Category Archives: Clinical

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

Latest posts by Adam Staten (see all)

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.

The Joy of Diagnosis: how to attract candidates to general practice

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

Latest posts by Adam Staten (see all)

file8841261948414Diagnosis is one of the most rewarding aspects of medicine and is one of the most attractive features of general practice.  There are few areas of medicine, arguably just general practice and the Emergency Department, where you get the opportunity to encounter a patient ‘fresh’, no prior history, no prior investigations, just you, the patient, and your clinical acumen. In general practice we often get the opportunity to make a diagnosis several times in the same ten minute period and, for me, the less investigating and referring I have to do to make a diagnosis the more satisfying it is.

I think this is an undervalued part of our job. An attempt to sell a career in general practice to medical students and junior doctors usually involves talk of holistic and continuous care, variety of work and variety of opportunity but rarely do you hear an emphasis on the pleasure of seeing droves of patients teeming with fresh pathology. True, much of the pathology is mundane, but then much of it really isn’t, and the enormous challenge in our job is recognising pathology in all fields of medicine, surgery, psychiatry, paediatrics and on, and on.

By far the bulk of medical diagnoses in this country must be made in general practice and yet it seems to me that we allow our thunder to be somewhat stolen by the physicians who set themselves up as the master diagnosticians and the keepers of arcane knowledge. Take the differences in the membership exams for the colleges of GPs and physicians as an example.

The MRCGP is an incredibly pragmatic exam, focusing on common conditions, current guidelines and safe management. It culminates in the clinical skills assessment which is run like a morning surgery but, as it uses actors for patients, features no real pathology. This is the one weakness in an otherwise excellent exam.

In contrast, the MRCP is an unashamed peacock of an exam that bears only the faintest resemblance to reality. I remember learning in great detail about the diagnosis and treatment of Waldenstrom’s macroglobulinemia in preparation for the first part of the written exam as the condition seemed to crop up over and over again in the mock exams. My new found knowledge made me feel all fired up to go out and diagnose my first patient. Then I discovered the incidence was between 2 and 6 per million and I find that, seven years on, I’m still waiting to make that diagnosis and I’m not quite so fired up.

The pinnacle of the MRCP exam is PACES in which there are several stations where you get six minutes to examine a single organ system of a patient in virtual silence. You are then given an opportunity to talk confidently to the examiners about an illness you have probably never seen before, and may well never see again.

In some ways the difference in emphasis is backward. I have never known a secondary care physician make a diagnosis without a battery of investigations to back it up, but it is rare for a GP to make a diagnosis without a heavy reliance on clinical acumen.

Clearly there is a balance to be struck. A detailed knowledge of weird and wonderful conditions can induce the paralysis of the differential when confronted with a strange array of symptoms, but the one advantage of the MRCP is that it forces candidates to trawl the wards looking for clinical signs and so it ensures that they become confident in hearing heart murmurs and tipping spleens in a way that the MRCGP doesn’t.

As guardians of NHS resources, is it not worth us ensuring that our new trainees feel more confident in clinical examination and less reliant on investigation? To this end, should the MRCGP have more emphasis on recognising real physical signs? I think that confidence in examination enhances the pleasure of diagnosis, and I think the pleasure of confidently making diagnoses should be at the fore of marketing our specialty to prospective candidates.

Escape to the Country: challenges of a migrant population for the rural GP

Version 2Bronwen Warner is an FY1 doctor at Oxford University Hospitals NHS Foundation Trust. She spent a month with Heilendi GP Practice in the Orkney Islands as part of her elective at Bristol Medical School.

Patients stumble into the waiting room, propelled by a passing icy squall raging outside. They are almost uniformly Caucasian, wearing warm, waterproof coats and practical shoes. But one speaks with a Cumbrian accent, and another clearly hails from the Home Counties; two more sound Scottish, but my gradually acclimatising ear picks up both a Glaswegian rumble and an Orcadian lilt.

What does a migrant population mean at your practice? Language barriers? Housing issues? Female genital mutilation? In my previous inner city Bristol practice, with its large Somali population, these overt problems were both rife and challenging. But the migrant community there was well-defined and easily identified: flowing burkas muffled under ill-matching quilted coats bought hastily in defence of the cruel and unfamiliar British weather could at least hint at the possibility and nature of any migration-related issues lying underneath.

In the Orkney Islands, the story is different. Patients may look the same and speak easy English, but there is a substantial migrant population with its own health issues. Of the 70 islands making up the Orkney archipelago, about 20 are inhabited.1 On average in 2012-2014, 751 people entered the Orkney Islands, with a net inflow of 86.2

Migrants to the Orkney Islands encounter a myriad of challenges. In addition to the usual logistical issues of registering at a new practice and waiting for transfer of notes, or struggling to agree a management plan for a longstanding condition with a new GP, patients face the further challenge of adjusting to new structures of healthcare provision. Here, the Out of Hours service in several of the Isles (the islands around mainland Orkney) is provided by a Nurse Practitioner, and all emergency transfers to hospital from outside the main island are done via boat or helicopter. The hospital has A&E, maternity and some outpatient services, but most specialties do not have a consultant resident on the islands and many ordinarily routine diagnostic and therapeutic procedures or consultant appointments take place in Aberdeen Royal Infirmary, necessitating a plane or seven hour ferry journey. The nearest ICU is in Glasgow.

The push-pull model of migration is well established: migrants seek a new home both to leave something behind and gain a better situation.3 GPs here agree on the prevalence of mental health issues. A number of patients have moved from ‘South’ to build a new life and escape from problems at home. However, many find the relative anonymity of city life a comfort blanket in contrast to the frank inquisitiveness of an island with a population numbering a few hundred, on which everybody knows everybody’s business. People can also find that the isolation from the friends and family they wished to escape is devastating, and struggle to cope without a supportive social network. The climate can also bring its own challenges: a dazzling sun bouncing off crashing waves through the long days of a summer holiday visit does not predict long dark winters and travel-impeding tumultuous winter storms.

For rural GPs, an understanding of the potential difficulties of a migrant population is vital to managing this patient group effectively. The conversation may be clear-cut, with new patients to a practice needing advice about the logistics of accessing healthcare in an unfamiliar rural setting. However, the scope for psychological issues, which may be longstanding or newly-brewed in an environment of failed adjustment, must not be underestimated. These factors might not always be frankly discussed, but should be at the back of the mind in every consultation.

It could also be worth, in a thriving suburban practice, having the discussion with your patient who is considering an ‘escape to the country’. Is he aware that his low grade non-Hodgkins lymphoma will not be monitored by a consultant a 20 minute drive away? Has she thought about how she will get to the shops in 10 years time when her now stable knees will not allow her to hop on and off the ferry to the mainland? Are they worried that a paediatric emergency in their new baby could necessitate an air transfer? Will his ‘escape’ destroy the inner demons of his depression?

Rural settings such as the beautiful Orkney Islands offer the opportunity for a healthy, active lifestyle in a stunning environment with multiple physical and psychological health benefits. Many migrants will be delighted with their choice of move and achieve the benefits they were hoping for. However, migrant populations in a rural practice bring new challenges to GPs – just as severe but less easily recognised than with an immigrant population from far afield. An awareness of these issues is vital to managing both expectations and problems if they arise. As one of the GPs in my Orkney practice commented, Folk come up here to get away from their problems, but they cannot get away from themselves.”

 

References

1.  The Scottish Islands Federation. Island statistics. 2001. [Accessed 21/4/16]. Available at http://www.scottish-islands-federation.co.uk/island-statistics/

2. National Records of Scotland. Orkney Islands Council Area – Demographic Factsheet. 2015. [Accessed on 20/4/16]. Available at http://www.nrscotland.gov.uk/files/statistics/council-area-data-sheets/orkney-islands-factsheet.pdf

3. King, Russell. Theories and Typologies of Migration: An Overview and a Primer. Willy Brandt Series of Working Papers in International Migration and Ethnic Relations. Malmö Institute for Studies of Migration, Diversity and Welfare (MIM) Malmö University, 2012.

 

Googling symptoms: let’s do it together

Ahmed Rashid

Ahmed Rashid

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

The English Health Secretary, Jeremy Hunt, recently sparked anger when he suggested that parents could look online to determine the severity of their child’s rash. The medical community rightly rebuffed this firmly, highlighting the potential harm that could be caused, notably through the brilliant use of the #rashdecision hashtag on Twitter.

We know, though, that members of the public are increasingly using the internet to seek health information. The NHS Choices website, for example, reports over 15 million visits per month1. Although the pursuit of online medical information seems to be prevalent across all age groups including older people2, it is especially common in younger people, where prior consultation with a health professional before searching is particularly low.3

So, is there some masked truth in what Mr Hunt had to say? Will a time come when the internet can take the place of human clinicians?

A recent clinical encounter prompted me to think about this possibility. One of the joys of clinical practice, and in particular working in general practice, is the stimulation of facing regular diagnostic challenges. The patient, a young man, came to see me with a longstanding skin complaint that affected his feet. Having unsuccessfully searched for a diagnosis online, he was in despair. After examining him myself, I was as stumped as he was and suggested we gave the internet searching another try. His search terms had been “lumpy feet” or variations on that. Having examined his feet, I opted for a more focussed search using keywords “papules medial heel”. I quickly recognised the trusted PCDS (Primary Care Dermatology Society) website, which helped us jointly agree on the diagnosis of piezogenic pedal papules – small fatty herniations through fascial defects of the heels4.

So this means we need new, easier-to-use, online resources with lay terminology and better instructions. Right?

Perhaps we do. And perhaps during my working life, doctors’ roles as diagnosticians will start to diminish. For now though, my experience is that far more patients I meet have accessed inaccurate or alarmist information than those that have benefitted from valuable explanatory material. A recent evaluation of publicly available symptom checkers confirms that there are serious deficits in both diagnosis and triage5. For now then, I’m happy to continue working with my patients to work out how we can best use the technology together.

References

1. Gann B. Giving patients choice and control: health informatics on the patient journey. Yearb Med Inform 2012;7:70-3.
2. Luger TM, Houston TK, Suls J. Older adult experience of online diagnosis: results from a scenario-based think-aloud protocol. J Med Internet Res 2014;16:e16.
3. Powell J, Inglis N, Ronnie J, Large S. The characteristics and motivations of online health information seekers: cross-sectional survey and qualitative interview study. J Med Internet Res. 2011;13:e20.
4. Ma DL, Vano-Galvan S. Piezogenic pedal papules. CMAJ. 2013 Dec 10;185(18):E847.
5. Semigran HL, Linder JA, Gidengil C, Mehrotra A. Evaluation of symptom checkers for self diagnosis and triage: audit study. BMJ. 2015 Jul 8;351:h3480.

Yonder: Rosacea, youth mental health, diagnosing arthritis and telephone triage

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.

Rosacea
Rosacea is a common, chronic skin condition in adults. As it predominantly affects the face, it has the potential to cause significant psychological and social distress. The internet has provided opportunities for patients to access information as well as interact with peers and experts. A US research team recently analysed posts on an online rosacea support forum to obtain insights into patients’ educational needs.1 They found that patients primarily sought advice about treatments, triggers, diet, and skin care. Perhaps unsurprisingly, there were also a large number of queries about the efficacy and adverse effects of therapies.

The authors suggest that doctors should make more attempts to include patients in their rosacea care and suggest that one way of doing this is to have them take pictures to track progress and keep a diary of potential triggers. They also suggest that proactively providing resources could help reduce confusion about the disease and treatments.

Youth mental health
Youth mental health is increasingly recognised as a priority area in health systems around the world. In particular, there has recently been an increased focus on early intervention and an Irish research team recently sought to examine the role of the GP in providing early treatment in this population.2

They combined a national survey of GPs with interviews of both health professionals and young people. They found that GPs were largely unsatisfied with their postgraduate training in child mental health and substance misuse. Access to services and youth workers were cited as key facilitators to improve care. Much like in the NHS, it seems an increase in funding for mental health services is also acutely needed in the Irish health system.

Diagnosing arthritis
Progress in rheumatoid arthritis management in recent years has meant that starting treatment early is more important than ever. However, this naturally relies on early identification and a Dutch rheumatology team recently examined the signs, symptoms, and investigations that GPs use in the diagnosis of inflammatory arthritis, analysing medical records.3 They used records from 16 practices and found 126 patients with new diagnoses of inflammatory arthritis. Information about classic inflammatory symptoms (pain, swelling, warmth, redness, reduced function) was frequently documented but items that they record as being routinely checked in secondary care (morning stiffness, family history and squeeze-test) were rarely used. In the UK, the increasing use of referral proformas with checklists may already have mostly ameliorated this issue.

Telephone triage
Practices are increasingly using telephone triage to manage patient flow but there are many unanswered questions about its effectiveness and safety. In the Netherlands, telephone triage in the daytime is done by practice assistants who generally have followed an intermediate vocational medical education of 3 years. A recent Dutch study sought to examine the adequacy of this triage, conducting a web-based survey asking practice assistants to assess the required type of care of written case scenarios with varying health problems and levels of urgency.4 They found that the required care was assessed adequately in 63.6% of cases, was over-estimated in 19.3%, and under-estimated in 17.1% and predictably, more experienced assistants and assistants with fixed daily work meetings with the GP performed better.

The authors conclude that telephone triage by general practice assistants is efficient, but potentially unsafe in highly urgent cases and suggest improved training is the key solution. As for NHS general practice, it seems increasingly likely that there will be more multidisciplinary working in years to come and this paper provides some insights into the kind of challenges (and opportunities) this may bring.

REFERENCES
1. Alinia  H, Moradi Tuchayi  S, Farhangian  ME, et al. (2016) Rosacea patients seeking advice: Qualitative analysis of patients’ posts on a rosacea support forum. J Dermatolog Treat 27(2):99–102.

2. Leahy  D, Schaffalitzky  E, Saunders  J, et al. (2015) Role of the general practitioner in providing early intervention for youth mental health: a mixed methods investigation. Early Interv Psychiatry doi:10.1111/eip.12303.

3. Newsum  EC, de Waal  MW, van Steenbergen  HW, et al. (2016) How do general practitioners identify inflammatory arthritis? A cohort analysis of Dutch general practitioner electronic medical records. Rheumatology (Oxford) pii:kev432.

4. Smits  M, Hanssen  S, Huibers  L, Giesen  P (2016) Telephone triage in general practices: A written case scenario study in the Netherlands. Scand J Prim Health Care 19:1–10.

Zika virus testing: practical management for primary care

PhotoCMousoulis

Dr Mousoulis

PhotoBSibal

Dr Sibal

Christos Mousoulis is a medical doctor specialising in Public Health. He is currently an Academic Clinical Fellow doing his health protection placement at Public Health England – West Midlands East team. His main interest is in Academic Public Health and in Clinical Trials in particular.

Bharat Sibal is a Lead Consultant in Communicable Disease Control working for Public Health England, Health Protection Team based in Birmingham. He has worked for WHO in Nepal and India and has wide interests in control of infectious diseases internationally.

Over the last few months a lot of media attention has being put on Zika virus and various national guidance has been produced. As Public Health England (PHE) Health Protection Team we have received a number of queries from GPs and other primary care colleagues regarding Zika virus testing and the role of diagnostics in primary care. PHE has produced various guidance on Zika virus and a specific one has been produced for primary care.1 We also read the article published in BJGP2 with interest and based on current guidance from PHE we believe that the following should be helpful to resolve queries from our primary care colleagues. Please note that these recommendations are being updated periodically to reflect up-to-date evidence which is available at: https://www.gov.uk/guidance/zika-virus.3

What is the test for Zika?
A blood test can confirm or exclude the presence of Zika virus in symptomatic patients only. Main symptoms are fever, headache, rash, joint pain and muscle pain. A clotted ‘red top’ (plain) or ‘yellow top’ (serum separator) blood, EDTA ‘purple top’ blood and a small volume of urine without preservative should be sent to the local microbiology/virology laboratory.1 The attending clinician should complete a standard, local laboratory form along with PHE – Rare and Imported Pathogens Laboratory request form (RIPL) available at: https://www.gov.uk/government/publications/rare-and-imported-pathogens-testing-form-to-submit-sample.1 The blood test is then sent to be processed by the RIPL. Travel history and clinical details should also be included on the form. The blood test is a PCR test, i.e. it tests for the presence of DNA of the virus in symptomatic patients only. It can only detect Zika virus during a seven day period following the onset of symptoms. It is not an antibody test, so it cannot confirm or exclude prior infection. RIPL is in the process of developing a prototype antibody test for Zika, but this is not yet widely available.

Who should be tested?
A pregnant woman with a history of travel to a Zika area during pregnancy, who reports clinical illness that raises the suspicion of Zika virus disease, during or within 2 weeks of travel, should be tested for Zika virus infection.4

All other pregnant women who have travelled to a Zika area during pregnancy should have a blood test done which will be stored.4 Please do not forget that all pregnant women who have travelled should also have a baseline ultrasound scan. Non-pregnant individuals who present with active symptoms suggestive of Zika infection should have the blood test as well. However, non-pregnant patients who were diagnosed elsewhere and who have recovered from their infection do not require further investigation and can be reassured that Zika infection is short-lived and self-resolving.5

What if the result is positive?
If a pregnant woman has a positive test she should be referred to the local specialist Fetal Medicine Unit.4 If there is evidence of a problem with a baby (e.g. found on ultrasound scan) from a woman who has or who may have been diagnosed with Zika, the RIPL can test amniotic fluid for the virus. This will only be the case if the patient and the clinical team accept the risk of amniocentesis and the option of therapeutic termination of the pregnancy for a positive result.4 If someone has been diagnosed with the virus, this does not necessarily mean that the virus has affected the baby. They will be cared for and monitored throughout the pregnancy by the Fetal Medicine Unit and their midwife.

References

1 Public Health England. Zika virus infection: guidance for primary care (4th February 2016) URL: https://www.gov.uk/government/publications/zika-virus-infection-guidance-for-primary-care [23rd March 2016]

2 Burke RM, Pandya P, Nastouli E, Gothard P. Zika virus infection during pregnancy: what, where and why? Br J Gen Pract 2016; 66 (644): 122-123

3 Public Health England. Health protection – guidance. Zika virus (17th March 2016) URL: https://www.gov.uk/guidance/zika-virus [23rd March 2016]

4 Royal College of Obstetricians and Gynaecologists. Interim clinical guidelines on Zika virus infection and pregnancy (29th January 2016) URL: https://www.rcog.org.uk/en/news/interim-clinical-guidelines-on-zika-virus-infection-and-pregnancy/ [23rd March 2016]

5 National Travel Health Network and Centre (NaTHNaC). Travel Health Pro (17th March 2016). URL: http://travelhealthpro.org.uk/diseases/zikavirus/ [23rd March 2016]

This milk tastes sour: cows’ milk allergy and industry-sponsored disease creep

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

Hospitals are awash with Pharma freebies. CCU is littered with the logo of the latest statin, the psychiatrist’s pen bears the name of the latest modified-release SNRI, and the chest clinic post-it notes are adorned with inhaler brands.

The paediatric ward is slightly different though. Just as the rest of the hospital is branded by Big Pharma, the paeds ward is branded by ‘Big Formula’. The logos on the pens and lanyards of the paediatricians, and the adverts filling their journals, are all for formula milk brands.

And the formula companies are now hungrily eyeing up primary care.  At a recent CCG educational event, our local paediatric immunologist gave a talk on cows’ milk allergy (CMA) in children.   We were handed glossy, branded copies of the MAP (Milk Allergy in Primary Care) Guideline.  We were offered “free” courses to study for a diploma, courtesy of the ever-beneficent formula companies.

According to the guideline, a diagnosis of CMA should be considered if a child has “one, or often more than one” of the following symptoms:

  1. Colic.
  2. Vomiting, ‘reflux’, GORD.
  3. Food refusal or aversion.
  4. Loose or frequent stools.
  5. Perianal redness.
  6. Constipation.
  7. Abdominal discomfort.
  8. Blood/mucus in stools of an otherwise well infant.
  9. Pruritis/erythema. Significant atopic eczema.
  10. ‘Catarrhal’ upper airways symptoms.

Remember: “One, or often more than one” of these.

I had my third child 10 months ago. She has had many of these symptoms fairly frequently. As did both of my other children. In fact, I would find it extremely hard to find any child who doesn’t have “one, or more than one” among the many children I see each day in surgery. They are all extremely common symptoms in infancy.

Most of these children with mild symptoms don’t ever come onto our radar as clinicians, as parents correctly realise that they are part of normal childhood. However, since the companies are now marketing their products directly to patients through websites (www.isitcowsmilkallergy.co.uk), TV adverts (here) and newspaper articles (more GP-bashing from the Daily Mail), I suspect we will be seeing much more of it. We are at great risk of medicalising normal infancy.

Financial links to a variety of milk manufacturers, including Mead Johnson Nutrition and Danone, have been disclosed by authors, as outlined in a 2013 BMJ article. Mead Johnson Nutrition are the very people behind my glossy handout, and the website and TV ads outlined above. This has echoes of the recent scandal around dementia screening, when campaigns to increase diagnosis turned out to have been funded by a drug company with a new product to sell (discussed here by Margaret McCartney).

I do not doubt for a moment that CMA exists, and I do not doubt that it makes some infants very ill. I do not doubt that specialised formula milk is an excellent treatment for these children.  I have seen and treated cases myself (both during my paediatric jobs and as a GP): of babies becoming very unwell due to CMA, and making a remarkable improvement with the correct milk.

I do however, have significant concerns about GPs being asked to diagnose and treat CMA on the basis of this low-threshold diagnostic guideline, which is promoted by milk manufacturers, and whose authors are paid by those very same companies.

Worst of all, these companies are marketing directly to patients to drum up business.

This is industry-sponsored disease creep, and we should be questioning it much further before accepting it.

 

This article is crossposted from Jonny’s own blog: https://jonnycoates.wordpress.com/2016/02/17/this-milk-tastes-sour/

Update 30th March. In response to feedback this blog was edited to remove a reference to the MAP guideline being funded by milk manufacturers. This was an error: the guideline itself was not funded by industry.

GP Journal Club 28th February 2016 – Bariatric surgery in the NHS

Paper: Douglas IJ, Bhaskaran K, Batterham RL, Smeeth L. Bariatric Surgery in the United Kingdom: A Cohort Study of Weight Loss and Clinical Outcomes in Routine Clinical Care. PLoS Med. 2015 Dec 22;12(12):e1001925.

Link: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001925

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 and is chairing the next #gpjc. @Dr_A_Rashid

Obesity is a public health issue and not a general practice one. Right?

I’ve recently had the good fortune to have talked about obesity with two wise and experienced GPs who held quite differing opinions on this. Although they were both in agreement that it is a serious and growing problem, one felt it was predominantly a social problem with solutions in policy and government whilst the other thought it a more clinical problem with solutions in the consultation room and NHS more broadly.

Although the social causes of obesity are unquestionable and the need for policy change is clear, the already alarming rates of obesity and related diseases mean that we probably need solutions across the spectrum. Weight loss surgery is a concept that often divides opinion amongst clinicians and patients alike. However, it has become an important aspect of obesity management in recent years and is now an established discipline across various specialist centres in the UK. Although the results of bariatric surgery RCTs have been promising, we know that trial findings are not always replicated in routine clinical practice. This month’s paper is a UK observational study that investigated whether there is an association between bariatric surgery and weight, BMI, and obesity-related co-morbidities.

As well as the focus on obesity and related diseases and the relevance to GPs involved in commissioning bariatric surgery services, the paper is also of interest because of the use of the Clinical Practice Research Datalink (CPRD) – an increasingly important research service in UK primary care.

I hope you can join us for the Twitter chat at 8pm on 28th February 2016. Please don’t forget to include the #gpjc hashtag in all tweets. Below are the 5 questions that we’ll be generally basing the chat around but please feel free to raise other points that come to mind when reading the paper.

  1. Was it appropriate to use the CPRD to answer this question? (Are there other data sources that could have been used?)
  2. Were all of the clinical outcomes relevant? (Which are the most important?)
  3. Are you surprised by the speed of weight reduction?
  4. Was it acceptable to use discontinuation of medication as a definition of T2DM and HTN resolution in the absence of HbA1c and BP measurements?
  5. Should NHS thresholds for bariatric surgery be changed?

Yonder: Health checks, insomnia, nursing homes and spirituality

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.

Health checks
The NHS Health Check programme has divided opinion ever since it was first launched in 2008. The idea of proactively checking and managing an individual’s vascular risk may seem sensible but the evidence about the effectiveness of this approach has been lacking and has led to much debate in the medical community in recent years. As part of a contract with general practices to deliver this programme in the North West of England, a team of researchers recently surveyed GPs and practice managers across 55 practices.1

Time and software were key barriers to implementation, and payments were considered insufficient to cover the considerable increase in nursing workload that was required. With fewer than half of respondents deeming the programme beneficial to their practice, the paper concludes that practices will need much more support from commissioners if the programme continues to run.

Insomnia
Insomnia is extremely common and the cause of enormous frustration for patients, families, and GPs alike. A recent UK-based study sought to understand more about the causes of this frustration by interviewing both patients and health professionals in primary care settings in Nottinghamshire and Lincolnshire.2 Clinicians focused more on treatments rather than insomnia itself and felt advice about sleep hygiene was often disregarded. GPs often colluded with patients to prescribe hypnotics to avoid confrontation, and cognitive behavioural therapy (CBT) was rarely considered, despite being a recognised management option. Patients, meanwhile, often used hypnotics in ways that were not intended and felt GPs focused too much on the underlying causes of the insomnia rather than the impact of it.

Improving undergraduate and postgraduate medical training, establishing a recognised primary care pathway including pharmacists and local mental health services, and increasing public awareness of non-pharmaceutical treatment options were all suggested as possible strategies by the study authors.

Nursing homes
Nursing home residents are typically extremely frail and often have multimorbidity, polypharmacy, and multiple, complex medical and social needs requiring difficult medical decisions to be made. In Sweden, much like in the UK, GPs are usually responsible for the care of individuals in this setting and a recent study sought to understand what Swedish GPs thought about this aspect of their work.3 They described a discordance between the demands from staff and the actual need of care for the individual patients. However, despite the challenges, working in this setting was considered important and meaningful, with GPs feeling confident in their ability to provide a holistic and balanced approach. A positive and continuous relationship with nursing colleagues was considered one of the key aspects of the job and central to ensuring the wellbeing of residents.

Spirituality
In recent years, spirituality has become an increasingly well-recognised aspect of wellbeing that should be addressed as part of a holistic healthcare approach — particularly, for example, at the end of life. Traditionally, hospital chaplains have been recognised as spiritual carers, although religion is just one of many ways individuals can experience spirituality. In order to assimilate current thinking about the role of the doctor in the discussion of spirituality, an Australian research team conducted a systematic literature review identifying 54 studies comprising 12 327 individuals.4 In the majority of studies, over half of participants thought it was appropriate for the doctor to enquire about spiritual needs. However, preferences were not straightforward and there was a mismatch in perception between patients and doctors about what constitutes this discussion and therefore whether it has actually taken place.

Although patients do not expect their doctor to be a spiritual adviser, they do want holistic care and strong doctor–patient relationships, and the authors suggest therefore that efforts should be made to identify those patients who would welcome such discussions.

REFERENCES

1. Krska J, du Plessis R, Chellaswamy H (May, 2015) Views of practice managers and general practitioners on implementing NHS Health Checks. Prim Health Care Res Dev 20:1–8.
2. Davy Z, Middlemass J, Siriwardena AN (2015) Patients’ and clinicians’ experiences and perceptions of the primary care management of insomnia: qualitative study. Health Expect 18(5):1371–1383.
3. Bolmsjö BB, Strandberg EL, Midlöv P, Brorsson A (2015) ‘It is meaningful; I feel that I can make a difference’ — a qualitative study about GPs’ experiences of work at nursing homes in Sweden. BMC Fam Pract 16:111.
4. Best M, Butow P, Olver I (2015) Do patients want doctors to talk about spirituality? A systematic literature review. Patient Educ Couns 98(11):1320–1328.

BJGP article on practices in special measures: CQC response

Devin GrayDevin Gray is a National Medical Director’s Clinical Fellow and a GP trainee, interested in driving system-level change to achieve better care and outcomes for patients.

This article was co-authored with Professor Nigel Sparrow OBE, Senior National GP Advisor and Responsible Officer, CQC and Professor Steve Field CBE, Chief Inspector of General Practice, CQC.

Thank you for the BJGP article, “CQC Inspections: unintended consequences of being placed in special measures”.The CQC welcomes opening the door to dialogue and discussion about practices being placed in special measures and wholeheartedly agrees with the need to work effectively together in enabling improvement.

Improving care under pressure

With unprecedented pressures in General Practice and across the whole NHS, we are aware of the context. Preparation for a CQC inspection may feel to some GPs as yet another task there is little time or resources for. So why engage with regulation?

At the CQC we are passionate about improving standards of quality and safety in healthcare. Through our work, we are for the first time able to provide a comprehensive description of what good care looks like.2 We support change and improvement by identifying and championing examples of good and outstanding practice, as demonstrated by our Outstanding Practice Toolkit,3 and by celebrating innovative ways of working in an ever resource-squeezed environment.

The intention of special measures

We do not underestimate the difficulties of being rated as inadequate for practice staff and patients. The intention of placing a practice in special measures is to make patients, providers and commissioners aware that we have serious concerns and to identify the need for urgent support. The special measures framework allows the CQC and NHS England to work together to ensure a timely and coordinated response to inadequate practices. It also provides clear timescales for addressing inadequate care, which was identified as missing in the case of Mid Staffordshire NHS Foundation Trust,4 allowing practices to access the support they need to get “back on a path to recovery and then to excellence”.5

The key is effective leadership

We have found that the vast majority (84%) of England’s GP practices are providing a good or outstanding service to their patients, with 12% rated as “requiring improvement”. So why are 4% of practices falling significantly short? As highlighted in the CQC’s recent State of Care report6, the key may be in leadership.

The CQC assesses the leadership and organisational culture of providers, rating them on how “well-led” they are. By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

As highlighted in your article, every practice in special measures has been rated inadequate in the “well-led” key question (in addition to being rated as inadequate in one or more of the other key questions – safe, effective, caring or responsive). Perhaps there is no better time to be considering the role of effective leadership in providing high-quality care as well as guiding practices through these difficult times.

“The NHS needs leadership of the highest calibre if it is to respond successfully to financial and service pressures that are unprecedented in its history.”7

The first practice to come out of special measures was only recently announced. The process of regulation has driven impressive levels of improvement in this practice in the six months since its initial inspection: “In contrast to our last inspection, we found a group of
GPs and nurses providing clinical care at the practice who were enthusiastic, motivated and co-operating well with one another8 and four of the five key questions ratings improved.

The process of turning a struggling practice around no doubt involves significant time and effort. Improvement does not happen overnight, and it does not happen without effective leadership. Investing in leadership has shown time and time again9 to pay off in the ongoing running of a well-led organisation that delivers good care to the population it serves.

Getting the right support at the right time

As mentioned in your article, there can be local awareness of issues long before the CQC inspects. In some cases, practices themselves have not been surprised by the rating. The CQC strongly supports the early identification of problems within a practice and early investment in support, rather than waiting for an inspection itself to raise the profile of the issues. This will involve closer collaborative working with Clinical Commissioning Groups (CCGs), NHS England and other members of the local health economy.

“At a time when there is growing interest in integrated care and partnership working between the NHS, local authorities and third sector organisations, collective leadership in local health systems has never been more important or necessary.”7

Looking to the future

As our health care economy continues to evolve, and new models of care emerge, the CQC is committed to understanding how we can best work together to support and champion change, and improve quality of care. Crucially, as a profession we must not let regulation act as a barrier to innovation.

Whilst there will be a few practices that need little more than hard resources to improve standards, our findings support a strong argument to be investing in leadership within practices. This has been a central theme in supporting Acute Trusts in special measures, and should be for General Practice. In recognition of this, the CQC is working collaboratively with other organisations to improve our assessment of leadership and organisational culture going forward.

We welcome the RCGP’s commitment to leadership development and its Pilot Scheme has clearly been doing essential work. Nevertheless, we must take more collective responsibility in identifying struggling practices early, championing innovation, driving improvement, and providing long-term support.

Deputy Editor note: If you do have any general points that you wish to put to the CQC please leave a comment. In the spirit of the article and the desire to have an open discussion they have promised to respond. However, please keep these to the general rather than raising specific concerns about specific practices.

References

1. Rendel S, Crawley H, Ballard T (2015) CQC inspections: unintended consequences of being placed in special measures, Br J Gen Pract DOI: 10.3399/bjgp15X686809
2. CQC: GP Practices Provider Handbook Appendices. March 2015
3. http://www.cqc.org.uk/content/examples-outstanding-practice-gps (accessed 6/10/15)
4. The Francis Report (Report of the Mid-Staffordshire NHS Foundation Trust public inquiry) and the Government’s response. December 2013
5. Department of Health: Hard Truths. The Journey to Putting Patients First. January 2014.
6. CQC: State of health care and adult social care 2014/14. October 2015.
7. The King’s Fund: Developing Collective Leadership. May 2014
8. http://www.cqc.org.uk/content/gp-practice-exits-special-measures-following-improvements-patients-1 (accessed 6/10/15)
9. The King’s Fund Commission: The Future of Leadership and Management in the NHS. No More Heroes. May 2011