I am left wondering about the intention of the initiative. Past experience tell us that low cost information campaign targeted at citizens, combined with a newsletter on local antibiotic resistance targeted at doctors and pharmacists, is associated with significantly decreased total rates of antibiotic prescribing but has no affect the population’s knowledge and attitudes about antibiotic resistance. Most often doctors are "pushed" to prescribe antibiotics and, alike for benzodiazepine, is the "fear of confrontation and complaints to deal later on with" the stronger driver of their prescribing. So, I would very much invest in high cost campaign and, perhaps , even consider the introduce a prescription ticket on some items, such as antibiotics and benzodiazepines. Overall, I believe that GPs should have more autonomy and decisional authority. Fear of receiving complaints has changed the way we practice medicine (defensive medicine) which is not good for the NHS and hence for the tax payers. "Because it has worked in the past", is a very scary concept as quite nicely put by Nassim Taleb in "The black swan".
The suggestion from the anonymus GP seems to be a sensible one. I am sure you have already considered that option, but if your intention is made crystal clear from the beginning and you look around carefully openly talking with colleague locum GPs, you shall find the partner.
It was May 2011 when I wrote "the NHS is being dismantled". Well, most of my expectations have been met. And we cannot blame it all on the Government. Some GPs have enjoyed "expansion of their business". Bidding for different practices, when they could not physically work in all of them, and most of the time reducing their clinical working hours instead, I am not so sure cannot be called privatization. Unfortunately, it may all come back hunting us. However, perhaps, it was unavoidable and it was right who just endorsed the change.
It is interesting...Up to 5 years ago it was indeed another story. There were no parterships available at all. Perhaps in GPLand, the culture of GP Entrapreneur was so strong, that many assumed that empoying GPs was going to be more "cost-effective". A few GPs started to think "big" and bidding for more than one practice. The phenomenon was clear, so that the
numbers of sessional GPs in the workforce
continued to increase. With the
continuing lack of partnership availability,
established GPs and newly qualifying GPs
coming into the workforce were more likely
to have a career in general practice as
either a salaried or locum GP. It turns out that many have been frustrated by the state of affairs in General Practice, first of all many Partners, now approaching the retirement age.
I have been lucky in having chosen – and be given the opportunity - to work in many different places during my career.
This was not a “cost-effective” choice, but it was in several ways “illuminating”.
It gave me the unique opportunity to see how the healthcare system and medical management may vary from Country to Country. I have observed that there are differences in how we deal with illness as individuals and as a society, as well as the way we prevent its onset. I have also grown to equally respect all those different modalities, and to reject any form of “superiority feeling” when comparing different medical management styles.
My travelling started as a “mistake”. In fact, it was triggered by two misconceptions.
I thought of Medicine as a pure science and I deliberated that training at the top institution must have provided me with the right formula to apply to my daily clinical practice.
I have assumed the grass is always greener on the other side.
I ended up working in the UK because my “heart”, rather than my profession, took me here.
20 years ago, after a short visit to London and its major hospitals, I had excluded this would have ever happened. I was not impressed at all then.
My search for the Holy Grail continued, unsuccessfully, for several years, moving across Continents and always going for the best placements.
I did not find “perfection” in any system.
However, I found my wife, and I landed in the very place I never thought I would have worked.
Things have changed in 20 years. It has changed the way I look at things – I am very much less judgmental nowadays - and the UK Healthcare System, in my opinion, has improved a great deal.
I want to help improving the status quo far more than I do aspire to contribute to the maintenance of a system as it is, as I believe it to be the “right one”.
I welcome different perspectives, when they come from patients as well as when they are proposed by colleagues. I can see in them opportunity of personal and professional growth.
I am a strong supporter of movement of medical professionals between Countries.
I reject any accuse or allusion that non-UK graduates may be somehow a burden or a risk to patients because they may have received an inferior academic training, or because they may be of “inferior quality”. Those positions are both wrong and offensive.
I also exclude English exam may be a way to make the NHS a “safer” place.
I instead propose that it would be mutually convenient to colleagues working for the first time in the UK - no matter how experienced or proficient in English - and to the patients, that full-registration with the GMC of FMG may take place only after 12 months of supervised medical practice.
I did love to have a supervisor/tutor, and I cannot think why anyone would feel differently.
I do understand the concerns about a slump in funding particularly paralleled by growing and ageing population, with increasing numbers of patients have multiple conditions.
In the other hands, we know that healthcare spending is not linear function of healthcare levels of a Country.
USA healthcare spending is 17.9% of the GDP, 53.1% of this coming from the Government as 22% of all spending. This is a lot, by any standard, but very few readers, if any, would say that USA has the best healthcare system in the World.
What UK is currently spending in healthcare is significantly more than in Countries where people enjoy better general health and greater longevity than in the UK.
It is time to reconsider where we should invest our money.
I strongly believe that it would be worthwhile investing more in healthy lifestyle education starting for very young age.
Children spend many hours at school.
Healthcare education is as important, if not more important, than many other educational subjects.
To date, prevention remains better than cure.
I suspect there is no way NHS may do without politics. In fact, it is a political choice to have a public healthcare system. Politicians have allured healthcare workers, GPs in particular, and they have been allured by private providers. There is no suprise there, But I find concerning that the NHS, as a public company, yet still a company, to survive it should have the stength of making hard choices. A company that tries to be the lowest cost and highest services enterprise and to do this for all customers segments, it will end up stuck in the middle. It will end up bad in everything.
Behind any crisis there is an opportunity. An opportunity for a change. Increasing indemnity costs and litigations are a widespread phenomenon in USA and Europe. Not only. Malpractice lawsuits have high visibility, particularly those resulting in large awards. To make matters worse, a lawsuit for a large amount of money constitutes front page news, whereas a physician's exoneration in a lawsuit is often a back page entry.
Malpractice most often takes place when "bad outcomes" are combined with "bad feelings." But nowadays litigation has become a common response to bad outcome in general. All doctors-even those who practice good medicine are therrefore vulnerable to litigation. Although many physicians continue to believe that litigation is something that happens "to the others," most are keenly aware of the risks.
Fact is that defensive medicine is becoming more and more common. I do not think this is good for doctors, for patients, and for the government. In fact, perhaps it would be the general population and the public healthcare systems to pay the highest fees. This is why, I believe, government should step in. Besides the rising costs, one of the major effects is a distinctly defensive approach to practice, with the patients seen as adversaries long before any hint of litigation supervenes. Frequent attention in the media to the issue of malpractice may increase the level of paranoia among practitioners, in which doctor-patient relationships become doctor-customer relations or-at worst-defendant-litigant relations; and medical services are viewed as some kind of product with concomitant warranties and guarantees. Defensive practice may also usurp the clinical judgment of practitioners, and doctors may lose enthusiasm for attending to the needs of patients because of a perceived loss of autonomous control over the interaction. Doctors will avoid high risk areas of practice (general practice, obstetrics, orthopedics, and emergency medicine) or may leave the field of medicine entirely. we already know that Emergency rooms are difficult to staff, and insurance companies are accused of profiteering.
I subscribe Nabi's thoughts and views.
However, I can see a struggle there, which is not just finding a GP to have the "gut to say no".
May I also add that, contrarily to what an anonymus pointed out, having travelled and worked quite a bit in my professional life, I Thank you Nabi for your heartfelt letter.
I subscribe your thoughts and views.
I would like to add that it is not just finding a GP to have the "gut to say no", or as an anonymous before me pointed out, about having more “caring” GPs.
I have travelled and worked a lot in my professional life, looking for the top healthcare system, victim of the misconception that the grass is always greener on the other side.
A fault of youth, I say today. I did not find such a place.
In the other hand, I learnt how similar problems can be tackled in different ways and I was reassured that the overwhelming majority of colleagues went into Medicine because they do care about helping people and do love their profession.
I have no reason to think that “anonymous” wrote about lack of caring attitude to upset all the readers who are also healthcare professionals. I believe that anonymous witnessed what I call frustration. It is with concern that I have seen this feeling growing steeply across Countries.
My view is that the situation we are facing is very complex and to be successfully addressed it does require a cultural change from all the stakeholders (sigh!).
Firstly, we should look at the role we played as healthcare professionals in “generating costumes”.
I have emphasized in different publications, how not appropriate antibiotic prescribing has at the best generated wrong beliefs among many patients. In turn, this has triggered a "business growth", which is a quite unhealthy growth.
We are stunned by the plethora of patients attending GP surgeries, OOH centres and A&E Departments with sore throat. Why patients are coming to the surgery for an antibiotic for sore throat?
Well, it happens that we have been prescribing antibiotics for sore throat for decades and we did advocate them. In other words, we did educate patients that this was the right approach and stepping back needs a very good explanation. In fact, this is a very hard thing to do (no just in Medicine, of course). Looking at the same aspect of care upon a different perspective, we could say that our profession has “facilitated” a “medicalization” of our society. To put it in another way, we are now dealing with the consequences of promotion of a service by sub-optimal clinical problem management.
Growth can be good or it can be bad. Too much growth can overwhelm people, processes and controls. It happens that the Public Finances and healthcare professional’s workforce are limited.
1. Stress quality controls
2. Stress ﬁnancial controls
3. Dilute one’s customer value proposition
4. Dilute one’s culture
5. Put one in a diﬀerent competitive space
It seems to me that NHS is experiencing all the five problems.
I am sure that NHS should be much less about meeting targets, but –with realism- about meeting healthcare needs using a finite amount of resources.
'Three week cough' lung cancer campaign prompted at least 200,000 additional GP attendances, new figures suggest
It is interesting indeed that it is believed that the "Be Clear on Cancer” [campaign] has found is not only did they have 700 more cancer diagnoses, but there was a stage shift. However, I would be very keen to know more on this. For instance, I believe the study compared the number of diagnoses made during the campaign months against the year before. I would be keen to know what did happen over the same period of time over the last 5 years. It is possible that numbers have been "swinging". Surely it is of some concern the significant increase in waiting list, and the extra-work as there are many other serious illnesses needing prompt attention.
I would have hoped for a more targeted campaign (smoker, perhaps over 40...).
Great letter. Thank you Dr Nagendra Sarmah. Positive changes can happen if we are able to identify what's wrong with the status quo. You gave us a quite clear picture.
I subscribe and very much welcome Dr Kailash Chand's letter. Politicians too often try to satisfy the "gut" of the voters, which would not be a problem if the "gut" had not been "ignited" by the press going after the "next scandal".
Dr Chand has only been rational.
RCGP (and BMA) may have to reconsider their mission, vision and strategy.
At the present, my humble opinion is that they lack of a clear scope and that I cannot see many colleagues around passionate about their memberships.
When being a MRCGP or a FRCGP is seen as being “financially” advantageous or a “must”, there is something wrong. The only thing I would advocate in the medical field are passion and dedication. The nearest you are to the pity “cash”, the worse it gets (pretty much everything).
As far as the exams are concerned, I would suggest to "breaking down" the assessments during the training years.
Furthermore, after many years of clinical practice, I can confidently say that non-clinical skills and values are grossly under-estimated.
A very bad piece of news for practicing healthcare professionals and patients alike.
To no surprise, nevertheless...
Just a couple of additional considerations: many drugs may be on prescriptions, but are available OTC. The decision to take or not to take them is already a "medical decision" . It can be argued that many of them may be actually dangerous if taken not in an appropriate way. So is the decision to take or, no to take, yourself or a relative, to see a colleague. Unfortunately it is technically impossible to "revert " to a non-medical doctor status. In the other hand, the new position of the GMC makes the situation clearer, rightly or wrongly so. As such, it is welcome.
It is believed that doctors may not be inclined seeking help for several reasons. Patients want healthy doctors and doctors feel there is enormous pressure on them not to ‘give in’ to ill health and there is a view that doctors who do take time off sick are perceived as a “problem”.
One of the reasons behind self-prescribing is convenience and feeling duty of being helpful to both family and patients.
Beauchamp and Childress’ Four Principles framework (respect of autonomy, beneficence, non-maleficence and justice) had been respected.
From the detailed review of the cases I was not able to find a clear dilemma between convenience and ethics. In fact, it is likely that the convenience for the self-prescriber was also convenient to the society.
Kant believes only actions performed for the sake of duty have moral worth. He seems to suggest that the greater one's disinclination to act for the sake of duty, the greater the moral worth of the action. Moral value is essentially established by the intention of the person acting.
Although convenience is often what drives physicians either to curbside or to self-prescribe, the question remains what motivates doctors to curbside rather than simply self-prescribe. One explanation for curbside requests is the physician’s concern about the legality of self-prescribing. Some regions in the USA and other countries have restrictions on self-prescriptions. A second reason may be that the provider wants to avoid the appearance of impropriety from the pharmacist. This concern is particularly valid if the prescription is for a controlled substance that is more closely monitored for inappropriate prescribing patterns (3).
A third reason to curbside is that the request is a way to obtain a second opinion. However, curbside requests rarely include a full medical history or physical examination. To ensure the appropriate prescribing of any medication requires access to information often considered highly sensitive and not readily shared by colleagues (eg, whether the patient smokes, uses oral contraception or consumes significant amounts of alcohol). In a formal encounter, the prescribing physician would have access to a patient’s full medication list, medical history and social practices that may affect the metabolism or side effect profile of the prescribed drug. In the practice of curbside prescribing, however, there may be an implicit assumption that the requesting physician has accounted for these factors when making the request, so these details are rarely asked of the requesting physician. In addition, because of the social stigma and sensitivity of some information, prescribing physicians should be sceptical about whether they have received complete answers even when brazen enough to request relevant information. The requesting physician may leave out information because of fear that the curbside encounter may not be protected by typical confidentiality constraints, yet again underscoring the ways in which it is different from a formal encounter.
Furthermore, it would be most difficult for the pharmacist questioning the prescription (4).
To resolve the dilemmas that may arise from self-prescribing, prescribing to family members, and curbsiding prescriptions, one option could be just not allowing all together this kind of prescribing, no matter the circumstances and the type of medication prescribed. Somehow this type of intervention, which seems to have been embraced by some Health Authorities, would simplify the decision for doctors.
However, this intervention may be obviously of nocument to patients in case of emergency. If the emergency situations are exempted, then doctors would be once again called to judge is there is an emergency or not. One of the main accuses to self-prescribing and prescribing to family members is that judgment can be impaired. It is therefore likely that judgment could be affected in emergency situations involving the own person or family members.
Ultimately, it appears that everything may be reduced to best judgment in the given circumstances and not allowing this type of judgment implies limitation of freedom and it can be detrimental for patients and the society.
With the Hippocratic Oath doctors swear they will prescribe for the good of patients according to their ability and judgment and never do harm to anyone. If the judgment is not obscured, or there is no reason to think that the judgment can be obscured, then it should be considered appropriate self-prescribing and prescribing to family members.
Mill argued that the burden of proof is supposed to be with those who are against liberty; who contend for any restriction or prohibition; the a priori assumption is in favour of freedom.
Joel Feinberg, American political and social philosopher, appears to agree with this concept, which is also echoed by later works from Stanley I. Benn and John Rawls, arguably the most important political philosopher of the 20th century.
For Gerald Gaus freedom is normatively basic, and so the responsibility of justification is on those who would limit freedom, especially through coercive means. It follows from this that regulations and laws must be justified, as they limit the liberty.
Further studies are necessary to investigate wheter if, how, and when, limitations of self-prescribing and prescribing to family members may be beneficial to patients and society alike.
1. La Puma J, Priest ER. Is there a doctor in the house? An analysis of the practice of physicians' treating their own families. JAMA.1992;267:1810-1812
2. Kuo D, Gifford DR, Stein, MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA. 1998;280:905-909.
3. Myers JP. Curbside consultation in infectious diseases: a prospective study. J Infect Dis. 1984 Dec;150(6):797-802.
4. Bake K. Should you dispense to M.D.s who self-prescribe? Drug Topics Nov. 17, 2003;147:57.
No one more than me would like to see the 'health tourism' flourishin as this would mean that we are doing so well to attract people from Abroad. The truth is that I have instead seen people going Abroad for surgery and treatments and as yet I have not seen the opposite happening. Perhaps in London may be a different story? I don't know. I see an average of 45 patients per day, but no sign to my desk of "health turism" in this Country. However, I wonder what happens to the many of us going to Spain, Italy, or France to retire. I wonder, if anyone has ever checked the figures...I think no one would oppose, even clients, if GP's were allowed to charge. But I agree with the previous post in full: "we are now tending to generalise this issue and put all oversease visitors in one category which is also unacceptable".
I can just subscribe all the above and repeat what I already stated on the matter.
This is that revalidation may well be, above all, an alluring trap for clients/patients looking for that reassurance so much needed by the public opinion/clients/patients to mitigate the greatest hindsight bias linked the Harold Shipman case.
The worse the consequences, the greater the bias: the already large Harold Shipman case bias was reinforced by a few other highly publicized press news, such as the Dr Ubani case.
It was thought to introduce revalidation perhaps to rebuild the public trust in doctors rather than because it was truly felt that our profession really needed revalidation.
I suspect, in that political climate, it was much easier jumping on the "revalidation bus", rather than objecting to it on the basis of its questionable benefits.
Another reason why jumping on the "revalidation bus" was and still is appealing is that revalidation is a business. A very large, new, profitable business.
The costs of this new business will be passed to the clients. I am not sure if this is clear enough.
It is my humble opinion that we are not too far away from the negative consequences of the rising malpractice litigation.
Litigations have changed the way doctors work no much because of new evidence and/or better clinical evidence based practice, but because of by ordering more tests and referring to specialists, or applying treatments even when they are unlikely to help, inevitably would reduce the risk of being sued.
This attitude may protect physicians, but it is less likely to help patients.
Revalidation may pose far greater risks to our profession than civil litigations are.
Keeping in mind the "law of small numbers", it may be easily anticipated that some group of physicians are at higher risk of being tagged as "in need of revalidation", or "poorly performing".
Those groups will be the small groups. Solo-physicians, now a minority, or foreign medical graduates, or even ethnical groups, to make a few examples. This is and will be because small samples yeld extreme results more often than large samples do.
Of course, following the same reasoning, it shall appear that one or more of those groups may do extremely well, but this will not be attracting any attention from the "Revalidation Team".
The halo effect of the Ubani case cannot be neglected either. Likewise, there will be an halo effect attached to received complaints.
For instance, I exclude that I have been right on all the clinical decisions, no matter how much effort I did put in them and how highly I think of them. In fact, I am sure that we do make "errors" on a daily basis and I am confident that in 20 years time, my today's best practice could be exposed to severe criticism due to new knowledge.
Perhaps, I have been just "lucky".
Does time we spend practicing and number of patients we do see counts and if so, what could be the practical implications?
To be able to answer this question we need to answer the following questions: "Do I think that a GP working 9 sessions per week would be likely to make the same number of "errors" - I am not considering purposely the rate errors/patients- of a GP working 5 sessions per week?".
Medical Professional Indemnity firms know the answer to this question and the reader may verify what this is asking for the formula being used to calculate the insurance premium .
You may therefore easily guess the answer to the second of my questions.
The point I am making is that Revalidation is a costly exercise not able to bring," per se", any improvement to our professionalism. If anything, it will give us negative feedback and outcomes.
I would very much welcome the same amount of money invested in Revalidation going toward to CME instead.
I would like to see money to be directed toward to helping colleagues in professional difficulties as the profession itself may benefit from it.
Revalidation is very much the fruit of negativity rather than of an attempt to respond to our educational and professional development needs.
My constructive string feeling is that, far more than revalidation, transparency, improved interactions between doctors (and patients), shared and informed decisions, are what our profession needs.
I am most confident than most doctors enjoy CME. Investing in CME is key.
Revalidation may be (and probably is), above all, an alluring trap for clients looking for that reassurance so much needed by the public opinion to mitigate the greatest hindsight bias linked the Harold Shipman case. The worse the consequences, the greater the bias. For the time being, revalidation is a new business. The costs of this new business will be passed to the clients. I am not sure if this is clear enough. We are not too far away from the negative consequences of the rising malpractice litigation. Doctors have changed the way the work no much beacuse of new evidence and better clinical evidence based practice, but ordering more tests and referring to specialists, or applying treatments even when they are unlikely to help. This attitude may protect physicians, but it is less likely to help patients. Far more than revalidation is, transparency and interactions between doctors (and patients), shared and informed decisions, are what Medicine needs.