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
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.
This is great news as the evidence develops. It would be good to see a NICE analysis on the cost benefit of such a two test approach. If it’s affordable then improving the risk assessment for men with a more sensitive and specific test has got to be a step forward. Biopsy is still the diagnostic test that will determine whether to adopt a watchful waiting approach or a more interventionist strategy. Prostate cancer causes significant morbidity as well as premature deaths. We should resist calls by populists and many Pulse contributors to have a nihilistic approach to this condition.
Well, I think you make a good point here. Actually several good points, although slightly incompletely.
1. I think your main point, although I may be wrong, is that pharmacist have a conflict of interest. At least I think they might. Namely, if you are paid to sell something you are more likely to err on the side of wishing to complete the sale.
2. Which links to the first, that pharmacists may not be sufficiently trained to present the known data in a dispassionate way and allow the patient ( or is it customer) to decide for themselves. They may not be able to discuss risk in such a way as to help them understand that there’s more to it than NNTs and NNHs
3. Pharmacists may not have the whole picture of the patient, their other diseases, foibles and family idiosyncrasies. Or completely identify and manage their ideas concerns and expectation
Balanced against all of these risks are the undoubted population benefits as described by NICE guidance for those at risk and the finite capacity of Primary Care to meet the need.
On balance, for me there is sufficient case that this approach will net benefit the population and therefore some individuals that it is worth piloting. We should quantify risks, benefits and costs. Then we’d be in a stronger position to be confident of rollout. I haven’t seen such an assessment, but there may be one already.
Christopher Ho | GP Partner/Principal27 Aug 2019 10:53am |Ivan Benett | Salaried GP|27 Aug 2019 10:25am
"Properly" resourced? You mean a more expensive 24/7 service nobody wanted and we can't staff properly? “
I’m not sure I can change your mind. It seems ideological set, and oppositional to anything other than everything is wrong. Never heard a positive word from you.
I certainly don’t intend trying now.
Tired person | Salaried GP21 Aug 2019 3:32pm "I was taught in Medical school that I was not becoming a Doctor to treat numbers... NICE insists in treating numbers... where do I stand?"
Well I would hope that when you became a post-graduate your GP trainer would introduce you to the concept of risk. It is crucial to managing an individual, when deciding with them what needs to be done to reduce the risk of any particular disease.
In finding out their risk, NICE and others look at populations to determine which factors and how heavily those factors influence risk. Some people and institutions have quantified those risks so that you can discuss them with your patient. As these values are taken from statistical analyses of population studies they have with them confidence intervals.
For example, a man with a PSA of 4ug/l have about 30% risk of prostate cancer. This risk is probably higher if you have a family history or symptoms. Its probably less if you have a normal prostate on DRE. Then you and the individual can make a decision about what to do next.
It is rare that for individuals any intervention or test is 100%, there are always levels of uncertainty and tolerances. We need to understand this and then need to be taught how to present all this in plain language to our patients.
No wonder you're tired if you are trying to explain to people that things are black and white.
Well said Martin, we need to be positive, patient facing and proud of the service we could provide if properly resourced. Good luck and keep it up.
This is no different to any risk assessment based on population studies. In other words there are always confidence intervals that always need to be applied to an individual. If you’re using risk estimates this should be part of the explanation. The key sentence is that the risk model performs well for populations. This is not surprising since they are based on population studies. An individual's risk is X +\- Y. More importantly is the discussion about what they can do to reduce their risk
Well written, but really? Another moan about incidental findings. Get over it. They are an inevitable consequence of investigations looking for pathology. Generally the more sensitive a test the lower the specificity. Until we get a newer test with better Sensitivity and Specificity. Rather than constant grumbling by populists wanting to endear themselves to a cynical readership, why not embrace the new reality? Teach how to deal with it. Start by learning about how to convey the limitation of testing to patients. We manage uncertainty all the time.
Doc | GP Partner/Principal24 Jul 2019 8:36pm
Ivan Benett- though what u add is correct- “ health” doesn’t address this.... see Black report etc...... social changes do!!!!
I agree (mostly). I don't say GPs should do it all, of course not.
Most of the 'investment' should be through public health measures which include societal changes.
But GPs should do our bit. Our main influence is in secondary prevention. Unfortunately the rule of halves still exists, we don't manage long term conditions optimally.
My point though, was to say that diseases are preventable. I wasn't saying who should prevent them.