Monday 26 October 2015

'One of the first duties of the physician is to educate the masses not to take medicines' William Osler



One of the first duties of the physician is to educate the masses not to take medicines Sir William Osler said just over 100 years ago. How much has changed since then?

The use of prescription medication has been rising dramatically in recent years. See CDC.gov US prescription statistics.  48% of patients in the US are on regular prescription medication. The number of patients taking 5 or more drugs rose from 6 to 11 percent between 2000 and 2008. In the over 60s 37% take 5 or more different prescription drugs regularly.  Figures from the UK are similar.
Although there are some over 75s who take no long term medication, they are rare. The majority take medication for a combination of chronic conditions like high blood pressure, reflux symptoms, joint pain, low bone density, angina, irregular heart rhythm, cholesterol, depression, peeing too much or too little, etc.

Some of this medication is intended to control symptoms, but the majority of drugs are taken in an effort to prevent future illness such as a stroke. The evidence for the effectiveness of this strategy is generally derived from research trials and evaluated by organisations such as the National Institute of clinical excellence, and similar organisations around the world using complex statistical techniques. This process is called meta-analysis (translation ."further analysis"), and the result is supposed to be so called Evidence Based Medicine in which we no longer rely mainly on the opinions of eminent experts, who may be biased, but are guided by an objective view of the available research conducted by a dispassionate and numerate expert.

Guidelines on preventative treatments are also produced by other organisations such as Royal Colleges of a particular specialty, and also by special interest groups such the British Heart Association.
The guidelines pretend that patients have only one long term condition, and take no account of multiple illnesses, even though patients with only one long term problem are a small minority.
Many patients will have for example, high blood pressure and diabetes and heart disease and joint pain and acid reflux, but the guidelines say nothing about how the treatment of any of these problems should be influenced by the others. As a result patients with terminal cancer are commonly still taking drugs designed to reduce a fairly small risk of a heart attack.

Guidelines calling for increases in the use of a particular drug treatment are widely promoted by the pharmaceutical industry, who advertise in journals, sponsor conferences on the relevant disease, finance health charities which increase awareness of the condition in the population, and lobby politicians. In recent years there has been a lot of publicity about dementia. It is unlikely that this would have happened without the potential for drug makers to gain huge amounts from the sale of new drugs for this problem. The fact that the drugs are of very doubtful benefit, has made the promotion even more vital to the makers profits. Pfizer issued a legal challenge to NICE and forced them to alter the advice that limited the use of the new drugs to only a few patients.

As well as the promotion of guidelines being heavily biased, the evidence on which they are based is also tilted in favour of the use of medications. The original research is mostly done by the drug firms, who own the data, do the sums, and then get the 'authors' to help write it up. However the conclusions are biased in various ways, as shown by ben goldacre in his book Bad Pharma. See wikipedia.org/wiki/Bad_Pharma The main techniques are:
 1 to do several studies and only report those with the best results, as has happened with Roche and trials of the flu drug called tamiflu.
2 to do lots of different statistical tests on the results, and only report the ones that come out best, pretending that that was the so called primary outcome you had set out to test.
3 losing inconvenient patients to follow up so their outcomes are not included. Merck did this with Vioxx which worked for arthritis but caused heart attacks. 
4 doing repeat analyses during the course of the trial and reporting the results when they are best, pretending that the trial was shorter than it actually was. Pfizer did this with Celebrex, where the trial lasted a year but they only published six months.
5 Giving all patients a pre trial course of the drug and excluding those who had side effects from the main trial.
The result of the above problems is that according to many doctors, Evidenced based medicine is largely broken and its conclusions should be treated with suspicion.


Another major problem with the guideline approach is that the patients in the trials are almost always very different from the patients who end up taking the drug. Trial patients are much younger and fitter, with more effective livers and kidneys to break down the drugs, and much less likely to have significant other conditions. They are also usually banned from taking significant amounts of other medications.

Licensing authorities around the world are aware of these problems and often ask producers to do so called post marketing studies, but these requests are usually ignored. Sometimes it happens that another organisation does some research into a new drug looking for other uses and discovers  harms. For example researchers investigating whether the newer selective arthritis painkillers might prevent bowel cancer found a large increase in heart attacks. In general there is very little systematic research into drug side effects and harms.  Most well known drug harms that we are aware of today such as kidney damage from anti inflammatory drugs, or diabetes from drugs for mental illness went unreported in the initial trials, and were only discovered after several years of widespread use. Other potentially serious harms are not being researched. For example we suspect that the main drugs for brittle bones may cause cancer of the oesophagus, that blood pressure drugs cause falls and broken hips, and that newer diabetes drugs cause deaths through pancreatitis and possibly pancreatic cancer, but the relevant companies are not forced to research these issues. Most glaringly, after 30 years of the use of Statin drugs by hundreds of millions of people, we are still very uncertain about the frequency of muscle pain and memory problems, that are reported by many patients but dismissed as nocebo (negative placebo) effects by those who advocate their even wider use. Similarly almost as many people take so powerful drugs called PPIs to reduce stomach acid and relieve heartburn. We know that these drugs increase broken bones, and hugely increase the chance of contracting the hospital superbug C. Diff, but we have very little idea of the scale of the problem. 

Even when we are aware of harms these are rarely communicated to the patient. One example of  a very 'dirty' drug category is the so called 'anticholinergic' class which has been around for a long time and is most often used to reduce urine frequency by inhibiting the main bladder muscle. These drugs have a long list of side effects which are almost universal, including constipation, irregular heart rhythm, impaired memory, blurred vision, dry mouth, but they are often prescribed by specialists who focus on the bladder and ignore the rest.

Similarly patients are discharged from hospital on a long list of medication that is seldom explained in detail even when there are likely to be significant harms. For example many patients who have an acute illness have a temporary disturbance of heart rhythm called atrial fibrillation. The hospital doctors have no idea whether this a long existing condition or a temporary one. There is an increase stroke risk with this condition of roughly 5% per year, and the doctors want to do anything they can to reduce that so they prescribe blood thinning treatment. The patients will have to have frequent blood tests, will be in increased danger if they have an accident, will not easily be able to have operations, and will be unable to take many other drugs which affect the way the blood thinner works. On top of this there is a significant risk of roughly 1/1000 per year of bleeding to death. This surely requires detailed discussion and yet this rarely occurs. Once it has been started it is a brave GP who stops it. If the patient has a stroke it will be his fault.

Another factor increasing drug use is the so called Quality and Outcomes framework (QOF), or 'points mean prizes' for GPs. This system has been going for 10 years or so and rewards the achievement of targets which can be for example control of blood sugar in diabetes or simply the prescription of certain drugs such as blood thinners for patients with Atrial Fibrillation. GPs can exempt patients for various reasons but have to be prepared to justify it. This so called exception reporting is closely monitored with the possible sanction of payments being withdrawn and a bad report from the Health inspectors. Not surprisingly people find that it is easier simply to prescribe the drug. Patients who are included in QOF are usually reviewed by nurses, who often lack detailed pharmaceutical knowledge.

Young doctors in particular find it hard not to follow guidelines even when they have a good reason to ignore them. All the guidelines state in their preamble that they are to be interpreted in the context of a particular patient. But in practice, when complaints are made, or inspections look at particular case reports there is a heavy onus on the doctor or nurse to explain why they have not followed a particular guideline.

Lots of eminent doctors are aware of the harms of the present degree of polypharmacy, especially in the frail elderly who are much more vulnerable to harm. Several trials have been done of stopping multiple medication in the frail elderly, often with great benefit both in terms of quality of life and also survival. But in practice very little of this is done. It is rare to find specialists stopping long term treatment, and although practices have annual drug budgets, these are ignored as there is no sanction if they are exceeded. Patients are supposed to have medication reviews at least every year, but it is common to see patients who have been taking a medication for many years despite not knowing what it is for and despite the original reason having long since resolved. Doctors are busy and it is easier not to raise the subject when going through a list of 9 or 10 drugs would take far longer than the 10 minutes allocated to the consultation.

So what have the overall results of this huge increase in resources devoted to long term medication.? The short answer is that we do not really know. Long term trends in the number of heart attacks and deaths from various conditions have continued without for example showing any evidence that long term outcomes have been improved by QOF.
So benefits zero to low. What about harms?

Money that could have been used elsewhere has been diverted, both to the direct cost of the drugs but more significantly to a huge increase in the number of medical appointments for long term conditions. Patients have certainly suffered adverse effects but they are impossible to quantify.
Life expectancy in the uk has shown the first downwards blip in a long upward trend which has been going on for generations. Perhaps polypharmacy is responsible.






Wednesday 21 October 2015

Everyone to have a 'Named GP' - who is he kidding?




Quite rightly Jeremy Hunt bemoans the fact that most people cannot name the doctor they last saw at their local practice, and do not feel that they have a lasting relationship with any GP. So he has insisted that patients should be allocated a particular named GP.

But all the things he and colleagues have done in recent years has actually caused the problem,  and this latest sop to daily mail readers will do nothing to reverse the sad trend he and his mates have caused.

 Is it really the Governments fault? Yes it is, and the reasons are as follows:

First and foremost the NHS has made life much more difficult for small practices over the last 10 years.  The admin burden of keeping up with ever changing rules and initiatives is huge and needs efficient management and economies of scale. Achieving so called Quality targets demands nursing and admin and IT skills which is hard for small practices. Satisfying the demands of the CQC, (Health Inspector), by providing a long list of practice policies and records of staff training is also much more difficult for small practices.

Despite small practices consistently outperforming in patient satisfaction surveys. Single handed doctors have been effectively hounded out, so that there are hardly any left, while large 10+ doctor practices, often part of large multi practice businesses, have mushroomed. In practices of this size ensuring that patients see the same doctor is very hard, and doctors are very unlikely to know their patients and their families. Continuity of care is almost impossible, and doctors are tempted just to move the problem on temporarily, rather than take the time needed to really sort things out. This is bad for the quality of care that patients receive, and almost certainly increases costs of drug prescribing and specialist referrals.

Formerly, most GPs would have a sense of ownership with regard to a practice whether or not they were in fact owners. That is now increasingly rare, with many GPs simply turning up, seeing patients, doing the minimum necessary paperwork, and leaving at the end of the day without any involvement in practice organisation.

So Mr Hunt is right to be concerned, but his concern comes very late in the day. if he is serious he needs to undo a lot of the changes that have happened in the last 10 years, which he shows no sign of doing at all so far. The named GP initiative is a meaningless farce which will do nothing to restore what we have lost.




Why GPs hate Specialists and Vice Versa

GP specialist relations are at an all time low. Why, and how can we make this better?

If one talks to GPs about what annoys them, you will find that it is rarely the patients. Obviously administrators are well up the list, but so also are hospital doctors. If you talk to specialists, their opinion of GPs is not high. Yet these doctors need to work together to help patients, so why is this aspect of the NHS so dysfunctional?

Let us go through the concerns on each side and look for solutions. (Some people will find this biased in favour of GPs)

GPs being asked to do work that would be much simpler and more efficiently done at the hospital.
Some examples:

A patient sees a GP shortly after a visit to outpatients for a broken arm as he needs a sick note for work. The details of his condition are not available to the GP as the letter (yes a printed letter!) will not be sent for a month or two. It would be much more efficient all round if advice about work and the sick note was done at outpatients, but this is often omitted by the clinic, even though officially it is there that this should be done.

A specialist, or his secretary, gets a lab report suggestive of infection. The result is then faxed to the GP, often with no other information about the medical context.  The GP is not informed whether the patient will be notified by the secretary. Sometimes, the GP phones the patient and finds that treatment has already been issued by the specialist. Sometimes attempts to contact the patient fail and the GP has to write a letter, which is expensive in staff time, and slow. The specialist who knows the context could easily contact the patient, decide on treatment, and issue a prescription. This again would result in better care and be much more efficient, and would avoid the chance of the GP dismissing an important result as insignificant.

A patient has a cataract operation and is issued with enough eye drops for a week as per hospital policy, he is then told to get a  prescription for another bottle from his GP who knows little about the intended treatment dose or duration. The hospital is able to negotiate prices for eye drops and pays typically about half the cost that is paid to a pharmacy.  It would be far more efficient for patients and the NHS, as well as ensure that treatment was actually given, if the hospital issued all the medication needed. Similar issues affect for example patients found to have MRSA prior to operations. Rather than the previous nurse having a large stock of antiseptic shower gel to be handed out, a letter goes out to the gp, with an instruction to prescribe. Ditto patients who need anticoagulant injections around the time of surgery. These are actually quite dangerous, and the potential for the GP to make dosing errors on the prescription resulting in the death of the patient is significant.

A patient sees his GP on the advice of the specialist, to discuss a recommendation for treatment or another referral. But routine letters often take 2 months or more and the specialist may well be unaware of this. So the GP has to ask his staff to ring the secretary (not easy), and ask for the letter to be faxed. Often the letter is still in the typing pool and there is a wait, and then another consultation. If the specialist was aware of the problem he would get the letter done faster and faxed, and he would tell the patient not to attend before the letter was likely to arrive.
Similarly we get letters recommending further tests to be done by the GP after a month or so, but the letter arrives several weeks after the proposed action. Hospital letters are rarely checked by the author, and frequently have significant typos and errors.
Of course it is absurd that we still don't have emailed letters. Hospitals do of course actually produce letters on computers, print them and send them,  and then we scan them into our computers, which is slow, labour intensive and uses a lot of computer disc space, but hospitals have no incentive to change to suit us. Similarly hospitals make no attempt whatever to address letters to the referring doctor. Even if specialists try to do this, the patient administration systems change the addressee to the doctor at that practice when the patient first attended the hospital even if that doctor has retired years agos.

Some specialists try to get around the problem by handwriting an "Urgent" prescription request, and either giving it to the patient or faxing it. The patient often expects a prescription to simply be issued. However, this is often difficult, either because of illegibility, or ambiguity about dosage or length of treatment, and it puts the GP in a tricky position, as he will be the one responsible.  GPs may have to ring hospitals to clarify the details, which is time consuming and irritating for the patient who does not expect delay. Commonly, GP prescribing software will warn of interaction with the patients other medication. Hospital doctors very rarely use such software( although their pharmacies have it), and the specialist is unlikely to be aware of less common interactions. Prescribing medication at the clinic, for issuing at the hospital pharmacy, would again be better care and more efficient.

Discharge letters, which in our area are the only hospital letters that are electronic, are a massive problem. They tend to be either late, or erroneous (for example medication given to the patient often does not match the medication list!) or lacking important information about follow up appointments. They are often several pages long with lots of irrelevant detail about DNAR forms and thrombosis risk assessment, with the information we need in a small paragraph somewhere on page 3 of 5. Commonly letters include requests for GPs to arrange further test such as blood tests or scans. Whether patients have been informed of this is usually unclear. Quite often the letter will say “GP to arrange scan”, and yet it has in fact already been requested. Our local trust frequently issues " amended discharge letters" sometimes in several editions, all of which require inputting into the patent record. It is rarely made clear what has been amended, if anything.
Sometimes, letters request that GPs request a repeat scan after an interval, and forward the result to the specialist. This can be tricky, with GPs outside the immediate area often not having access to requesting scans at that hospital, and GPs rarely have a system to arrange tests on certain dates. The potential for the ball being dropped and the patient suffering as a result, is huge. It would not be difficult for all such follow up tests to be arranged and administered by specialists, and it would save huge amounts of GP time.

Then there is the patient who has a scan arranged by specialists, and they are told they will have an appointment to discuss the result. But 2 or 3 weeks later the patient has heard nothing and rings the hospital to be told that their appointment might be a month or two yet, and they should visit their GP. Sometimes GPs can look at scan reports (though not images) on the hospital IT system, but the consultation is difficult as the GP is not in a position to plan further action. If, as is not rare, the report is bad, the GP has to break bad news without the necessary knowledge to inform the patient in detail of their options. The GP then has to ring the specialist to demand an urgent appointment,which can be difficult or impossible.

As well as the extra work pushed onto GP’s there is a huge difference in approach best summarised by the famous William Osler who 100 years ago taught young doctors to Ask not what disease the patient has but rather what person the disease has?

Specialists unfortunately often fail to consider the whole patient. A typical example is a patient with moderate Parkinson's who sees a heart specialist with angina caused by narrowed arteries to his heart. He has a series of tests which last a few months, during which time his ability to walk declines, so he is actually getting much less symptoms from his heart. However, on the basis of the pictures of his heart arteries they decide to offer a heart bypass operation. This may offer a slight survival advantage, but there's a significant risk of damaging the brain during the use of the heart lung machine. The op goes ahead and the patient suffers severe confusion afterwards, which improves very slowly. If the surgeon had looked at the whole patient he would have appreciated that the patients chance of more than a couple of years of quality life was minimal, and that his brain was the important issue, not his heart. The harm easily exceeded the benefit, as was entirely predictable.

Then there is the tendency of many specialists to be economical with the truth about the medication they advise. They very rarely take the trouble to tell patients to stop treatment that is no longer needed. They tend not to explain side effects, and they often prescribe drugs that are not licensed for the patient’s condition without informing the patient. This practice is strongly discouraged by the GMC, but it is regarded as normal practice by many specialists.
 There are many illnesses for which drugs offer very little benefit and often risk significant harm, but specialists rarely feel comfortable not offering any treatment, so it often ends up with the GP explaining the downsides, which is not an easy job. If there was a simple rule that prescribing unlicensed medication was not a job for GPs, it would mean that specialists would have to justify their practise to their hospital peers and argue for the necessary budget.
If GPs and specialists worked together the amount of harmful overprescribing that occurs in the UK would be reduced, and money would be better spent elsewhere.


Another problem occurs when GPs are sent reports typically from so called MDT meetings about patients with cancer. The report may detail spread of a cancer and the need for a particular treatment, but often fails to indicate whether the patient has been informed. Patients can now demand access to their GP records online, and it is not rare that very bad news is discovered accidentally.

Then GPs are often treated in a disrespectful way in terms of referral forms, being expected to simply complete a series of tick boxes, often with insulting boxes of text, for example " Does This patient meet the criteria for referral? ". It has been shown time and again that doctor’s intuition is at least as important a clue to serious illness as the presence of particular symptoms, and yet this is ignored, and GPs are treated as idiots. Paper referral forms also ignore the fact that GP records have all been electronic for at least 20 years. If referrals were simply vetted by the specialist, with dubious ones being discussed on the phone, that would be efficient, educational and preserve good relations.

So what about the faults of GPs? Poor referrals are a major issue. GPs often refer patients to a surgeon for knee or back pain for example, when the symptoms are mild and the patient is high risk. The specialist has to disappoint the patient, which is no fun. GPs often try to bend the rules on which referrals are urgent, querying skin cancer when patients have rashes which are obviously not is a common example. Often GPs feel pressure to comply with patient’s requests even though they are aware that they are ignoring the interests of specialists and of course the patients categorised as non urgent.
Specialists are also painfully aware when GPs miss stuff which should have been obvious. Cases do get easier to diagnose in the so called retrospectoscope.

Patients are regularly admitted to hospital as emergencies for long term problems such as asthma or diabetes, that could easily have been treated by GPs. Some of these cases reflect the fact that the specialists are seeing a selected group and are unaware of the patients who have been successfully treated by GPs. Many of these patients are very poor at managing their illnesses but often the GP care is also at fault.  

So what can be done? Specific changes are obvious from the above but we also need some systemic change.
In many European countries all specialists are required to spend a few months working as a junior GP, which would be a big help. Similarly, it would be reasonable to require some broad education for all specialists in subjects such as communication skills, and keeping up to date on pharmacology , especially on the dangers of multiple medication.

Abolishing the foundation trust v GP purchaser provider split that has been created by the internal market would probably help a lot. Some of the most absurd issues like the lack of swift electronic letters to GPs would quickly get sorted.

The old system whereby a lot of GP education was done at evening meeting with local specialists would be a huge help. This was abolished by Academic GPS several years ago. They wanted GPS to learn from each other, often together with nurses and other staff. This was a laudable aim but the result in many areas has been very poor quality meetings, and that GPS and specialists rarely recognise or speak to each other. Facilitating email and phone liaison would help a lot but at present hospitals discourage it as there is no payment tariff for dealing with a patient without bums on seats.













The UK - A country fit to grow old in?


What are your chances of your old age in the UK being a matter of loneliness, confusion, fear, incontinence, neglect, and suffering? That is unfortunately the fate of the majority of people today, who are unlucky enough to live past 85. With the number of elderly growing, the situation is likely to get worse.

So, why is care so bad?
The biggest single reason is that we do not make it a priority. Let's look at a typical English old peoples home. They are typically conversions of large old Victorian buildings, usually with cheap and ugly extensions. They are privately owned and run, and paid for by sale of residents family assets, until they are exhausted, after which the local council is responsible. Many homes have gone bankrupt, usually after a debt financed takeover. This then results in residents having to move to another home with new staff and new neighbours.

In a typical home the residents usually sit together against the wall of a lounge, with a TV in the background showing something they have neither chosen or are able to follow. There is a smell of urine. Quite often, one or two residents become agitated and cry or scream, which is logical enough as they are actually locked in. Doors can only be opened with a key code which the residents do not remember.

The staff (on minimum wage and doing unsocial hours), have no time to organise activities or respond individually to the patients. There are no staff with nursing qualifications, so that they cannot do basic nursing. Simple tasks like giving insulin injections are done by various visiting community nurses, who rush in and out and have no time to look after the whole patient.

The medical and nursing needs of the residents are severely neglected. Community nurses tend to resent the fact that the homes do not provide nursing care to their residents, and just do the basic injections and dressings. Care home residents are also neglected by GPs and hospital specialists. GPs are called in by the staff only when residents get an acute illness. There is little or no continuity of care, and there is a huge overuse of medication, much of which is likely to be harmful. The medication is reliably administered by the care staff as that is one of the things that gets checked in inspections, and long term drugs are rarely properly reviewed by a doctor. GPs have  poor access to patient records when visiting patients in Care homes, as their records have become computer based, without anyone sorting out or paying for an effective mobile solution. GPs are not paid extra to look after care home residents although they are well aware that the 70 pounds a year they are paid per head does not pay for many doctors visits. They cannot actually refuse to accept care home residents onto their lists but there is a real disincentive against providing good and accessible care and becoming popular with care home staff.
Out patient visits to hospitals tend to be a waste of time as care staff can rarely take the time to accompany patients. There is no effective attempt to do or record advance planning to help decide what to do in case of serious illnesses. We know that most elderly wish to avoid hospital admission if at all possible, but we do nothing to implement their wishes. Patients tend to be discharged from hospital on lots of medication such as for blood pressure or cholesterol which is designed to prolong life when the aim should be quality of life not quantity. But hospital doctors feel they have to follow guidelines, which are based on research that is simply not appropriate for frail elderly patients. Admissions are difficult to prevent because care staff cover their backs by calling ambulances, and patients get admitted to hospitals even when their life expectancy is very short. Hospital staff understandably concentrate on curable cases and  many many people suffer a lonely, neglected, and frightening death in hospital against their stated wishes.

What are we doing about this? For most areas not much.

But some areas such as Sheffield have arranged systems led by Community Physicians specialising in the care of the elderly and in which GPs are supported and paid to do regular visits and work together with care home staff and other community staff. Time is taken to discuss and record advance plans with patients and relatives.  The overall costs are lower, as the big expense, which is hospital admission, is cut by 15%. See the RCGP study on Sheffield Care Homes initiative 

We can also look, surprise surprise, to Scandinavia or New Zealand, where elderly people first move to retirement villages. There they are helped to remain independent and activities are organised to keep mind and body preserved as much as possible. There are usually gardens, and greenhouses and residents are not locked in as in the UK. When frailty increases they move to the residential block next door and there is usually also a high dependency unit with qualified staff for the sickest residents.

We could emigrate, but that's tricky, so let's change the dysfunctional set up we have in most of the UK.