue that assessing effort is almost impossible and most certainly people are generally more interested in performances. Thus, performace should be the answer.

 

But then, it is also true what Peter says: ‘If stronger muscles result from an anomaly we can describe and name, we might consider this unfair and exclude the athlete; if it comes from a fortuitous combination of many genes, not all well understood, we may not’.

 

Overall, I think it would be fair assessing people based on performances and looking at their wellbeing above all. Ultimately, I am sure that performaces would drop should their wellbeing be compromised.

 

Reference 
1. Toon PD. Genes, gender, sport, and justice. Br J Gen Pract 2009; 59(568): 871. View title page online  

 

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Date: 18 Nov 2009
Topic: Response to 'GPs' views on the practice of physician-assisted suicide and their role in proposed UK legalisation: a qualitative study'
Comments by: Mr B Cosway, Mr D Arnold, Intercalated BSc medical students; Dr Iain J Robbé, Clinical Senior Lecturer, School of Medicine, Cardiff University
 

We would like to congratulate Hussain and White¹ for their paper regarding the views of general practitioners on physician-assisted suicide. We agree that this qualitative approach has filled what was previously a void in current understanding.

 

However, we do have concerns regarding the inclusion of only GPs who had a specific interest in medical ethics or terminal care. While we agree that a higher quality of data may come from GPs with these special interests than those who may have given the topic less thought, we question whether those without an interest in these fields have not considered their opinions regarding this current and controversial topic. Furthermore, if a revised bill is passed in to law then it seems likely that all GPs will play some role in the implementation. We therefore suggest a more typical sample of GPs would be required for a true representation of views.

 

We hope that research into this topic continues and we propose a quantitative analysis of the proportion of GPs willing to support the bill and the extent to which they would involve themselves in assisted suicide. This could then be expanded to other healthcare professionals that may be affected.

Reference
1. Hussain T, White P. GPs’ views on the practice of physician-assisted suicide and their role in proposed UK legislation: a qualitative study. Br J Gen Pract 2009; 59(568): 844-849. View abstract online

 

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Date: 8 Nov 2009
Topic: Response to ‘Health inequalities in the UK: remedy requires action beyond redistribution of wealth’
Comments by: Dr Fergus Dignan, Frampton Mansell, Gloucestershire

I read with great interest the article on health inequalities in the UK by Edin Lakasing¹ in the October edition of the BJGP, but I was surprised that no reference was made to 'The Spirit Level: Why more equal societies almost always do better'.²

 

Lakasing emphasises the main ailment of our society, that is the obscene wealth divide between the top 20% and bottom 20%, and he is right in saying that: ‘It is clear that there are limits to what medicine can achieve in redressing health inequalities’.
 
The Spirit Level describes the effect of widening wealth gaps in western societies. The UK and the USA have a 10-fold difference in income between the top 20% and bottom 20% and also have some of the worst parameters in the western world. Interestingly, the Scandinavian countries and Japan have the narrowest income gap and also the best health and social statistics.
 
What is this connection between income gap and societal health? The clue is in the title of the book. It is what happens to people’s spirits when they exist in an unequal society. I am not talking on a supernatural or religious level. I am talking about feelings of well being and personal contentment. One can imagine how someone on a sink estate in a major city feels when looking at the lives of the very wealthy. No chance of ever aspiring to that life, so why bother making any effort at all?
 
The solution therefore is to dramatically narrow the income divide in our society. No easy task, I know! I would commend all GPs, and other health care workers for that matter, to read 'The Spirit Level'.
 
References
1. Lakasing E. Health inequalities in the UK: remedy requires action beyond redistribution of wealth. Br J Gen Pract 2009; 59(567): 782-784. View title page online
2. Wilkinson R, Pickett K. The Spirit Level: Why more equal societies almost always do better. Penguin, 2009.

 

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Date: 8 Oct 2009
Topic: Response to ‘The Commercialisation of GP services’
Comments by: Tim Parkin
 
This interesting paper¹ discusses the award of GP service contracts to commercial organisations and the lack of evidence of the impact of this on value for money and quality of service. We believe our paper ‘Quality of care in a franchised GP group’² does present such evidence as applied to the awarding of contracts to existing local GPs. We would invite the authors to consider this information.

References
1. Heins Elke, Pollock AE, Price D. The commercialisation of GP services: a survey of APMS contracts and new GP ownership. Br J Gen Pract 2009; 59(567): e339-e343.
View abstract online

2. Parkin T, Orchard J, Parkin T. Quality of care in a franchised GP group. Br J Healthc Manag 2008; 14(11): 492–499.

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Date: 7 Oct 2009
Topic: Response to ‘London Allergy Show 2009: an exhibition of black magic’
Comments by Lindsey McManus, Education Executive, Allergy UK 

 

I would like to add my comment to this discussion on the London Allergy Show.  I work for Allergy UK, we are a Patient Information Organisation, a charity, backed by some of the leading experts in the field of allergy, and we cover all aspects of allergy.

 

When the Allergy Show first started we had stands there ourselves.  Sadly after a couple of years we chose not to continue, for exactly this reason. Although we may have been the 'voice of reason' at the show we did not feel comfortable being associated with the kind of exhibitors that you have mentioned.  We now know however that the show is in new hands and we have been in talks with them. Hopefully this will make a difference to future show.

 

What I would like to say is that if there are any GPs who would like any help or advice on Allergy please do not hesitate in contacting me at Allergy UK.  We do have an excellent education programme for Health Care Professionals alongside a wealth of information for members of the public. 

 

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Date: 22 September 2009

Topic: Response to ‘James Mackenzie lecture: Practice, politics, and possibilities’¹

Comments by: Dr Victoria Hartnell

 

Where is all the discussion? If ever there was a rallying call to the apathetic and apolitical, this is it. Is there any discussion between the RCGP leadership and the BMA leadership to co-ordinate ‘marketing’ of generalists? I am convinced perhaps by the humour as much as the clarity of the arguments, that Martin Marshall does the same job as me; not always a familiar feeling in this august publication.

 

Reference

1.  Marshall M. Practice, politics, and possibilities. Br J Gen Pract 59(565): 605–612.

View abstract online

 

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Date: 27 August 2009
Topic: Quo Vadis? Point of care testing: a patient’s perspective
Comments by: Francis FitzGibbon, Lisburn, County Antrim

UK government policy in recent years has been advocating and encouraging patients to take a more active role in managing their own healthcare. The outcome of the recent Lord Darzi review, High Quality Care for All, 2008 together with various other NHS policies like the IT initiative Connecting for Health, has supported the introduction of new technologies known as Point of Care Testing (POCT). 

 

Many of these devices can now be purchased by patients over the counter for home testing in high street pharmacies and even supermarkets. Whilst in the hands of a trained physician these devices may be useful in assisting a GP to perform a patient diagnosis faster, as a patient I am concerned that their use by untrained lay users may lead to more harm than good.

 

Interestingly, when I last visited my GP, I asked him whether the practice itself would use POCT more widely, apart from the usual dipstick tests, such glucose, cholesterol coagulation, and urine testing. He explained that POCT would not be further used in primary care for the following reasons:

1. Primary Care Trusts already have an arrangement with their local hospital based Pathology Service for carrying out patient test requests.
2. There is no available funding in primary care to cover the additional cost of POCT.
3. Due to the daily patient workload here is no available staff or time to carry out POCT more widely.
4. For more advanced testing and diagnosis GPs prefer to refer patients on to specialists outpatients clinics.

As a patient I can see the obvious benefit of having an earlier test result by POCT instead of having to telephone the GP clinic, a week later. If patients could be told their test results on the same day of their appointment they would prefer it, also presumably GPs would be able to make an earlier decision regarding their treatment.  In the light of these constraints, I wonder whether POCT will ever reach its maximum beneficial potential.

 

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Date: 12 August 2009
Topic: Response to ‘Do the Quality and Outcomes Framework patient experience indicators reward practices that offer improved access?’
Comments by: Dr John Orchard

 

This paper asks the wrong question.¹ The correct question is why do patient surveys not reflect improved access. Since 2003 we have taken over the management of two local failing practices. Despite achieving maximum clinical QOF points, providing instant access, myriad increased services, including increasing the medical and nursing staff by 500%, we cannot change patient perception sufficiently to reach target patient satisfaction scores.

 

A nearby practice has done nothing to change its attitude or accessibility but has moved into a LIFT centre: result, increased patient satisfaction. Patient surveys measure perception not performance and should be scrapped. Practices in deprived areas that require most funding to improve health care will be penalised by illiterate and uninformed patients: the same patients who fail to attend same day appointments in practice, urgent hospital out-patients, and who are verbally and physically aggressive to staff.
 

Reference
1. Baker R, Bankart MJ, Murtagh GM. Do the Quality and Outcomes Framework patient experience indicators reward practices that offer improved access?
Br J Gen Pract 2009; 59(565): e267–e272. View abstract online

 

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Date: 15 June 2009
Topic: London Allergy Show 2009: an exhibition of black magic
Comments by: David J Jackson, BSc MBBS MRCP, Department of Respiratory Medicine, Imperial College London

 

The 6th annual ‘Allergy and Gluten Free Show’ took place this weekend at the Olympia hall in London. Unfortunately, the majority of stands selling allergy tests and treatments were promoting products with as much in common with allergy as flying pigs has with swine flu.

 

For a small fortune members of the public were ‘tested’ for a range of allergies with machines measuring muscle energy levels, and told that spraying your skin with oxygen reduces an allergic reaction. Others were sold home blood test kits for measuring their Immunoglobulin G levels despite the fact that Immunoglobulin E is the most important marker of allergy.

 

Asthma sufferers were shown ways to cure their asthma through a series of manoeuvres with their thumb and finger described as ‘identical’ to the value of salbutamol. Thousands of the general public parted with their hard earned money on tests that have no biologic plausibility let alone an evidence base to them.

 

There was a deafening silence from the Department of Health who failed to provide a representative and in so doing ignored a fantastic opportunity to educate the public on a group of diseases that affects about 20 million of them.  Instead the public were educated by individuals with no understanding

 

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Date: 8 Jun 2009
Topic: Fairy Fabric Care advertorial
Comments by: Dr Nigel Walsh MRCGP

 

I am writing to you in regard to the ‘article’ by Dr David Atherton which appeared in the BJGP dated June 2009.* Dr Atherton is stated to be Consultant Paediatric Dermatologist at Great Ormond St. Hospital and is skincare advisor to Fairy Non Bio and Fabric Softener.

 

The ‘article’ seems to be an advertisement endorsing the use of Fairy Fabric Care products which he states have been evaluated for skin safety but have also been shown by the manufacturer to be as ‘gentle next to skin as clothes washed in water alone’.

 

Dr Atherton’s article includes a colour photograph of himself. I could hardly believe to read that an eminent physician at a teaching hospital would descend to promoting a commercial product in this fashion. The general advice on baby skin care is most informative but the juxtaposition of the product photographs is objectionable.

 

I note that the article is not stated to be an advertisement, that the products are not therapeutic substances (and therefore not subject to government regulations) but unlike other opinions in the journal there is no reference as to funding or competing interests.

 

I would be most grateful to receive your views on the ethics of such an article and whether Fairy Products paid the journal for this ‘advertisement’.

 

* Web Editor's note: the advertorial appeared on the back cover of the June 2009 issue of the BJGP.

 

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Date: 8 Jun 2009

Topic: Response to ‘The end of practice-based research?’ — craft innovation versus practice-based research

Comments by: Nigel Masters, GP, Highfield Surgery, High Wycombe, Buckinghamshire

 

I would like to contribute to the debate in the letters section about modern day practice based research.¹ As full-time general medical practitioner over 27 years I have been generating ideas and ways to help patients at the frontline of primary care. Some of these ideas which I refer to as a craft innovation have been used throughout the world to improve patient care, and some have been published in peer review journals. It may help to describe some of this work as it can slip across academic borders from time to time and so could then be considered proper clinical research.

 

While doing my GP training I developed the foot pump nebuliser² which has been widely used in the UK and world and it is still manufactured 27 years later.³ I wrote an article in Modern Medicine (now defunct) which resulted in an article in the Observer Business news and eventually a peer reviewed journal.⁴

 

Later I explored nebulised opiate delivery⁵ and the myth of medication caries.⁶ These papers explored issues of affecting everyday work: safety in drug delivery and whether medicines prescribing was causing tooth decay. Admittedly, at this time I was a part time lecturer in an academic department and this was helpful in providing some support for these papers. Further research explored housing design and mental ill health and this was published in the Journal of Psychiatry.⁷ Later I tracked the spread of hepatitis carriage through my Vietnamese patients which resulted in an editorial in the British Medical Journal.⁸

 

After I left my inner city environment and went for a normal shire county practice where I continued to try and innovate and improve patient care. In 2004 I won the national GP enterprise award and the BUPA communication prize for clinical indications on prescription. This work has never been peer reviewed but can be seen on the web⁹ and is widely used by many practices to inform modern medicine delivery. Our practice won a national award for holistic care of chronic obstructive pulmonary disease (COPD) patients in 2006¹⁰ and is delivering a COPD disease strategy across a collaborative of 33 practices.

 

New tools have been developed which include the world’s first smoking pack year calculator.¹¹ This website was launched in June 2007 and has over 200,000 calculations performed! The websites have been funded from prize money and are free to view. Just recently I have become once again a finalist in the GP enterprise awards for the croup calculator¹² a new exemplar for dose prescribing in children by increasing confidence and safety in prescribing dexamethasone for croup in young children. This dexamethasone calculator is free from me by contacting me at my email address.

 

This work is really a hobby and I have never received any academic funding which in any case might be difficult to obtain as I am not linked to any university department! Thus although my work is practice based it cannot be considered academic but at times and with support it can reach peer reviewed journals. I consider that this innovative craft seam at the primary care coal face is under threat and needs to be nurtured and I am grateful for competitions such as the GP enterprise award that try to highlight these hidden nuggets that can really benefit patients.

 

References

1. Murdoch JC. The end of practice-based research? Br J Gen Pract 2009; 59(558): 52. View abstract online

2. RCGP occasional paper 29. Trainee projects 1985: 42.

3. http://www.asthmarelief.co.uk/

4. Dunn AM, Darvell F, Wilson RSE. An evaluation of the foot pump as a driving source for nebuliser solutions. Br J Dis Chest 1985; (79): 172-176.

5. Masters NJ, Bennet MRD, Wedley JR. Nebulised morphine a new delivery method for pain relief. The Practitioner 1985; (229): 649-653.

6. Masters NJ. The Practitioner Medication Caries: a dental myth. 1987;(231): 56-64.

7. Birtchnell J, Masters N, Deahl M. Depression and the physical environment.  A study of young married woman on a housing estate. Br J Psych 1988; (153): 56-64.

8. Masters N, Livingstone A, Cencora V. Hepatitis B :prevention in primary care. BMJ 1989; (298): 908.

9. http://www.clinicalindications.com/

10. Tutt C, Masters N. Recording ‘pack years‘ aids assessment of risk and diagnosis of COPD. http://www.eguidelines.co.uk/

11. http://www.smokingpackyears.com/

12. RCGP News, June 2009.

 

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Date: 29 May 2009
Topic: Response to ‘Frailty: an emerging concept for general practice’
Comments by: Avril Danczak, GP, Manchester

 

Jan De Lepeleire et al¹ have highlighted a very important area in the assessment of older patients. I fully endorse their emphasis on the ways that frailty may be reversed. However, frailty can be a prognostic indicator that should alert us to other issues, such as effective planning for end-of-life care. Frailty can be useful as a component in the identification of an irreversible decline.

 

Patients and relatives often need clear information about this state, which is also crucial for carers (professional or laypersons). At the end of life, frailty increases and may alert us to:
* the need to stop active or inappropriate interventions,
* to plan the place of end of life care,
* to ensure proper symptom control,
* to stop the revolving door cycle of fruitless admissions that can mar the final days/weeks of some elderly patients,
* to prepare relatives and carers that death is approaching, and
* to help relatives/carers prepare for death and appropriate grieving.

 

I was a little disappointed that the paper did not discuss this area in more detail. We are already moving away from the idea that palliative care/terminal care only applies to malignant conditions. Death is, at some point, inevitable. Part of our duty to patients and carers is to ensure that death is managed appropriately and with dignity. We need better understanding of when frailty is irreversible as well as an optimistic and rehabilitative approach to reversible factors.

 

Reference
1. De Lepeleire J, Iliffe S, Mann E, Degryse JM. Frailty: an emerging concept for general practice. Br J Gen Pract 2009; 59(562): e177-e182. View abstract online

 

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Date: 6 May 2009
Topic: Website for GPs with colour vision deficiency
Comments by: J Anthony B Spalding, formerly a GP, UK. Barry H Cole, Emeritus Professor of Optometry, University of Melbourne, Australia. Fraz A Mir, Consultant Physician, Addenbrooke’s Hospital, Cambridge, UK.

It remains a common opinion in the medical profession that colour vision deficiency has little or no effect on the work of the doctor. In fact this is not true. There is now much evidence that doctors with this deficiency can misread colour codes and physical signs that involve colour and that they can be unaware at the time that an error has been made.

 

Advice is needed to avoid this situation. But the problem remains that there are few teachers with the knowledge to advise in the necessary detail. Advice is frequently inadequate or is not given. Some doctors may find their own way to adapt and, of course, those with a mild deficiency will be little affected

 

However, a website is now available that gives the evidence that confirms the above statements and this includes the previously unpublished comments of medical students with the deficiency. It offers advice to doctors, medical students, and prospective medical students who have colour vision deficiency. It aims is to explain how to be aware of the difficulties, how to respond to them, and how to make an informed choice of specialty. Access to the website is via: www.colourmed.com

 

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Date: 20 April 2009
Topic: The patient–doctor relationship: a synthesis of the qualitative literature on patients' perspectives
Comments by: Sarah Ryan

 

I am currently a sixth form student, interested in the issue of what patients consider to be a good doctor. In February this year I produced a questionnaire administered in a highly-regarded local general practice, to about 80 patients over 3 days, specifying that patients be selected for the questionnaire only if they had requested to see a particular doctor, and asking them to rate the attributes of that doctor and comment on what they valued in their relationship with the doctor.

 

The findings of my research broadly confirmed the conclusions of the Ridd et al article in the April BJGP.¹ However, in this area of research a finite conclusion is hard to come by. This may be due to humans’ intrinsic nature, as patients will always have their own opinions. The study of doctor–patient relationships is really a study of the way human beings interact, and although there are obvious professional boundaries, many of characteristics that the research concludes deepen this relationship (such as trust, understanding, equal participation, and loyalty) are congruent with any relationship. Maybe the key to a having a healthy patient–doctor relationship is for both sides to view each other how they would view any other person.

Reference
1. Ridd M, Shaw A, Lewis G, Salisbury C. The patient-doctor relationship: a synthesis of the qualitative literature on patients' perspectives. Br J Gen Pract 2009; 59(561): e116-e133.
View abstract online

 

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Date: 3 April 2009
Topic: Response to: ‘Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial’
Comments by: Jacqui Footman BA(Hons) PGCE, Information Officer, South Molton ME Support Group, North Devon

I am concerned that this article by Koch et al¹ may discourage GPs from thorough testing for patients with CFS/ME. At the ME Research UK conference in 2008 Dr Gavin Spickett, consultant leading one of the NHS specialist CFS/ME services, stated that significant numbers of patients referred to the service in fact turned out to have other (more treatable) conditions.

 

I have a particular and personal interest in this topic in so far as I languished under a diagnosis of CFS/ME for 4 years without further medical testing. I did receive what could be considered the best NHS care currently available for ‘CFS/ME’ but nevertheless in my prime at age 43 waved goodbye to a promising teaching/management career. I was subsequently found (sort of by accident) to have Crohn's disease, which had clearly gone undiagnosed for many years.

 

When lupus tests had come back negative, raised plasma viscosity tests had been ignored as unexplainable and few further tests done for several years. Now, some months on from an ileal resection (but after 5 years on Incapacity Benefit) I am eventually less disabled by fatigue. With testing, I recently discovered I also have osteoporosis and low Vitamin D. Many patients with chronic pain are being found to have low vitamin D, and what a simple thing to resolve once the test is done! How much better would my bone density now be if I had been tested and treated 5 years sooner?

 

I write to urge GPs to take testing and investigation more seriously and to avoid jumping to conclusions of somatoform illness, particularly when fatigue extends to CFS/ME, in order to help prevent further tragic and possibly avoidable losses. Most patient support groups recommend Health Canada's Clinical Guideline for help with this.²

 

References
1. Koch H, van Bokhoven M, ter Riet G, van Alphen-Jager JMT, van der Weijden T, Dinant G-J, Bindels P. Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial. Br J Gen Pract 2009; 59(561):e93-e100. View abstract online.

2. Carruthers et al. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols. J Chronic Fatigue Syndrome 2003; 11(1). Overview available at http://www.mefmaction.net/Patients/Overviews/tabid/122/Default.aspx

 

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Date: 1 Apr 2009
Topic: Response to ‘The contraceptive revolution’: slow progress in provision of modern contraception
Comments by: David Metson, Easthampstead Surgery, Bracknell, Berkshire

 

In Hannaford and Belfield’s recent editorial on 'The contraceptive revolution', they state that there has been some excellent progress but there was 'work still to be done'. ¹ One aspect of this is surely the implementation of the 2005 NICE guidelines which recommend greater provision of long-acting reversible contraception (LARC). ²

 

NICE stated that LARC methods were more cost effective than the combined pill and increased intake would reduce the number of unintended pregnancies. Action is needed to reduce the figure of 30% of births being unplanned and 200,000 terminations of pregnancy occurring annually in England and Wales.³

 

How are we doing? A Family Planning Association (FPA) survey in 2006/7 found that only 14% of women using contraceptives chose LARC methods.⁴  In contrast, the use of LARC is greater elsewhere; for example, in France 32% of contractive users choose coils.

 

In 2008, 90 randomly selected GP practices in the Thames Valley were asked whether they fitted LARC. Thirty-two (36%) practices replied. The number fitting IUCDs, IUSs, and implants was 14 (44%). A further nine (28%) practices fitted only IUCDs and IUSs, and 5 (16%) of practices fitted only IUCDs or only implants. Four practices (13%) fitted no LARC.

 

It is disappointing that 3 years after the NICE guidelines were published, less than half of the practices who responded to the survey were fitting the full range of LARC. Reasons given for not fitting LARC include 'the high risk of problems and complications' and one practice said they would stop fitting if funding was withdrawn.

 

It is surprising that fewer practices fitted implants than coils when implants need less skill to fit than coils. The new QOF points may increase provision of LARC but GPs will be rewarded for merely suggesting these methods and not actually fitting them.

 

This small study suggests that while there has been some progress in implementing the NICE guidelines, there is much work still to be done.

Reference

1. Hannaford P, Belfied T. The contraceptive revolution: some excellent progress but work still to be done. Br J Gen Pract 2009; 59 (558): 4-6. View abstract online

2. National Institute for Health and Clinical Excellence. NICE clinical guideline 30. Long acting reversible contraception: the effective and appropriate use of long-acting reversible contraception, 2005. http://www.nice.org.uk/CG030

3. National Collaborating Centre for Women's and Children's Health. Long-acting reversible contraception - the effective and appropriate use of long-acting reversible contraception. London: RCOG Press, 2005.

4. Family Planning Association. Newsletter Nov 07.

 

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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: Jun 2009
Topic: Is it time to say farewell to oxytetracycline and tetracycline?
Comments by: Angus Thompson, a former Prescribing Advisor from Somerset with an interest in antimicrobial prescribing; recently joined the Unit for Medication Outcomes Research and Education (UMORE), University of Tasmania, Australia.

For decades oxytetracycline and tetracycline have been part of many prescribers’ armamentarium in the fight against infection, but do they still have a role today?

 

Most often prescribed in 4 times a day regimes, requiring dosing on an empty stomach, away from milk, indigestion remedies, iron, and zinc which may impair their absorption — let’s face it, they are hardly the simplest of drugs to take effectively! In an era when promoting best practice in the use of antibiotics is a priority, continuing to use drugs where there is a high probability of poor compliance and consequently a risk of sub-optimally effective therapy seems rather irrational.

 

So if we do not use oxytetracycline or tetracycline, what would be used instead? If a member of the tetracycline family is indicated specifically, for example in acne or certain respiratory tract infections, then doxycycline is the clear alternative. With no need to take on an empty stomach or avoid milk, and its patient-friendly, concordance promoting, once-daily dosing; surely it’s a closed case?

 

But what about the budget some may ask? The implication being that as oxytetracycline and tetracycline have been around for decades they must be inexpensive. Certainly at just £1 for a week long course oxytetracycline is; but the same cannot be said of tetracycline which costs around £9 for the same quantity. This makes it significantly more costly than virtually any other oral antibiotic used in primary care these days, including doxycycline which is now similarly priced to oxytetracycline.¹

 

And what about microbiological appropriateness? The current version of the Health Protection Agency antibiotic prescribing guidance for primary care includes doxycycline in all those scenarios where a tetracycline is indicated.² Consistent with this is the statement in the British National Formulary that ‘microbiologically there is little to choose between the various tetracyclines…’.³

 

A further potential advantage of doxycycline is that, unlike oxytetracycline and tetracycline, it is not prone to accumulation in renal impairment and can therefore be used, with care, in this significant group of patients.

 

It would seem the only potential down sides to the use of doxycycline when compared to oxytetracycline and tetracycline are possible photosensitivity reactions and the need to swallow the capsules with plenty of water to reduce the risk of oesophageal irritation. But when considered against the other arguments to make doxycycline the tetracycline of choice, these are of modest significance.

 

In other areas of prescribing long established drugs have stood the test of time and in some cases found new niches, but in the case of the older tetracyclines, there would now seem to be a good case to drop them from our primary care formularies.

References
1. NHS Business Services Authority. Drug Tariff, January 2009. NHS Business Services Authority, Newcastle.
2. Health Protection Agency, London. Management of infection guidance for primary care, 2001 (reviewed June 2008).

3. BMJ Group and RPS Publishing, London. British National Formulary, Edition 56; September 2008.

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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.

 

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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:

1. 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.
2. 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.
3. 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.
4. 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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