Nothing to see here – General Practice serves our children well

20 Feb


February 19, 2013 UK readers awoke to the headline that NHS is failing the children. Why?

  • Kids with meningococcal disease are turned away rather than sent to hospital to be cured;
  • Children with asthma are not given adequate treatment;
  • Too many children are admitted to paediatric wards with minor illnesses
  • Doctors prescribe too many drugs which have not been tested on children
  • General practitioners do not have proper postgraduate training in child health

At face value such accusations are depressing. The accusations sully the credibility of GPs who are constantly berated for some failing or other every week in the Britain.

Here I hope to show that the accusations are baseless. General practitioners are fantastic physicians who can manage any patient in first contact doctor setting from cradle to grave.

Meningococcal disease in children

This myth perpetuated in the article that children are turned away is based on an article published in 2006 [http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)67932-4/abstract, accessed Feb 20, 2013]


Much has changed since that article was published. In any event the study makes no mention of the fate of the fatalities many of whom, one may argue, would have died anyway. Be that as it may, meningococcal disease is less common now Haemophilus influenzae type B (HiB) immunisation is universally available in UK.


Screen clipping taken: 20/02/2013 22:22

Nearly 70% reduction in cases since 2006 is attributable to the immunisation program. Given that millions of GP visits are children, the fact is the chance of any one GP diagnosing a case of meningococcal disease is vanishingly small today. Thus the hazard referred to is scaremongering. The British public deserve better information to make decisions about their kids who develop fevers and blanching rashes. Sadly a reputable charity, The Meningococcal Foundation perpetuates the hazard speculating there are nearly 3,500 cases of meningococcal disease annually in Britain. The figure for 2012 is 443 recorded cases, and many are adults.

Childhood Asthma

Asthma in children is a common condition. General practitioners diagnose the condition regularly. It is a core competency of MRCGP curriculum to diagnose, treat, and manage asthma.

What we cannot do is make parents give the treatment as often as may be needed. We cannot make children and teens take their inhalers regularly. Important risk factor for poor asthma control in youngsters include: parents/carers who smoke, overcrowding, damp, dusty environment. Prematurity is an independent risk factor for bronchial hyperreactivity/asthma. This is important with the upsurge in assisted conception and attendant increase in multiple births which often end in premature delivery of the babies.

Asthma UK does a good job helping people with asthma understand their condition and manage it properly, including an excellent section on inhaler usage.


Screen clipping taken: 20/02/2013 22:36

It is not doctors’ fault that many children have poorly controlled asthma and asthma-like conditions. People with asthma must take more responsibility for the correct management of this long term condition. Wringing of hands that doctors are not treating people with asthma properly perpetuates a State-controlled solution for every ill affecting individuals. This requires better reading comprehension, better education of children to take responsibility for their actions/conditions, and better access to online resources for everyone to improve information flow.

The story about asthma can apply to every long-term condition. There is not space here to enumerate many of the places to look for advice, though NHS Choices and BBC Health deserve wider readership at least in UK.

Minor illness admissions of children

It is a truism that all serious illness begins as minor illness. The trick is to spot which cases may progress. Doctors receive many years of training to learn how to spot the the worrying case. It is an art not a science in this. Suffice to say, like many of my colleagues, I will refer a child to hospital when I fear that worry will stop me sleeping at night about a particular case. This is, I know, not scientific, but when the hairs on the back of my neck stand on end, the child in front of me at that moment will be referred to see a colleague in paediatrics.

If one admits too few patients to hospital, too many unwell children will be taken to Emergency Department out of hours. If one admits too many children, there will be no space for the truly ill child referred by a colleague. All GPs know this. Yes some of us are high referrers while others are not. No-one has discovered what is the ideal referral rate. This is well known to the profession and health economists.

Therefore the accusation in the article is baseless.

Prescribing untested drugs to children

This is a specious argument. With the widespread availability of the British National Formulary for Children, there is a sound basis for prescribing for children in UK (and elsewhere). Yet another baseless accusation threatening to undermine the professionalism of the medical profession in its management of children.

Too few GPs have postgraduate child health training

This is baseless accusation too. General practice curriculum described by RCGP includes core competency in child health. Further, nearly 80% GPs have some postgraduate training in paediatrics before they complete general practice training (at least in UK) [personal communication from Doctors.net website].

Conclusion

The British public has a fantastic primary healthcare service which serves our children well. With a little bit of research it is obvious the article which prompted me to write this is full of inaccuracies and unfounded accusations.

19 Feb

A Better NHS

Frank

“Forgive is a verb, not a noun. Every day I try to forgive and hopefully move a little further down the road”

Marian Partington has been on that road for a long time. In 1973 her younger sister Lucy disappeared. She wasn’t found until 1994, when her dismembered and decapitated remains were discovered in the basement of Fred and Rosemary West’s house. It was another year until Marian and Lucy were reunited because her remains were needed during that time as an exhibit at the West’s trial. When at last they were together, Marian cradled Lucy’s beautiful skull in a brown blanket and kissed her forehead, just as she had cradled and kissed her own children.

That same year, Marian went on a silent retreat trying to get to the roots of her own forgiveness. The first thing she experienced when she arrived home was not serenity or acceptance, but…

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A personal response to the Francis Report (Part 1)

7 Feb

Form filling and tick boxes

Do Not Attempt Resuscitation [DNAR] Form

Background

End of life care is an important part of primary health care and general practice. There are strong ethical and moral arguments going back to biblical times to refrain from postponing inevitable death with futile treatment. For example, consider patient who is 93 years old and no longer recognises anyone because of dementia, and is always curled up in bed and seems to survive on vapours only because feeding is challenging. When this poor person has a cardiac arrest it is not ethically right to commence CPR.  Common sense supports this attitude too. However in our ever increasing secular world with fear death such a patient as this is too often treated aggressively because of fear of upsetting a relative. To avoid such conflict, “DNAR” orders now prevail throughout the health service.  The Liverpool Care Pathway for End of Life tells us how to use the DNAR properly because there have been concerns about abuses.  A standard form has been developed in NHS to further reduce any misunderstandings and permit even better deaths with fewer futile resuscitation efforts.

Figure 1

Source – Mt Vernon Cancer Centre

The problem – another form

The mission creep with forms should not countenanced.  We have enough to worry about without the insistence by jobsworths that their form MUST be used for whatever it is they are responsible for.

Doctors, especially General Practitioners already have allowed ourselves to be forced to use official forms for suspected cancer, chest pain clinic referrals, district nurse referrals, hospital transport requests, community COPD clinic, community diabetes clinic, dermatology Clinical Assessment and Treatment Service and many more.

I believe any referral a doctor writes the words matter more than whether or not they are written on a particular form. The words on a sheet of paper and signed by the doctor is a legal document.  In my opinion, anyone who fails to act on our request is interfering with patient care and ought to be penalised. This is supported by GMC guidance “Good Medical Practice: Duties of a doctor”.

Figure 2

Source – GMC Guidance on Good Medical Practice

Who or what will stand up for doctors to halt the onslaught of forms from all directions before my profession drowns under the weight and has even less time to do what doctors do best which is assess people who come to the Doctor for help with clinical problems?

My concerns are covered by Recommendation Number 5 of the Francis Report

Figure 3

Source – The Mid Staffordshire NHS Foundation Trust Public Inquiry

The Francis Report is nearly 1700 pages long; it was published on Wednesday 6th February 2013.  The Inquiry is established under the Inquiries Act 2005 and is chaired by Robert Francis QC, who will make recommendations to the Secretary of State based on the lessons learnt from Mid Staffordshire.  It will build on the work of his earlier independent inquiry into the care provided by Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009.

The doctor will see you now… if you are truly ill.

31 Jan

Why is everyone scared of missing cancer? [BBC Radio 4 PM, 30-Jan-2013]
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Personally public needs to (wo)man up and face the fact we die. And most of us die from heart disease or lung disease.

Doctors know, though many politicians and public do not, that early diagnosis of cancer often fails to prolong life of patient. For example, read Prof Baum opinion about breast cancer screening

Medical industrial complex loves us diagnosing cancer early because lots of tests, procedures, and drugs will be thrown at the poor patient for “extra” disease free months/weeks. Has anyone stopped to check the ROI for the vested interests in the management of people who are diagnosed early?

Meanwhile, earlier diagnosis of depression may be useful though you know that many people with “affective disorders” and other psychiatric c condition’s are also a construct of the medical industrial complex – DSM V is an opportunity to medicalise more situations that are part of normal living.

Perhaps, earlier diagnosis of erosive arthropathy may have benefits for sufferers. This population of patients is tiny compared with cardiac and respiratory and psychiatric patients.

So to cardiac and respiratory disease.  If the politicians are to be believed, people with BMI 19-25 who never smoke will not develop heart or lung disease.  This is magical thinking. One patient at my cardiac rehabilitation class who was thin, young, with cholesterol < 4 and no family history of heart disease, and never smoked.  Apparently cardiac rehabilitation clinics see significant number of such people.

Sadly there are a large number of people with chronic lung disease who never smoke – many of these people have asthma. Even with good inhaler use and compliance, many of these people will develop COPD which is supposed to be a disease of smokers only.

So in spite of the propaganda, seeing your doctor at your time and choosing is actually not going to save your life.  Remember healthchecks are useless. Thus, the media and many public voices should stop whinging about access to primary care and GPs.

4 Jan

Great work again from the pen of @skwalker1964 Wonder if Charity Commission could/would revoke the charitable status of REFORM. Evidently it is not a neutral organisation with 2 important members now Tory MPs!

The SKWAWKBOX

One of the things I’ve come across during the recent FOI information I’ve been working through was a reference by the South West pay-cartel’s ‘Communications Lead’ to a paper by a ‘think-tank’ that supports its position:

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Here’s the full wording of the press release. It’s not exactly light reading, but I encourage you to read it, as it’s important for understanding just how the Tories really view the NHS – and the depths of deceit to which they’ll stoop in order to have their way with it:

A “glaring contradiction” in Government policy is hindering its efforts to improve the NHS, according to a new report by the independent think tank Reform. Its wish to achieve a higher quality and more efficient NHS is undermined by its support for national pay agreements for all NHS staff. Instead Ministers should give full support to those NHS organisations, such as the South West Consortium, which 

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2012 in review

3 Jan

The WordPress.com stats helper monkeys prepared a 2012 annual report for this blog.

Here’s an excerpt:

600 people reached the top of Mt. Everest in 2012. This blog got about 2,700 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 5 years to get that many views.

Click here to see the complete report.

2 Jan

An interesting meeting in July 2013 via @DeborahBowman call for papers

Centre for Medical Humanities Blog

Philosophy and Psychiatry: the Next Hundred Years
The St Catz Colloquium
Making Change Happen
St Catherine’s College, Oxford
July 25 and 26, 2013

As the third of three forward-looking symposia marking the centenary of Karl Jaspers’ General Psychopathology, the St Catz Colloquium is now open for expressions of interest and submission of abstracts.

The St Catz Colloquium will examine key aspects of how philosophy and psychiatry working together can make change happen. There will be four main sessions over two days

  • Making Change Happen in Philosophy
    The first session will explore how policy, research and practice in mental health, including first hand narrative reports of people who use services, can support research in philosophy
  •  Making Change Happen Nationally
    The second session will present the other side of the coin: it will explore through a series of case studies how philosophy can influence policy, research and practice in mental health

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29 Dec

Thank you to Nick Bennett [@peds_id_doc] Assistant Professor in Pediatric Infectious Disease for permitting me to repost here.

The message:  many febrile illnesses in our [Western – developed country] community are due to viruses for which there are generally no effective treatments. If you or your children have a fever it may last up to three weeks and this is not affected by the use of oral antibiotics. So, in almost all cases treat the symptoms – fever control, pain management, light diet with plenty of fluids. [A Cochrane review for basis of this approach in case of respiratory tract infectionshttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004417.pub3/full]

culture and sensitivity

I joke that, as a Peds ID doc, it is my duty to say this at least once a day…

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Ok, I may not literally be slapping people upside the head, but there are certainly times when I’m doing it in my mind. The situation is common enough – a patient, parent or doctor, faced with symptoms consistent with an infectious disease, considers using antibiotics to treat bacteria. After all, we know that bacteria kill people, right? But in many of these situations the patient really has a viral infection – and viruses aren’t affected by antibiotics. So at the very least we’re wasting money and drugs. Worst case scenario? We’re promoting drug-resistant bacteria, antibiotic allergies and side effects – that in some cases can be life-threatening.

But aren’t there clues to help us make the distinction? Real clinical signs and symptoms? Well, lets review a few.

White pus on…

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Ensuring Physicians’ Competence — Is Maintenance of Certification the Answer?

27 Dec

 “Pressed by their leaders, external stakeholders, and a public troubled by lapses in the quality of care and unsustainable cost increases, physicians are facing stiffer challenges in initiatives designed to link more closely the goals of learning with the delivery of better care and measures of greater accountability… ”

So begins Ensuring Physicians’ Competence — Is Maintenance of Certification the Answer? in this week’s issue of NEJM .

While the essay focuses on US system of reaccreditation, the opening remarks could apply to any (Western) healthcare system which desires its doctors to deliver best possible healthcare to citizens with greater accountability for the medical profession.

I want to know how my leaders allowed the demise of self-regulation to occur after several hundred years of autonomy.

Why does the author of the article believe there is no chance the medical profession can return to less fettered self-regulation?

Is it really in the public’s interest for politicians and healthcare payers to control medical profession ever more tightly? Is the cost for such regulation really affordable?

It is my opinion, that the majority of doctors are self-directed learners who perform better under less scrutiny rather than more. Healthcare innovation may well be stifled by the drive to tighten regulations for physician practice.

This is apparently a global phenomenon at least in the rich countries with managed healthcare systems. National medical bodies may need to work together to fight this threat to the effective care of our patients.

The increasing threats to independent practice and the profession of medicine are contrary to the human values in healthcare that is at the heart of what we do.

NHS will order doctors to work at weekends

16 Dec

ImageHere is a list of my objections to the proposal by Commissioning Board medical director Sir Bruce Keogh announced in today’s Sunday Times for general practice in UK to be open for business at weekends

 

 

  1. For GP, it may be practices, not doctors ordered to be “open”
  2. Cannot see this working unless adequate resources released to pay the support staff, let alone the extra doctors. And the support staff will need to agree to work too!
  3. Will not be helpful for patients unless hospital services are also fully open for business when we are. At least Bruce Keogh understands this
  4. The idea that this is necessary is politically driven and not based on evidence. Accept that some areas may benefit from this (e.g. inner city populations) but rural areas and leafy suburbs unlikely to benefit.

It would be better to spend the money on a EHR which OOH GPs can access at any time (and write in!) – allows centralised OOH service allowing those who wish to work unsocial hours to do so.

In short, the proposal should be strongly resisted at the present time. Doctors (and nurses) need to be nurtured not threatened to get the best from us!

Finally, does the public really want their GPs to be available 7 days a week?

Illusions of Autonomy

Where medical ethics and human behaviour meet, by Dr Philip Berry

Enjoying every second

Cada lugar, cada rincón, cada momento compartido arreglando el mundo entre imprescindibles

The Commonplace Book

Jim McManus blogs on public health, ethics, books, theology and more