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
Strangely, I find myself in total agreement with Vinci Ho. I’m going to say it shameful and disgusting how the Government has dragged its heels on protecting the front line.
If only clinical decision making were a simple as feeding a figure into an algorithm. Set aside the issue that risk is an estimate based on (usually) 95%confidence intervals, themselves based on study populations that may not reflect our patients, and all the other weaknesses of studies.
Perception of risk varies from one to another, the value placed on harms varies as does the value of a potential benefit. Societal norms, and health beliefs and peer group or family pressure also play a part. The JW's rejection of blood transfusions has little to do with an assessment of harm or benefit.
Whole patient medicine means taking all these factors into account and coming up with a join decision with the individual.
But it would help if Pharma, Government and Researchers would come up with better ways of informing us accurately, rather than telling us we're getting it wrong, and undermining our confidence and credibility.
"Christopher Ho | GP Partner/Principal02 Mar 2020 10:57am
"Austerity my arse, Ivan."
At least you make me laugh! Seriously, you don't believe there has been an austerity agenda? Seriously, you don't believe it's had an impact on health and social care? Seriously you believe a 'big state', by which I think you mean more public spending on public services, leads to poverty. And you reckon I don't understand economics? I'd say don't make me laugh, but it's too late.
Last Man Standing | GP Partner/Principal03 Mar 2020 6:05pm
SENIOR GMC STAFF SHOULD LAY DOWN THEIR PENS AND SPECIALIST LATTES AND SO SOME REAL WORK SEEING PATIENTS BUT OH NO THEY CAN@T PUT THEMSELVES AT RISK....ARMCHAIR WARRIORS....
Such strong and unsubstantiated sentiments...Anonymous too....it's almost as if you've been in trouble with them.
I agree with Kailash and would add that the biggest impact on the NHS has resulted from swinging cuts to social care. This has limited our ability to prevent people needing admission to hospital, and impeded our ability to discharge people home. Longer lengths of unnecessary stays lead to exponential increases in hospital acquire morbidity.
However, dwarfing all of this has been how austerity generally has impacted on determinants of health, in particular poverty, clean air, and social resilience.
Boris has made big promises. He needs to deliver now. I hope these pages (amongst many others) will hold his Government to account.
I called for advice as to whether I needed testing. As in Venice 10 days ago. It took 60 minutes to get the advice I wanted! Many would have not bothered holding on. Staff were all very polite. Surely at times of predictable high volume there should be more people on the phones
I think the ‘mythical’ doctor in Devon was Doc Martin, a caricature of a surgeon who becomes a GP because he can’t cope with blood. In my 35yr experience there are very few genuine time wasters. So called time wasters present repeatedly with minor symptoms because they have concerns that they may be serious or some other covert issue that troubling them.
Charging people will only increase unmet need and exclude those in most need. There is already a rule of halves which estimates that 7/8 chronic diseases are not optimally managed. Charging will also aggravate the inverse care law so eloquently described by Tudor Hart. Even today Marmott has described worsening of health inequalities.
I suggest you take these issues up with your trainer, course organiser and fellow trainees.
Simplistic populist views like yours are all to prevalent in these pages. They are not a solution to increasing demand.
Very amusing I’m sure. Indeed there has never been evidence of long term benefit from intra-articular steroid injections.
However, there IS overwhelming evidence that statins reduce MI, stroke and death in people with coronary disease, cerebrovascular disease and peripheral vascular disease.
Whilst these populist articles can be entertaining, and I hope I’m not a kill joy, I do think that they should restrain themselves from spreading falsehoods.
You can’t on one hand promote EBM, then ignore the evidence you don’t like.
The more we reduce the role of General Practitioners, the less we are able to maintain continuity and proactive care. We will lower our status and diminish General Practice. Like giving up 24hr responsibility we threaten the list system of Primary Care which in the cornerstone of the NHS. More fragmentation of management of LTCs will leader to ever higher demand on in-hospital and community services. Stopping GP visiting will lead to a worse service. It is the wrong thing to do.
At the risk of ending up in the dog house, you shouldn’t let the tail wag the dog. Your work load sounds a bitch. Perhaps pack in some of the longer hours.
Back in the day of course we would see 30 patients a surgery, two surgeries a day. 9-10 surgeries a week. Plus home visits, about 5 usually, but up to 10. Night calls to the house on a rota plus weekend surgeries and on call. Siriusly, every dog has his day.
More don’t. Charging people for appointments undermines the very principles of the NHS and would penalise the poor, the least assertive and the very ones who need to see a doctor. It is an appalling idea in every sense and will worsen current inequalities
As previously discussed this is a good idea so long as there are appropriate safe guards and pharmacists are adequately trained. Patients must retain the right to be actively involved in decision making. Their decision note to accept advice should remain paramount
The NHS should work for all, at the point of need irrespective of personal affordability. It is not for the Private sector, doctors, or medical insurance companies.
Unfortunately, it does not work as well as it might, even though clinical and managerial grades are working individually flat out.
There remains inequalities, the inverse care law persists, the rule of halves still fails those who have chronic diseases. Access is woefully poor for acute but non urgent (need to be seen same day). Preventive and health promotion services are under resources. Staffing levels are too low and skill mix is inappropriate.
So should we turn to a Private system of care.
All evidence suggests these systems disadvantages those least able to speak or pay for themselves. Make huge amounts of money for their managers, share holders and senior doctors. They leave large swathes of people without cover, including those with long term conditions.
Our system isn’t perfect, but because of chronic under resourcing, pitifully managed reorganisations, and incoherent workforce planning.
Apparently we will be treated to a large cash infusion for buildings - desperately needed - what we need is not pre-election give always, but planned and thoughtful development
Sharing records electronically, with appropriate consent improves care and reduces the risk of harm. It should be unbraced and encouraged. If there are resource implications, including workforce, they should be factored in. Now that Boris has found the magic money tree, resources should no longer restrict our ambition for seamless information. There is a good case for making this a priority.
Angela Parker | Locum GP30 Sep 2019 10:19am Well said. You will not get much support in these columns, but you are right in my view. This proposed injunction from RCGP goes precisely against our main injunction to make the best interest of our patients our prime concern. Don’t allow those who comment in Pulse to batter away your principles and humanity, as it seems to have done to many.
Having said that, there are resource implications to uncovering unmet need, which should be addressed by Government and negotiators.
Well, while you wait for someone clever to respond...
First of all QRISK 3 doesn't put above 10% until you get to about 63yrs, if all other factors are OK for men.
The 10% threshold is not arbitrary, but at a point where NICE judges the benefits of intervention with statins to outweigh the harms. In the USA the threshold is lower, 7.5%. This is NICE recommendation, not mandated.
Of course risk goes up with age. I would submit that having a discussion about heart health at or before you get to 60 is a good idea. Most heart attacks and stroke happen after that age. It doesn't have to be a GP, but it is usually us who prescribe the Statin, if needed.
The recommendation to achieve lifestyle change is not frivolous, indeed everyone accepts that stopping smoking is a must. Then its management of risk factors including BP and diabetes.
People with Diabetes, Chronic Kidney Disease (GRF
DrDeath | GP Partner/Principal17 Sep 2019 12:08pm
Correct of course.
So you retire at 60, decide to get a healthcheck efore you go to visit your brother in Australia for the trip of a lifetime.
And a Senior Railcard. Don't forget that
WhoamI | Locum GP16 Sep 2019 9:56am - All guidelines, whether NICE, American, Scottish, or European, emphasise lifestyle first, and other risk factor management. We should indeed spend time on lifestyle management and optimising co-morbidities like BP and diabetes. Statins are we not part of the management approach to primary prevention. Some will also wish to take advantage of the added reduction in risk that statins offer. They should not be denied the option.
Meddyg | GP Partner/Principal14 Sep 2019 2:37pm
" 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"
- should we not treat heart attacks because people would die anyway? well then why not prevent them if we can?
Why use Statins for prevention of Cardiovascular Disease?
Dr Chand has put the case against the use of statins, and not for the first time. His main argument seems to be that the beneficial effect of statins are outweighed by the harmful and costly effects. He makes the case that the absolute benefits of statins are small, even if the relative risk benefit seems better. His arguments deserve a response since an intervention must prove that on balance the benefits outweigh the risks of harm, are affordable, and take into account the wishes of the patient. He cites occasional trials without reference, and we are supposed to take his word for it that he has covered the whole literature in a balanced way.
Surely, in order to have a balanced view, all the literature should be considered. Fortunately, we have an independent organisation that does just this already. It is not influenced by ‘pharma’ and has experts and lay people who study the whole body of evidence before making recommendation in Guidelines. It also has Quality Standards (QS) Committees that translate the guidelines into Quality Statements where evidence suggests that recommendations are not being implemented. I have to declare that I have been on some of the guideline groups and quality standards committees. I know the rigour and impartiality that is applied by NICE.
So what does NICE recommend for people who already have known cardiovascular disease? The first priority is for lifestyle change and risk factor management, of course.
QS 100 (2015) draws on many of the NICE guidelines published around CVD prevention. I would urge the reader to consider them all. In summary I draw out the relevant statements.
“Quality statement 6: Statins for secondary prevention: Adults with newly diagnosed cardiovascular disease (CVD) are offered atorvastatin 80 mg.
The rationale is that High-intensity statins are the most clinically effective option for the secondary prevention of CVD – that is, reducing the risk of future CVD events in people who have already had a CVD event, such as a heart attack or stroke. Evidence shows that atorvastatin 80 mg is the most cost-effective high-intensity statin for the secondary prevention of CVD, which can improve clinical outcomes. “
“Quality statement 4: Discussing risks and benefits of statins for primary prevention: Adults with a 10-year risk of cardiovascular disease (CVD) of 10% or more for whom lifestyle changes are ineffective or inappropriate, discuss the risks and benefits of starting statin therapy with their healthcare professional.
The rationale for this is that people who are better informed and involved in decisions about their care are more likely to adhere to their chosen treatment plan, which improves patient experience and clinical outcomes. “
“Quality statement 5: Statins for primary prevention: Adults choosing statin therapy for the primary prevention of cardiovascular disease (CVD) are offered atorvastatin 20 mg.
The rationale here is that High-intensity statins are the most clinically effective treatment option for the primary prevention of CVD – that is, reducing the risk of first CVD events. After a discussion of the risks and benefits of starting statin therapy with a healthcare professional, a person may choose statin therapy as an appropriate treatment to reduce their risk of CVD. When a person decides to have statin therapy, a statin of high intensity and low cost should be offered. Atorvastatin 20 mg is recommended as the preferred initial high-intensity statin to use because it is clinically and cost effective for the primary prevention of CVD. “
One of the key arguments Dr Chand makes is that some trials do not show an all cause mortality benefit. This is true, but they do show reduction in CVD events. They could hardly continue once the Primary Outcomes had been met, until an all cause mortality benefit had been achieved. This would not be ethical.
Of course, no treatment will prevent death in the end. What we desire is to live a healthy life until we die. Living with the disabling effects of a stroke and a failing heart is perhaps to be more dreaded than death. So, preventing these events is a goal in itself, even if (on average) we don’t live longer.
In the end we have to give a balanced view for our patients, given their individual risk of an event or further event. It would be great to extend life, but it is also essential to minimise the risk of disability. The higher risk you are of an event, the greater the likely benefit. For the individual a relative risk reduction is important. Risks of harm and side effects must be considered but should not exclude treatment. Patients must be allowed to decide for themselves and recognise the value of lifestyle change and risk factor optimisation.
Dr Chand's arguments are valid, to an extent. However, there is a danger that his views create a dichotomous view of the benefits and harms of statins. The truth is more nuanced.