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Independents' Day

Tom Marshall

  • GP point-of-care testing 'effectively reduces antibiotic prescribing in children'

    Tom Marshall's comment 09 Nov 2018 3:03pm

    The study was in Belgium, which has a relatively high antibiotic prescribing rate compared to other countries [Ref](

    It might not work here were we are starting from a somewhat different baseline.

    Belgian GPs are also paid fee for service, patients don't register with a practice and can consult any GP.[Ref]( So really quite a different system.

  • 150,000 patients with resolved AF 'should still be on anticoagulation'

    Tom Marshall's comment 15 May 2018 4:24pm

    As far as I am aware an AF Resolved code means the patient is no longer included on the AF register. This may be why 90% of these patients are no longer receiving prescriptions for anticoagulants 90 days after the AF resolved code.

  • GPs reminded not to prescribe anticoagulants to at-risk patients

    Tom Marshall's comment 22 Jun 2017 5:23pm

    Some really interesting points raised in the comments.

    It might help if I explained a bit more about how we did the study. We looked at all AF patients in a series of snapshots. We identified which AF patients had a prescription for anticoagulants and which did not on a specific date in each of a series of years. We then categorised them according to whether or not they had contraindications.

    Contraindications were defined as a clinically coded diagnosis of:
    major bleeding (gastrointestinal, intracranial, intraocular, retroperitoneal),
    aneurysm (within the previous 2 years),
    haemorrhagic stroke (within the previous 2 years),
    bleeding disorders (within the previous 2 years) (haemophilia, thrombocytopenia etc),
    peptic ulcer (within the previous 2 years),
    oesophageal varices (within the previous 2 years),
    proliferative retinopathy (within the previous 2 years);
    allergy or adverse reaction to anticoagulants (ever);
    pregnancy (within previous 9 months);
    severe hypertension (mean of 3 most recent blood pressures 200/120 mm Hg)
    Most contraindications were major bleeding, the next most common were aneurysm and haemorrhagic stroke.

    It is a really good question whether these recorded contraindications were really associated with more adverse events. This would require us to extract a very different set of data: the longitudinal records of AF patients on anticoagulants to see how many bleeding events and strokes they subsequently had. We suggested this type of analysis in the discussion.

    Yours sincerely
    Tom Marshall

  • GP-led diabetes model 'saved NHS £2m by cutting heart attacks and amputations'

    Tom Marshall's comment 12 Dec 2016 9:19am

    As there is no control group it is hard to know if Portsmouth's reductions in admissions are any more than found anywhere else. Nationally there was a 25% reduction in admissions for diabetes related complications reported by a group in Imperial College from 2004 to 2009. So this kind of change in admissions can happen anyway.

    Unfortunately we can't know if this worked from this evaluation. As Marmaduke points out it will collapse if unfunded and it is unlikely to be funded without a convincing evidence base. Particularly given some of the other concerns raised.

    Authors: A. Calderón-Larrañaga, M. Soljak, E. Cecil, J. Valabhji, D. Bell, A. Prados Torres, A. Majeed
    Does higher quality of primary healthcare reduce hospital admissions for diabetes complications? A national observational study
    Diabetic Medicine June 2014; 31(6): 657–665.

  • Occupational health professionals reject GP calls to overhaul fit notes

    Tom Marshall's comment 12 Dec 2016 8:57am

    GP opinion:
    - sick notes take up GP time
    - GPs find it difficult to refuse patients because they have an ongoing relationship to consider, therefore they don't encourage early return to work

    Occupational Health opinion:
    - patients need to have illness reviewed because this will deter them from taking excessive time off work

    My opinion:
    - I agree with the anonymous hospital doctor who suggests abolishing sick notes completely
    - I suspect that the more you make people responsible for certifying themselves the less time they will take off work

    But this is too important to be left to anyone's opinion. We could get past opinions. We could introduce 14 day self certification in some regions and not in others. We could then look at what happens to:
    - days taken off sick
    - GP consultations for sick notes
    - we could even ask the general public what they thought of the new arrangement

    Or is that just too sensible to actually happen?


  • CVD health check can be limited to one in 12 adults, study finds

    Tom Marshall's comment 09 Nov 2016 3:13pm

    Just to clarify. The process of ranking patients by pre-calculated risk requires only the cardiovascular risk factors which are already available in electronic patient records. Electronic records have everybody's age and sex. They have smoking status and blood pressure for the majority of patients. In fact the ranking would work almost as well even if we only had records of our patients' age and sex.

    I hope this clarifies. I will get back to worrying about President Trump now.

  • GPs 'likely' to face litigation from 'ambulance chasers' due to electronic patient record access

    Tom Marshall's comment 03 Mar 2015 11:56pm

    One of the anonymous correspondents refers to the view that it does not require much thought to refer to "the duty of the doctor" and that this indicates a degree of self righteousness. I would just like to make clear that the thoughtless and self-righteous author of this point of view is not myself but the GMC. (Point 11 below)

    This can be confirmed by looking at their website. The exact text is below.

    Develop and maintain your professional performance

    7. You must be competent in all aspects of your work, including management, research and teaching.1, 2, 3
    8. You must keep your professional knowledge and skills up to date.
    9. You must regularly take part in activities that maintain and develop your competence and performance.4,
    10. You should be willing to find and take part in structured support opportunities offered by your employer or contracting body (for example, mentoring). You should do this when you join an organisation and whenever your role changes significantly throughout your career.
    11. You must be familiar with guidelines and developments that affect your work.
    12. You must keep up to date with, and follow, the law, our guidance and other regulations relevant to your work.
    13. You must take steps to monitor and improve the quality of your work.

  • GPs 'likely' to face litigation from 'ambulance chasers' due to electronic patient record access

    Tom Marshall's comment 03 Mar 2015 10:37am

    As the author of the original article in the BJGP I would suggest that those wishing to comment might like to read it (it is short!) before shooting from the hip.

    The situation that I pointed out is unrelated to government policy on giving patients access to records. It is simply a statement of the current legal position. Dr Caroline Fryar from the MDU confirms what is written on their website about doctors needing to justify departures from national guidelines.

    A previous post observes that it takes a lot of time and effort to keep abreast of guidelines. This is no doubt correct, but it is the duty of a doctor (according to the GMC) to be aware of relevant clinical guidelines. The required standard of care is informed by clinical guidelines. The question is asked "When should I spend time with my patients being a doctor?" the answer is that both the providing care informed by clinical guidelines is being a doctor.

    A number of correspondents seem to feel that accessing medical records is an unnecessary intrusion. Let us imagine an analogous case. The brakes fail on my car and as a result I crash. I recently took my car to the garage for another matter and I believe that they checked the brakes. Do I have the right to ask for their records? Clearly I do. On looking at their records I find that a mechanic has recorded that the brakes were faulty but nothing appears to have been done. Are they at fault? They say they informed me and I did not want to incur the expense. I say they did not. There is no record of them having informed me.

    Is this really so different to the iron deficiency anaemia which was not investigated or AF without an offer of anticoagulants?

  • Six in ten patients on statins 'not at high risk'

    Tom Marshall's comment 10 Aug 2013 0:52am

    A clarifications

    The headline "One in ten patients on statins 'not at high risk'" is incorrect. We found that six in ten patients started on statins for primary prevention were not at high risk.

    One in ten low risk patients aged 30 to 74 were started on treatment during our two year follow up study. But because there are a lot more low risk patients than high risk this one in ten constituted most of those started on statins.

    Most statins for primary prevention were being prescribed to the wrong patients.
    Most of the right patients were not prescribed statins.

    I don't have a good explanation for this phenomenon, so any suggestions are welcome.