Monthly Archives: March 2014

RCGP National Council Elections

The Royal College of General Practitioners National Council Elections will take place in April, with 6 places on the council being up for election. John Cosgrove and Martin Brunet will be standing for the election and would be very glad of your vote! Here are their manifestos:

MARTIN BRUNET

It has become increasingly apparent in recent years that the hallmark of General Practice –holistic, patient-centred care – is under serious threat. While policy makers play lip-service to the importance of the family doctor, their actions have led to a fragmentation of the NHS, loss of continuity in care and over-reliance on tick-boxes and targets rather than time spent listening to patients. For thirteen years I have fought this by small-scale disobedience in collaboration with my patients in the consulting room, but in the last three years I have felt the need to speak out, challenge the policies and try to help bring about change. The Royal College is one of the few bodies that seems to want to do the same, and were I to be elected to the Council I would work hard to help the College stand up for the principles of our profession, and the care of our patients.

I write regularly about issues in healthcare, both on my practice blog and a Pulse blog entitled Beyond the Headlines. Particular concerns are overdiagnosis, overtreatment and the need to reduce conflicts of interest within medicine. As part of a campaign to encourage the GMC to keep a register of doctors’ interests, I helped set up the website whopaysthisdoctor.org.

I am flabbergasted by how often a proposal will come from our leaders which will so obviously fail what could be called the ‘Sensible GP Test’ – that is: ‘If I asked an average group of sensible, coal-face GPs about this idea, what would they say?’ From the dementia DES, through GPPAQ, to removing practice boundaries via requiring practices to check the residency rights of immigrant patients, policy after policy has failed this test spectacularly and yet still seen the light of day. The dementia DES in particular, and the drive for early diagnosis without any proposal for extra support, has been ill-thought out both in terms of its practical application and its overall effect on patient care. I have been one of its most vocal critics, including writing in the BMJ and speaking at the RCGP annual conference last year. I have not always been in agreement with the College on this issue, and debated against the College dementia lead, Jill Rasmussen, at the National Dementia Congress last year; the large swing away from unquestioned early diagnosis among the conference delegates helped convince me that challenging these issues is important, and can bring about meaningful results. This is something I intend to keep on doing.

JOHN COSGROVE

How can we free up time for ourselves and our patients?

GPs as a profession must define for ourselves what is and what should not be our responsibility. For too long, society and politicians have directed to us whatever issues they cannot solve and then blamed us for outcomes beyond our control, whether it be A&E attendances, failing hospitals, “benefits cheats”, infant mortality or “missed diagnoses”. The result is widespread overmedicalisation, which we must reverse.

GPs should be the last resort for self-limiting illnesses, employment, relationship and emotional difficulties or primary prevention, not the first. We must restore this balance to survive in the face of an ageing population desperately in need of our medical skills. Screening and case-finding are no substitute for caring medical generalists.

RCGP should define appropriate practice, not lawyers, to allow GPs to continue to absorb risk and spare patients and the NHS from the harms of over-investigation and over-treatment.

Council must be transparent. New policies should be published for appraisal by all members before approval. This is essential if College is to engage with members and capitalise on their expertise to develop optimal policies, responsive to the needs of hardworking GPs. This will also strengthen Faculties, the life-blood of College, by enabling them to facilitate debate at the local level.

These are the principles which will guide how I will represent you at Council.

@DrJohnCosgove www.DrCosgrove.net/RCGP

NHS sight tests include unevaluated screening examinations that lead to waste

A salutary lesson from optometry on the pitfalls and costs of unregulated private screening by ophthalmologist Michael P Clarke in BMJ 19 March 2014

The Tyranny of Preventative Medicine

Exif_JPEG_PICTUREThe idea that we should aim to reduce the risk of developing an illness through preventative medicine is very seductive and highly political.

Preventative medicine has been around a long time. The writers of classical antiquity such as Hippocrates and Galen felt that a regimen that included plenty of exercise and a good diet promoted health.  As we found out more about diseases, it became clear that many could be prevented through avoiding what was clearly harmful, such as typhoid-infected water or cigarette smoke. Some infectious diseases could be prevented through vaccines. Public health measures such as improved sanitation and infant vaccination have arguably done more than anything else to improve the health of our population.

When we now talk about preventative medicine, we usually mean something rather different: modifying the risk factors that are associated with and may cause certain illnesses, such as heart disease, strokes or cancer. The growth in the technology of laboratory medicine has made it possible to measure many biological parameters, such as cholesterol and glucose levels, quickly and cheaply. The power of computers and the organisational abilities of large academic departments have made it possible to analyse enormous quantities of data to look for smaller and smaller associations between risk factors and illnesses. Modern researchers trawl through huge amounts of information in an effort to come up with something of significance. These results are often challenged and revised, so there is a constant ebb and flow of bewildering information, difficult for the doctor and patient to make sense of. We used to be exhorted to ‘go to work on an egg’. Eggs then became demonised as bearers of the deadly cholesterol, but now they help to combat Vitamin D deficiency and are not so bad after all. Whilst we worry about how many eggs to eat, the economic and social inequalities that are much more important determinants of health are largely ignored.  Politicians find it convenient to hand over the public health agenda to GPs in their consulting rooms, who are given the responsibility to interrogate their patients about their exercise, diet and drinking habits. Those most in need of help in these areas are trapped in deprivation, and struggle to make changes.  Major factors such as unemployment go unacknowledged, and interventions that could make a real difference such as minimum alcohol pricing are rejected.

The idea that we should aim to reduce the risk of developing an illness through preventative medicine is very seductive and highly political. It is thought to be more cost-effective to modify the risk factors in a population than treat the final condition, so prevention has become the paradigm in many countries. Politicians benefit because they think it saves money and looks as though they are caring. Pharmaceutical companies benefit from the huge expenditure on drugs to lower blood pressure, glucose and cholesterol. Academics and experts benefit from funding for research to bolster the claims. GPs are remunerated if they meet the targets for lowering blood pressure etc. So this alliance of vested interests pushes the preventative medicine agenda further and further as the goalposts are moved, definitions are broadened,  and new ‘conditions’ such as ‘pre-hypertension’ and ‘pre-diabetes’ are described.

Do the patients benefit? The effects are so small that it is often difficult to know. For example a Cochrane Review of treating mild hypertension ( as GPs are encouraged to do and rewarded for in the UK) in otherwise well people over a 5 year period showed that there was no significant reduction in mortality, heart disease or stroke – but 9% of patients treated experienced side effects. A similar study looking at statins to prevent heart disease in well people showed that 60 people had to be treated for 5 years to prevent one heart attack.  If you are that 1 in 60 then it probably would have been worth it. If you are one of the 59 then you would have had no benefit from the regular pill-taking, but could well have experienced side effects. We live in a society where people are so terrified of risk that many find it difficult to weigh up its significance. I recently saw a woman in her 80s who smoked heavily but who was worried because she put butter on her toast instead of margarine. The infinitesimally small risk associated with the butter was completely dwarfed by the huge risk from her age and smoking, yet she was so concerned by the warnings about the evils of butter that she was frightened about the harm that came from enjoying her breakfast.

The preventative medicine message is that danger and risk lurk in every uncorrected biological parameter and every bacon sandwich. The only salvation can come from embracing the benefits of modern drugs and repeated visits to the doctor. People have surrendered their trust in their own bodies as the miraculous self-correcting living organisms that they are and have become patients. In doing so they have lost something of their own humanity and human dignity.

Whilst all this has been going on, what about those people who really are unwell?  In an era of finite or shrinking resources they have become the second class citizens. GPs are busy managing risk factors that were never going to cause an illness, coping with side effects from drugs that were of no benefit, and chasing up well people for health checks that they don’t really need. Inevitably this means less time for those who really are ill. So, people with no health problems become patients and sick people whom doctors were trained to help are neglected.  Truly a victory for preventative medicine.

Dr. Jonathan Sleath is a GP in Herefordshire.

The difficulties of the delayed diagnosis for dementia in primary care

Originally posted on Living well with dementia:


If a surgery appointment is booked for someone over 65, a ‘participating GP’,  might be incentivised to ask about memory problems in a patient at risk of dementia due to heart disease, stroke or diabetes.

There is a concern that some people are missing out on a timely diagnosis of dementia.

It is claimed that some people go undiagnosed for around ten years even, and a large proportion of persons with dementia have never received a formal diagnosis of a dementia.

The concern is that people with much lesser degrees of memory impairment will be plugged into the system, according to Dr John Cosgrove.

At worst, this policy, where individuals are said to be ‘ambushed’ in the video above, may put people from going to see their GPs about other problems.

The risk factors, heart disease, stroke or diabetes, are not known to be risk factors for many types of dementia…

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