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Election Time

Well I’m standing in the RCGP National Council elections. There are 20 candidates for 6 places, and the rest of them are a pretty impressive bunch – I’m in serious need of an election strategy.

I have had a think about this and decided the obvious thing to do is to find something clever I’ve written about a popular, vote-winning cause and remind you of my great eloquence and wisdom – job done; I could clock off early with the briefest of blogs and you could get back to whatever you are supposed to be doing, relieved that you need worry no more about how to cast your vote. Only I’m having trouble finding anything.

It’s not that I haven’t said anything clever or wise, of course. I’d be the first to admit how wonderful my writings really are, it’s just the pesky comments that have been left show that other people don’t always see it that way. There’s my erudite pronouncements on Government dementia policy, for instance. This is certainly popular (well it’s always in the news anyway, and most GPs I know are less than enamoured with ill-thought out policies like the dementia DES), and I thought it was pretty good, but someone else decided I was corrupting young minds through teaching such nonsense to GP trainees on our VTS scheme – now that’s hardly the sort of person you’d want on the National Council, is it?

Then there’s the whole issue of immigration. If I’d stuck to a rant about GPs not being an outlet of the border agency and how we had better things to do than check someone’s immigration status I’d have probably got away with it, but I did have to go on about the ethics of the whole thing and the immigrant’s basic right to healthcare – the comments testify to my naivety. Let someone like that on the Council and the nation would go bust within 6 months; we all know deep down that health tourism was the single biggest cause of the crash, after all.

As for the post on declarations of interest and the crazy idea that all doctors should have to provide a public declaration on a GMC website – it could have been a real winner if only it were patients who were voting and not doctors. It has too much of a turkeys-voting-for-Christmas feel about it to get me elected. No-one left a comment on that one – perhaps raising an objection in public only draws attention to yourself, or maybe no-one was that bothered. I have a sneaky feeling, though, that most GPs are far too busy with the strain of general practice to have time to develop a conflict of interest even if they wanted to – so maybe this wasn’t such a vote loser as it first seems.

Saying we should campaign for prisoner rights won’t cut it – prisoners, almost by definition, are not on our lists; arguing that we really should consider the idea of e mailing our patients – that’s not going to help (although I did say Skype was a crass idea, so maybe I’ll get half a vote for that); as for defending the LCP, that was a classic case of sinking with a lost cause – even the greenest of politicians would have seen the writing on the wall and told me to get out quick before I was damaged by association.

With extensive scouring through the archives proving so fruitless, I was about to give up when I remembered this: it’s called 10 Minutes for the Patient, and I think it works. Maybe you’ll take the time to read it and you’ll agree with me that we need to keep the presence of the Health Secretary out of the consultation so that we can get on with really treating the sick. Maybe you’ll think to yourself, ‘this Brunet bloke – he’s a bit naive sometimes, bit of an idealist, not really grumpy enough for a good blogger, but you know, he’s not too bad – we could do with a bit of new blood on the RCGP to liven things up, perhaps he’s worth a punt after all.’

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…

View Original 421 more words

Community Pharmacy – so tell me why?

John Cosgrove John Cosgrove:

Mark Robinson suggests that community pharmacists have a key role to play in managing demand and therefore reducing overtreatment.
Whether demand for healthcare services is increasing because of changes in illness behaviour or solely because of an ageing population with greater healthcare needs is a matter of debate. The blame game is not helpful. Managing demand rather than fuelling it, however, is essential.

[The re-blogged version of this piece seems to have been truncated, so do please make sure you click through to the original]

Originally posted on themmpblog:

There is so much talk about community pharmacy we are again in trouble not seeing the wood from the trees. Integrated here and integrated there, vital roles and changing care models are all the rage. Sometimes I am not sure where community pharmacy sits, who they ‘face’ and what they are a part of.
But it might be helpful to explain to managers some of the issues that they really face and where they might sensibly use community pharmacy – ‘the healthcare professional on the high street’.

The NHS is in a tizzy – demand is increasing and activity is brutal. Bursting at the seams and not going to get any better in the near future. To the positive some services like stroke have been a success, but that is about bypassing all of the tosh and taking people straight to where they get the best intervention. I can’t wait to see the results of the urgent elderly assessment centres – you just know it makes sense.

The world and their aunty, however, are talking about additional services and very few people are talking about people – with the exception of Jeremy Taylor who is pushing his water uphill. The NHS England managers are fixated on doing more for less as a mechanism of retaining the hordes – rather than about changing the world. It is totally wrong – you should be looking to do less, better.

View Original

10 Minutes for the Patient

Mr Jones comes to see me. He is only 62, but has high blood pressure, had a stroke two years ago and still has a noticeable limp as he walks down the corridor to my room. Like most patients, Mr Jones knows that he has 10 minutes for the appointment and has spent the time in the waiting room wondering how best to use it. His knee has been bothering him for a while and he has decided it is time to bring this to my attention, but he also knows that his review is due and he won’t be able to leave my room without having had his blood pressure taken.

What Mr Jones really wants to talk to me about, though, is that he’s been having trouble maintaining an erection. He’s not quite sure how to broach that subject, so he plays safe, taps his knee as he sits down and opens with ‘It’s this, doctor. Giving me some trouble, that’s the main thing.’

Like any good GP I clock that if the knee is the main thing then there must be something else as well, and make a mental note to come back to that later – but his blood pressure check is flashing on my computer screen, vying for my attention.

The clock

Steve Grosbois via Compfight

We talk about the knee for the first minute of the appointment, and then I reach for the blood pressure cuff. There is a good reason to tackle this first, since getting him up onto the couch to examine his knee might adversely affect the reading. The numbers are the same as last time – 145/85 – which is a bit awkward, as six months ago this was ok, but in the meantime the Government has changed the goal posts. Now the target is to get blood pressure below 140.

2 minutes

We spend a couple of minutes talking about this, discussing his medication and why we might need to increase his treatment. Since he’s not keen on extra medications – and I’m not convinced about the new target – we decide that he will borrow one of the practice machines and check his blood pressure at home. I wonder if I have just put the problem off for another day.

4 minutes

The amended blood pressure target is not the only new directive to be imposed by the Department of Health this April, so there are more boxes to tick before we can get back to the knee. There’s the new activity questionnaire for starters. Making some assessment of exercise has its place, but I am now required to ask the same questions of all patients with hypertension, however appropriate – or not – it might be. It seems wrong when I ask Mr Jones how much vigorous exercise he undertakes, and he becomes defensive when I enquire how many hours per week he spends doing housework, but we battle through. The advice we receive on the administration of the test states that it takes 1-2 minutes to complete; by the time I have added advice to do more exercise, and received the inevitable reply that this is not easy with only one good leg, that’s a fifth of his appointment.

6 minutes

We return to more familiar territory – I need to ask about smoking – we both know we’ve been here before when I ask if he’s still smoking. He shakes his head and replies: ‘Not the right time, doc.’ The expression on his face asks why I keep going on about it, when he’s made it quite clear he has no intention of giving up.

‘Have you any concerns about your memory?’ Mr Jones is a little taken aback, as he’s not heard this one before, but he is in an at risk group for dementia and so this is the question I am required to ask. It could only taken a moment – a simple ‘no’ and we move on – but who doesn’t sometimes forget things? Mr Jones sometimes goes into a room and forgets what he has gone there for – is that what I mean? It takes a little while to explore this further, before we both decide that he is not showing early signs of dementia. He taps his knee.

8 minutes

There’s a blood test to sort out. He’s on a statin for his cholesterol, and although the guidelines I read tell me not to perform regular cholesterol checks once treatment is stabilised, the GP contract insists that I check it annually. Still, I like to keep an eye on his kidney function so it’s not entirely wasted. The forms take a while to print out.

‘Do I have to fast?’

‘No, that’s ok’

9 minutes

There’s not enough time to get him up on the couch to examine his knee properly, but I know he’ll need an x-ray to look for arthritis so I do a quick examination in the chair and print another form for him.

10 minutes

I have forgotten that the knee was only the main thing and make it clear that the consultation has ended. Mr Jones leaves with the forms. He’s happy with the x-ray, but he’ll have some explaining to do for Mrs Jones when he gets home. He’ll say the doctor was very busy and promise to ask next time.

The 10 minutes belong to the patient.

We need to give them back.

Mr Jones is not a real patient, but I know of many who share some of his frustrations.
 
This post has been reblogged from The Binscombe Doctor Blog

Why case finding and screening are one and the same [5 min]

Peter Gordon explains clearly and logically in this 5 minute video why case finding and screening are in fact one and the same.