Monthly Archives: January 2015

Cannabis effects and future health policy

IMG_0151Roy Robertson is Professor of Addiction Medicine at the University of Edinburgh.

The paper Cannabis, tobacco smoking, and lung function: a cross-sectional observational study in a general practice population was published in the BJGP this week. Access the full paper here.

Cannabis and its effects on health are complicated and wide ranging. Like other drugs with an impact on multiple systems there is a considerable literature about negative features and, as with alcohol when much of the measurable effect is the reason for its ingestion, there are mixed views about its value. Added to the balance of benefits versus damaging side effects is its illegality, at least in most administrations. This is clearly changing in several countries and will allow a naturalistic experiment to be evaluated over the next few years. An upcoming United Nations debate in 2016, sponsored by Mexico and Uruguay, will further expose the legal control system to change and may revolutionise the availability in many western countries including the UK. At the present time it looks like cannabis use may well increase over the next decade and, if commercial interests enter the frame then there may well be a much broader range of people participating in its use. The possibility of major manufacturing and marketing companies taking control raises many spectres for medical services used to managing the ravages of alcohol.

For medical people the damage caused by cannabis is increasingly evident. Dependency, behavioural problems and mental health issues have dominated the debate but respiratory effects are recognised and the combination with tobacco clearly is a toxic mixture. As a generation of individuals who have used cannabis reach middle and later life cumulative effects may well become evident and the damaging effects of several decades of use may increase. Making a causal relationship between cannabis and increased incidence of lung cancer and chronic obstructive airways disease is difficult without a cohort study and to try to attribute an increased caseload to the increased effects of tobacco brought about by cannabis dependency requires skilful interpretation of datasets.

[bctt tweet=”For medical people the damage caused by cannabis is increasingly evident.”]

As ever with public health policy decisions have to be made on the basis of data accumulated and evidence pointing in a clear direction. Possibly more urgent is the need to have a direction of travel. This is something governments need to put in place before the regulatory landscape changes. It would therefore seem sensible to convene a discussion on reducing cannabis related harm and to establish an evaluation framework which might give important answers over the next few years and longer. This is never a comfortable or popular area for politicians so pressure will need to come from elsewhere. At present the main lobbying groups are towards decriminalisation and increased availability but the importance of scientific evaluation and monitoring of change needs some leadership.

URTI, menopause, universal health coverage, and chocolate cravings

F1.largeAhmed Rashid is an academic clinical fellow in general practice at the University of Cambridge. He writes the regular monthly column “Yonder” in the BJGP: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature. Twitter: @Dr_A_Rashid

You can download the PDF here at BJGP.org.

Childhood upper respiratory tract infection (URTI). Childhood URTI is one of the commonest reasons for parents to consult in primary care. One would think that this makes it an easy type of consultation for doctors to tackle. However, the age-old antibiotic debate still rears its ugly head and has the potential to lead to much miscommunication and misunderstanding. With antimicrobial resistance high on the public health agenda, these interactions have received particular attention recently. In a study published in Patient Education and Counselling, researchers in Bristol interviewed 30 such parents from a variety of socioeconomic areas.1 They found that parents’ perceptions about the credibility of diagnosis and treatment recommendations were highly influenced by clinician communication. They suggest clinicians should focus on symptoms of particular concern to parents and give more precise safety net advice. Interestingly, they found the term ‘viral’ often trivialised the condition and contradicted the parents’ perception of severity. Although an important part of the antibiotic discussion, this explanation needs to be used sensitively with parents.

[bctt tweet=”BJGP Blog – parents found the term ‘viral’ often trivialised URTIs and needs to be used sensitively.”]

Menopause. Throughout the world, experiences of menopause vary enormously and these are greatly shaped by socioeconomic and cultural influences. Although women’s perspectives about menopause have been investigated extensively, men’s views on the subject have received much less attention. Menopause can cause an array of physical and psychological symptoms that have the potential to dramatically affect quality of life and relationships. In order to understand men’s views about menopause, a group of Turkish researchers interviewed 33 married men from Istanbul who were aged 40–77 years. The study, published in the Journal of Pakistan Medical Association, highlighted a clear lack of basic knowledge and a lack of understanding about the treatment options available.2 Participants varied in their willingness to discuss intimate issues but there were clear concerns about their own sex lives. The authors state that clinicians should remember to involve men when delivering health information to women at this crucial time.

Universal health coverage. The NHS is fantastic and we should be proud of it and celebrate it every day. Despite all the problems and challenges, we must not take for granted the fact that health care in this country is free at the point of use. Across the developing world, the drive to reach universal health coverage relies enormously on primary care infrastructure and many countries look towards the British model as a gold standard. In Sub-Saharan Africa, health reforms have tended to be top-down ignoring the perspective of rural communities. Malawi has adopted an ‘essential health package’ to support universal free health coverage and in a recent BMC Health Services Research article,3 rural community residents highlighted various shortcomings of the system, including geographical inequities, affordability and transport problems, healthcare worker shortages, and poor quality of services. It provides a good example of how rural communities are often overlooked in health reforms and should provide local evidence reflecting context-specific needs.

Chocolate cravings. Chocolate has been around for centuries and remains a popular food type and flavour throughout the world. As well as being incredibly popular, it also elicits strong cravings. It was therefore a good choice for a group of health psychologists wanting to examine two mindfulness techniques. The study published in the British Journal of Health Psychology involved a group of 137 university students wishing to reduce their chocolate consumption.4 Participants were allocated to either a ‘defusion’ or ‘acceptance’ mindfulness strategy, or to a conventional relaxation strategy as a control intervention.

The results indicate that individuals in the ‘defusion’ group successfully resisted chocolate over 5 days, although this was not the case for the ‘acceptance’ group. The study demonstrates that although mindfulness can be useful, determining which strategies are helpful for different situations should help enhance the efficacy and cost-effectiveness of interventions.

[bctt tweet=”BJGP Blog: A ‘defusion’ mindfulness strategy could help you resist chocolate…”]

References

1. Cabral  CIngram  JHay  ADHorwood  J, TARGET team. {2014‘They just say everything’s a virus’ — parent’s judgment of the credibility of clinician communication in primary care consultations for respiratory tract infections in children: a qualitative studyPatient Educ Couns 95(2):248253

2. Hidiroglu  STanriover  OAy  PKaravus  M. (2014A qualitative study on menopause described from the man’s perspectiveJ Pak Med Assoc 64(9):10311036

3. Abiiro  GMbera  GBDe Allegri  (2014Gaps in universal health coverage in Malawi: a qualitative study in rural communitiesBMC Health Serv Res 22(14):234.

4. Jenkins  KTTapper  (2014Resisting chocolate temptation using a brief mindfulness strategyBr J Health Psychol 19(3):509522.

 

Jeremy Hunt and A&E: does he think people are unteachable buffoons?

DSC02665Adam Staten is a GP trainee in Surrey and is a Twitter newbie @adamstaten.

When Jeremy Hunt decided to take his children to A&E rather than wait for a GP appointment, or indeed rather than making use of the out of hours GP service, he defended his decision with a speech that included an incredibly bleak assessment of the British people. His declaration that people could no longer tell what is urgent and what is not is tantamount to describing the population as a mass of unteachable buffoons. Perhaps Hunt is projecting when he sees the public as mindlessly staggering through life constantly posing a great danger to themselves and requiring a doctor to be within arm’s length at all times.

It seems he feels that the gene pool that gave us the industrial revolution has degenerated to such an extent that it is no longer possible to teach them that a sore throat is not an emergency but that crushing central chest pain is. Hunt’s response to this is to give the people what he deems they need, GPs available all day every day.

This response is short sighted and risks entrapping the NHS in a vicious cycle of provision and demand. Increasing availability to the service will only serve to increase dependence. If we are deciding that people can’t decide for themselves what needs to a see a doctor and what does not, and what needs to be seen urgently and what does not, then surely we will need GPs available 24 hours a day, seven days a week. Then we will need more GPs available 24 hours a day. Then what? The demand is potentially limitless, trying to keep up with it is not a long term option but tackling it at source may be.

[bctt tweet=”Hunt’s response is short sighted and risks entrapping the NHS in a vicious cycle of provision and demand.”]

A cheaper and more sustainable solution would be to make a concerted and co-ordinated effort to educate the people, ideally whilst they are at school and receptive to education. For some reason we commonly do this with sexual health education but not for general health education.

There is good evidence to show that sexual health education at school works, causing adolescents to start having sex later, have fewer sexual partners and use condoms and contraception when they do have sex1. School based interventions on alcohol have also been shown to be both effective and cost –effective2.

Rampant though chlamydia and gonorrhoea may be, they will hopefully never become quite as rampant as coughs, colds and twisted ankles. Why then do we not employ the same strategy for other minor health problems? Imagine the savings in time and resources if every musculoskeletal injury presenting to primary care had already been appropriately rested, iced, elevated and treated with analgesia, or if every patient knew that antibiotics will do nothing to improve their coughs and colds? It would not be difficult to create lesson plans to teach this.

I will confess that I haven’t thoroughly costed this idea but I feel relatively safe in the assumption that it will be cheaper and easier to implement a programme whereby willing local GPs are paid the going locum rate to deliver occasional health education lectures in schools than to browbeat a whole profession into providing ever more extended hours. The legwork to provide the content for these education sessions has already been done, the information is available on the NHS website, but if people won’t access the information for themselves then we should take it to them.

We have all taken an oath that includes a commitment to teaching, perhaps now is the time to take this teaching outside the profession so we can ease the burden on our NHS.

 References

  1. Kirby, D (2008) The impact of abstinence and comprehensive sex and STD/HIV education on adolescent sexual behaviour Sexuality Research and Social Policy 5(3): 18-27
  2. NICE (2007) School Based Interventions on Alcohol NICE Public Health Guidance 7

Student Writing Competition

We have a competition for students to write an article suitable for the ‘Out of Hours’ section of the BJGP. The closing date is Monday 2nd March 2015 so there is plenty of time yet.

We’re interested in passion and opinion with the theme: ‘The GP in the Digital Age’. The poster is below – please email it around and feel free to download, print, and nail to any suitable noticeboards.

Download (PDF, Unknown)

 

 

Quality indicators for child health in the UK

Peter_Gill_Peter Gill is a paediatric resident at The Hospital for Sick Children in Toronto, Ontario and an Honorary Fellow at the Centre for Evidence-Based Medicine at the University of Oxford. Follow Peter on Twitter @peterjgill

In the December 2014 issue of the British Journal of General Practice, several colleagues and I published a set of paediatric quality indicators for UK primary care.[1] The paper represents the main findings from my doctoral thesis completed under the supervision of Prof David Mant and Anthony Harnden at Oxford University. It is exciting to see the paper in print (it provided a morale ‘boost’ after working a stretch of nights) accompanied by a thoughtful editorial.[2] But having returned to the ‘coal face’, I am reminded of the integral role of quality indicators in clinical practice.

Why develop indicators?

Caring for children is an important part of UK general practice yet several studies have demonstrated that care quality can be improved. However, only 3% of Quality Outcomes Framework (QOF) markers relate to children and there is no set of child-relevant indicators for UK primary care. For years, the call to develop and integrate child health indicators into QOF has fallen on deaf ears despite evidence that leaving out indicators probably has negatives consequences for care quality. Therefore, we sought to develop a set of quality indicators for children and adolescents which cover a range of paediatric care and reflect existing UK evidence-based national guidelines.

What did we do?

In just over 2000 words, the BJGP paper outlines how a set of 35 indicators were developed; it looks deceiving simple. In reality, the study is the culmination of five years of work with invaluable contributions from many (including funding bodies). First, we selected priority areas [3] after searching the evidence [4], evaluating unplanned hospital admissions [5] and interviewing GPs [6]. Second, we reviewed NICE and SIGN national guidelines relevant to children in primary care before translating key guideline recommendations into quality indicators. Third, a UK-wide panel of GPs with a special interest in child health assessed the validity and implementation of indicators using the RAND methodology.

We believe the 35 indicators have high levels of clinical support, reflect national guidelines, and could be feasibly implemented in the UK. Rather than narrowly focus on easily measurable aspects of care, we address broader determinants of child health outside of clinical guidelines (e.g. child safeguarding and professional development) and prompt GPs to critically reflect on their actions (e.g. rationale for antibiotic prescribing).

How can the indicators improve quality?

There are many ways in which the care quality can improve with implementation of the indicators. For example, the indicators may lead to the earlier diagnosis of easily missed conditions such as Coeliac disease and Type 1 Diabetes which may improve quality of life and reduce complications. In 2008, there were 6300 paediatric medication related safety incidents; the prescribing indicators may improve medication safety. Appropriate evidence-based management of common conditions such as asthma, may reduce emergency department visits and secondary care referral. Each indicator, after appropriate piloting in general practice, could potentially play an important role to improve care quality and identify which areas require increased attention.

What next?

The NHS is an exemplary model of a health system with robust primary care. But, at the risk of being cliché, any system is only as strong as its weakest link. Quality indicators, whether linked to QOF or used as an audit tool, must cover the full range of UK general practice. The on-going restructuring of the NHS may only further marginalise the care of children and adolescents whose interests are often poorly represented.

These quality indicators provide a starting point. They are a set of tools for clinicians working with children. What we need now is for individuals to pick up the tools and get to work. In the US, primary care indicators were signed into law by President Obama in 2009 through the Children’s Health Insurance Program Reauthorisation Act. Why are there not similar initiatives in the UK? Bold steps are needed to implement paediatric indicators in UK primary care.

[bctt tweet=”BJGP Blog: Bold steps needed to implement paediatric indicators in UK primary care.”]

The paper is Open Access and available at http://bjgp.org/content/64/629/e752

 

References

1.     Gill PJ, O’Neill B, Rose P, Mant D, Harnden A. Primary care quality indicators for children: measuring quality in UK general practice. Br J Gen Pract. 2014 Dec;64(629):e752-7. doi: 10.3399/bjgp14X682813.

2.     Dowell A, Turner N. Child health indicators: from theoretical frameworks to practical reality? Br J Gen Pract. 2014 Dec;64(629):608-9. doi: 10.3399/bjgp14X682585.

3.     Gill PJ, Hewitson P, Peile E, Harnden A. Prioritizing areas for quality marker development in children in UK general practice: extending the use of the nominal group technique. Fam Pract. 2012 Oct;29(5):567-75.

4.     Gill PJ, Wang KY, Mant D, Hartling L, Heneghan C, Perera R, Klassen T, Harnden A. The Evidence Base for Interventions Delivered to Children in Primary Care: An Overview of Cochrane Systematic Reviews. PLoS One. 2011; 6(8): e23051. doi:10.1371/journal.pone.0023051

5.     Gill PJ, Goldacre MJ, Mant D, Heneghan C, Thomson A, Seagroatt V, Harnden A. Increase in emergency admissions to hospital for children aged under 15 in England, 1999-2010: national database analysis. Arch Dis Child. 2013 May;98(5):328-34. doi: 10.1136/archdischild-2012-302383.

6.     Gill PJ, Hislop J, Mant D, Harnden A. General practitioners’ views on quality markers for children in UK primary care: a qualitative study. BMC Fam Pract. 2012 Sept 14;13(1):92 doi:10.1186/1471-2296-13-92.

Introducing GPs Anonymous

photoPeter Aird is a GP in Bridgwater, Somerset.

Is it just me or is being a GP increasingly being portrayed as something for which one ought to be ashamed? If so, then perhaps we should consider if we need some help.

With the latest suggestion that patients will be able to bypass their GP and refer themselves for cancer investigations, perhaps it’s time to face up to an uncomfortable truth. We’ve been told enough times by enough people – perhaps the implication is true: we’re not up to the job. It’s all the fault of we GPs.

We mustn’t  go on denying it any longer – convincing ourselves we’re OK – after all, until we acknowledge our problem how can we expect anything to be done to help us. We will just go on making everyone’s life a misery.

We all know how embarrassing GP behaviour can be – you know the kind of thing, spoiling everything for everybody on Christmas Day by turning up at a family gathering rather than opening our surgeries as normal – and thereby compelling people to waste hours in A&E departments with their sore throats and itchy toes. And then, of course, there is the wilful ignoring of our patients who clearly have cancer whilst, at the same time, putting an unnecessary burden on secondary care services by admitting patients to hospital just for the fun of it.

So let’s all face up to our problem. I’ll go first by introducing myself:

My name is Peter – and I’m a General Practitioner.

There that wasn’t so bad -to be honest it’s a relief to have it out in the open – I hope you can find it in your heart to accept someone as shameful as me – after all the hurt I’ve caused. If you’re similarly afflicted, come and join me – I’m setting up ‘GPs Anonymous’ in the hope that together we can support all of us who are stricken with the affliction that is ‘being a GP’.

But perhaps you’re still unconvinced you have a problem. Can I urge you then to ask yourselves these four screening questions? Answer two in the affirmative and you may have a problem – answer ‘Yes’ to all four and you’re in real trouble.

C – have you ever felt you wanted to cut down how much general practice you do?

A – have you ever been annoyed by criticism of your actions as a GP?

G – have you ever felt guilty for what you have done as a GP?

E – have you ever started early in the morning doing your ‘GP thing’?

Extra phone lines will be installed should demand for this new service prove overwhelming.

[bctt tweet=”BJGP Blog: Peter Aird is joining GPs Anonymous. Try the CAGE questionnaire.”]

So why do people fall into the destructive behaviour patterns of general practitioners? Well there seems to be a genetic component in some cases – seeing your parents behaving as GPs seems to predispose some to follow a similar path – though, thankfully this is becoming less common. Others experience a little bit of general practice early on in their medical career and naively imagine that it’s a good thing – something they can control. After all, just one attempt at a ten minute consultation can’t hurt can it? But before long they’re out of control – only in it for the extortionate pay, long hours of ‘off duty’ and the kicks one gets from the systematic mismanagement of those who thought they were there to help.

It’s a tragic condition but, with the arrival of ‘GPs Anonymous’ at last there is some real hope for change. Perhaps together we can rid the country of the blight that GP’s have become.

And then won’t everyone be happy?

The BJGP Blog

IMG-low resEuan Lawson (@euan_lawson) is the Deputy Editor, BJGP.

Welcome to the BJGP Blog.

The aim, as the tagline suggests, is to bring opinion to all facets of general practice and primary care. The BJGP is an academic journal; we publish research papers and we hope they influence policy and care. The BJGP Blog is something we want to do to add value to our output. There are dozens of potential ways journals may have influence: via the patient and the clinician as they come to decisions about the best care for that individual; commissioners facing choices about the future services in their locality; educators finessing the message for their learners; academics teasing out the nuances of research findings; and the list goes on.

Clinical topics, academic debates, policy and news, education, popular culture… we want to peer into all the nook and crannies at the BJGP Blog and we look forward to the discussion.

Please get in touch if you’d like to contribute.