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At the heart of general practice since 1960

Challenge on Labour's hospitals

GPs are being beleaguered by patients alarmed by the latest health scare, and often the warning systems are inadequate, writes Emma Wilkinson

GPs have had to become increasingly adept at crisis management over the course of the last year.

Health scares over cox-2s, SSRIs and the new combined DtaP/IPV/Hib vaccine have all filled GPs' surgeries with worried patients.

But the systems in place for providing GPs with rapid, clear, sensible advice do not seem to have improved with regularity of use. Too often, GPs have to reassure patients without the information they need to offer an informed choice.

Dr Jim Kennedy, RCGP prescribing spokesperson and a GP in Hayes, Middlesex, believes the current system is far too reactive ­ with the drug regulator waiting for a scare to hit the media before acting.

'We get a media scare and then the MHRA [makes a statement] and then we get the scientific data on which it made the decision.'

Dr Kennedy suggests the MHRA needs a dedicated web resource to allow it to quickly and easily access drug safety information.

'We need to develop a rapid response system: a database of drug use from a population of half a million or a million and based on GP records.'

Dr Chaand Nagpaul, member of the GPC prescribing subcommittee, adds that the current system for alerting GPs is inadequate and fails to prioritise important information. 'The cascade system relies on faxed sheets of paper,' he says. 'It would be infinitely better to have it available electronically and categorised carefully.'

Professor Hugh McGavock, who was a member of the MHRA's Committee on Safety of Medicines between 1998 and 2001 and is a former GP, is critical of its lack of GP representation.

'There needs to be much greater interest in the views of GPs, which were accounted for very lightly,' he says.

Professor McGavock feels a more GP-centred CSM would take a more practical, sensible approach to evaluating drugs.

Dr Kennedy agrees: 'There are GPs on the MHRA but there is an argument about whether it adequately understands how these drugs are used in general practice.'

Another recurrent complaint from GPs is the inconsistency of guidance they

receive from different sources and the changing views of the drug regulators.

Dr David Tooth, a GP in Rotherham, says: 'NICE recommended cox-2s so we switched our patients over, then we have to take them off Vioxx so we put them on Celebrex and then we had to send out another letter. I feel sorry for the patient. All they want is an anti-inflammatory that works.'

Part of the problem may be that GPs no longer trust the CSM to make the most appropriate decision for patients.

Professor McGavock fears it has been too badly damaged by its links with the pharmaceutical industry. 'The CSM should be solely concerned with the interests of the public and concerns about the drug industry should be dealt with by a separate Government body,' he argues.

Such views were mirrored a fortnight ago by the Commons health select committee, which called for the CSM to be reshaped as an organisation that solely deals with patient safety.

Dr Kennedy warns that the evaluation of drugs is too often driven by fear of potential risk to patients and fails to take into account the benefits of drugs. 'We have reasonable systems for picking up risk but we don't have good systems for picking up benefits and being able to balance risks and benefits,' he insists.

Dr Tooth agrees. 'Newspapers print stories in black and white but GPs spend their time explaining that life is shades of grey.'

A brief history of health scares

HRT Risk of breast cancer

In July 2002 a major US trial into HRT was halted after

reports of increased risks of breast cancer, heart disease and stroke.

The Women's Health Initiative study had been testing combination HRT in women in their 60s and 70s to see if it could prevent heart disease.

But the unusual treatment group did not prevent a panicked reaction in the press and prescribing rates plummeted.

'It's done a lot of damage,' said Dr Martyn Walling, a GP in Boston, Lincolnshire.

'It didn't really relate to prescribing in this country but a third of women stopped taking HRT immediately.'

Then in 2003 the Million Women Study hit the headlines with claims that HRT had been responsible for 20,000 cases of breast cancer.

Dr Walling said: 'The Million Women Study did the most damage because of women's fears about breast cancer.

'There should be more discussion before these things come out. A lot of women are having a miserable time because of epidemiologists.'

Cox-2s Heart attack fears

On Thursday September 30 last year, Merck announced it was withdrawing the cox-2 inhibitor rofecoxib (Vioxx) from the market.

A study had uncovered worrying evidence of a link with heart attacks and strokes.

The story exploded across Friday's newspapers and news bulletins, and by Monday, GPs were being hit with the first wave of worried patients.

Dr Shaun O'Hanlon, a GP in Guildford, Surrey, spent the weekend frantically ringing around his patients trying to calm their concerns.

'The first I heard was on the news on Friday evening but fortunately we managed to ring some patients over the weekend,' he said.

Dr O'Hanlon received no information from the MHRA until the middle of the following week and guidance on the rest of the cox-2 class did not arrive until December.

'All our patients have stopped taking cox-2s now, but when patients first came to see us we didn't know what to tell them,' Dr O'Hanlon said.

'There should be a more rapid cascade system.'

SSRIs Linked with suicides

Controversy over SSRIs was sparked in 2002 as the BBC and the Guardian alleged a link with suicides.

But it wasn't until December 2004, after two years of deliberation, that the CSM issued revised prescribing advice. SSRIs were safe in adults but potentially risky in children, it concluded.

GPs have been buffeted by accusations that they are over-prescribing SSRIs, with the latest criticism coming just a fortnight ago, from the Commons health select committee.

Dr Clare Wilkie, a GP in Brixton, south London, said: 'It's one of those instances where GPs can't do right for doing wrong. Some years ago we were being criticised for not picking up on depression and not treating it adequately.

'The question is whether to give antidepressants or not. So often it's medicalising sadness, which you can't hope to change with drugs.'

MMR Autism claims

In 1998, one of the most notorious of all scientific papers was published in the Lancet.

In the five-page research letter, Dr Andrew Wakefield suggested the MMR vaccine could cause autism.

Almost overnight, uptake of MMR slumped from over 95 per cent to 78 per cent ­

12 per cent less than is needed to preserve herd immunity.

It has barely changed since, despite numerous studies ridiculing Wakefield's claims.

'Before 1998 we had no problems with MMR uptake', said Dr Nigel Lord, a GP in Altrincham, Cheshire. 'Then there was an initial rapid dropping off of uptake and now levels are lower than they were but they are steady.

'There will always be people who have made up their mind not to have the vaccine. All it takes is for the seed of doubt to be planted and the consequences will last for years and years.'

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