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Patrick McNally

  • Pharmacist to dispense high-dose statins without GP prescription under NHS plans

    Patrick McNally's comment 04 Sep 2019 11:03pm

    Statins used to be like Ramipril.
    Now they're like amlodipine. They used to require LFTs at baseline, 3 months and 12 months.

    Happily my CCG now supports a "fire and forget" approach. So we still do the baseline LFTs, but none thereafter unless symptomatic.

    This simplifies an "offer of station therapy" greatly. If the patient is ambivalent, I do the script, point them to some further reading, put on repeat and forget about it. Either they keep requesting, or they don't.

  • My short-term plan to save general practice

    Patrick McNally's comment 29 Jan 2019 7:42am

    Nice article.

    which model salaried gp contract provides for a half-day cpd per week?

    my current gms model contract provides for 1 working week, pro rata, per year. That's a big difference!

  • Could knowing the price of NHS treatments help patients grasp their true value?

    Patrick McNally's comment 21 Oct 2018 9:28pm

    This is wonderful: (from Dr Eduardo)
    "I think that Dr David Turner's idea should not be easily dismissed. Also, Tony's input is a meaningful one. "

    The opposite of the usual critical dismissive attitudes online!

    I have experimented talking with patients about costs of treatments, but usually this does not go well. In one memorable example a patient refused to pay for over the counter medication, because he "pays his taxes". I pointed out that this year we had already spent his taxes on an endoscopy and a scan, but again this was not well received.

    I duly set up the script for paracetamol or loratadine or whatever it was.

  • GPs could be asked to do C-sections under proposals to retain maternity unit

    Patrick McNally's comment 29 Sep 2018 0:36am

    *ringring*

    "Yes, hello, MDU? I'd like to discuss a change to the scope of my usual practice.

    Yes, I'll be doing the odd C-section on Wednesday afternoons.

    No, I'm not giving up the day job.
    Yes, I am still a GP.
    No, I haven't retrained as an obstetrician.

    Well... I assisted at lots of C sections during my GP training, it didn't look too difficult?
    Honestly, how hard can it be?

    Oh, and I'll be dropping my usual Wednesday afternoon duty surgery, to do this.

    Oh, a £600 discount on last year?
    Sounds great"...

  • A right Royal mess: Why is RCGP still endorsing ‘Emma’s Diary’?

    Patrick McNally's comment 29 Sep 2018 0:27am

    Congratulations Dr Ryan -
    RCGP have dropped their support for this abomination -

    https://r1.dotmailer-pages.com/p/49LX-45X/my-week-in-focus?utm_campaign=624742_LONDON%20%26%20SOUTH%20ENGLAND_Weekly%20Digest_28_Sept_18

  • GPs should not screen patients over 70 for prostate cancer, researchers say

    Patrick McNally's comment 29 Sep 2018 0:23am

    Unless I'm mistaken, LUTS are a symptom potentially suggestive of prostate cancer. (A pretty rubbish symptom, poor PPV, sensitivity, specificity etc, the whole lot).

    What 70+ year old doesn't have LUTS on direct questioning?

    So we are rarely "screening", but investigating.

    (There's also a problem with using the word "screening", to mean individual risk assessment).

  • Pharmacists want to be able to swap GP-prescribed drugs for generics

    Patrick McNally's comment 28 Sep 2018 10:08pm

    Dermot:
    "In fact high street pharmacists should be phased out."

    Are you really a locum GP?
    Or are you a dispensing practice partner?

    Because if we didn't have high Street pharmacies, would you suggest we should all get into the dispensing game?

    In 2018, pharmacists add value to the NHS, on tight margins. They are promised a certain margin over and above cost price, to keep the lights on.

    Script switching to branded generics that undercut the NHS list price, is CCGs trying to undermine this agreement.
    That's not ok, any more than CCGs trying to claw back practice funding.

    http://www.pulsetoday.co.uk/clinical/clinical-specialties/prescribing/medicines-optimisation-schemes-simply-rob-peter-to-pay-paul-gps-should-boycott-them/20035359.article

  • Myth: ‘We know what a normal heart rate is for a child’

    Patrick McNally's comment 26 Sep 2018 8:28pm

    Playing devil's advocate here -

    Sometimes we need to put our "clinical experience" to one side, and just rely on the algorithm.

    I had a child with fever and tachycardic in my consulting room a while ago. Child looked ok. But no focus (other than pink eardrums, but what child doesn't have pink drums after a bit of crying),

    I was so tempted to say,
    "They'll probably be fine".

    Instead, I said, "they'll probably be fine. However, look at this traffic light triage system".

    I pulled up the NICE traffic lights for febrile children on the screen, and showed mum.

    "The heart rate is red. That means that even though your child looks ok, a few children like this may become seriously not ok in the next few hours. Could you take them to hospital?".

    Child had meningitis, sepais, antibiotics, lumbar puncture, PCR demonstrating viral meningitis, etc. Required lots of inotropes and supportive care to survive.

    It taught me that sometimes I should trust my gut. But sometimes, I should ignore my gut, and defer to the algorithm.

    I saw the child again recently, for nothing too serious, burst into tears after they left, and felt on top of the world for the rest of the day.

  • LMC warns against GPs using practice address to register homeless patients

    Patrick McNally's comment 08 Aug 2018 6:34pm

    A+E commonly uses
    "No fixed abode
    ZZ99 1AB"

    Or similar.

    I recently accepted this address, in a "synch PDS to spine" for one of my patients who is sofa surfing.

    Unfortunately this breaks electronic and also paper prescribing! Suddenly scripts will only issue as "record for notes" implying that you did a paper script. Needless to say we have gone back to a local address.

    Odd how the hospital gets away with ZZ99 ...

  • In full: Dr Arvind Madan's resignation statement

    Patrick McNally's comment 05 Aug 2018 5:09pm

    Sorry that comment obviously copy pasted badly into the text box!


    Whatever you think about them, the GMC's guidance on use of publically accessible social media is very clear - if you say you are a doctor, you must identify yourself:

    "Anonymity
    17
    If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely.

    Pulse may be " intended for healthcare professionals only" and require professional registration details, but we should still hold ourselves to the same standards here, as we would in a face to face professionals meeting. I wouldn't say anything here that I would be uncomfortable saying to a colleague.

    I wrote about this back in 2013, when the guidance was newly released:

    http://triptogenetica.blogspot.com/2013/03/doctors-nyms-social-media-good-medical.html

  • In full: Dr Arvind Madan's resignation statement

    Patrick McNally's comment 05 Aug 2018 5:07pm


    YOU ARE HERE:HOMEPARTNERS PRACTICE BUSINESS
    NHS England's top GP resigns following Pulse comments
    5 August 2018

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    Comments (1)
    The NHS England director of primary care Dr Arvind Madan has resigned following his interview with Pulse.

    Ha admitted that he had been posting provocative comments under the pseudonym ’Devil’s Advocate’ on the Pulse Today website.

    In a statement, he apologised to small practices following his interview in Pulse, where he suggested GPs should be ’pleased’ when small practices closed.

    The BMA has released a statement ’in response to the resignation of Dr Arvind Madan’.


    Dr Mark Sanford Wood, deputy chair of the BMA’s GP Committee, said that the BMA had written to NHS England ’raising concerns and demanding action’ earlier in the day.

    More to follow

    GPs should be ’pleased’ when small practices close, suggests NHS’s top GP
    Read: Dr Arvind Madan’s resignation in full
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    What NHS England's top GP really thinks
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    READERS' COMMENTS (1)
    Patrick McNally | Salaried GP05 Aug 2018 5:05pm

    Whatever you think about them, the GMC's guidance on use of publically accessible social media is very clear - if you say you are a doctor, you must identify yourself:

    "Anonymity
    17
    If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely.

    Pulse may be " intended for healthcare professionals only" and require professional registration details, but we should still hold ourselves to the same standards here, as we would in a face to face professionals meeting. I wouldn't say anything here that I would be uncomfortable saying to a colleague.

    I wrote about this back in 2013, when the guidance was newly released:

    http://triptogenetica.blogspot.com/2013/03/doctors-nyms-social-media-good-medical.html

  • NHS England's top GP resigns following Pulse comments

    Patrick McNally's comment 05 Aug 2018 5:05pm

    Whatever you think about them, the GMC's guidance on use of publically accessible social media is very clear - if you say you are a doctor, you must identify yourself:

    "Anonymity
    17
    If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely.

    Pulse may be " intended for healthcare professionals only" and require professional registration details, but we should still hold ourselves to the same standards here, as we would in a face to face professionals meeting. I wouldn't say anything here that I would be uncomfortable saying to a colleague.

    I wrote about this back in 2013, when the guidance was newly released:

    http://triptogenetica.blogspot.com/2013/03/doctors-nyms-social-media-good-medical.html

  • Analysis: GP prescriptions drop by almost one million

    Patrick McNally's comment 12 Jul 2018 1:10pm

    For all long-term stable chronic disease management medications, I now aim for repeat dispensing, a batch of three 3-month prescriptions. Obviously medicine is complex so there are many exceptions but this is my preferred option. It means patients will be requesting repeats only once every 9 months, giving me a chance to remind them about bloods, monitoring, etc.

    I simply do not have time to be messing around with short duration prescriptions for long-term medicines.

    I'd be interested to know how practice differs between dispensing and non dispensing practices; I imagine 3 month supplies on one script are a bit less common if the practice runs a dispensary!

  • New data protection regulations – what GP practices need to know

    Patrick McNally's comment 30 Mar 2018 8:13am

    Hmm. Patients will have a "right to erasure"? But the Medical record is my documentary evidence of my practice. If they exercise this right, how would any subsequent Medical negligence claims possibly go ahead?
    And what about where it is in the patient's interest, or that of others, that certain information is recorded, whether they like it or not?


    Ah - having just checked the ICO guidance, it looks like we have a blanket exemption to erasure requests:

    "
    The GDPR also specifies two circumstances where the right to erasure will not apply to special category data:

    if the processing is necessary for public health purposes in the public interest (eg protecting against serious cross-border threats to health, or ensuring high standards of quality and safety of health care and of medicinal products or medical devices); or
    if the processing is necessary for the purposes of preventative or occupational medicine (eg where the processing is necessary for the working capacity of an employee; for medical diagnosis; for the provision of health or social care; or for the management of health or social care systems or services). This only applies where the data is being processed by or under the responsibility of a professional subject to a legal obligation of professional secrecy (eg a health professional).
    "

  • NHS England issues guidance to curb over-the-counter prescribing

    Patrick McNally's comment 30 Mar 2018 8:00am

    "we can prescribe decent amounts (not 32 paracetamol at a time)"

    This used to be my main concern about this, until I discovered that the 32 paracetamol limit doesn't apply to pharmacists. It's only relevant to regular shopkeepers. Whereas pharmacists can exercise their professional discretion and work out that the patient isn't suicidal, they just have arthritis and have been getting paracetamol for ages.

  • NHS England to reclaim £260k from practices over lost GP correspondence

    Patrick McNally's comment 27 Mar 2018 10:29pm

    If these "confirmation slips" are the same ones I saw, they seem a medicolegal nightmare.

    I think I remember it was something like,
    "I confirm I have read the correspondence and the patient's medical records and can confirm that no harm resulted from the delay in receiving this information".

    That would require us to second guess every consultation or decision about that patient in the light of the information. An interesting intellectual challenge, but not something we can allow time for, to do it justice.

  • Why it’s time to re-think guidance on 28-day prescriptions

    Patrick McNally's comment 14 Mar 2018 6:34pm

    Most long term repeats on 3 months now for me. Or, if patient is on a mountain of medicines, I might use repeat dispensing.

  • GPs offered up to 50% cut of savings generated by slashing their own referrals

    Patrick McNally's comment 01 Mar 2018 9:22pm

    Not sure I agree with Dr Peter Swinyard:

    ‘From a patient perspective, it means GPs are paid to not look after them. '

    Surely if the GP receives extra funding but doesn't refer the patient, then the GP is being funded to look after that patient in primary care? That sounds reasonable to me.

  • Calling time on the all-you-can-eat NHS buffet

    Patrick McNally's comment 01 Mar 2018 9:16pm

    Canoeing - complain.

    Though I would probably prescribe canoeing if I could.

  • Calling time on the all-you-can-eat NHS buffet

    Patrick McNally's comment 01 Mar 2018 9:14pm

    I have this discussion often with patients:

    "Could you buy this medicine over the counter?"
    "But it's free if you prescribe it"
    "Free to you maybe, but not free to the NHS"
    "Oh but it's not too expensive for them, is it?"
    "Well, the tablets cost pence, but add in my time prescribing, pharmacist time dispensing, the dispensing fee, that's the real cost..."

    Some of these patients canoeing, and I prescribe. Others agree to buy the paracetamol.

    Then again, I did see a GP who was prescribing stretch mark cream to a patient a while ago. So maybe not everyone is up for an argument.