Dr Ivan Benett has been a GP in Central Manchester for 30years. He has held various educational posts, served on the LMC Executive, has been PCG chair and chair of the PCT professional executive until 2005. Following this he gained a PG diploma in Cardiology & became a GPwSI in cardiology. He has been on the NICE guideline groups for CKD, Post-MI care, chest Pain, Parkinson's & AAA, and expert group for Quality Standards in Heart Failure and CKD care. He is a Fellow of the RCGP & RCP and standing member of a NICE Quality Standards Advisory Committee. He was the Clinical Director Central Manchester CCG until December 2015. Currently he sits on the GM Clinical Senate and is a Non-Executive Director at the Central Manchester University NHS Foundation Trust with an interest in Patient Experience and is 'Freedom to speak out" guardian
I agree that prescribing homeopathic remedies should be promoted. They are inexpensive and will not cause physical harm. If used properly and holistically can help people with their symptom of ‘shit life syndrome’. There is a risk of over dependence, as with conventional medication and doctor patient interaction, but this has to be managed.
It isn’t just the dillusiI n and succession that gives homeopathy its healing powers. Indeed some say that this is bolony or worse. It is the power of the human interaction and therapeutic relationship that does the trick.
Surprisingly I think you’re on to something Shabi
An excellent development, essentially replicating Manchester model. Great opportunity for locality integrated teams, extended same day access, better long term condition management and continuity of care.
BUT needs more capacity with a larger workforce to meet the needs of the locality population (which varies from one to another depending on demography and economic factors). In particular need a smaller case load per GP. Greater opportunity for flexibility of career choice and specialisation
Certainly this needs to be costed, but it is a really sensible way forward of taking relatively low risk work out of hospital care. This is not complicated and need not be contentious.
Then perhaps we can move to a more systematic approach to offering PSA testing to those at high risk, and those who want to know. At this point I will duck out of the volley of bullets heading my way.
Excellent news. Increasing capacity to match ungent (same day) demand is obviously the right thing to do.
Another hysterical headline in Pulse stemming from a fundamental misunderstanding of testing. Every test, in this context, ECG in people suspected of a critical inherited conduction or structural defect, will have less than 100% sensitivity and specificity. This means it is nnevitable that the test will miss some cases and I dentist false positives.
In the context also of individuals the tests will highlight that persons risk and so indicate whether further diagnostic tests should be presued.
If I had a family history of sudden cardiac death, or my son or daughter wanted to engage in extreme or elite sports, I would very much like to be sure their ECG is normal. Indeed I might well wish them to have an exercise ECG and Echocardiogram if they were engaged in very strenuous sports.
Whether the benefits and costs work out at a population level would depend on results of randomised clinical trials and a cost-benefit assessment.
Meanwhile, I think it is reasonable to do an ECG on this group of young people if they request it, and take it further if there is any abnormality.
The headline is misleading. In fact what the evaluations say is 'NHS England’s evaluation of the first wave of seven-day access pilots found that extending access to routine general practice across seven days had ‘no demonstrable impact’ on either emergency admissions or out-of-hours services, but that minor illness attendance at A&E departments did reduce in 13 of the 20 pilot areas by an average of 14%.' This is a good outcome against a background of rising attendances.
The extended hours services were never going to impact on admissions, nor designed to, which are of much higher acuity. By the time they present they are far to ill to have been dealt with in an extended hours context. These people need to be seen much earlier in the downward trajectory of their illness, as soon as they start to deteriorate. So they need an early warning system to alert their doctors to their deterioration eg weight gain in heart failure. This is not what the extended hours services are designed for. They are there to manage the same day urgent care demand, yes often for minor illness, that would otherwise go to A&E. Reducing A&E attendances by 1:8 I believe is pretty good. Added benefit is for greater choice especially for people at work.
The downside is less continuity but for these cases (of same day demand) people usually don't mind. In turn this potentially releases in-hours time for people with long-term conditions (incl. mental health)to see their usual doctor, which is where continuity of care is especially important and makes a great impact.
sceptic | GP Partner/Principal08 Dec 2018 11:02am Nikolova | Locum GP08 Dec 2018 12:23pm and others - The SPRINT trial was funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01206062.). No Pharma involvement.
Among nearly 10,000 patients at high risk for cardiovascular events but without diabetes, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive-treatment group. The intervention was stopped early after a median follow-up of 3.26 years owing to a significantly lower rate of the primary composite outcome in the intensive-treatment group than in the standard-treatment group.
NB same was not shown in the ACCORD trial of a similar population but with diabetes.
You can't just discount the SPRINT study because you don't like it. However, I would suggest waiting for a holistic assessment from NICE before changing UK targets.
PS Statin trial trials also show benefit
Those demanding NNTs are right to do so, but risk confusing population based benefit with individual based risk management.
So would I take a statin if I'm in a high risk group?
Hell yes, if Chances of harm low and it doesn't cost me much.
Leave population based considerations to commissioners
Why caution? We need to review in light of all new evidence. Also need cost-benefit assessment and cost per QALY. Need to wait for NICE review
I would caution changing practice on the basis of this study. Far better to implement current risk and intervention recommendations from NICE than change. We already fail to estimate risk on 2/3 eligible people, and fail to prescribe in 2/3 of those at 10% 10 year risk.
Obviously statins mandatory for secondary prevention unless good reason.
This is the important message: Public Health England advice to offer the test to ‘any well man aged 50 and over who requests it’.
Although PSA does NOT fit criteria for screening populations, it can estimate the risk of prostate cancer for individuals, At least then they can decide how to proceed. These possibilities should be discussed before the test is taken, but come into sharp focus if the level is raised.
For example if level persistently 4 then there's a 30% chance of cancer (and a 70% chance of not cancer).
As for 70s, I would still test if symptomatic. You'd look a bit silly if you missed it
"BMA GP Committee clinical and prescribing policy lead Dr Andrew Green told Pulse: ‘It is interesting to note that even in the screening-hungry States the appetite for this test is decreasing." Indeed, but PSA is not a screening test. Although the number of tests has reduced, it is still a common request in USA, as it should be here for people with a family history or of African origin.
Merlin - really not true. I mean really not true. No interest from Pharma to promote statins
Yes, I think it’s appropriate to review this advice. The absolute benefit is low and there’s a risk of polypharmacy. It is not true that NICE didn’t know what it was saying, as someone suggests, but that the best evidence at the time (which was not good in older people) suggested good relative risk improvement. It will be interesting to see what the panel comes up with. I suspect that those with diabetes will be recommended to continue, those at lower risk should make an informed decision, weighting margin benefits against possible harms and cost.
Meanwhile PLEASE continue to advocate statins for secondary prevention.
Whilst a repeat PSA is important, especially after no vigorous activity or ejaculation, if his level remains above 4 he will have a 30% chance of having prostate cancer. Sure, that means a 70% chance of not having cance. An MRI scan can help but the only real way is a tissue diagnosis. Even so active surveillance is a reasonable option.
I find that most people when told they have a 30% chance of a cancer that carries significant morbidity, are reluctant to wait and see, notwithstanding their relatives advice.BUT that’s their choice.
In the issue and fashion for a nihilistic approach to early diagnosis, when faced with the persistent rule of halves I suspect the pendulum has swung too far.
Of course, as we strive for early diagnosis, we risk over diagnosis. This is one of the costs. But
patients should be fully informed of this risk before taking the test, knowing that some will be unnecessarily medicalised. Medicine is complex like that. Not black and white, right or wrong, safe or dangerous.
So many people with diabetes, AF or cancers would prefer early diagnosis. Their chances of avoiding complications or events reduced by early intervention. And some will be unnecessarily medicalised.
The rule of halves still exists, well maybe the rule of 2/3s since QOF. Sadly this will worsen with the loss of QoF and this populist approach to early diagnosis.
What a surprise that so many comments are negative to the use of guidelines. Of course they are 'only' guidelines, but they are also the basis of Evidence Based Medicine.
I don't think it is unreasonable to ask people which guidelines we follow in any given clinical situation.
HOWEVER, I have often expressed the limitations of guidelines and evidence based medicine. There are often good reasons for deviating from guidelines, but if we do, we should be able to justify why we did so. I think it is reasonable to ask this too.
For many decisions, of course, there are no guidelines. In any case we should be able to justify our decisions by demonstrating the balance of benefit against risk, and taking account of the individuals wishes against the effect on others (affordability, cost, opportunity costs and harm).
We need not be defensive about this move, but welcome the opportunity to explain why we made the decision we did. It might surprise our accusers of the depth of complexity of clinical decision making.
We are also in a stronger position if we have involved the patient and carers in the decision making if appropriate. Complex decisions can be shared with colleagues and peers to show that we acted reasonably.
This is great news for people with child care needs, those who work, those with carers who work, and everyone with a same day need or concern that isn't 'urgent'.
It will take that stream of work out of A&E and also free up in-hours time for those who need proactive care for a long term condition from their own GP.
Increasing capacity not only good for access, but also for continuity for those who want it.
Also doctors who don't want the commitment of partnership and prefer flexibility or a portfolio career, or those who want a break for what ever reason, can be accommodated in the work force. Everyone a winner
If they provide a more accessible service for patients and they are cost-neutral - that's a good thing - right? And if it save admin time or unnecessary consultations, that's a good thing - right? If they are time neutral and provide a better service, that's good - right? So why the negative headlines?