Dear Anon 2.02pm. I assume you are a GP and that you are in favour of zero tolerance.
I wonder what you would think if one of your patients wrote on a facebook group page that they recommended people stayed well clear of your practice solely on the basis of something you have written? A zero tolerance approach would be to remove them from your list for defamation.
Vinci Ho asks why I wanted to write this article in the first place. It's a good question.
It's because there is a growing assumption out there that the only strong, self-respecting response to abuse is to fight back with zero tolerance and I think this needs to be challenged.
I am absolutely NOT saying that we should be doormats, or accept abuse (and thank you Shaba for pointing this out and I agree with your comment entirely that abusive behaviour should be met with consequences). Nor am I saying that we do not have a right to work without being abused - of course we do. However, whether or not I have a right to avoid abuse, stuff happens anyway - and when it does happen, I am more interested in outcomes than rights.
What I AM saying is that Zero Tolerance is a closed mindset that does not allow for more imaginative solutions. If, by asserting my right to avoid abuse, I remove someone from my list and they go on to abuse a neighbouring GP then that is a poor outcome. If I confront the abuse in-house, deal with it so that there is behavioural change and the abuse stops happening, that has to be a better outcome. It's not soft, it's not cowardly and it requires a great deal of self respect to do it well.
Of course it is difficult, and sometimes we won't be able to bring about behavioural change, so the option to remove someone always has to be there, but it needn't be our first reaction.
This is an interesting and, in my view, very important debate. I'm grateful for the constructive comments - both those that were sympathetic to my point of view and those who disagree with me. As for some of the other comments, I wonder if the authors noted the irony that in arguing for a zero tolerance attitude towards any form of abuse they were being...well if not quite abusive then certainly more than a little rude.
I thank Kearney et al for their comment, which certainly justifies a response.
Firstly, it is disappointing that they have failed to mention the UKNSC, which confirms my assertion that the proper body for the assessment of screening programmes has simply been sidelined in this debate.
Kearney states that:
'We don’t have the luxury of waiting for perfect evidence. We have an ever growing burden of non-communicable disease that risks overwhelming our health and social care systems'
Is this true? The incidence of cardiovascular disease has been falling steadily since the 1950's and life expectancy has never been better - why is there an urgent crisis that cannot wait for robust evidence? When people are sick and suffering (as in West Africa with Ebola) there can be an urgency which justifies intervention without robust evidence, but this programme involves taking perfectly well people, telling them that they have risk factors for disease and asking them to take treatments that can be immediately harmful on the basis that they might stop something happening in the future. Such an intervention might be able to be justified, but we surely need robust evidence before we inflict this on the nation.
The health check is not, as Kearney claims, simply 'a delivery mechanism for interventions that are all based on robust evidence of effectiveness and cost effectiveness,' since population screening is not recommended by the UKNSC for any of the individual interventions - on the grounds of insufficient evidence of benefit or analysis of harms. Evidence for opportunistic identification hypertension or diabetes, is very different to that required to justify population based screening.
Apart from vaccination, the big winners in public health have always been to change the health environment of the nation rather than to encourage health interventions in the individual - factors like better hygiene, the smoking ban, minimum alcohol pricing and legislation on sugar in foods are where the nation's health is really affected.
If there is any actual benefit at all in the health check it is likely to be small, and unjustified by the huge cost, not of the test itself, but of the years of medicalisation that follow it.
Ivan, this isn't an angry comment, but the difference between seeing your doctor and shopping is continuity of care. When shopping it is continuity of the brand you want, and this is the same whenever the shop is open. With a doctor you want the person that you know. This will always be what is sacrificed with 7/7 opening.
Sorry, wrong link above! http://www.jbs3risk.com/pages/DOI%20for%20JBS3.pdf
It would be helpful if declarations of interest could be made for an opinion piece like this. Unfortunately he does have quite a few ties to industry: http://www.bmj.com/content/349/bmj.g7235.full?ijkey=D4LA32zo30IYBbS&keytype=ref
I have to disagree with you both. The point of this post is that ACR has been retired after negotiation between the Department of Health and the GPC, and so it is bizarre that the CQC should unilaterally bring it back to life. It raises real logistical problems for practices who now have to tick this box again, and it is not at all clear how the CQC will monitor it since it is no longer part of QOF.
However, since the comments have shifted to the merits of ACR measurement, let me comment on this. We should never forget that this is a surrogate marker and far removed from meaningful clinical endpoints. In fact, it is a surrogate marker for renal damage, which in itself is only a surrogate marker for anything clniically relevant to the patient (like morbidity or mortality).
Measuring ACR in a young type 1 diabetic may be of useful value, but most of the patients caught up in QOF are older type 2 who will never have significant nephropathy in their lifetime, but will easily be overtreated with more and more medications to achieve tight blood pressure control, and may suffer harm as a consequence.
The only reason why measuring ACR does not cause more overtreatment than it might is that we already have targets for BP in patients with diabetes, and will use an ACE in preference whether they have albuminuria or not. - hence the ACR measurement very rarely makes any real difference to a patient's treatment: it has largely been an expensive waste of NHS resources.
In reply to Ivan Benett.
Of course there are explanations for the discrepancy in our practice figures - and care homes is a huge factor here. My point, however, is that this only shows how inaccurate the calculator is at practice level. For those practices which are inner city and have no nursing homes the figures will be at the other end of the spectrum - but those in charge of the figures will not look for a sensible explanation like demographics, but be quick to call them laggards and demand an 'improvement in performance.' This will lead to a pressure to diagnose in order to reach a target, which will lead to overdiagnosis and misdiagnosis - a very serious issue indeed.
Diagnosing dementia is important, but it should only, ever, be for the best interest for the patient and not to hit a target.
As for the young minds in my care on the VTS - they are a pretty savvy lot and I'm sure they will be able to tell for themselves whether or not I am spouting nonsense.
In reply to Emer MacSweeney.
Thank you for your comment. However, I'm not sure I should be congratulated. My point with the Delphi figures is that they were never intended to be extrapolated to practice level, or used to generate diagnosis rates or targets. To do this is a complete misuse of the research and makes the figures meaningless (for all practices, not just my own) - I should no more be congratulated at rolling a double 6 in dice than 'achieving' a high diagnosis rate.
What worries me greatly is for those practices (and their patients) who have been given low figures. Whether or not I am congratulated is irrelevant, but a practice given a low diagnosis figure will be put under huge pressure to 'improve', despite the fact that their figure will be more a quirk of local demographics than a marker of poor care. This pressure will not be good for their patients and is likely to lead to overdiagnosis just in order to get numbers up.
In response to Mark Stuthers:
The patients who suffered during the MMR debacle were the parents of babies due to have the vaccine. For a couple of years during the controversy I would say about 80% of the 8 month baby checks I conducted were dominated by the dilemma parents seemed to be faced with. They felt caught between a rock and a hard place, and many were terrified. It is clear now that this uncertainty and fear was totally unjustified - and it was due to a small minority of doctors being given a grossly disproportionate amount of airtime, and a totally unbalanced media campaign spear-headed by the Daily Mail.
In response to Mark Stuthers' comment:
What I mean by that statement is that 19 (it is now at least 21) negative articles and not a single article giving the positive side of the LCP is not a balanced debate. It is right that we hear of stories where the LCP has not been properly implemented (and these should all be thoroughly investigated at local level), but where are the articles detailing where someone has died a peaceful and dignified death using the LCP effectively, appropriately and with good communication? None of these has been printed because they don't fit with the Mail's campaign - and yet they are far more common.
The patients who suffer are those who know they are terminally unwell and are now being filled with fear about what might happen to them, and have had their trust in their doctors undermined by this destructive camplaign. They have enough to be afraid of as it is. Most expected deaths in the community will involve pre-emptive prescribing and the use of the LCP - and it has led to a vast improvement in care - yet now I am havnig distressing conversations with patients fearful that I am going to subject them to some hidden evil in the form of the LCP. Even in hospital, where predicting death is much more challenging due to the uncertainty of acute illness, 94% of families felt that they were involved in the decisions that were made.
It is tragic to hear of situations like the one above where things have gond badly wrong, and poor communication between doctors and patients and family is usually at the core of this. Poor communication is never to be excused, and problems with it are not unique to the LCP by any means.