Should we be Paranoid, or Infuriated?

Paranoid?

or Infuriated?

Much of the time, it seems that the obvious reason for the development of bizarre QOF target hoops through which we have to to jump, or absurdly unfair articles in the press about GP pay, is that some people really do have an axe to grind, and they are out to get us.

Typical suspects include politicians (and their cronies) trying to open up the NHS to competition from for-profit business, but the culprits can also include the media, the pharmaceutical industry and NHS bureaucrats.

One can apply the 'cui bono' test to pinpoint the guilty party among those who would benefit from any particular new imposition, and it commonly points to a likely suspect. This is known as the 'conspiracy theory' and it does have a lot going for it. However, there are examples where it seems to be very difficult to spot anyone who benefits. Not long ago, the NHS prescription charge was raised from £7.85 to £8.15. This means that in pharmacies and dispensing doctors' surgeries all over England, staff are counting out £1.85 in change over and over again; this involves a minimum of five coins, all of them different. Pharmacies have to pass all this money on to the NHS so they are understandably unwilling to bear the loss they would have if they allowed card payments.  Pharmacies now regularly run out of coins and have to go their local bank to get more, if they are lucky enough to have a branch nearby. If they can, staff will encourage punters to claim exemption. So they will have more work to do than if the charge was £8, but due to increased exemptions, the money raised is less than previously, meaning nobody benefits. So much for conspiracy.  For this, it seems another theory is needed - commonly known as the 'cock-up theory' (perfectly illustrated by the Health and Social Care Act, if you need an example). The most elegant expression of this is known as Hanlon's Razor, an adage stating: 'Never attribute to malice that which is adequately explained by stupidity.' But hang on, what is £8.15 in euros?

How much is safe to drink? Dame Sally boobs on booze

Dame Sally Davies tells us that ‘no level of alcohol consumption is safe’. Is she right? And why has the advice changed, and why is it different in different countries? Getting to the truth is tricky, and here is why. 

  

When she started the job as Chief Medical Officer Professor Dame Sally Davies – who was formerly one of the most specialised of super specialists – dealing with sickle cell disease- got on the wick of many doctors with her instructions. She said that we should lead by example in terms of lifestyle, and make every consultation count in terms of imposing an agenda of well meaning health advice on obesity etc. even when we are dealing with patients struggling with major medical problems.

Now she has really poured salt on the wound with her advice reducing the maximum safe limit for alcohol intake – especially with reference to cancer. For a while  GP’s will be getting an increase in patients presenting with minor symptoms who are terrified that they are caused by cancer which is related to their modest consumption of alcohol.

Meanwhile lots of health experts continue to insist that moderate drinking has overall health benefits, and guidance from around the world on safe levels of consumption varies widely even though the experts are looking at the same evidence. Surely, an issue which has been debated and studied by huge numbers of people for decades should have clearer answers.

Well, no actually. It is extremely difficult to be sure about issues such as this. The reason is that direct experimental evidence is very difficult to obtain – you could conceivably split imprisoned convicts into groups and administer alcohol in varying quantities – but it would not be allowed. Studying what happens to people in the population has a lot of potential errors and possible biases, and this is the reason why there is so much disagreement in interpreting the research that has been done. Similar issues apply to lots of other questions about the health effects of meat in the diet, sunlight, vitamin D, Hormone Replacement etc.

There are 4 sorts of evidence that are relevant to these sorts of issues and it is worth understanding each one as you usually need more than one type of evidence to really nail something as a probable causative factor in a certain disease. 

The easiest sort of evidence comes from large surveys of people with a particular disease asking them about their habits, occupations, drug use etc. and looking for statistical associations. This method is called a Retrospective Case Control study. It is quick and pretty good at excluding possible causes, but suffers from several possible sources of bias, which makes its positive conclusions about causation relatively unreliable. It is difficult to recall past habits correctly leading to ‘recall’ bias. (Although some studies get around this by searching health records for example for a history of medication use).  The control group who have responded to the request to take part in surveys may be unrepresentative of the general population in many ways. This is called ‘selection bias’. Lastly this sort of study can suffer severely from so called ‘confounding’ where some other causative factor that may be unknown and that is not being measured differs between the groups being compared. For example, lots of effort has been spent on comparing different sorts of occupations with the aim of working out to what extent ‘stress’ and poor job satisfaction causes disease. However it has been very difficult to rule out other factors such as smoking, poor diet, and lack of exercise as they tend to more common among lower status workers.

A more laborious, but more reliable method is to identify the suspected culprit at the start of the study and arrange to follow a cohort of subjects over a period of time and count the number of people falling ill in the separate groups. This is called a Prospective Cohort study and is much more reliable. However, it is still difficult to choose a control group that matches the study group who are being exposed to the risk or treatment, so that confounding and selection bias are still possible. ‘Recall’ bias is still possible if people lie about their habits – which is possible with questions about alcohol.  The other big problem is that it takes several years from when the study is started to the day the data is analysed.

One feature of both prospective and retrospective studies that strengthens their conclusions a lot is a so called ‘dose response’ effect. When the smoking habits of British doctors were studied back in the 1950s it was the fact that the risk of lung cancer strongly and progressively increased with increasing tobacco consumption that clinched the argument.

The most reliable evidence comes when the researcher is able to randomly select a group of subjects, and expose them to the relevant factor, while keeping the ‘control’ group unexposed. This is called a RCT or randomised controlled trial, and is accepted as the most reliable evidence. However, it is expensive, and usually has far fewer participants, and it can often be criticized as not being relevant to the ‘real world’.

The 4^th very important line of evidence is called ‘biological plausibility’. This is when there is evidence that the factor under suspicion has some known effect on the organ concerned. For example it is experimentally provable that a small concentration of CO2 in air will reduce the transmission of infra red radiation – so that the mechanism of man made climate change is clear.

If we have evidence of all 4 types pointing in the same direction then the case is very strong. Unfortunately that is not common and there are many subjects where we are not even close. We know that we have to be distrustful of conclusions based on one type of study alone as this has led to some famous errors in the past. The most famous example is that of Vitamin C. Retrospective studies showed that consuming fruit and veg was associated with much better health outcomes, and everyone thought that it must the anti-oxidant Vitamin C that was the important ingredient.  However, when Randomised Controlled studies were done with half the subjects taking a supplement, they showed no benefit whatever. We now think that people who eat fruit and veg are generally more careful with their health, and perhaps there are other chemicals rather that make the difference.

And so to Alcohol. We must of course first make clear that we are not talking about 5+ drinks a day or 35+units per week. It is abundantly clear that this does a lot of harm, raises blood pressure, leads to violence, social disorder, harms mental health etc etc. Everyone thinks of liver cirrhosis but this is actually fairly rare from alcohol and requires a much higher intake.

But is low to moderate consumption harmful - or possibly beneficial?

Retrospective studies have generally failed to show that mortality is increased, which is against a major harmful effect, but have suggested an increased cancer risk, but a reduction in heart disease.  One of the big problems with such studies is that smokers tend to drink more alcohol, and it is difficult to disentangle the effect of each. But in the last 10 years or so there have been some prospective studies which have probably produced more reliable evidence. There have only been a few of these and the results have varied which has led to fierce argument over their interpretation. The issues are whether Cancer risk is increased, and if so how much, and whether Heart Disease is prevented by low or moderate intake.

I myself am influenced by the 4^th sort of evidence, which is whether there is a likely mechanism that fits the facts observed. It does look as the effect of alcohol on cholesterol and also on blood clotting might well explain a protective effect, and it fits in well with the results of the trials. But the Sally Davies faction say that the observed beneficial effect is an artefact due to the tendency of some teetotallers to be reformed alcoholics so that their bad outcomes worsen the picture for the whole group of non drinkers. Perhaps I am biased but I do feel that they would not make similar arguments if the results came out in their favour, and the protective effect has been observed in countless studies. The size of the protection is not trivial – about a 10-20% reduction in heart attacks, which is as more than low dose aspirin. For comparison consistently taking a statin drug will reduce risk by around 30%.

As far as Cancer is concerned, the strongest effect is that on cancers of the mouth and throat and oesophagus. Here the smoking confounding is the big problem. A large prospective US study concluded that the effect of alcohol was confined to smokers.

Unfortunately, there is another result which is far less palatable (joke). That is that there is a pretty definite effect on Breast Cancer risk. Since this is a common and serious disease this has to be taken seriously. I had thought that alcohol intake might lead to obesity and that might explain the statistical correlation but they have looked at that and decided that drinking and obesity don’t actually go together that much in women. Overall, it is estimated that about 10% of all breast cancers are caused by alcohol.  So If all women stopped drinking altogether we would have 10% fewer cases. The mechanism is thought to be that alcohol affects the metabolism of female sex hormones in the liver.

Whether other solid cancers such as bowel and prostate cancer are affected by low to moderate alcohol intake is disputed. Some large studies have failed to show an effect. In a large recent prospective US study there was no statistically significant definite evidence of an increase in cancer in non smoking men.  

The new guidelines proclaimed by Sally Davies suggest the same limits for men and women. This disagrees with almost all other national guidelines on the subject and all the basic science about how men and women handle alcohol.

If there is a risk for women of breast cancer which seems likely, what can be done to reduce it?

 First of all be lucky.  Failing that you can stay slim, take exercise daily, and have babies and breastfeed them for a long time. In terms of preventative drugs there is a lot of interest in good old aspirin.

And if you are a man? -------------------- See you down the pub!

Where have all the Doctors gone?

In 1985 around 3000 doctors graduated from university in the UK, and at that time there was a small but significant number of unemployed doctors. In 2015 the equivalent figure is 7500, an increase of 2.5 times, while the population of the UK has only risen by a few percent. How therefore is it possible that for the last few years, advertised jobs in General Practice and some specialities such as Emergency Medicine and Paediatrics commonly receive no applications?

And how can understaffing be causing huge problems in hospitals and primary care in many, though not all, parts of the UK? 

There are many reasons of course, and it is worth examining them in detail. It is not just a question of UK graduates going off to work abroad. Although that drain is increasing, the large majority only stay away for a year or two.

It is important to clarify that some specialties, for example surgery, are very popular and highly competitive. So we have to look at the problem areas specifically.

Emergency medicine has some obvious downsides as a career as it is a 24/7 job, and it attracts very few of the female doctors who now make up 65% of medical graduates. Importantly, it has a low status in the hierarchy of medical specialties, below Elderly medicine, and only just above General Practice! Even more significantly, it has become a sort of medical dustbin which has to deal with the consequences of all of the failings of the rest of the system. If medical wards are full because the council haven't got care arrangements sorted out for frail elderly patients, or because the heart specialist wants to keep a patient in hospital to get them ahead of a waiting list for a stenting procedure, it is the emergency department that has all of its treatment bays occupied. It is now common for emergency department doctors to have to treat patients who are lying in ambulances parked outside their departments. link to the Daily Mirror

Junior doctors working in Emergency Medicine also complain of unsocial hours ie shifts finishing at 2am, and working the majority of weekends, with no flexibility in the rota and little chance of more than 2 consecutive days off during Christmas. In combination with not being allowed to take leave for courses, and not being able to choose their holiday dates, this is enough to put most young doctors off.  

I have little experience of hospital Paediatrics, but it is very strange that a field which used to one of the most popular should have plunged to the bottom of the list. This may be a consequence of the way that brave and outspoken figures such as Professors Roy Meadow and David Southall have been punished for their exposure of parental child abuse. See Paediatricians letter to the GMC

General Practice traditionally occupies half of all doctors, but this proportion has been declining fairly steadily in recent years, and the number of doctors joining GP training schemes has been below the intended level for a while. This has partly been due to restrictions in GP training budgets, which are needed to fund the jobs in General Practices, but also because of a considerable shortage of doctors wanting to be GPs, despite the fact that it is a much shorter career path (3 years v around 7 for most specialists). GPs are also generally paid better than specialists with no obligation to work outside normal hours.  It is particularly odd when one considers that the newer medical schools have specifically been created with a focus on General Practice with subjects such as consultation skills at the top of the curriculum.

Anecdotally, young doctors seem to be put off mainly by the sheer difficulty of the GP job.  By trying to deal with 18 patients in a morning at 10 minute intervals, often negotiating a plan of action to deal with multiple problems, while also remembering to tick the boxes that are needed for QOF, and maintain a good medical record with a list of important diagnoses. They are afraid that the time pressure will lead to them making mistakes, and they think that brain surgery is likely

 to be easier! The oft quoted saying is that GP is the easiest job to do badly, and the hardest job to do well.

But this is only part of the story. Other important causes for the GP shortage are that the work has increased rapidly because of the QOF and other initiatives that have loaded them with extra work. The number of GP consultations per patient per year has increased from around 4 in 1995 to nearly 6 now.See the NHS report on GP consultation rate

According to a recent report from the Primary Care Foundation  Making Time in General Practice  a large number of these consultations are unnecessary. In particular, their analysis suggests that 4.5% of GP consultations or around 17million GP appointments a year are due to Hospitals pushing work onto GPs that they should be doing themselves. The main categories of this are telling patients to get prescriptions and certificates from their GP that they should themselves be providing, and patients having to go to GP’s to sort out problems with delayed and cancelled hospital appointments and to get hospital test results.

This is odd because the number of hospital doctors has been rising rapidly in recent years. Between 2009 and 2014 the number of consultants rose by 4.1% annually – from 37,000 to nearly 44,000 according to NHS workforce statistics  Meanwhile the GP workforce in so called Whole time equivalent doctors, has actually fallen slightly in the same period according to the Royal College of GP's report  

The GP shortage has been exacerbated by a large increase in the number of Doctors taking early retirement. This has been a result of various policies introduced in recent years. QOF has reduced job satisfaction among GPs. Doctors in small practices have been pushed into joining up with larger practices which they rarely find congenial. Doctors have been forced to pay a lot of money into their pension scheme so have large so called pension pots. When it was announced recently that tax relief on payments into the scheme would be stopped for larger pension pots it made it much more attractive to start taking the pension early, while still working part time.  

Then these 55+year olds who were claiming their pensions were forced to take part in the system of professional " Revalidation" introduced by the government in the wake of the Harold Shipman affair.  Under these rules, continuing to be licensed to practice depends on a satisfactory yearly appraisal, with a minimum number of sessions worked, evidence of audit projects, evidence of a completed professional development plan, discussion of complaints and feedback, and evidence of compliance with GMC guidance. Liability insurance costs are rising by 20% or so per year and are now around £11,000 per year for a full time GP. see GP magazine. As a result of all this, a huge number of experienced GPs, who would otherwise have continued as part timers, are deciding that it is not worth the hassle, and are retiring completely. This wastes a very valuable resource as these doctors tend to be very cost effective in terms of prescribing and referrals, and tend to be more efficient in terms of patients needing less follow up visits.

This change was introduced at the same time as a new stricter exam taken by Junior doctors training to be GP's. In the first cohort the pass rate was only 65%, which meant that the supply of new GPs was at least for a time cut by nearly a third.

The result has been that in some areas there are now few UK graduate GPs. Doctors naturally tend to want to work with a team of colleagues who have had similar training and experience, which has exaggerated the differences.  The difference in the GP workforce between for example Cambridge and Scunthorpe is now enormous. The less popular areas are now struggling very badly to recruit GPs, who are likely to leave again if they get a better offer. Several practices have simply closed, although this means the partners sacking long term employees and thus being liable for large redundancy payments.

Practices are not allowed to employ doctors who have not successfully completed GP training even as temporary staff, although they are allowed to use nurses and pharmacists without any particular GP training, so there is no potential for hospital doctors to help out. Instead nurses, and pharmacists, are being employed to fill the gap. This is economical for the practice but tends to increase overall demand on the health service through increased referrals. Referring patients to specialists might be thought to reduce GP workload but in fact the opposite is true, as each outpatient visit usually leads to another consultation with a GP.

Overall, there should have been plenty of doctors in the NHS, but the authorities have turned what out to have been plenty into a famine. None of the authorities mentioned above have direct responsibility for this issue, but it does seem short sighted that none of them seems to have anticipated the entirely predictable damage caused by their policies on workforce supply, and hence on the NHS.

Unless perhaps they did?

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