Agreed. Strange to be appreciated, although, to be honest, most of the time we are anyway.
Well done Clare. A rude question, explained by the fact that I'm nearly 62 - how old are you?
I agree with scrapping QOF, but not short term, but for good. Three quarters of preventative medicine is not cost effective and based on weak, if any evidence.
Look at Malcolm Kendrick's latest blog about placebos, specifically the placebos used in the major stain trials. Amazingly, the adverse event percentage for the statin in question was almost exactly the same as that of the placebo, in every trial. So what, you may say - the interesting thing is that the rate of adverse events varies from single figure percentages in some to over 80% in the meteor trial. Isn't it handy that the placebo adverse event rate always mirrors the statin adverse event rate, almost as if they'd been chosen with side effects in mind? The drug companies will not release the details of the placebos used either.
If you believe our active problem lists, some our patients could be accused of being spiders - how else can you explain the eight hip replacements?
Don't forget all those with viral urtis that are also 'at risk' of secondary infection. Apart from the standard diabetes, long term steroids, copd, asthma, ckd, rheumatoid, ihd, pulmonary fibrosis, previous sepsis, previous pneumonia etc we can usually rationalise (conjour up) justification for antibiotics if we are feeling pressurised, or just want to go home. This isn't by any means just a current GP perpetuated thing - my father told me that just after penicillin arrived it was tried for almost any dying patient - but it is now so much part of lay consciousnesses maybe we should try to manage it other ways than just direct confrontation. Perhaps a secret placebo, or a drug that has statistically significant benefit, with very little clinically significant benefit, (you know, like statins) but which also doesn't lead to multiple resistance - let's push that one for urtis, if we can find it. Then the patients would get what they want, and those that actually DO develop secondary bacterial infections would naturally self refer and we would manage those appropriately.
In my view, there are very few cost effective preventative measures.
1 Childhood immunisations.
2 Not smoking.
3 Taking exercise.
4 Not getting fat (part of number 3)
5 Not getting addicted to things (especially with reference to number 2)
These are cost effective because 2 to 5 can be advised by anyone, not just GPs, and the onus is on the patient, and 1 is NOT a rolling programme with follow ups, regular clinics and monitoring, and drug costs.
Over the years we have been asked to take on activities that may cost us some time/money in the short term, but in the future we would reap the benefits, eg treating hyperlipidaemia, treating mild hypertension, ckd, osteoporosis, etc, and yet we are busier than ever, and the NHS is broke! The whole idea was based on a false premise, that if these patients didn't suffer what treating x was meant to prevent, that they would reduce their service usage (jargon for 'not bother the doctor') and we would all be happier. The sad truth was that not only are some of these measures not preventing very much (look at NNTs for hyperlipidaemia and mild hypertension) they are also not reducing demand. These things would be fine if they fulfilled their promise of making the population more healthy, and reducing demand, but they haven't and they don't.
My personal list of worthwhile 'preventative medicine'
Not smoking - saves the individual money, unquestionable benefit, no need for me to intervene to 'monitor '
Childhood immunisation - some cost, but relatively fixed, no maintenance costs, benefits mostly not in doubt - read history books for justification, some negative pr from some groups, but mostly supported by the public.
Exercise - benefits don't seem to be in doubt, motivating people seems to be a problem . The fact that there is no direct government intervention suggests that it is not cost effective, so it is left to us to 'encourage'.
Addiction avoidance - self evident, and not just opiates and other recreational drugs and alcohol, but also gambling and obesity - the harm associated with these activities is huge and very costly, and not getting in to that state in the first place is clearly desirable, but does anything work?
Things NOT on the list
Treating and managing mild to moderate hypertension - the NNTs alone are pretty unimpressive, before you add the drug and management costs, side effects, and huge anxiety generated in patients for what in the end is just a small risk factor.
Primary prevention treatment in hyperlipidaemia - see above.
Chasing 95% of patients on the asthma register for annual checkups. They don't come because they feel well, or they can't be bothered. Yes we probably pick up a tiny few whose control could be improved, but is it cost effective?
Pre-diabetes - we know that a large percentage of fat people become diabetic, and we know that to qualify as a type 2 diabetic you have to exceed certain diagnostic criteria. We now have to give special attention to those people near but not over the threshold, on whom we can devote time we cannot spare to encouraging them to mend their ways before it is too late, despite our relative lack of success of motivating the established type 2 diabetics. I'm not pretending that special attention will not work with some people, but again, is it cost effective? How many of the dozens of other things that people want us to do are we prevented from doing because of the priority given to preventative medicine at all costs?
I will of course address someone by whatever pronoun he, she, they, or even it prefers, but we all know, certainly all that get this journal, that a post operative transgender woman is actually a castrated men with breast implants who has had his penis amputated.
Cardiff in the late 70s, my intake was roughly 2/3 regional accents, and the general impression was that a lot, like me, were state educated. But in those days, fees were free and grants were grants, not loans.
Visits as a 'as well as the rest of the work' task are of course a chore, whereas if they are 'instead of the rest of the work' duty, they are usually both manageable and even enjoyable. Certain provisos of course - you have to be a big enough, (as in number of doctors) practice, and the designated doctor has to have enough to do. In our case, covering maybe 400+ square miles, 15,500 patients, including 4 homes and a minor injuries unit, the 'driver doc' usually is occupied all day. If the duty is quiet, she/helps out with the mobile sick in the surgery. Most doctors, partners and salaried, LIKE visit days, I accept that there is pressure of workload, but I would rather get rid of the things that I believe are a waste of time (in my case, almost everything to do with cholesterol and statins, mild to moderate hypertension, most of the ckd burden, and chasing stable asthmatics that don't want to have an annual review) and carry on doing things that the patients want and sometimes need, and that I mostly enjoy.
'Dear grown up doctor, I've been asked by another grown up doctor to refer you this patient. Please find enclosed a copy of my original referral letter, and the grown up's reply telling me what to do.'
How often do you get outpatient review letters arriving before the discharge letter for the original admission? Sometimes the discharge never comes and the important diagnosis may not be coded because the doctor reading the outpatient follow up letter wrongly assumes that it has already been coded. Having been burnt once I now always check and about half the time the discharge letter hasn't yet (if ever!) arrived.
So 2 groups of patients at 60, neither have ever had a heart attack or stroke, can choose to go onto statins. Those that do all die at the same rate and date (statistically) as those that don't. Those that do have fewer strokes/chd than those that don't, therefore those that don't have fewer NON strokes/cod (whatever those may be). Who is to say that those in the the statin group have had a better life? They certainly haven't had a longer one. Meanwhile the £££ cost mounts, as do the side effects.
How strong is the correlation between statin use and dementia?
If the net result is the same number of deaths, fewer from heart disease/strokes, more from other causes, AND all the side effects from statins, before we even talk about the cost, both of the drugs and also all the monitoring that goes with it, what is the point? All that money, and all those side effects, just to change the cause of death on a death certificate, but not to change the date?
Guidelines are not evidence however, you have to look at the evidence behind the guideline, and how strong the evidence is. The guidelines are also carefully worded in that they say that stains are the most effective intervention, and that atorvastatin 80 mg is the most effective statin, but nowhere does it actually say by how much risk is reduced - and don't forget the inflation of apparent risk by making it relative instead of absolute. Re the all cause mortality, and the treatment cohort having fewer strokes and heart attacks, it was pointed out that the statins have saved them from the poor quality of life associated with stroke and heart failure - all well and good, but as the mortality was unchanged , ie the patients overall died at the same expected time, then other causes of death must have gone up, some of them, I would guess also have a poor quality of life, cancer and degenerative neurological disease, to name just 2. I would not take a statin myself for primary prevention, I have to declare that point, but it is a view I have taken from examining the original papers, not the guidelines.
Óral rehydration sachets when reconstituted taste like Ribera and salt. Drinking ordinary tap water is another good way to become rehydrated - when your pee looks the same colour as the tap water you have rehydrated.
Bugger! Thinking of you, mate.
I am nearing the end of my first year post 24 hour retirement. When I did 9 sessions of work, 1.5 were endoscopy, the earnings going in to the pot. I ditched those when I hit 60 and now do 6 sessions of GP a week, and yes, I enjoy it. The interesting thing is that I actually do the same number of sessions that my 25 years junior partners are doing in their 'full time' contract!