Monthly Archives: June 2016

‘An eye for an eye makes the whole world blind’ – reflections on working with Syrian refugees

image Nikesh Parekh

Dr Nikesh Parekh

Nikesh Parekh is a GP trainee, a research fellow in ageing and part-time public health medical associate in London. Colin Tourle is a semi-retired GP in Hailsham.

There are 1.5 million Syrian refugees in Lebanon, of which the vast majority are hidden away in camps near the Syrian border. These are some of the most impoverished victims of the war in Syria, who lack the financial resource to travel further afield for safety.

With the support of Iasis medical charity (www.iasis.org.uk), we were privileged to travel to three refugee camps within a mile of the Syrian border in Lebanon’s Bekaa Valley to provide medical clinics.

The camps encompass vast swathes of land with back to back tents. Word would spread that doctors have come to offer free help and before long a mass of people, usually 75% women and children, would be gathered outside eager to be seen. Crowd control was nothing short of the chaos at a sporting event! It was hard seeing children queuing outside a dust filled tent waiting for us to see them when one could only feel they should be playing in a garden somewhere with a football or trampoline.

We had never quite anticipated how varied the presentations might be, from the expected urine and skin infections, to eczema, to renal stones, to muscle pains, to hypoglycaemic episode, to a likely bone malignancy. Recognising the likely bone cancer in a 7-year old boy was particularly moving. This child needed a haematologist and costly intervention. How on earth will this really happen – where is there a specialist hospital unit? Will the Lebanese doctor discriminate against the Syrian? Who will transport the child back and forth? Who will cover the costs? Who will look after the immunocompromised child if chemotherapy is the treatment of choicer? Is it too late anyway? These were all the kinds of questions one reflects on, and the unknowns are heart breaking.

Making a diagnosis is always a game of probability, but never really more so than in this resource limited setting, where health literacy of patients was minimal and gathering a good history was challenging even with translators. Attention was often diverted onto their painful stories of loss and despair in this prolonged war with no end in sight. The refugees just want to go back to Syria, the land where they grew up, where they had a living, where they had good memories with their families and friends, and where they were individuals as opposed to ‘refugees’. They certainly do not want to make a trip to Europe as far as possible.

Various pressures were on us and it is emotionally, physically and logistically intense – seeing as many people as wanted to be seen, being in a completely unfamiliar clinical setting where the concept of privacy in a medical consultation is non-existent, knowing that unless someone is life-threateningly ill you wanted to avoid hospital because patients knew that it was chargeable and would be reluctant to go. No one has money, and dignity is dying out fast.

There were some just excited by the opportunity to see some new faces in their camp. We knew they were not sick and they knew they were not sick but we accepted this and made a non-verbal deal; We would examine them and show off the stethoscope and they wouldn’t spend too long pretending to have a problem with every organ system. These sorts of cases made us both reflect on a question one inevitably has at the back of their mind but we didn’t dare ask for fear of the answer – how much of a medical difference am I truly making? – but we realised that we don’t need to answer this question because there was no doubt that the presence of a doctor to show care and provide reassurance without asking for anything in return was worth gold. It gave back some dignity, reminded these innocent victims that they are humans and that the world cares for them. They are not forgotten despite their isolation behind white plastic tent sheets labeled with the blue, bold letters ‘UNHCR’.

Next GP Journal Club is Sunday 3rd July at 8pm: migraine and CV disease in women

image1The next GP Journal Club will be discussing the BMJ paper:

Migraine and risk of cardiovascular disease in women: prospective cohort study by Kurth et al. 

You can download it here.

Migraine occurs in 15% of the UK adult population and is three times more common in women. This large cohort study from the US suggests that female migraine sufferers are at increased risk of experiencing cardiovascular events. What will this mean for those of us in primary care who have responsibility for managing cardiovascular risk? Should we be advising all female migraine sufferers to take a statin, for instance?

Please read the article and consider your response to the following questions, which will form the basis of our discussion:

  1. Was their PPI strategy appropriate? Would the study have benefited from more patient involvement?
  2. Elevated cholesterol and hypertension were treated as binary variables, is this acceptable
  3. 15.2% of the women reported a diagnosis of migraine at baseline. Is this what you would expect if the cohort was representative?
  4. Does it surprise you that the effects of migraine weren’t modified by other factors such as hypertension and smoking?
  5. Based on this study, should we be paying more attention to assessment of migraine sufferers’ CV risk?

Hope to see you all on Twitter next Sunday at 8pm.

Lucy Pocock

Shared medical appointments: better by the dozen

Jonny Coates

Jonny Coates

Jonny Coates is one of the First5 GPs that’s not in Australia.He works in Newcastle upon Tyne.
Jonny Coates

file0001900347815A great deal of medicine is education.  The title ‘doctor’ is derived from the Latin word for teacher.

Before getting that title, I spent three years working as a TEFL (Teaching English as a Foreign Language) teacher: first in Spain, and then with VSO in Eritrea. I’m no expert educationalist; but I learnt enough to see that a 1:1 interaction is often not the best way to impart complex information.

In general practice, I see patients exclusively on a 1:1 basis, in short 10 minute bursts. I have to explain and discuss difficult concepts, and am often left frustrated that I can’t do this justice in a rushed 10 minute consultation. Many of my patients share this frustration.

It’s all the more frustrating, because I often have almost-identical conversations (let’s say lifestyle change in diabetes) numerous times each week, with different patients. I’ve often wished I could have all those patients sat together, and instead of delivering six sub-optimal 10 minute explanations, I could spend an hour doing it really properly, and have more in-depth discussion.

But the increased time we’d have wouldn’t be the only advantage. What I learnt from teaching – whether it was classes of 8 businessmen in Barcelona, or 80 school students in Eritrea – is that learning in groups provides the opportunity to learn from each other; for ‘horizontal’ as well as ‘vertical’ (top-down) learning. It is active learning: the concepts are brought alive through being discussed.

So when I read about ‘shared medical appointments’ on the RCGP Bright Ideas website it rang a whole heap of bells. Here was a way of consulting that sits between the 1:1 appointment and a group education session (where a teacher addresses the group, but only as a group, not individually).

And so, I wrote to Rob Lawson, the article’s author, who set up a group of like-minded clinicians.  Now, a few months down the line, we’ve tried them in our practice.

We invited patients to have their COPD reviews in a group.  Patients were seen in the waiting room, on a Saturday morning. They were given refreshments on arrival, and signed a confidentiality agreement. The practice nurse and pharmacist collected key data: FEV1, their MRC dyspnoea score, smoking status and sats, and put all this information on a white board.  Then I came in, and proceeded to consult with each patient in turn.

The nurse facilitated these conversations, directing me and other patients as appropriate. When an issue came up that had relevance for numerous patients (as it invariably did – smoking, spacers, nebulisers, inhaler technique, pulmonary rehab, rescue packs) I spent longer discussing it, often using the whiteboard for explanations. Other patients with relevant experience chipped in.

Patients really liked it, evidenced by their evaluations (see below), but more importantly, by the practice grapevine – conversations with receptionsts, overheard things in the waiting room. A common refrain was how much they’d learnt, and how good it was to know that other people were in the same boat. The appointments themselves felt warm and supportive, and there were lots of laughs; a breath of fresh air for us clinicians.

 

evaluation-image

Some great things happened, during and after the appointments:

We had an unprecedented uptake in pulmonary rehab classes. Like many practices in deprived areas, we’ve previously had very low uptake in these classes (and the same is true for DESMOND for diabetes). There was some great peer-peer learning and motivation: a patient saying how good they feel for stopping smoking/doing exercise/using a spacer is much more powerful than me as a doctor saying it. Connections formed between patients – e.g. two patients who previously didn’t know each other, but walked home from the appointment together, and agreed to give pulmonary rehab a try together.

Patients got answers to questions they didn’t want to ask themselves. For example, a patient raised panic attacks in the context of COPD: we know these are a big issue for patients with respiratory disease but it’s often not raised by either patients or doctors. We were able to go into this in detail, and it was clear that this resonated with many other people in the group. This was extremely powerful in normalising what they were going through, and how to seek help. There were challenges of course, mainly logistical: space (we can’t use the waiting room during the week), staff time, recall systems. These are surmountable, but need thought if we are to extend the use of these consultations. In terms of resource, we expect that these should be at least cost neutral (compared to current ways of working) once we get teething problems out of the way.

Our biggest concern as clinicians before doing these, was confidentiality. However, in common with the experience of other countries, patients didn’t raise any concerns about this. We only discussed things that patients themselves volunteered, so the patients were in control of what was disclosed. In fact patients were surprisingly candid.

Where next? We plan to continue piloting these, and diversify into other disease areas. Diabetes and childhood asthma/eczema are the next areas we’re trying, and I’d like to try them in chronic pain in the future. Elsewhere, they have been used for a huge variety of conditions (acute and chronic), with great success.

If you are a clinician interested in finding out more, or trying these for yourself, the UK SMAC group now has 40 members from primary and secondary care. We are holding a meeting in Sheffield in October, and new members are welcome. If you are interested, please get in touch by leaving a comment, or by emailing Rob Lawson, the secretary of the UKSMAC group: roblawson@core-health.com.

The Affordable Care Act and USA Healthcare: Reaping the Whirlwind

image1Professor John Frey III is now retired from the University of Wisconsin Department of Family Medicine and Community Health but is still an active teacher, research collaborator, journal editor and ‘faculty whisperer’ about career transitions at all stages of professional life (a free service but you have to buy lunch). He lives most of the year in Santa Fe New Mexico but also part time Madison Wisconsin.

United States presidential elections are ridiculously expensive, far too drawn out, and provide an enormous amount of money for the media consultants to try to convince voters – or more likely scare them – into one position to the other. It is hard to imagine what the initial Republican Clown Car full of candidates must have looked like to the rest of the world. Culling them to a single individual has not helped all that much. Why those who suffer adverse effects from social determinants of health such as poverty, social isolation, family dissolution and low educational achievement continue to vote against their own interests and are attracted to a jingoist real estate developer and ‘small government’ libertarians has been and will be a subject of continuing analysis. Twentieth century history had lots of examples of dangerous demagoguery and likely so will the 21st.

The current situation seems to say “experience and ideas and policy don’t matter, only generalized anger”. Health care always comes up in the Republican debates as “get rid of Obamacare” as I have mentioned previously, with nothing to replace it.[1] Donald Trump infuriates the Republicans by not following the party line on health care and seemingly wants not only to keep the Affordable Care Act (ACA) but improve it in some way that he seems reluctant to describe. But Trump’s daily policy swings assure only that whatever he says he would do will likely turn out to be something else. Health care is more central in the Democratic duo, framed as a ‘pragmatist’ who can get improvements to the Affordable Care Act done versus an ‘idealist’ who advocates a national health system run by government. Having worked hard to help create two Democratic Pyrrhic victories – Eugene McCarthy in 1968 which helped elect Richard Nixon and George McGovern in 1972 which assured a repeat victory by Nixon – I personally am not anxious to stick to the purity of progressive beliefs and bring the world President Trump. Despite different visions of progress in health care, there has been movement, with Secretary Clinton suggesting permitting some people who are still working to enroll in Medicare – the program for elderly and disabled – as an addition to the ACA.

Meanwhile, the ACA moves on to insure more and more people, with the percentage of uninsured now at its lowest point in history. Young people were supposed to be the low risk participants that would offset the high risk pool, and that has happened to a great extent, although not at the levels that the government had hoped. To their credit, young people realize that having health insurance actually frees them to experiment with jobs and careers that don’t carry health benefits. As a result they are busier than ever with entrepreneurial startups and small businesses which are the life blood of society. Not tying health insurance to a job has had a positive effect on what has been labeled the ‘gig economy’ – freelancing and session work controlled by the person rather than the company. If an insured young person in the gig economy breaks a leg, it won’t mean that they have to go live with their parents because they are bankrupt. There has also not been the predicted disconnect between work-related health care as a benefit which has been the foundation of US health insurance. Companies still offer it to most employees, in part because it is a large tax deduction that industry does not want to lose and also because there is renewed competition for workers as the economy speeds up. Private coverage was declining before the ACA was passed but appears to have leveled off. While a substantial victory for the forces of good, the ACA has exposed other problems with the way Americans think about health care and have infused our culture since the mid-20th century.

Two historic cultural problems:

Insurance companies are our friends and protectors

The reforms that had led to a five year leveling off of the cost of health care in the US are now starting to be threatened by two themes that are deeply ingrained in the US psyche: first, the belief that private insurance rather than the government works in the best interests of the people and, second, that getting something for ‘free’ will create an overuse of health services by patients. These two beliefs were sowed in the wind of public opinion back in the mid-20th Century and now the country is reaping the whirlwind. While the rest of the economically developed world adapts health systems to a changing society, the US remains stuck in 75 year old arguments.

The fact that private insurance companies compensate hospitals and physicians and pay for drugs for claims submitted to Medicare always comes as a surprise to the public – and sometimes to physician colleagues. Private insurance companies are contracted as ‘fiscal intermediaries’ for state and federal governments to manage programs like Medicare and Medicaid, for the elderly and the poor. The public has the image of an office building of government bureaucrats in green eyeshades and quill pens in Washington writing checks for over a trillion dollars to health care providers. But these contracts with private insurers limit the percentage of management fees the insurance companies can charge. Allowing ‘only’ a 4% overhead charge to manage Medicare may seem restrictive compared to the up to 20% overhead allowed by the ACA that companies can charge for private plans for the ironically titled ‘medical-loss ratio’ which treats payments for medical care as a ‘loss’ to insurance companies. But because there are more than 55 million of us on Medicare and growing daily, the billions of dollars that insurance companies get yearly to manage a straightforward program with minimal complexity is not so shabby.  But, despite a great deal of research to the contrary,  the public still feels that private insurance companies with high overheads and deceptive practices deliver better quality care than government programs. The Republican Party takes advantage of that belief to denigrate Medicare and Medicaid and the ACA and threaten to turn those programs to the private sector. (Sound familiar?) Not coincidentally the Republicans receive a great deal of money from insurance companies and present no alternative to the ACA other than ‘trust the insurance companies rather than the government’.

On the Democratic side, Senator Sanders picks up on one element of the progressive agenda which started in the late 1940s with President Truman and dwells on the ‘single payer’ mantra which, like so many other sound bites, is not really understood even by those who advocate for it.[2] The problem with ‘single payer’ is that, unless there is a rapid realignment of payment toward primary care and a change from the fee-for-service, production model which dominates US health care, it really would rapidly bankrupt the system. Ontario, in the Canadian single payer system, has moved most of its primary care to a capitated model and salaried service in part because of the strains of fee-for-service care but even with that change, continues to struggle with the right governance and accountability.[3]

In many ways, the whole debate for this presidential election threatens to be a war of sound bites, ‘single payer’ on the left vs. ‘end Obamacare’ on the right with neither party having the skills or the American people having the patience to actually understand what those phrases mean. And no one is discussing the 30 million Americans – the young, the low income families, and the undocumented workers who remain without health insurance.   While ‘universal coverage’ may mean what it says, it may have an asterisk next to it saying “except the 11 million undocumented workers who live here now and who we would like to ignore”. No one wants to have a serious conversation about immigrants at any level.

Being insured yet with ‘out of pocket’ expenses:

I have a photo from a collection from the National Archives of photos taken during the 1930s that shows a general practitioner sitting at his desk with a stern look on his face and a sign that reads ‘Consultations: Cash Only’. While one might be amused by the 80 year old photo, offices and hospitals are more subtle about it now but still demand payment from the patient, even if the patient has health insurance. ‘Co-pay’ and ‘deductible’ are the terms used these days for the portion of the bill patients must pay and are among the more maddening aspects of US health economics. Patients who have to make frequent visits may have $40 charges for each visit in addition to their insurance and so patients with chronic diseases which require frequent monitoring can quickly run up bills that keep them away even though they are ‘insured’. Drug costs are another example. I am on an anticoagulant for which I had a ‘co-pay’ of $15/month for the past year but my most recent refill said I had to pay $50/month for the same drug. The pharmacist gave me no reason and the health plan gave me no warning. All insurance products carry what is termed ‘deductibles’ which is the amount of money patients must pay before the insurance actually pays. The tiers of the ACA have decreasing deductibles with increasing cost of overall insurance. Patients still roll the dice when they are ‘covered’. A recent study reported that two thirds of Americans could not cover a $500 emergency and health insurance deductibles are ‘limited’ to $6850 under the least expensive plan in the ACA market! Such reliably conservative sources as the Wall Street Journal and Forbes have written about how the cost of health care for the average family is rising, even as more people gain insurance, and this cost is creating delays in getting care or receiving appropriate preventive screening. Bankruptcy from lack of insurance is being replaced by bankruptcy from deductibles. What is going on??!!

Underlying all this is the peculiar US cultural belief that if you get something for nothing, you will both over use the service and not value it. When, in the 1980s,  Health Maintenance Organizations (HMOs) made it possible for visits for preventive care and chronic illness to be free, the use of services saw an 18 month uptick but then settled into a predictable pattern of use. Nevertheless, the country has been furiously backpedaling away from the idea of free-at-the-point-of-service care, adding co-pays and other costs to patients to try to steer them away from, for example, emergency rooms or certain medications. It reminds one of the airline industry where what appear to be inexpensive trips suddenly become expensive because of add ons like paying for bags, paying for a seat with leg room, or paying to get on early, all of which add billions of dollars of revenue that was not planned by travelers.

So there continues to be a dance that insurance companies, employers, state and federal government and citizens engage in that keeps health insurance from being simple to understand and that gives energy to the call for ‘single payer’ without having to deal with the insurance companies and their deductibles. The problem with that approach, sadly, is that the largest single component of the US Gross Domestic Product is unlikely to go through a radical change without resistance from those who stand to lose – including doctors, hospitals, Pharma and insurance companies. And if the NHS, with a long history of being widely accepted as the way to do medical care right, continues to struggle with history, economics and a changing world, one can imagine what lies ahead for the Affordable Care Act, which the Republican congress wants to undermine rather than fix.

A colleague, Paul Gordon MD MPH, a Professor of Family Medicine at the University of Arizona, is on sabbatical bicycling across the United States listening in small communities to people’s opinions and thoughts about Obamacare and writing and recording these stories. It is literally a ground level view of what is happening. (You can read Paul’s stories on his blog: https://bikelisteningtour.wordpress.com/ ) He reports the ambivalence and lack of clarity about the ACA that shows how far the country has to go to get it right. However, the percentage of people who see the ACA as positive is climbing and the percentage of those who are negative is dropping and the lines are likely to cross with the next presidency. But that may not happen if the forces of deception, greed and world class dissembling continue to dominate US politics. Paul Starr’s opening line from his landmark book on the history of American medicine, “the dream of reason did not take power into account” summarizes what lies ahead whatever happens in the US elections.[4] Perhaps a corollary to Starr’s comment is that the dream of reason did not take mindless demagoguery into account, either.

Footnotes

[1] Frey JJ 3rd. Is Obamacare working? Br J Gen Pract. 2014 Jul;64(624):360-1. doi: 10.3399/bjgp14X680653.

[2] Oberlander J. The Virtues and Vices of Single-Payer Health Care. N Engl J Med.2016 Apr 14;374(15):1401-3.

[3] Marchildon GP, Hutchison B.  Primary care in Ontario, Canada: New proposals after 15 years of reform. Health Policy. 2016 Apr 23. pii: S0168-8510(16)30087-2. [Epub ahead of print]

[4] Starr P. The Social Transformation of American Medicine. 1982. p 3. Basic Book Inc. New York

Casting down the pseudo-religion of clinical examination

Des Spence

Des Spence

Des Spence is a GP in Maryhill, Glasgow.
Des Spence

file3371281797656The glass bounced off my back and smashed into the drinks gantry shattering a whisky bottle. All I remember is the glass, the blood and that terrible screaming. Glass fights are dangerous, especially as barman, and for $1.80 an hour I often wondered if it was worth it. But it had its compensations for it was the best practical module on communication skills I ever had and I have used my experiences everyday of my medical career. Teaching undergraduates for the last 10 years I have enjoyed regaling them with my ‘pub communication’ stories.

I am convinced of the value of teaching communication skills but what of the scared cow, clinical examination? I was taught by rote – rigid application of clinical skills – inspection, palpation, auscultation and percussion. I was humiliated for not hearing split heart sounds, ridiculed for missing bronchial breathing, scolded for not saying “ninety-ninety” instead of “one-one-one” and I was laughed at for missing a breech presentation.

My objection is not that many of my tutors had a charisma bypass nor their dissocial personality disorders, my issue is that most of what they taught me to be unquestionable ‘fact’ was in reality complete nonsense. I will go further, not only were most of the clinical signs utterly worthless but many are downright dangerous.

How many times have I heard creps at the lung bases and in good faith organized a chest x-ray only for this to be reported 16 weeks later as being normal? I wonder about the times clinical examination has falsely reassured me leading to a delay in diagnosis – to my shame I can think of a few. The real unquestionable fact is that clinical examination is neither sensitive nor specific and devoid of any quantifiable predictive value of disease. Let’s be honest, most of clinical examination is merely the pseudo-religious ceremony of medicine passed down from our distant pagan healer ancestors.

I am, however, forced to pass these dark arts onto the next generation of unsuspecting doctors (secretly I subvert the students but please don’t tell my university). Even the iconic stethoscope is in reality little more than a simple stage prop used by insecure junior doctors who lack the gravitas to convince patients that they are doctors.

It is time for the unbearable and unthinkable but we must cast down the false deity that is clinical examination. In the new dawn light we should take the few worthwhile glittering gems from clinical examination but ditch the rest. Instead, let us teach students about health seeking behaviour, dealing with uncertainty and how to rationally investigate and manage common presenting symptoms. This might end the modern tsunami approach to investigations whose huge yield of minor incidental findings then burst and flood out the NHS outpatients. This might actually help prevent the rampant health neurosis that we as a profession are thoughtlessly inflicting on our poor patients.

Please, put your tumblers down for one last moment as I have a final point of heresy. Ultrasound is cheap, quick and easy, so why don’t we teach students to use an ultrasound probe? This could be used in many different clinical situations but I guess it might be heavy to wear round the neck! All I remember is the glass, the blood and that terrible screaming.

Genuine patient participation: implementing change in Islington

Philip WrigleyPhil Wrigley is a Commissioning Manager in Islington where he has worked for over 12 years; he currently leads on LTCs and Self Care – prior to 2004 he was a professional actor for 25 years.

There is a scenario frequently used by visual comedians which opens with an elderly, infirm lady standing at a busy crossroads looking a little glum as she watches the traffic whizz past. Our hero, (Benny Hill, Norman Wisdom, et al), assuming that she is trying unsuccessfully to negotiate her way to the other side, takes her by the arm and merrily frogmarches her to the other side. Setting her gently down and beaming at her, he stands back expecting grateful thanks. Instead he is met with a barrage of abuse and repeated thwacks from her handbag and walking stick. The woman of course had had other intentions: she wanted to go across the other road or in the opposite direction or she was standing waiting for her friend, etc. Whatever the reason for her irritation, the point is – the last place she wanted to be was where she ended up.

The story highlights the problems of well-meaning people (in our case care professionals) who fail to take into account the real needs and goals of the people whom they are trying to help. It’s extraordinary in this day and age that we still consider actually taking note of the views of patients/service users/people to be such an innovation.

In Islington for the last few years, we have been trying to change the way that our whole workforce delivers care, by ensuring that we commission services which support and promote a more personalised and collaborative interaction with our residents who are using the health and social care system.

The change is not an easy one and involves that heart sink phrase: “culture change”. As commissioners we tend to over use the phrase and it loses some of its weight. It is important constantly to remind ourselves that changing the way people work and interact with others is extremely difficult and can be the cause of a great deal of anxiety on both sides of the interaction.

In Islington we believe that it is not unreasonable to expect residents to take on some of the responsibility themselves and to work with their care professionals to take control of their own wellbeing. In order to take that opportunity, they must be provided with the education, support and the tools to take on the shared responsibility. We acknowledge that this concept is new for both professionals and the population itself, so expecting a whole workforce to move away from the paternalistic approach to healthcare and treat patients as experts in their own care can be unnerving to say the very least.

If this change is to happen the whole system needs to be committed to the approach and the people who will drive the change are the commissioners. No single method is correct but it must also be recognised that no single method will ever be enough. At Islington CCG, we like to refer to ourselves as a “patient centred care organisation”. This may be wishful thinking but I believe we are a little further down the road towards this goal than many other organisations.

The most important thing for us has been a commitment from the top in the CCG and the Council and we are lucky enough to have some extremely charismatic and committed leaders, both at a clinical and commissioning level. Make no mistake this is crucial to any shift in attitude and needs to be in place before you can start to drive the change from the bottom up. Professionals need to be secure in the knowledge that they have the approval from above in order to start changing the culture on the ground and to be confident that this is a strategic approach.

Once the commitment is in place from people who are passionate about care and support planning you have won the first battle, though the way ahead will undoubtedly present further skirmishes. Our commissioning approach to embedding person centred care in Islington is basically not to concentrate it on a single area but to try and make it business as usual across the whole health and social care setting. We have a range of initiatives which we are using to influence professionals across the whole system. As long as the people who implement the changes at the coal face can witness the improvements to patient care, patient well-being and their own job satisfaction, it doesn’t matter that there is no single implementation process. In fact if change is coming from all angles then that is a signal that you are getting it right and that the message is being broadcast and received across the whole landscape.

There are naysayers who will complain that there isn’t sufficient evidence to show that it works, but honestly, there is actually a lot of evidence out there and even in situations where it is thin, there has to be a point when you turn and say, “It’s just common sense to treat people as grown-ups and as experts of their own health conditions”. We just need to learn to step back from our compulsion to do things for people and start to work with them instead.

Home surveys and colonoscopies: coping with risk and reassurance

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

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DSC05260Today I am writing from the most middle class circle of hell; the circle of hell where sinners are stuck in a perpetual home buying chain. Of all the costly obstacles to selling and buying houses, I have found the home survey amongst the most frustrating. The survey of our house was bizarrely damning and, whilst the surveyor found no actual evidence of things having gone wrong, he was full of apocalyptic ideas of things that might go wrong.

Annoying though all this was, I felt some kinship with the surveyor. I recognised the words of a man who was covering himself against future litigation. Lines such as ‘this type of guttering can leak, if it leaks it might cause damp, if there is damp the woodwork might rot’ brought to my mind entries in children’s medical notes which effectively read, ‘this child has the snuffles, I can see no evidence of meningitis, sepsis, Kawasaki’s etc. etc., but should any of these things happen take the child to hospital.’

Our surveyor suggested going to some pretty extreme lengths to make sure all was well. He suggested tearing up some floorboards to make sure the floor joists weren’t rotten, dismantling the bathroom units to make sure there were no leaks, and re damp-proofing the house in case the existing damp course was insufficient. Essentially he would remain unsatisfied until our house was reduced to a pile of rubble atop which he could stand and declare ‘there was nothing wrong with that house.’

He was suggesting causing quite a lot of damage looking for problems that probably weren’t there. And this made me think of the new cancer guidelines which are based on symptoms with a positive predictive value of 3%. These symptoms trigger investigations which, of course, have inherent complications and risks. Some studies have found that colonoscopy, for example, can result in up to 4% of people being admitted to hospital within 30 days of the procedure. Even prostate biopsy has a mortality rate.

So are we now like my surveyor? Are we not to be content until we can stand atop the psychological and physical rubble of our patients and declare ‘there was no cancer here’?

The home survey was essentially pointless. It reported so little hard fact that a buyer either had to just ignore it and go ahead with the purchase anyway or, like our buyer, take it all at face value and walk away. So this begs the question, is the way we practice medicine becoming pointless too? Is our clinical assessment of no value without investigations to back it up? Will we reach the point where the guidelines will make it indefensible for us to say that someone doesn’t have cancer without the caveat that they should be subjected to a battery of invasive procedures just to make sure?

Our buyer could not be reassured without the fabric of the house being placed in jeopardy. How many patients will wish to jeopardise their own fabric for reassurance? As society becomes more risk averse, striking the balance between reassurance and investigation is surely going to be one of the trickier issues our profession faces in the coming years.