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Knackered



I think I’ve worked out why I feel completely knackered all the time. It’s because I am completely knackered all the time. And the very latest NICE guidance neatly illustrates the problem.

Just in case you missed it, it’s about AF – and, in particular, assessing and treating stroke risk in our fibrillating patients.

Now, without wishing to sound like Doc Dinosaur, time was when that particular intellectual process involved me thinking: ‘Hmmm, I reckon I’ll give you some aspirin.’

Then it became a bit more refined, evolving to: ‘I ought to give you warfarin, I know, but that’s a prize pain in the butt, so I reckon I’ll give you some aspirin.’

Until finally, in the last couple of years, we reached the cutting edge of AF risk stratification and started using the CHADS2 score – which meant plugging the relevant figures into the formula, coming up with the risk calculation, taking away the number we first thought of, and thinking: ‘I reckon I’ll give you some aspirin.’ And picking up some QOF points.

I’ve only just got my head round this, and I’m pretty proud of how up-to-AF-speed I am. Now NICE tells me it’s all wrong. Aspirin is completely useless,apparently, though please don’t mention that to the fibrillating hordes who’ve been taking it for years. Instead, I’ve got to apply a revised formula, CHA2DS2-VASc, which I don’t think I understand and certainly can’t pronounce. Then I also need to use a new one, HASBLED, to work out the risk of bleeding. And finally, there’s some sort of Clot-Off between CHA2DS2-VASc and HASBLED, and the winner dictates treatment, which is, er, Gawd knows.

Anyway, the point is, in terms of AF, I thought I was at the very peak of my powers – and yet I’ve been told to up my game. And that punishing principle of, ‘You’re working at capacity, so now we’re going to work you that bit harder’ is being applied to every other facet of general practice, too, from appointment provision to admission avoidance and all points in between.

And that’s why I’m so tired. But at least the NICE guidance is only the draft version. So we simply need some objective measure to prove to NICE that we’re too exhausted to implement anything else. And it’s at this point I’d like to introduce the concept of KNA2CKER2-Ed. I suspect you know your score already.