Prevention is valuable; but we focus far too much on what the NHS can do, and far too little on the wider determinants of health.
Addressing homelessness and poor services for young people in need, reinstating sure-start, improving local authority funding and opportunities such as better leisure and community facilities, integrating public transport systems and supporting cycling and other systems to counter the obesogenic environment... These are all likely to have a higher yield than much of the secondary prevention undertaken in primary care. Some of them - like improving services for looked after children and young people and for homeless people - might well be cost-saving in the medium to long term.
Vaccine programmes are worthwhile, of course - they are highly effective and often cost-saving.
DOI - I haven't managed to get registered on Pulse in an appropriate way. I am a former GP, and am now a public health doc (consultant in communicable disease control) and chair of the BMA Public Health Medicine Committee.
I'm sorry, the conversation from Johnson et al has so debased my expectations that I briefly thought that "spe" in "in spe vivimus" might be related to one of BJ's schoolboy slang vulgarities - "spaff". (It's not. It's "hope" - closer to French "éspère"
PS - I have said on here many times before, but for the sake of transparency - I used to be a GP, I am the former editor of a vaccination magazine, and I am Chair of the BMA PUblic Health Medicine Committee - but I have not been a GP for some time. Pulse did not - at least when I registered - have an option that described me - the closest I could get was "Salaried GP". But it's pretty inaccurate.
Most people miss out on vaccination because they didn't get the appointment, missed it because they forgot or were busy. A study in a religious community in North London in which it was assumed low uptake rates were due to objections to vaccination - it turned out it was because of their large family sizes. It's much harder to get the little one to the surgery/clinic when you've got several older children to get to school etc.
Investment in better systems is required; including in identifying people who missed their vaccination and making it available to them in a way that works for them... Part of this could involve a change to incentivisation payments - paying GP practices (properly!) to do the extra work that's required.
Simply saying "it's antivax sentiment innit" is an easy (but maladaptive) way to avoid addressing these issues.
This should of course be properly resourced and commissioned.
Antivirals are not very useful for treating people with flu. IN most cases they get better perhaps half a day earlier than they would have done - if the antivirals are given relatively early in the illness. Not much of a gain.
(There may be more benefits in people who get really ill and need to be admitted - these are probably people who fail to clear the virus as quickly as normal.)
But what antivirals are really good at is reducing infectiousness. The quantity of virus in respiratory secretions, and the duration of viral excretion, are hugely reduced by antivirals.
Now, that doesn't benefit the patient taking the antivirals directly. But it does considerably reduce the likelihood of their spreading it to others.
The other thing that antivirals are OK at is preventing or reducing the severity of illness if they are given before the onset of symptoms.
So... While I am NOT arguing that this should be part of a GP's work, there is a very good scientific case for providing antiviral chemoprophylaxis is institutional settings such as care homes.
It seems greedy, having been quoted in the BMA press release, to have a second go via the comments, but I shan't let that hold me back…
It is, of course, important to maintain confidence in vaccination; and there is great interest in "antivaxxers", "antivaccine sentiment", "vaccine hesitancy" and so on.
BUT - I am not aware that, in the UK at least, there has been a significant change in antivaccine sentiment.
What there HAS been, of course, is continuing cuts and disruption to primary care and public health services and (at least relative to need) funding. This makes it harder to provide vaccination in a way which makes it easy for all those eligible to take up the offer. In my opinion, the drop (which is very small) could be due to a number of factors, including:
* less investment and or time for data collection and entry;
* less time/personnel to chase up missed appointments
* less time/personnel to ensure good systems for sending appointments;
* less time etc to identify people who've missed appointments opportunistically;
NB - this is emphatically NOT a criticism of NHS (or PHE) personnel, but an observation about the underinvestment in primary care and public health.
And on Day 2 he will solve world poverty.
Guidance from the GMC and others is clear.
" If the police do not have a court order or warrant they may ask for a patient’s health records to be disclosed voluntarily under section 35 of the DPA 2018. However, while health professionals have the power to disclose the records to the police, there is no obligation to do so. In such cases health professionals may only disclose information where the patient has given consent, or there is an overriding public interest.
"In this context a disclosure in the public interest is a disclosure that is essential to prevent a serious threat to public health, national security, the life of the individual or a third party, or to prevent or detect serious crime. This includes crimes such as murder, manslaughter, rape, treason, kidnapping and abuse of children or other vulnerable people. Serious harm to the security of the state or to public order and serious fraud will also fall into this category. In contrast, theft, minor fraud or damage to property, where loss or damage is less substantial, would generally not justify the breach of confidence necessary to make the disclosure.
"Health professionals should be aware that they risk criticism, and even legal liability, if they fail to take action to avoid serious harm being caused to others. Guidance should be sought from the Caldicott guardian, or defence body where there is any doubt as to whether disclosure should take place in the public interest."
A classic example of something that is done because there is pressure from politicians, some members of the public (and possibly some traditionalist medics) rather than because there is any evidence base for it. Now, what else can I think of along those lines...
This is a very odd report. It seems almost designed to generate (potentially damaging) speculation.
It states that Potts:
"…had been subject to investigations - though not by the GMC - following complaints from a patient about her blog on battling bipolar disorder."
It goes on to say that the coroner
"…will be writing to the practice, NHS England and the General Medical Council raising concerns about her situation."
Which raises all sorts of questions - to the extent that it invites speculation. What will he say to the practice, to NHS England, and to the GMC?
If the GMC weren't investigating, why is he writing to them? And who was investigating her? NCAS? If so, why didn't he say he was writing to them?
If GMC wasn't investigating Potts, what other reason would he have for writing to them? Is he referring somebody to the GMC, in which case, who?
The report states that the practice had suspended Potts, and that the coroner had said
"It seems to me the suspension and investigation was something of a sledgehammer being used to crack a nut."
So he appears to have criticised the practice - was he writing to the GMC to refer partners? (I have no reason, other than this vague report, to think that is what he was doing; but from this report it's reasonable to conclude he could be.)
I wonder whether the coroner had actually been so irresponsible as to make a statement that would invite such speculation. Or did Pulse précis things down to an extent that the meaning - originally clear - was obfuscated, leaving us all speculating.
There is BMA guidance, but it is internally contradictory. It states:
"f an “on-call” doctor is on duty, whether in or out of hours, it is unlikely that any useful purpose will be served by that doctor attending the nursing or residential home. In such cases we recommend that the GP advises the home to contact the undertaker if they wish the body to be removed and ensures that the GP with whom the patient was registered is notified as soon as practicable."
But then, re expected deaths in care homes:
"If the doctor who has been treating the patient is not immediately available, a colleague should attend and then ensure that the doctor of the deceased patient is informed of the death as soon as possible and arrangements are put in place for the issuing of the MCCD and relatives informed of these."
What is the point of the "colleague" attending if they cannot write the MCCD?
"When we see only the evidence that confirms our own world view it is never challenged."
Part of this is down to powerful politicians and senior civil servants ensuring that civil service bodies (such as PHE) are not permitted to pursue or report any evidence that might undermine ministerial views.
And the BMA blames their lawyers. I've expressed an opinion. See http://www.ganfyd.org/index.php?title=Firearms
When I was training in public health there was a Venn diagram with three overlapping circles:
* need - defined as the ability to benefit from an intervention
* demand - the amount of clamour from patients or the population for an intervention
* service provision.
We would discuss the extent to which the need and the provision overlapped. Occasionally there would be a service for which there was a demand, but no need (little or no evidence of efficacy); if this was provided by a new clinic there would be a rush of referrals, and sometimes we would (perhaps dismissively) refer to provider-led demand.
We also discussed how a new clinic could uncover previouisly unmet demand - if there's nowhere to refer a patient to, there are no referrals. Systems assessing needs based on the number of referrals don't work if referring practitioners know there's no service to refer to...
In the case of child and adolescent psychiatry in general - and possibly easting disorders in particular - there has been a lot of publicity recently about "parity of funding" and stigma. We know that services are appallingly underresourced. We know that if young people were dying of accident or other diseases at the rates they die of mental health related problems there would be an outcry - but the stigma associated with mental health allows people to distance themselves and blame the victims.
I've no idea what to do about this!
Ugh, got interrupted and ended up posting garbage... What I think I meant with my second point was that there's a risk that OH doctors will not be familiar with the actualities of how fit notes are requested and provided in reality. One of the things you learn in public health is that specialists over-value their own speciality: to a surgeon, all problems can be solved with an operation; to a tertiary care paediatrician meningococcal septicaemia is a common problem that the public should know more about... I exaggerate, of course; but you'll recognise a kernel of truth in this.
Whereas it is GPs who actually sign and provide (I imagine) the vast majority of fit notes - I'd be amazed if more than 1% of them was provided by OH doctors. (I'd bet surgeons do many times more than OH doctors do.)
This isn't to knock OH doctors; but to recognise that they see OH issues all of the time, and from a very different perspective from other clinicians.
There appear to me to be at least two problems here...
The number of GPs at ARM vastly outnumbers the number of occupational health doctors. There is a risk that the OH doctors' professional views become irrelevant against such huge opposition - one of the problems with democratic principles.
However, there's also a risk that - since fit notes are issued almost exclusively by GPs (I imagine - does anybody have the facts) - it's GPs who do this, know about it, and know the true costs and benefits of the current and proposed systems.
I'm convinced by the GPs' arguments; but it would be nice to see the pros and cons laid out clearly on both sides.
Yesterday the Pulse registration process kept insisting I wasn't on the medical register (I double-checked at myGMC to confirm I'd entered the correct number, and my details in the same way - I had).
Today, however, it appears to be working.
As it happens, I am not a salaried GP - but there was no choice that fitted any better than that, so that's what I'm described as...