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Book Review: The State of Medicine by Margaret McCartney

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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thestateofmedicine300The State of Medicine is an eloquent, passionate, comprehensive, and, in many ways, dispiriting overview of the repeated damage inflicted on the NHS at the whim of successive governments. The frustration of the author, a GP from Glasgow, pours from every page, every paragraph and every sentence, as she contrasts the efforts of doctors to practice evidence based, safe, humane and cost-effective medicine, in a system that is routinely upended and overhauled according to manifesto sound bite, political opinion and, occasionally, outright self-interest.

Whilst the general themes of this book will surprise few who work in the NHS, the actual facts and figures, such as the vast sums wasted on management consultancy firms, may make the eyes of even the most hardened cynic water.

Each chapter begins with an interview with someone who is able to give a different perspective on our collective woes. Amongst these are some real gems that offer unexpected insights into different niches of the NHS world. The words of an A&E consultant who was working at Mid Staffs during the scandal may send a there-but-for-the-grace-of God shiver down your spine, and the thoughts of a Nobel prize winning economist will have you bewildered that there are still so many advocates of insurance based health care systems.

Dr McCartney offers a clear account of the follies of the last few decades and a personal view of where and how the NHS should proceed from here with ideas such as buffering the NHS from policy makers, funding it properly, treating health professionals with respect, and actually basing policy on evidence.

The message of this book is important. We must hope that it reaches a general readership, or, hoping even more bravely, that it reaches an audience amongst the political classes.

Time for the old guard to join the social media fray?

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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OLYMPUS DIGITAL CAMERAThe news is everywhere. I don’t mean this in the way that I might if I were a dewy-eyed aspiring journalist, seeing fascination and potential scoops in everything around me. I mean that news coverage seems to be literally everywhere; on the TV, on the radio, on the computer, on the phone in my pocket, on a big screen in Waterloo train station. It’s inescapable. And when it comes to health news, or more particularly doctor news, it never seems to be good news.

Headlines such as: “1 in 4 cancer cases missed: GPs send away alarming number of patients” (Daily Mail, 1st March 2011), “These overpaid doctors must stop whingeing” (The Times, 28th May 2014) and “Study reveals scale of errors on doctors’ prescriptions” (The Guardian 2nd, May 2012), are depressingly commonplace.

Even when we try to recruit the help of mainstream media it seems to get turned against us. The BMA tried to make the point that ten minute appointments are potentially dangerous for patients so that general practice might get the support it needs to provide longer appointments.  To convey this message the ticker feed of the BBC news channel informed the viewer that “GPs are putting patients in danger with ten minute appointments” as though it is out of sheer contempt for our patients that we refuse to give them any more of our time.

It’s not just us. The junior doctors were subject to The Sun’s ‘Moet Medics’ smear campaign and, when the consultant contract negotiations re-opened recently, the BBC obligingly ran a story entitled “NHS consultant paid £375,000 in overtime” to point out that it isn’t only GPs who are workshy and overpaid.

I thought it was just me making my wife feel uncomfortable by screaming at the TV in the evenings, but a recent study in the BJGP exploring why younger GPs are leaving the NHS found that 63.4% of them are also pretty miffed at this continual public abasement.1 Thus far, shouting at the TV seems to have achieved relatively little but there is an alternative. The junior doctors used social media pretty effectively to counter a lot of the negative media coverage during the last round of strikes. The noise on social media outlets revealed widespread public support for the juniors, which helped to strengthen their resolve and legitimise their cause.

Unfortunately, I suspect that many GPs, dare I say many older GPs, are wary of being too vocal on social media, with a hint of concern that opening a Twitter account is akin to giving your patients a key to the back door and painting a target on your back for the GMC to aim at.
This is a shame because social media is our best tool for getting across our side of the argument and it is also a fantastic way of opening up a dialogue with the public. These arguments would be well explored by the reluctant older generation of GPs who have earned experience and gravitas by passing through the mill of the NHS over the last few decades and who can spot the same cycles of mistakes re-appearing over the horizon.

Having a good rant on a blog is incredibly cathartic, I can feel myself relaxing as I type, but it is also a way to reach thousands, potentially tens of thousands, of people in a matter of hours which is exactly what some successful GP bloggers do.

Social media is an effective means to counter the denigrations of our profession and, so dependent has the mainstream media become on social media that, if we make enough noise, we might even begin to influence them. And that might even mean the occasional positive headline.

Reference

1. Doran et al. Lost to the NHS: a mixed methods study of why GPs leave practice early in England. Br J Gen Pract Feb 2016, 66 (643) e128-e135

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.

GP trainees: a subtle thread of generalism in secondary care

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

The current struggle to recruit into general practice has been well described and the concern around it has rightly focused on how a shrinking workforce will continue to provide 90% of patient contact in the NHS without imploding.

Having recently completed the last of my hospital placements as a GP trainee, I have been reflecting back on my time in hospital and have come to believe that falling numbers of GPs in training will also impact secondary care services in a number of subtle ways. The on-call rotas for many specialties are bulked out, and in some cases sustained, by a steady flow of GP trainees. Even at the embryonic stage of their careers it has been my experience that GP trainees tend to take a more holistic approach than their specialist counterparts who are often necessarily focused on gaining procedural experience. More than this, GP trainees are often the only members of specialist teams with any recent general experience and these teams rely on their GP trainees to stem the haemorrhagic tendency for in-house referrals that can swamp hospital services.

I have been surprised at times how quickly doctors lose confidence and competence in vast areas of medicine once they enter a specialist training pathway. Even those working in the general environment of A&E often consider whole specialties, most notably psychiatry and gynaecology, as outside of their remit. I can’t deny some frustration in being the psychiatry SHO called upon to ‘risk assess’ a stream of teenagers who have attended A&E drunk and upset after an argument with their partners, or in being the gynaecology SHO receiving referrals for every woman with a set of reproductive organs in anything less than perfect working order. Often a gynaecology referral is completed with the phrase ‘I haven’t examined her because you’ll have to do it anyway’, a logic that serves only to perpetuate the referring doctor’s own skill fade.

There is a great deal of risk in this pigeonhole approach to medicine. I have seen this recently in the form of a young woman who was unable to walk unaided and who was triaged directly to the antenatal ward, despite the presence of upgoing plantars, simply because she happened to be pregnant. She was later urgently transferred to the local neurosurgical centre for treatment of her spinal cord compression secondary to TB.

By way of contrast, during these 2 years I have had frequent cause to speak to GPs: while accepting referrals, in seeking more information about patients, or while trying to arrange a discharge. Not once have I encountered a GP who begrudged the conversation or flinched at what, at times, have been almighty dumps from secondary to primary care. It is that level of confidence, competence, and willingness to take responsibility to which we as GP trainees should aspire. Even before we finish our training, GP trainees are valuable to much of the health service as a subtle thread of generalism woven into the secondary care tapestry that, in some small ways, eases the frequent dysfunction and disjunction of secondary care teams focused on single organs.

While serving this purpose we should counter the frequent question: ‘Why are you wasting your time with general practice when you could be a good specialist?’ with what I feel is the more obvious question: ‘Why on earth do you want to devote your career to 25 feet of bowel lumen or to two aerated sacs of flesh or to the prostate and testicles when the whole of medicine could be open to you?’

General practice should be an easy sell and we all need to be more enthusiastic salespeople of it for the sake of ourselves and our secondary care colleagues.

The Locum: Assassin of Independent Contractor Status

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

In the June issue of the BJGP there was a debate as to whether GPs should maintain their status as independent contractors. To me this seemed like a macrocosm of the decision that all newly qualified GPs have to make when it comes to finding a job.

Since the new contract for general practice it seems to have become the norm for a new GP to take a salaried job which provides stable employment and predictable pay without the burden of extra responsibilities born by partners. Generally this is considered a stepping stone to partnership.

But the status quo is being upset by the increasing popularity of locuming. Dr Larry Locum seems to be the man who has his cake but eats yours. Advocates of this way of working describe it as a Nirvana of convenient working hours, minimal responsibility and good pay. The appeal is obvious and, as the pay for salaried roles gets squeezed, the appeal is growing. Although this life has potential to be unstable many of my cohort feel that this is more than offset by the flexibility and the remuneration.

Whilst many still see a period of doing locums as a prelude to seeking permanent employment there is a growing number of GPs who feel no compulsion to take either a salaried role or a partnership after years of enjoying locum life. Interestingly, medical chambers are also filling up with GPs who have been partners but now wish to locum.

Could this way of working pose an existential threat to the partnership model?

Without wishing to sound mercenary, a big part of the problem is pay and, in particular, the complexity and opaqueness of partner pay. Ask a salaried doctor how much they get paid and they can tell you their pay per session. Ask a locum and they can tell you the going rate. But ask a partner and their eyes glaze over and they start talking in tongues, using phrases like ‘notional rent’, ‘local enhanced services’ and, of course, the ‘QOF’. Meeting the shifting targets of the QOF alone seems as fiendish as a battle of wits with Professor Moriarty. This complexity, combined with the fact that partners often seem to work harder and bear more responsibility than their colleagues, makes partnership seem daunting and uncertain.

Clearly there are less tangible rewards in partnership. People talk of the ability to guide your practice in the direction you wish it to go, or the emotional satisfaction of nurturing your own business but, to the uninitiated, these rewards can seem fairly trifling compared to the possibility of losing your house if things go really wrong.

Compared to becoming a locum, where the pay can be closer to that of a partner, becoming a salaried GP is increasingly seen as an under rewarded role and yet it is still the predominant job type on offer in the jobs market. Whilst many practices seek to employ salaried doctors the logical choice from the perspective of a GP registrar is between seeking one of the few available partnerships or doing locums, or at least having time free in the week in which to do locums on top of a part-time salaried role.

This tension between the demands of new GPs and the supply from practices is in danger of making the locum role the norm with the attendant possibility of sleep walking the partnership model of general practice out of existence. Without partnerships the debate over the independent contractor status of GPs will be moot, it will simply cease to exist.

A letter to the Health Secretary

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

LETTER TO THE HEALTH SECRETARY

Dear Mr Hunt,

Many congratulations on being re-appointed as Secretary of State for Health in the Conservative cabinet. May I suggest we treat your re-appointment as a fresh start?

As a gynaecology SHO performing intimate examinations I was once told to ‘go in like a butterfly and come out like a lion.’ The idea was to cause minimum discomfort by combining a gentle approach with a swift withdrawal. This was not a strategy you adopted when you began your intimate examination of the NHS in 2012. It did in fact feel quite rough and quite prolonged. This time around perhaps you could be a little more gentle with your ideas and re-organisations and, when we finally get a period of stability, come out like a lion and stop meddling.

On many occasions you have talked of ending a culture of bullying within the health service and yet have yourself employed a beatings-will-continue-until-morale-improves attitude when dealing with its staff and this has endeared you to few. Attempting to bully the allied health professions of the NHS to fall into line with your ideas has not won you many friends.

For years NHS staff have hardly been able to turn on an NHS computer terminal without being greeted by your semi-psychotic stare and oddly geometric haircut as your picture has headed the endless bulletins and memoranda that spew forth from the Department of Health. Whilst producing a new edict may feel like a good days work to you, for those of us receiving it, it feels like an imposition, an interference and the promise of much more work for very little gain.

The smoke and mirrors re-organisations of the health care system that health ministers like yourself are fond of, the kind that generate a lot of activity, a rebranding or two and an apparent improvement in outcomes, actually distract from the business of treating patients.

Please remember too that the health care system is just that, a system for delivering health care. It is not a government tool to be used to address whatever national woes are troubling the electorate at any given moment. The NHS is not a branch of the benefits system nor is it an outpost of the immigration service.

Please dispense with ethically barren ideas such as denying benefits to people who refuse treatment for obesity. Doctors, nurses and other NHS staff should not feel obliged to coerce patients into treatments for purely financial reasons. Ideas such as this are eye catching and superficially gratifying to our vindictive sides but are unethical and unworkable in reality.

Neither can GPs solve the problems with immigration. Whilst it may seem an appealing idea to catch unsuspecting illegal immigrants whilst they are at their most vulnerable, the point when they seek medical help, most GPs would be reluctant to guilefully dupe immigrants into believing they were going to be given treatment for their illnesses before gleefully slinging them into detention. Please resist the compulsion to medicalise problems that are essentially social and political.

No-one would say that the NHS is a perfect system, but it is a good system. There is work to be done and changes to be made but trying to force all of them through between election cycles is devastating to the day-to-day functioning of health care.

You may like to think of the NHS as a wild stallion galloping powerfully through the plains of the UK. To tame it you can tie it up, beat it and try to break its will. This might work but, at the end of it, your stallion will be damaged both inside and out. Or you can whisper to it, coax it to your will with gentle reason and calm debate, and together we can ride off into the sunset.
I wish you well in your second stint at the helm of the NHS, and I hope you will wish us well in return.

Yours sincerely.

NHS and astrology: GP with a special interest in witchcraft

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

When MP and member of the health select committee David Treddinick suggested that the NHS should offer astrology to its patients he was widely ridiculed. To me it seemed wildly unfair that this man was so heavily criticised for expressing his personal views. Although he has no experience in healthcare provision, and although he holds beliefs that are almost universally disparaged, I see this as absolutely no reason why he shouldn’t hold a position on the most influential health committee in the House of Commons. If I believed in earthly politics he is exactly the kind of man I would vote for.

To the best of my knowledge I am the only GP in the country who has a specialist interest in witchcraft. When I realised that my surgery stood at the intersection of two particularly propitious ley lines I could feel the Wicca spirits practically insisting that I undertake some rigorous further training in spell casting, crystal healing and blind optimism. Once my training was complete I began offering the service to my patients and, I must admit, I have now almost entirely moved away from traditional general practice.

It is easy to deride a service like mine as ‘hocus pocus’ but I have a long waiting list full of free thinking individuals. My patients include those clear minded people who know that the Illuminati are suppressing the truth that vitamins will cure cancer so that big pharma can continue to make money from pointless ‘medicines’, or other people who can see that the childhood vaccination programme is merely a fiendish government plot to stop our children dying.

Fortunately my waiting list is oddly self regulating. Curiously many of my patients seem to pass over to the next world despite my attentive ministrations. Whilst many in modern medicine would see the death of a patient as something of a failure, I tend to think of it as a referral onto secondary care. In fact, once my patients have passed over, I am able to hand their care over to my in house psychic who continues to soothe their chakras in the afterlife. Unfortunately a small fee has to be charged for this service.

This is supposed to be the era of evidence based medicine so how is it possible that the medical establishment wilfully ignores the evidence that thousands and thousands of people are willing to pay good money for these services? I may not have a double blinded, placebo controlled, randomised trial providing an evidence base for my treatments but I do have a pretty strong sense that there is more to this life than we currently understand and surely that is evidence enough to justify some NHS expenditure into the area?

So I applaud David Treddinick for his ideas and I am grateful that we still have strong input from politicians into our health service. Without it how would MPs be able to give a voice to people like myself at the highest levels of government and influence health policy accordingly? How else would we ever make the NHS provide such services as my own?

May the spirit of the mother goddess be with you all.

The onesie: a red flag sign for GPs

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

Cold reading is the art of obtaining information about a person by making a rapid assessment of their body language, manner, age, dress and behaviour. It is commonly used by psychics, mediums and illusionists. General practitioners do it too, whether it’s noticing the subtle nail changes in an undiagnosed psoriatic, or clocking the smell of stale alcohol on the problem drinker.

We find clues about patients all over them and all around them. In exams the signs are usually obvious, it may be the inhaler and BM monitor carelessly left by the bedside or a medic alert necklace turned face down on the chest. In practice signs may be less obvious, less tangible, but equally revealing. Your recognition of these signs may not be conscious but they form part of your assessment none the less; the fifteen year soft neck collar of the somatising patient, the midwinter tinted glasses of generalised oddness, or the teddy bear sign of pseudoseizures are a few examples.

Dress, in particular, is one of the key components of the mental state exam but judging it can be tricky. One man’s chic is another man’s psychotic. However there is one item of clothing that requires no interpretation. There is one item of clothing that is a clear cry for help. You may have found yourself in the consultation room struggling to listen to a middle aged woman’s account of her sore throat or aching knees because you can’t stop wondering why this grown woman is wearing a Babygro®.

[bctt tweet=”BJGP Blog: Struggling to listen because a grown woman is wearing a Babygro®?” via=”no”]

Rather than resisting this thought process you should embrace it. This is the era of holistic medicine and all patients are supposed to be seen as part of their bio-psycho-social milieu. The onesie is a gift to the busy, time pressured, general practitioner because it is the psycho-social snapshot par excellence.

This is an item of clothing that declares to the world that a patient lacks the gumption and will power to struggle into a second garment. It is an item of clothing that declares to the world that an adult’s self-worth has sunk so low that he does not mind being seen in public dressed as a baby. The wearing in public of a onesie by anyone over the age of two years should be considered a clinical sign, Staten’s sign if you will, of extreme psycho-social distress and should prompt an urgent mental state assessment.

The evidence supporting this new clinical sign lies somewhere just below grade 5 and thus it is an area requiring further research. Yet it seems likely an extra question will be added to the PHQ-9, ‘on how many days in the last two weeks have you worn a onesie in public?’. Be vigilant, if your patient is onesie positive, then they are in need.

Folie à deux: The case of Ed and Dave

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

La folie à deux is a shared psychosis in which two people share the same delusion. As it is rare I felt compelled to share an interesting case that I have recently encountered. This unusual case concerns two men in their forties, let’s call them Ed and Dave.

These two men share little in common but both have interesting past psychiatric histories. Ed has had a previous prolonged episode of shared mania, a folie à plusiers if you will. For nearly thirteen years between 1997 and 2010 this manic episode led him to borrow and spend far more than he could afford and so he accrued huge and devastating debts. Dave, on the other hand, is a suspected case of dissocial personality disorder as he shows a callous disregard for the rights and feelings of others. It’s not known whether he harmed animals as a child but it seems likely that, at the very least, he whipped horses and chased foxes.

In recent times these two men have come to transfer a delusion between themselves. They have become convinced that the NHS should be run according to what people want rather than what they need and they share the delusion that this is best achieved by providing ever increasing access to general practice. For Dave this delusion has led to him calling for GPs to provide appointments for twelve hours a day every day. For Ed it is the delusional certainty that he can provide 8,000 more GPs to provide instant access to general practice.

As with all delusions it has not been possible to dispel these beliefs by providing superior evidence to the contrary. It doesn’t matter that the Royal College of General Practitioners has told both these men that there simply isn’t enough GPs, or even GPs in training, to fulfil their commitments. It doesn’t matter that it has been pointed out that the proposed working conditions will perpetuate and accelerate the mass early retirement of those who are able, and the mass emigration of those who are not. The delusion remains fixed.

These two hear voices too. But rather than internally generated voices that they cannot block out, they hear voices from outside that they refuse to pay attention to. It matters not that healthcare professionals insist that money is better spent on social services to aid in the discharge of medically fit patients from hospital, or that money should be invested in primary healthcare facilities and services, or even on public health education to ease the burden on these primary care facilities. Their condition dictates that they obsess about making headline grabbing statements about appointment times and GP numbers.

Like much mental illness this powerful delusion is not only a danger to Dave and Ed but potentially a grave danger to many of those around them. Treatment is difficult. The police have been reluctant to enact a section 135 on the premises of No. 10 Downing Street and so strategies to deliver treatment are limited. Mental healthcare specialists have mooted the idea of infusing the Westminster water supply with olanzapine but clearly this poses an ethical dilemma. Many worry that monotherapy with olanzapine will not be enough and, ethically speaking, are we not obliged to treat with something far more potent?