Tag Archives: Health

Access to General Practice and Emergency Department attendance in UK. A link to poverty?

16 Jun

The paper from Imperial College evaluating Emergency Department use with reference to access to a General Practitioner during the year 1 April 2011- 31 March 2012 here in England caused a small storm when it was published last week (June 13, 2013). At face value, the results play into the Government’s narrative that GPs are lazy, do not see enough patients, and Emergency Departments are overwhelmed by honest citizens who were not able to see there GP at the time of their choosing (Cowling et al, 2013). The perception was propagated elsewhere, including the fledgling The Conversation UK .

Here are some reasons why the conclusions are flawed in my opinion.

  1. The General Practice Access Questionnaire surveying the percentage of people who stated that there was poor 48 hour access to see their general practitioner is widely discredited by general practices as bearing no relationship to the reality of access to their practices
    1. Too few non-British respondents compared with true practice profiles (84.9% white) and relatively too many men (49.8%) compared to usual pattern of GP utilisation
    2. Many respondents actually have no idea how their own practice operates, this particularly true of male patients who use GP infrequently.
    3. No stratification for illness episodes people felt required 48 hour (or less) access to GP
    4. No effort to look at patient outcomes from failure to see GP within 48 hours.
    5. < 4% practice population completed the forms which is arguably too low to be meaningful (2 million respondents of population of 56 million)
  2. Hospital Episode Statistics ED minimum dataset too simplistic
    1. No detailed disease code for reason for attendance
    2. No outcome data as a result of (a)
  3. Indicator variables for the Strategic Health Authority in which a general practice is located were included to account for unobserved variation in regional health system characteristics and policy. This is too crude to assess pockets of deprivation which every practice has, and some more than others.

Cowling et al observed that

The median percentage of a practice’s registered population that had tried to see a GP within two weekdays in the past six months was 59.3% (IQR: 54.9–63.6%). This demand was not always met: the median percentage that was subsequently able to do so was 82.0% (IQR: 74.0–89.3%).

You must keep in mind that this number refers to the GPAQ results, not actual numbers. The GPs I know do not recognise the result as properly describing the access to their practices.

In their discussion

In 2011-12, 9% of respondents to the GP Patient Survey who were unable to obtain a convenient appointment on their last attempt report subsequently going to an ED or walk-in centre, which accords with the results of our analysis.

Which simply validates their dataset rather than really telling us any more about the reasons for the behaviour.

And Cowling et al are dismissive of data which does not support their thesis suggesting to me that their minds were made up before this statistical paper was completed and the data have been made to fit the narrative.

Previous research of 68 general practices in London, England did not identify a statistically significant association between patient-reported access to general practice services and the rate of self-referred discharged ED visits, possibly due to insufficient statistical power. This explanation may also apply to a similar analysis of 145 practices in Leicestershire, England, which included all types of ED visit in the outcome variable.

Referring to North America data on GP access is not helpful because there is not universal coverage for primary health care like here in UK. In fact, it can be argued that the data confirms poverty and low social class as determinants of unplanned hospital (e.g. Emergency Department) use.

Looking at some common conditions which may influence ED

the prevalence of obesity in the registered population had a statistically significant positive association with the rate of ED visits (RR = 1.006; P = 0.021), whereas the prevalence of asthma and hypertension did not

indicates to me that the population who filled in the GPAQ do not properly represent disease prevalence or people who attend the practice regularly do know how to access their GP promptly and do so successfully. This mocks the conclusions of the study.

The results of this study do not support the hypothesis that timely access to GP could reduce self-referrals to the Emergency Department. What the study tells us is that some white English people cannot be bothered to wait to see their GP for self-limiting conditions. There is some evidence supporting the view that self-referral to Emergency Department is associated with low social class, poor education, and poverty. This is inferred from the observation that obesity has a positive association with ED attendance; obesity is closely linked to unfavourable social factors http://www.guardian.co.uk/news/datablog/2013/jan/23/fact-checking-obesity-poverty-link This is exacerbated in the current economic climate and further worsened by a Government pushing much and more onto General Practices since 2004 a lot of which is clinically useless. For example, Health Checks, GP access initiatives, ambulatory blood pressure recording to diagnose hypertension, routine reviews of people with long term conditions who are stable.

I believe part of the problem of perceived poor access to see a GP has been created by the UK Government fanning flames of expectation by the worried well. Practices must make more routine appointments available for people with long term conditions, must not turn away anyone who wishes to be seen in hours, and can no longer depend on expert community nursing to help out. Finally, the hardships many of my patients face in their living conditions because of unscrupulous landlords and local authorities turning blind eye to the tenants’ grievances is exacerbating the problem.

The paper by Cowling et al does support the Government’s assertion that General Practice and GPs are not working hard enough. It is clear to me that the research is flawed and the main conclusion is unfounded.

June 2013


Underactive thyroid disease – a modern approach

9 Jun

The Problem

A patient comes to the doctor concerned about longstanding fatigue symptoms. She knows of a family history of underactive thyroid disease and is worried her thyroid is not working properly

Introduction and some basic concepts

[from Basic endocrinology : for students of pharmacy and allied health sciences, edited by Constanti et al (1998; ISBN 9780203301739) ]

The thyroid gland lies in front of the trachea below the larynx. The hypothalamus and pituitary control normal secretion of thyroid hormones. The thyroid hormones in turn control the body’s metabolism. The two active hormones are iodinated derivatives of the amino acid tyrosine. Nearly 90% of the output is thyroxine (T4) containing four iodine atoms while nearly 10% of the output is triiodothyronine (T3) containing three iodine atoms. In health < 1% “reverse” T3 (rT3) is released; this increases in presence of severe illness or starvation. In the bloodstream the thyroid hormones are extensively bound to plasma proteins, principally thyroxine binding globulin (TBG).

Note that in patients on T4 replacement all T3 is produced by peripheral conversion, and so circulating T4 levels may need to be maintained slightly above the “normal” reference range to generate adequate tissue T3 concentrations.

So far so good that is what medical students and other healthcare professionals have been taught to decades. The thyroid stimulating hormone from the pituitary goes up when/if thyroid hormone levels too low, and vice versa.

However this is not the whole story. A more detailed appreciation of the nuances of thyroid hormone metabolism are required to appreciate why so many people with underactive thyroid disease continue to struggle to regain normal health. For example, the story of Coralie Phillips and Donna Roach gives pause for thought about one of the most neglected conditions in general medicine http://www.thyroidbooks.co.uk/ .

Underactive thyroid disease (UAT) is considered simple to diagnose and simple to treat. Luckily this is the case most of the time. Unfortunately when the approach does not seem to be working effectively patients are labelled as difficult or dismissed as mentally ill instead. The medical establishment generally has failed to treat people with UAT scientifically by looking at factors which may conspire to prevent the neat outcome which is expected.

The purpose of this brief essay is to highlight these pitfalls in the hope that fewer people with UAT will suffer in future.

Modern thyroid hormone biochemistry

Role of vitamin D

It seems that adequate levels of vitamin D are necessary to maintain thyroid health.

For example (http://www.endocrine-abstracts.org/ea/0032/ea0032p1008.htm): In this study of 100 patients with autoimmune hypothyroidism compared to 100 subjects as control group, the higher vitamin D deficiency rates besides lower vitamin D levels in the Hashimoto group together with the inverse correlation between vitamin D and anti-TPO suggest that vitamin D deficiency may have a role in the autoimmune process in Hashimoto’s thyroiditis.

Conversely, some evidence emerging that high levels of T3 may suppress vitamin D levels (e.g. http://endo.endojournals.org/content/154/2/609.short) This may be one mechanism for bone losing state of untreated hyperthyroidism (or over-treatment of UAT)

Role of vitamin B12

A new abstract summarises the impact of low vitamin B12 on thyroid disease (and other [geriatric] conditions http://www.bioline.org.br/abstract?rc13008):

Vitamin B12 deficiency is a common condition in the elderly. It is repeatedly overlooked due to multiple clinical manifestations that can affect the blood, neurological, gastrointestinal, and cardiovascular systems, skin and mucous membranes. The various presentations of vitamin B12 deficiency are related to the development of geriatric syndromes like frailty, falls, cognitive impairment, and geriatric nutritional syndromes like protein-energy malnutrition and failure to thrive, in addition to enhancing aging anorexia and cachexia. Therefore, interventions must be developed to include their screening and diagnosis to make early and appropriate treatment to prevent its complications before they become irreversible.

Role of trace minerals

A detailed overview of heavy metals by a nanotechnology team illustrates how important optimising the levels can be for cellular health and ascorbic acid/Krebs cycle [http://www.ijsrp.org/research-paper-0413/ijsrp-p16110.pdf]

Iron (Fe) Contained in hemoglobin and myoglobin which are required for oxygen transport in the body. Part of the cytochrome p450 family of enzymes. Anemia is the primary consequence of iron deficiency. Excess iron levels can enlarge the liver, may provoke diabetes and cardiac falurer. The genetic disease hemochromatosis results from excess iron absorption. Similar symptoms can be produced through excessive transfusions required for the treatment of other diseases.

Copper (Cu) Contained in enzymes of the ferroxidase (ceruloplasmin?) system which regulates iron transport and facilitates release from storage. A structural element in the enzymes tyrosinase, cytochrome c oxidase, ascorbic acid oxidase, amine oxidases, and the antioxidant enzyme copper zinc superoxide dismutase. A copper deficiency can result in anemia from reduced ferroxidase function. Excess copper levels cause liver malfunction and are associated with genetic disorder Wilson’s Disease

Manganese (Mn) Major component of the mitochondrial antioxidant enzyme manganese superoxide dismutase. A manganese deficiency can lead to improper bone formation and reproductive disorders. An excess of manganese can lead to poor iron absorption.

Iodine (I) Required for production of thyroxine which plays an important role in metabolic rate. Deficient or excessive iodine intake can cause goiter (an enlarged thyroid gland).

Zinc (Zn) Important for reproductive function due to its use in FSH (follicle stimulating hormone) and LH (leutinizing hormone). Required for DNA binding of zinc finger proteins which regulate a variety of activities. A component of the enzymes alcohol dehydrogenase, lactic dehydrogenase carbonic anhydrase, ribonuclease, DNA Polymerase and the antioxidant copper zinc superoxide dismutase. An excess of zinc may cause anemia or reduced bone formation.

Selenium (Se) Contained in the antioxidant enzyme glutathione peroxidase and heme oxidase. Deficiency results in oxidative membrane damage with different effects in different species. Human deficiency causes cardiomyopathy (heart damage) and is known as Keshan’s disease.

Fluorine (Fl) Constituent of bones and teeth. Important for tooth development and prevention of dental caries. Derives from water, tea, and fish.

Cobolt (Co) Contained in vitamin B12. An excess may cause cardiac failure.

Molybdenum (Mo) Contained in the enzyme xanthine oxidase. Required for the excretion of nitrogen in uric acid in birds. An excess can cause diarrhea and growth reduction.

Chromium (Cr) A cofactor in the regulation of sugar levels. Chromium deficiency may cause hyperglycemia (elevated blood sugar) and glucosuria (glucose in the urine).

A recent Turkish paper indicates low zinc levels in saliva (and so plasma) in people with UAT [http://www.turkjem.org/sayilar/79/buyuk/1-4.pdf]. It is not known if this is a cause or effect of UAT but suggests that people with UAT should ensure zinc levels are optimised.

Role of reverse T3?

A recent study highlights the dangers of subclinical hyperthyroidism considering healthy aging associated with decline in T3, unchanged levels of T4, with rise in TSH and rT3 [http://goo.gl/WCUk8]

The process of normal aging affects the hypothalamic-pituitary-thyroid axis in a number of ways, resetting of the set point being the most important of them. Contrary to the earlier belief, longevity has been reported to be associated with high serum TSH. Most recent studies have demonstrated an age dependent decline in serum free T3 levels, whereas FT4 levels remains relatively unchanged and TSH & rT3 levels increase with age. Two recent meta-analyses have shown increased risk of adverse cardiovascular outcomes in patients younger than 65 years of age, but not in those more than 65 year old. There is a good number of evidence documenting increased mortality in elderly individual with sub- clinical hyperthyroidism, which should be kept in mind while treating mildly elevated TSH in these patients. It is also important to remember that thyroid functions in the elderly closely mimics that found in sick euthyroid syndrome.

People with UAT recognise that rT3 levels can rise while they are ill. They make a good argument that rT3 levels ought to be checked in cases of poor response to standard treatment. If rT3 is raised then clearly the the patient is ill and efforts need to be made to restore her/him to biochemical euthyroid state.

Thyroid stimulating hormone response is not predictable

A recent paper by JEM Midgley highlights the problem with depending on TSH to determine whether or not a person with thyroid disease is adequately treated [http://jcp.bmj.com/content/66/4/335.abstract and http://www.hindawi.com/journals/jtr/2012/438037/]

Our data suggest that the states of hypothyroidism, euthyroidism and hyperthyroidism can be regarded as differently regulated entities. The apparent complexity could be replicated by mathematical modelling suggesting a hierarchical type of feedback regulation involving patterns of operative mechanisms unique to each condition. For clinical purposes and assay evaluation, neither the standard model relating logTSH with FT4, nor an alternative model based on non-competitive inhibition can be reliably represented by a single correlation comparing all samples for both hormones in one all-inclusive group.

Conclusion and approach to the patient

UAT is a common condition though there is still a lot to learn how to accurately diagnose it in all patients. Even if the diagnosis is not elusive the patient’s response to treatment is occasionally not what is expected.

To ensure improved diagnostic accuracy free T3 ought to be checked for all patient suspected of suffering UAT.

Thus it is my practice to check the following in a person who presents with a longstanding history of fatigue with no obvious abnormality on physical examination:

  • Full blood count with vitamin B12, folic acid and transferrin saturation index for iron status
  • Thyroid function test, including free T3 as well as free T4 and TSH
  • C-reactive protein
  • Vitamin D level and calcium profile

If patient is proved to have UAT, treatment is started at 25 mcg daily of thyroxine. The patient will be reviewed approximately 2 months later when thyroid function is rechecked with fT3, as well as checking thyroid peroxidase autoantibody (for autoimmune thyroid disease). If there has been a poor response to treatment, copper, zinc and 9am cortisol level should also be checked. rT3 should be checked in all poor responders to treatment too; this is recommended by Thyroid UK.

For details about signs and symptoms of UAT see for example: patient.co.uk

Some patient resources


Thyroid UK – http://thyroiduk.healthunlocked.com/ http://www.thyroiduk.org.uk/tuk/index.html


American Thyroid Association – http://www.thyroid.org/

Association Française des Malades de la Thyroïde – http://www.asso-malades-thyroide.org/

Petition – Better Endocrinological Service and Treatment for Thyroid Patients in United Kingdom

If you agree that more should be done for people with thyroid disease, then please sign the petition here

David Lewis
June 2013

Vitamin B12 deficiency – time for a rethink?

2 Mar

Traditional view

NHS Choices offers a traditional view of vitamin B12 metabolism and diagnosis and management of vitamin B12 deficiency anaemia.

An up to date review was published recently link

Vitamin B12 deficiency anaemia or folate deficiency anaemia develops when a lack of vitamin B12 or folate causes the body to produce abnormally large red blood cells that cannot function properly.

The main symptoms of vitamin B12 deficiency or folate deficiency anaemia are:

  • tiredness
  • lethargy (lack of energy)

View from special interest group(s)

Conversations with members from Pernicious Anaemia Society and B12 deficiency support group indicate there is more to the cobalamin metabolism story than the traditional view describes.

Recent articles and abstracts scattered through the scientific literature point to a more sinister effect on human biology when there is functional deficiency of B12.

Adenosylcobalamine, the adenosyl form of Vitamin B12, is needed to keep the TCA cycle running smoothly, and many people with B12 deficiency suffer a “dreadful fatigue”. But it’s a complicated process getting B12 into mitochondria, and an awful lot of things can go wrong.

A key to better understanding is awareness of biochemical reactions in which vitamin B12 is a crucial. These include [link]:

  • conversion of odd chain fatty acids (specifically propionate) into succinate
  • conversion of homocysteine into methionine via methyl group donation

Medically Unexplained Symptoms – is this a B12 deficiency syndrome?

This week it was proposed that any patient with medically unexplained symptoms should be referred for CBT. It was estimated this may save the NHS £3 million per year. No mention by the authors of the report to explicitly exclude functional deficiency of vitamin B12 [Advances in Psychiatric Treatment (2009)15: 146-151doi:10.1192/apt.bp.107.004606]

Do not forget magnesium deficiency – it is important to ensure magnesium levels are normal in any patient who is taking high dose proton pump inhibitor especially if also prescribed a diuretic agent.

The neuropsychiatric changes caused by functional B12 deficiency may predate the typical changes seen in the blood by months (perhaps years). These are detailed by MacDonald Holmes [JMD Holmes – British Medical Journal, 1956].

McAlpine (1929) said, ” Mental changes occur not uncommonly in pernicious anaemia. They range from states of depression accompanied by loss of mental energy to definite psychoses…” [McAlpine, D. (1929). Lancet, 2. 643]

When there is doubt about the status of vitamin B12 rather than repeat the test in 6 weeks in “borderline cases” as is the present practice, serum methylmalonic acid levels and serum homocysteine levels should be measured.

Measurement of methylmalonic acid, total homocysteine, or both is useful in making the diagnosis of vitamin B12 deficiency in patients who have not received treatment. The levels of both methylmalonic acid and total homocysteine are markedly elevated in the vast majority (>98%) of patients with clinical B12 deficiency including those who have only neurologic manifestations of deficiency (i.e., no anemia). [Stabler, S NEJM 2013]

Implications for general practice

Clearly there is a need to review how we view vitamin B12 metabolism. Recognition in primary care of functional deficiency of vitamin B12 will require medical curricula to pay better attention to this. Haematology does not have a monopoly on clinical features of vitamin B12. There are too few haematologists and neurologists, at least in the UK to provide clinical opinions when vitamin B12 deficiency is suspected. This leaves it to general practice and family doctors to learn more about the protean manifestations of altered vitamin B12 metabolism.

With performance managed healthcare becoming the norm around the world, it may be time to press for explicit scrutiny of vitamin B12 levels in patients with long term conditions including many in the following systems: gastrointestinal, hepatic, psychiatric, neurological, endocrine, renal, and non-malignant anaemias. Only then might we be certain that a scourge of (modern) society will be beaten.

David Lewis



I would like to thank @b12unme for educating me about this issue. Any errors and omissions are mine.

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].


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.

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]

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.

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…


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…

View original post 1,359 more words

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.

eLearning Needs in NHS Sept 2012 #mobimooc

13 Sep

Mobimooc 2012 is up and running.  2 webinars have been well attended.  Regrettably the timing is not great for me – but the team has recorded the lectures 

By coincidence two new systems are due to launch in my region of UK.  An electronic prescribing system (EPS) and new telephone triage service (NHS 111)

NHS 111

http://goo.gl/ra2IE points to introduction to the system.  The NHS has also provided online introduction with accompanying slideshow here with direct link to the video Introduction to NHS 111

Here is a great example of mLearning in action but the local NHS managers insisted on practice teams send delegates to a meeting somewhere in my town.  Clearly this was a poor use of time for my practice manager.  With such a good presentation created, it is clear to me that the time taken for many people to get to the meeting would be better spent watching the slide show.  How patronising of our service managers!  There is apparently good evidence that the new system will be good for patients and reduce some of the demand on emergency services from (trivial) emergencies.

It does look like no-one locally is aware of mobile learning project management.  Here is  an excellent opportunity which has passed us by!  Notice there is no system on the website to help visitors assess their learning after reading the transcript while watching the slide show.  Why is the slide show an embedded video rather than posted on Slideshare, Brainshark, or other public cloud service?  How hard would it be to have a feedback form?

Whether the UK really needs another emergency number is a moot point now.  As a GP, this system looks to me a threat for the future primacy of General Practice as the first point of contact for health care questions by UK citizens.  This is sad.  In the not too distant future UK may come to regret the demise of the family doctor as an independent gatekeeper to healthcare services.  That is a discussion for a future post.

Electronic Prescribing System

I wish to share the following from my local medical committee concerning the roll out of the new electronic prescribing service because the rational behind it is described and the questions from my representatives focus us on another opportunity for eLearning.

NHS Bedfordshire and NHS Luton are working for Electronic Prescription Service (EPS) Release 2.  This will mean that the PCTs would then be enabled to allow practices and pharmacies to take part in EPS, if the practices and pharmacies want to.  This is part of a national programme.  We were told that EPS has been available in Hertfordshire for some time and that just under 30 practices are taking part in EPS there.  
We’ve seen documentation from Bedfordshire and Luton about what EPS is; what practices would have to do under EPS; what the criteria would be for selecting patients who could use EPS and what participating practices would need to do to support patients in making their choice; how patients would nominate which pharmacy they want to use for EPS and what the participating practice would need to do to facilitate this.

Beds LMC members recognised the positive objectives of the scheme, e.g.
It is supposed to reduce GP work load ultimately
It may be more convenient to the patient
It may reduce waste
It is understood that EPS will be optional for practices.
But Beds LMC members did have some concerns:
To what extent is it a whole new area of unfunded work in general practice?
Beds LMC members thought that EPS would create the following work:
1. GPs will be expected to identify suitable patients.
2. The GP has to look at all applications for it and make sure they do not have any of the exclusions (large groups of patients such as those on controlled drugs, anticoagulants and some others).
3. The GP or GP staff will be expected to promote and explain the process and follow this up in writing and collect a signature 
4. The practice will be expected to telephone suitable patients and offer it to them.
5. Time will be need to train GP staff.  Nothing about backfill for this.
6. All prescribers will have to use smartcards and be wary of prescribing some formulations or brands of medication which do not have a suitable barcode.  Not all practices use their “smartcards” when consulting because they cause their system to run slow and time out.  So clinicians log in and work offline.
Patients with regular repeat prescriptions tend to be patients on chronic disease registers.
On the rare occasions when patients such as this come in “just for a repeat prescription” it gives the GP an opportunity to pick up on preventative care, QoF items and other aspects of the health and wellbeing agenda.  In other words, the aspects GPs do not always have time for when dealing with acute illness in a 10 minute consultation.  Could the use of EPS actually reduce the level of care available for some patients?
Concerns that the EPS will not be a simple scheme, as some items cannot be included in EPS, so there would have to be two prescribing systems for EPS patients: one for EPS-included medications and one for EPS-excluded medications
Is there any evidence that EPS has saved time for GPs or staff in primary care?
If any Hertfordshire practices who are using EPS would be willing to share any of their experiences or would be able to answer any of the specific concerns listed, it would be very interesting to hear from you?

Here is my response:

Wow! How can such a simple idea as electronic repeat prescribing become so complex?

FIrst thoughts: I want nothing to do with a system with more bureacracy to set up. We have enough to deal with without this additional burden.

Second: The system is doomed unless bandwith of broadband connections is increased to cope with the demand from our desktops (and mobile devices). Currently broadband speed is around 10megabits per second down and 0.5 mb/s up, at least in Watford. Divide this by 8 prescription terminals and you can see the speed drop makes the system inoperable.

Third: Barcodes are not immune from corruption; at least several times a week a popup warns there has been a problem and the barcode should be scratched out. How do you do that with an electronic script?

Fourth: The main benefit of EPS is prescribing from mobile devices. With 4G/LTE imminent this seems practical so long as all prescribers have feature phones with the necessary hardware. I fear the powers that be are focussing on the wrong systems. We need secure login systems for iPhones/iPads and android devices to make EPS useful (e.g. prescribing urgent scripts on home visits, or residential facilities)

FIfth: How are pharmacists supposed to be persuaded to adopt this?

Sixth: Prescribing2U is already available. How does this differ from EPS 2?

Seventh: All HCPs who access clinical system must log in with NHS Smartcard. If there are hardware problems managing this, the IM&T teams across our area must fix these before rolling out EPS.

This system is being imposed on us on the background of a longterm agenda to cut the printed script costs.  There is also an agenda to improve security of prescribing.  Since proposed several years ago, IM&T systems and devices have evolved.  Mobile devices are so much more capable than before.  For example, my smartphone (HTC One X) is more powerful computer than my desktop system 10 years ago!

There is nothing in my local medical committee concerns nor in the NHS EPS background documents to indicate any desire to develop a mLearning project to aid in the implementation of this system.


Two new systems are being implemented shortly with the intention of improving patient care in an NHS region.  Two sophisticated organisations are responsible for the roll out of NHS 111 and EPS.  Neither seems to embrace education technology which, in my opinion, would ease the pain involved in changing behaviour of health care professionals and the public.

There is clearly a very long way to go to embed eLearning into the NHS.  This is a terrible state of affairs for a developed society.  It is ironic that some countries with large health care burdens (e.g. sub-Sahara Africa countries; South America countries) may be receiving superb instruction in mLearning systems.

I would love to see some discussion about the particular systems described above – your experiences of similar systems in your country, ideas on how to improve implementation, or anything else you think would be interesting.

Thank you in advance…

Royal College of Surgeons of England ends quiet alliance with sister Colleges

8 Mar

At the EGM of the RCSEng tonight the illustrious Royal College Surgeons rejected joining with RCGP, BMA, RCN and other health bodies in rejecting the Health and Social Care Bill.

A clear break in the unity of the medical profession has happened.

The RCSEng folks should be ashamed of themselves for paying lipservice to the democratic process. The pre-meeting vote for withdrawal of the bill was in favour of this stance (84% of the 175 delegates).

In my opinion, history will show that this is the day (night) when the Royal of College of Surgeons loses whatever respect it held with its colleagues in the health service.

It is postulated that the RCSEng would not ally with the others because it wishes to remain apolitical so as not threaten its charitable status.

Whatever happened to the duty of surgeons to uphold the welfare of the citizens who are served by its members?

Has No 10 blackmailed, sorry persuaded, RCSEng executive that they risk something precious if they reject the health bill AND ally with the rebels?

A meeting stuffed with ex-PRCS’s and a Lord or 2 and a sitting member of the Government surely had nothing to do with an independent vote.

Primary care, where the bulk of the Health and Social Care Bill is focussed, has been betrayed by our (general) surgical colleagues.

Perhaps some of these surgeons should stop calling themselves doctors and accept they are primarily technicians who have no part to play in the politics of healthcare.

Grassroots surgeons and doctors who are dedicated to the welfare of their patients and work hard despite the constraints of an enlarging bureaucracy must stop being in thrall to the “elites” who populate the medical establishment. The top dogs, esp in RCSEng, but also in some of the other colleges, have shown their true colours – better to keep the government happy than nurture the respect of members of their institutions.

A very sad period in our profession is drawing to close with tonight’s decision.

In the past the RCSEng has been the worst offender in looking after doctors in training, esp GPs in training rotating through their specialties. That was over 10 years ago.

Presently, surgeons are no longer being included in undergraduate teaching clinical rotations because the teaching has been shoddy if present at all.

RCSEng is responsible for helping train the doctors of tomorrow. Well, I for one would like to see this role diluted further because frankly the surgeons cannot be trusted now to communicate the proper values we need for team working between disciplines.

Actions do have consequences. I would like to see the other medical royal colleges aggressively attack the RCSEng for failing to vote to join hands to protect the NHS.

Here are the motions and the votes:
(a)Considers that the Health and Social Care Bill, if passed, will damage the NHS and widen healthcare inequalities, with detrimental effects on education, training and patient care in England. ( Total votes cast 175)

For -101
Against -70
Abstain – 4

(b)Cannot support the Health and Social Care Bill without seeing the NHS reform Risk Register (Total votes cast 176)

For – 93
Against – 70
Abstain – 13

(C) Calls upon the RCS (England) to publically call for withdrawal of the Health and Social Care Bill (Total votes cast 176)

For – 76
Against – 99
Abstain -1

(D) Calls upon the RCS (England) to seek alliance with the BMA, RCN, RCM and other willing Royal Colleges and NHS stakeholders organisations to collectively call for the withdrawal of the Health and Social Care Bill. (Total votes cast 176)

For – 71
Against – 101
Abstain – 4

(e)Calls upon the RCS (England) to hold a joint press conference with the BMA and other willing Royal Colleges and NHS stakeholder organisations, to make a joint public statement calling for the Bill to be withdrawn. (Total votes cast 176)

For – 70
Against – 104
Abstain -2

Healthcare Rationing in UK – Health and Social Care Reform Bill unfit for purpose?

18 Jan

UK readers will be aware the government is pressing ahead with reforming the NHS despite failure of Parliament to agree the legislation yet amid concerted opposition for across the political spectrum and in the face of opposition from health professional organisations.

It is gratifying for GPs like me to read in this week’s BMJ the opinion of Professor McKee who is a Public Health expert: the reforms make no sense.

Expert struggles to understand NHS Bill (18/01/2012)
A top public health expert has described the government’s new Health and Social Care Bill as “completely unintelligible”.
Professor Martin McKee from the London School of Hygiene and Tropical Medicine, UK, describes his efforts to understand the bill in the British Medical Journal today (January 18).
“I know my students will expect me to explain the changes proposed by the Department of Health in England,” he writes. “If I am to do so, I need to understand them first. Here lies the problem. No matter how hard I try, I can’t – despite 25 years of experience researching health systems, including writing over 30 books and 500 academic papers.
“I have tried very hard, as have some of my cleverer colleagues, but no matter how hard we try, we always end up concluding that the bill means something quite different from what the secretary of state says it does.”
For a start, Professor McKee says, he can’t understand the problem the changes are trying to solve. Arguments that the NHS is performing badly have been totally discredited, he writes. In fact, independent sources have shown that the NHS is now improving at a faster rate than almost anywhere else, and would have done even better if it was not continually reorganised.
Secondly, he is struggling to understand what is being proposed. Private companies are increasingly being used, yet the prime minister insists that he will not privatise the NHS.
Lastly, he cannot understand why so much is happening now, and why the bill is already being implemented even though it has not passed into law.
“I’m hoping that someone, somewhere … will be able to help me,” he concludes.

http://www.bmj.com/content/344/bmj.e399 [subscription required, sorry]

So (1) Why are GP commissioners and other commentators on the NHS reforms so sure the proposals will work?  None, as far as can be seen, have anywhere near the academic credentials of Professor McKee.  Can we, the public, trust the judgement of the talking heads on our TVs and radios?   (2) In my opinion the people tasked with safeguarding the NHS should stop acting as if the NHS reforms are going to happen.
George Bernard Shaw advised reasonable opposition to imposed changes over 100 years ago. That is one history lesson many have forgotten. The Commissioners appear so caught up in making the local NHS look ready for change they have forgotten that, likely as not, another reorganisation will be foisted on us in 10 years or so?   If fewer people engaged with “the next big thing” I do not think we would not be in such a mess.
Meanwhile there is another debate about public service pensions which is obfuscating the real issue which is the Health and Social Care Bill.  This must not be allowed to mask the clear and present danger to the NHS.   If you feel as strongly as I do about the threat to healthcare which is being rushed in before the legislation has passed all the legal hurdles it is still not too late to make your views known to your MP and the House of Lords.

Illusions of Autonomy

Where medical ethics and human behaviour meet

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

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