www.northerndoctor.com

Now here - northerndoctor.com at Wordpress.

I have moved...

I have switched over to Wordpress after too many evenings wrestling with the formatting in Blogger. I can still be found here at http://www.northerndoctor.com/ or simply northerndoctor.com as they seem to prefer there. (I am no longer sure of the significance of the www bit.) Or you can of course use the www.northerndoctor.wordpress.com address and you will be redirected to northerndoctor.com.

If you have still been using http://www.northerndoctor.blogspot.com/ then it is all going to go a bit quiet for thee (and also for me) if you don't change your links.

Thank you so much and apologies for the high faff factor.

*Update*
Sunday 5th October. It all seems to work well on my own computers but I am in work at the moment and there is some alarming '404' style action on the PCT computers. They do seem moderately decrepid so I am not sure of the problem here. It all works fine on my Blackberry! Hopefully, it will right itself somewhere in the ether and I will not need to do anything. However, if not then please let me know.

More eleutherococcus

I am having a bit of a bad science rush of blood to the head after reading through Ben Goldacre's, er, Bad Science book last week.

Budding triathletes
Eladon have been making some suggestions that the use of Eleutherococcus senticosus is supported by 40 years of Russian research and I quote:

"is used to this day by top class Russian athletes being first recommended by the former USSR Ministry of Sport for use by all Russian athletes including the Olympic teams as long ago as 1962."

There does seem to be a lot of literature on this stuff aka Siberian Ginseng from the Eastern bloc and it is not the most accessible in the world. I am not entirely familiar with current trends in Russian high performance athletics so I won't comment further. But I would highlight this systematic review from Canada which found no effect. Predictably the trials which had dubious methodology showed an improvement and those that were more rigorous did not. I am not too disappointed; my triathlon ability is more likely to be improved by a structured programme of regular exercise (ie more than once a week).

Their Elagen Sport capsules also have Coenzyme Q10 in them. Dr Aust can advise you further on this here.

They will supply you with 90 capsules of their Elagen Sport version for £14.95 here. I couldn't help noticing that there are now 50 years of scientific research on this page. It may help as they say - or it may do chuff all if the systematic review is on the button.

Eladon has a very clear statement at the bottom of their home page that they are not making any medical claims. Hmm...

‘Quack’ remedy for bored housewives?
According to Biochemist Dr Nicholas Miller, B.sc, P.hd, health food supplements are often perceived to be 'quack' remedies taken by bored housewives and bewildered hippies, however, few can deny that early 21st century lifestyles tend to be high-stress, high-pressure, performance orientated and plagued with toxins and pollutants of first-world technology. Eleutherococcus with its anti-stress, anti-toxic and stimulatory effects can delay hardening of the arteries, allow for harder work for longer hours without damage to health and can allow people to tolerate higher than normal levels of poisons. Its effect of generally strengthening the immune system combats poor diets and day-to-day viruses and has also been shown to be useful in the treatment of nervous disorders such as depression.
Dr Miller believes it is only a matter of time before the West accepts Eleutherococcus as an officially recognised medicine. “While of undoubted benefit for the sick or convalescent, it is also of boundless value as an invigorating prophylactic to ensure continued good health,” he remarks. “Eleutherococcus is for everybody, especially the overworked or the run-down - the major problem is to tell people in a way as to remove the barriers of cynicism and disinterest.”

The first sentence of this statement is a triumph of misdirection. I can see I am going to have brush up on my Russian and get into some of these papers.

No more anonymity

Me!

A short announcement - I am no longer blogging anonymously.

I am quite comfortable with being associated with any of my posts and I can see no reason for me to hide who I am. I enjoy ambling my way through the more attack-minded blogs but it isn't the route for me. I plan to continue blogging pretty much exactly as I have been doing.

Er, what's an adaptogen?

I couldn't help noticing the blurb in this advert in the back of a triathlon magazine I was recently perusing.

Sport Elagen

combining the adaptogenic effects of ES with the anti-oxidant and catalytic
properties of Co Q10

scientifically designed for sportsmen and sportswomen

Phew. I have to admit this is the kind of pseudo-scientific hogwash that really sets my bullshit detector clanging. The advert has a website at the bottom - http://www.elagen.com/

I thought I would start picking the bones out of this advert...

It turns out ES is Eleutherococcus Senticosus - a herb. Elagen capsules are "a highly concentrated pure root extract measured to the correct potency proven to provide maximum effect."

One of the first questions you might ask is what is an adaptogen? I have no recollection of the mention of adaptogens in any physiology lecture I have attended or any textbook I have ever read. Maybe I was snoozing in my lectures but luckily the website is on hand to inform me:

In the 1950's Prof Brekhman of the pharmacological department of the Far East Scientific Centre of the Russian academy of Sciences recognised the potential value of the root and initiated extensive research into its properties. He subsequently classified Eleutherococcus as an 'adaptogen'. An adaptogen is a natural plant substance, which acts to normalise the body's systems in harmony with the normal metabolic, biochemical and immunological processes, as such adaptogens are innocuous and cause no harm. Adaptogens should have a non-specific action, such is the ability of Eleutherococcus to modulate stress and improve performance under a wide variety of stressful conditions.

So adaptogens have a non-specific action that causes the body to work normally. Hmm, never mind the hundreds of thousands of years of evolution that has resulted in the mind-boggling sophistication and elegance of human homeostasis. An adaptogen can make homeostasis even better! It would, of course, be tremendously difficult to prove it wasn't working.

I wonder if this feeds into the psyche of some athletes when it comes to performance enhancing drugs. At one end of the spectrum is the sheer naked cheating of a blood doper. By some artificial means the oxygen carrying red blood cells are augmented. However, at the bottom end this can all get much more woolly. Does taking an adaptogen constitute cheating through performance enhancing substances? The answer is probably no; not unless placebos appear on the international list of proscribed drugs.

The Law of Unintended Consequences

The substance misuse team I work for had the misfortune to be subjected to a partial tendering process a few years ago. The service was split down the middle and tenders invited for the criminal justice side of the service. This has had some nasty and utterly ludicrous knock-on effects. No one considered the Law of Unintended Consequences...

This takes a bit of explaining but stay with me.

The Intention - Background

The Community Drug Team (CDT) used to look after all heroin users - both on the 'core' service side and 'criminal justice' side.

The criminal justice side of the drugs team looks after those users that come to our attention through the courts, through arrests and after release from prison. They are often subjected to drug rehabilitation orders from the courts or are out on licence with specific probation conditions attached to their freedom. The core service looks after everyone else. The contract for the criminal justice work went to a national drugs charity. The CDT was split with half the keyworkers going to the charity to work and the others staying with the core service.

The core work remains in a NHS Trust and the charity uses exactly the same premises with a different set of staff to see the patients. There are now two entirely separate administrative systems running in parallel when there was previously one.

Still with me?

The Consequences - the Law kicks in

Unfortunately, when some muppet at the PCT negotiated the contract they neglected to include anything on the crucially important business of giving drug users Hep B vaccinations and testing them for blood borne viruses such as Hepatitis C and HIV. A fairly basic requirement for this patient population. Despite discussions this remains at a complete impasse.

The core service lost its full-time lead doctor as it can no longer can justify employing a doctor to cover the whole week. This means in the early part of the week they have no one on site to give medical support to the keyworkers, to give advice, see patients, replace missing prescriptions etc. Innovation in the service has ground to a halt.

I work for the criminal justice side. The absence of a contract for Hep B/C means that despite there being a clear clinical need and the fact that I am appropriately trained and fully qualified to administer vaccines, as well as counsel and then test for Hep C/HIV, I am not allowed to do so. I sit within 2 feet of a fridge full of vaccines and a trolley with the tools of the trade for blood-letting. The contract says no. I am supposed to refer the patients to their own GP. Utterly moronic.

While I sit ignoring this travesty of clinical care the keyworkers from the CDT walk past my room bemoaning the fact they have no GP to get advice from on till the end of the week. I am hamstrung when it comes to getting involved. I am powerless to offer any advice as I am, in effect, working in a parallel medical universe.

No prizes for guessing the losers in this inelegant arrangement.

Joined up thinking? Centrally funded? Welcome to the consequences of a health service where we fragment care. It is a nasty little glimpse of the future where the purchaser-provider ethos overrides common sense provision of routine clinical care.

Shipman's long shadow

After my shifts at the out of hours this weekend I noticed something about the morphine. In the last week I was the only GP that signed out any morphine to take on home visits.

Now there are a couple of possibilities: either I am the only doctor that has been required to go on any visits in an area that covers an area across three counties in the past week or I am the only doctor who took morphine out when I did it. I am pretty sure I know which it is.

I have had a lot of discussions with colleagues recently about using and carrying morphine. Many are deeply anxious about using a drug that has been demonised by Shipman and been the object of such severe scrutiny by the authorities. If anything goes wrong with morphine and it is highly likely you will be suspended pending a full police investigation. And things can go wrong. Even with the greatest care in the world, morphine, just like any other drug, has potential side effects. One of those side effects being that the recipient stops breathing. There is an excellent drug, naloxone, that reverses the effects of morphine. And it works just like this Trainspotting clip - a magical, instant recovery.



But the fact is that most GPs do not see the benefits of morphine to their patients outweighing the potential disadvantages to themselves.

However my opinion doesn't square with the evidence. The Healthcare Commission annual report on 'The safer management of controlled drugs' suggests that opiate use actually increased by in 2007. (Thanks to NHS Exposed for highlighting the report in this post last month).

Perhaps I could agree that I have seen an increase in prescribing of morphine and other opiates in palliative care in the past few years. I am also aware that amongst GPs that do prescribe 'core drugs' in palliative care it is common practice to prescribe a whole box to leave in readiness as the patient gets to the end stages. These often go unused and the data says nothing about actual morphine usage.

From the report:

"I am very pleased to hear the post-Shipman tighter governance arrangements have not been a barrier to patients receiving opioid treatment.

I suspect that the increased use of Schedule 2 controlled drugs is partly due to their increasing use in the management of persistent non-cancer pain "

Dr Roger Knaggs
Specialist Pharmacist - Pain Management
Nottingham University Hospitals NHS Trust

My practical experience as a GP is that there very much is a barrier to some patients getting morphine. Most GPs are not carrying it and that is a pretty sizeable issue to overcome. Of course, a doctorate pharmacist in a secondary care hospital would remain utterly ignorant of this.

It is encouraging that opiate prescribing hasn't dropped through the floor but I remain highly sceptical that morphine use has increased as a primary care drug for patients in acute pain or having a heart attack. While one can still expect morphine if one is dying or in chronic pain it is being eradicated as a drug for the acutely unwell in their own home. I wouldn't expect this to show up in these statistics - it is always going to make up a fraction of the total morphine prescribed.

The report doesn't go into these details but it does note the relatively greater increase in drugs such as oxycodone. I asked a palliative care specialist last year why oxycodone is a better drug than morphine and he freely admitted he couldn't give any clinical reasons. Perhaps it is the placebo effect of fancy packaging or perhaps simply because it is not morphine. (I also noticed the increased prescribing of benzodiazepines by nurses but that is a rant for another day.)

The Healthcare Commission's report should not lull anyone into complacency. It is very possible that we are leaving patients in pain on occasions and inadequately treating life threatening conditions as a consequence of a state noose of controlled drug regulation around the necks of clinicians that use morphine in patients' homes.

We need some further research into the actual patterns of use of morphine post-Shipman and and exploration of GP attitudes to this group of drugs. Any potential collaborators please feel free to email.

The GP bag - or mine at least

While I was on the subject of the doctor's bag I thought I would share mine. It makes me look more like I a plumber than a GP. Despite media reports to the contrary, as a salaried GP, I am not quite as expensive as a plumber per hour at weekends.

It is a touch redolent of a Gladstone bag as favoured by those GPs more inclined to the 'Grand Old Man' image.

G.O.M. isn't really my preferred style...

Giving it all up

One of the most insidious changes in 2004 that the reorganisation of out of hours care has precipitated is the way that GPs now approach the treatment of emergency medical problems. A minority of GPs including principals work shifts out of hours and most GPs get significantly less exposure to acutely unwell patients than they did in times past.

I do a number of appraisals for the PCT each year when I get to sit down with fellow GPs and have a blether about the state of the nation. As well as artfully facilitating their self-directed educational processes we, as appraisers, are encouraged to introduce an element of challenge. I like to ask what emergency drugs they carry nowadays.

Increasing numbers do not carry anything. No penicillin in case of the dreaded once-in-a-career case of meningococcal meningitis, no adrenaline for severe allergies and certainly no morphine for pain or heart attacks. Nothing. Not even an aspirin. Even in a relatively rural area oop north most GPs prefer to have a mobile phone and the ambulance control emergency line on speed dial. (And that is the conscientious ones; the rest ring 999 and suffer the callhandler protocols.)

It is a further worrying erosion of our professional position but it's one that doesn't have to happen. As GPs we do all have the choice to keep up those skills, to keep ourselves equipped and not shrug off care to the nearest paramedic and A&E department.

Playing with fridges

I was watching the Tweenies with my children recently and they have a 'Be Safe with the Tweenies' mini-series. Most of these are about relatively obvious risks such as the dangers of walking in front of swings or running out into the road. This episode was all about the risks of getting stuck in old fridges and it seemed unnecessarily macabre to my mind. The kids didn't seem too bothered and I didn't dwell on it further other than to consider how tricky it might be for a 6ft high polyfoam Tweenie to get into anything but a drive-in fridge you might see in the USA.

At work, I have been doing some digging into the literature for an old paper related to the problems of reducing people off benzodiazepines. There has always been some concern that stopping benzos suddenly could cause seizures. The 'paper' was in the British Journal of General Practice 20-odd years ago. This oft-quoted piece of the literature turned out to be a letter in the back pages of the BJGP detailing a fairly gung-ho trial where a number of patients prone to fits had their benzodiazepines dropped like a stone. Thankfully, all was well for those patients but I was left reflecting on the ethics of research from a bygone era.

You may wonder how ethically dubious research and child fridge misadventures are linked. Take a look at this remarkable 1958 paper on how children behave when locked in fridges. I picked up on it via this blog entry highlighted on badscience.net. Yes, they did actually lock children in a simulated fridge and then observed their response.

A classic of medical research. Now trying getting the consent form for that signed these days.

Floods cause chaos

No, not here. In India 56 have died and there have been 3 million affected in over 1700 villages in the Bihar region and Nepal has also been affected. The WHO page is here and gives an update on the crisis.

The information available on the WHO site is remarkable. The South East Asia Regional Office have detailed reports (India and Nepal) on the current situation. It goes as far as to list individual camps with numbers of people, those pregnant or post-partum and also any disabled refugees with how many wells and toilets to which they have access.

One of the hardest things about absorbing information on the WHO site is that the numbers de-humanise the suffering. I guess it is the same with many of these situations. Of course, television pictures help but it can be hard to raise an emotional response. Reading the names of schools being used as camps helped me bring it back a little. Try substituting your local primary school name and then imagine your entire local population sheltering there.

The first things these people need is clean water, somewhere to crap and the kids need an emergency measles immunisation programme. And food and shelter of course. This is a standard response to a humanitarian crises but it is interesting as most people would not immediately think of the measles. It can tear through the child population and I have commented before on the potential for measles to kill. I always finds the WHO helps give me a bit of perspective and this damp week is no exception.

Incidentally, I am not aware of any evidence that our MMR catch-up programme and an increase in measles cases is in any way related to the sodden British summer.

Never trust a GP in a leather trilby

The Jobbing Doctor comments on The Mail's malignant article this morning. Let me draw attention to one aspect.

Compare and contrast:

The Mail September 5th, 2008

"Their [principals] pay has shot up 58 per cent to an average of £113,164 but they are seeing fewer patients and working seven fewer hours a week."

BMA News September 6th, 2008

"Average pay of a salaried GP as of of 2005/6 was £46,905 but this was because many worked part time: 23.8 hours a week on average according to the NAO... This would make a pro-rata average yearly salary of £74000..."

It would be easy to see how it might be a great idea to employ salaried GPs as part of large private enterprises. Please see Rules 1, 2 and 3 below on some of the issues that have to be addressed if we go anywhere near this sort of model.

Incidentally, I am not surprised that The Mail have attacked Dr Gupta - have you seen his hat?

If I were in charge... Rule No.1

I thought I would spend some time reflecting on what changes I would make if I were in charge.

Just complaining about the system could start to wear people down.

I think there are some fundamental principles that need to be embraced in primary care. Some of these are already being achieved and some of these are pure aspirations, some are being eroded and are now in serious danger of falling off the edge.

Here are my first thoughts:

Rule 1. Every person in the UK is entitled to care from a named GP.

This seems simple but in practice it is easily eroded. What is indisputable is that people value continuity. They may also need to access Walk-in Centres and NHS Direct but when you have any kind of illness that can't be resolved completely in a single contact then it is stark-staringly obvious that it helps to see the same GP again.

Pulse reported on this in the past month. There is something of a paradox here in this survey but extending hours doesn't tend to do much for continuity when the evening/weekend clinics are share out. The ideal continuity of care would mean you could access the same GP 24 hours a day 7 days a week. This is clearly not likely to result in a very happy and effective GP workforce. We tried it in the past and it ended up with a singular lack of GPs. I have been that GP and it is Officially Miserable.

I think the named GP should work a certain minimum number of sessions to be eligible to be a 'named GP' and be reasonably accessible to the patient. I don't think that person has to be a principal and they could easily be salaried (but see Rule 3). I don't have a huge problem with the accessibility being measured in some way. However, previous methods of measuring accessibility to GP appointments have, if anything, damaged continuity of care as practices have offered same-day appointment systems and other dubious innovations to ensure access targets are met.

There should be special protection under this rule for the housebound, elderly, disabled and residents of nursing homes etc. It might even be worth measuring continuity in this group of patients. How many different GPs have they seen in the past 12 months? I would wager that quality of care is inversely proportional to that number. One large practice near us has a 'duty doctor' who will do visits on their designated day for the whole practice. In a practice of nearly 20 GPs it can be a while before you see the same GP again...

That named GP should be actively involved - not just the 'registered GP' so often quoted that has never met the patient.

So it is simple: one patient, one genuinely responsible GP.

If I were in charge... Rule No.2

Rule 2. The 'named GP' should have a maximum number of patients on their list.

Pulse report on this today - in a situation of economic constriction one way of maintaining income is to keep patient lists high.

However, I haven't added this to my list because I am concerned about greedy principals. GPs only let this slide out of desperation. We all know it is bad for care but if the money ain't flowing, they can't take on staff and they just have to absorb the work. It's nasty for everyone.

The main reason for adding this is to give a measure of protection against the corporatisation of medical practices. Setting a maximum number of patients would make it harder for practices to shrink partnerships and employ nurses, salaried GPs etc while they adopt a CEO GP role and absorb the profits. It helps maintain Rule No. 1 as a reasonable prospect. The maximum number could be altered from region to region depending on factors such as deprivation, health care needs and geography. It should never be open to manipulation on pure economic grounds.

It would also protect patients against these same excesses from cold-blooded private organisations with profit motivated agendas. It might have the unintended effect of capping GP salaries but most GPs don't want to get rich, they just want a fair salary for a fair day's work.

However, these first two rules don't exclude a different model for general practice. If a big company makes sure that there are named GPs active in looking after a reasonable number of patients then that's fine as long as Rule No. 1 and Rule No. 2 are observed. So I thought we needed a Rule No. 3...

If I were in charge... Rule No.3

Rule 3. The 'named GP' must retain a measure of control over how that clinical care is delivered.

This is more nebulous and needs further refining. Fundamentally, this is to protect patients against the worse excesses of top-down central government control over patient care and retain the capability to meet local need.

I think this control could vary from model to model. I think that there are very few models of primary care in this country that work as well as the democratic medium-sized practice with a strong primary health care team all contributing to the care of patients. The input of clinicians in this model is readily apparent. However, I do not think it is necessarily the only model of care that could work for the whole of the country.

A salaried 'named GP' in a larger company would still have to have an input. The company would be expected to demonstrate, as part of its contract to deliver primary care, that it is responsive to input from clinicians.

People complain about a 'postcode lottery' but local variation in care is essential to meet local differences in health care need. I think there is scope for variation in the delivery of care and (shh, say it quietly) there may well be some areas, perhaps severely deprived urban areas, that will benefit from a polyclinic. If they met these three rules then I would be more relaxed about Darzi.