Don’t trust a medical journal with an intervention in the title

Don’t trust a journal that has an intervention in its title. I’d suggest exercising an extremely high degree of scepticism as the odds are the papers will be of even lower quality and more biased than normal.

These journals have already made a fundamental assumption that their pet intervention is effective. They are often engaged on a mission to ‘build the evidence base’ – muddled thinking in which it is believed that evidence-based medicine is some grand edifice to be built by drawing up plans and it is the task of researchers to work toward that goal. Medical journals are already flawed in lots of ways without starting with this crucial misconception. Peer review is already limited as a tool to establish quality and I struggle to believe that peer review in these journals is likely to be done by anyone other than those already sympathetic to the intervention in question. What hope is there?

Think of it another way. I’m quite prepared to accept that the publications of trials for pharmaceuticals have lots of very serious problems. But how would you react if Big Pharma presented you with a paper from the Journal of Simvastatin or the Journal of Citalopram?

I agree with Cameron that GPs need to address social exclusion

Cameron accuses GPs of giving GP preferential access to ‘dinner party’ cliques

This Pulse article has, predictably, got many GPs in a right lather. I agree with Cameron that the health service needs to address access to primary care and that tackling social exclusion with progressive policies should be central to any reform.

I just completely disagree on his proposed solutions.

The abolition of practice boundaries will do nothing to improve access for the poorest people in our society. It is a policy squarely aimed at the middle classes. Abolishing practice boundaries will destabilise many practices and jeopardise universal service provision. The wholesale opening up of primary care to private services and the voluntary sector will fragment care. That will break up the system and inevitable means that those least able to navigate the system will do badly.

The deputy editor at Pulse (@stevenowottny) is right that it is an extraordinary outburst. It will infuriate many GPs and the ‘dinner party’ comments are comprehensively wide of the mark. It says rather more about how Cameron and the political classes like to do business than how GPs manage their clinical workload.

This will do nothing to engage GPs in a constructive relationship and there is already a risk that the profession spends more than enough time navel gazing. Energy spent debating whether £68 per hour is too little for commissioning work doesn’t paint a picture of a profession committed to the poorest in society. Most worryingly these ill-judged comments will distract from a fundamental issue – the need to address health inequalities through primary care and the risks of dismantling the NHS.

BJGP: who wants to be a GP? Not very many apparently.

This BJGP paper asked young doctors about their intended future speciality.

The study sent participants questionnaires 1 year and 3 years after they qualified. The cohorts of 2000, 2002 and 2005 were chosen and every doctor from every medical school in the UK was included in the sample. The response rate was 57% after year 1 and 63% after year 3.

The results suggest that the proportion of newly graduated doctors that want to be GPs is only around one-fifth. Yet the Department of Health expects around half of them will end up being GPs. Why the discrepancy? Are young doctors opposed to general practice? Do they regard general practice as a second-rate career choice?

Interestingly, the highest rates of choice of GP as a career were found in the new medical schools (Peninsula, Brighton and Sussex, Hull York, East Anglia and Warwick) at 27.6% and 61.5% in years 1 and 3 respectively. The lowest rates were at Cambridge and Oxford. Only 10.9% of Oxford doctors had GP as a first choice 1 year after graduation compared with the highest figure of 31.4% found at Peninsula.

The authors state (in the slightly elliptical fashion so beloved of authors):

Further study is required to understand the reasons why a career in general practice is wanted by many fewer newly qualified doctors than the NHS needs. Such a study might consider the extent to which the level of choices for general practice in different schools may reflect the different entry aspirations and characteristics of their students; and whether it reflects the degree to which intentions are moulded by undergraduate experiences and the content of teaching and training.

I think it is likely that (ignoring for a moment the influences suggested by the Sutton Trust’s findings) Cambridge and Oxford select some of the most academically gifted students in the UK. I suspect many of these students believe that hospital specialities are the most important medical specialities and they aim for those.

Perhaps one of the reasons they believe that (and perhaps it could simply be true) is that they have old fashioned curricula. There is little in many courses to disenchant medical students of the view that hospital specialities, preferably those found in a tertiary centre, are the pinnacle of medicine. The old-fashioned curricula place a high premium on didactic learning whereas new curricula are highly community-orientated and more likely to encourage students into community medicine options. In addition, the new medical schools have admission policies that are less academically inclined and encourage wider participation and recruitment.

I don’t think many doctors come to general practice as some expression of failure. I’m heavily involved with organising GP placements for undergraduates and we tend to get universally excellent feedback about the placements. Students value the time they spend in general practice.

The adrenalin buzz of hospital medicine fades for most people as time goes by. Every now and then I like to get up early enough to watch the sun coming up over a distant hill but there are only so many times I wanted to do it when gazing from the window of an acute medical ward. It’s easy to start to think that perhaps one’s work-life balance could be adjusted and general practice offers some hope of a satisfying career and a home life.

It remains important to ensure that doctors get good exposure to primary care and community medicine as undergraduates but despite the ongoing imbalances in many curricula I’m not sure it is too worrying that doctors’ early career choices don’t reflect the long-term outcomes. That’s the thing about general practice. It’s a grower.

Lambert T, & Goldacre M (2011). Trends in doctors’ early career choices for general practice in the UK: longitudinal questionnaire surveys. The British journal of general practice : the journal of the Royal College of General Practitioners, 61 (588), 397-403 PMID: 21722447

Bury the bill

This week I’ve spent some time in meetings that have made it clear how damaging the cack-handed management of the NHS reforms has been. I’m exhausted by the complexity of the changes, the range of opinions expressed in every corner, and above all with the uncertainty of everything.

The editorial in the BMJ last week summed up my feelings about the Health and Social Care Bill. Tony Delamothe, Edward Davies and Fiona Godlee make the case to “sweep the bill’s mangled remains into an unmarked grave and move on”. They state that we don’t need it to achieve change and yet we are promised even more bureaucracy.

 

Primary care trusts could still be reformed to put the GPs in the driving seat, as was originally intended, thus obviating the need for vastly more disruptive, and costly, structural change. Choice of any qualified provider could still be limited to services covered by tariffs to ensure that competition is based on quality.

We didn’t need legislation to achieve these aims. Whatever happens now it is crucial we see some progress – it feels like the NHS has been completely hamstrung. There are still monumental gaps in everyone’s understanding of how the NHS will work. No one can plan any care and organisations are unravelling before our eyes with no clear idea of the next step.

Medical students and CAM teaching

I have just been delving into BMJ Open for the first time and happened upon this article on complementary and alternative medicine (CAM) and factors influencing its inclusion in the undergraduate medical curriculum in the UK.

It is a GMC requirement, stated in Tomorrows’ Doctors in 2009 (applicable from 2011/12 intake), that graduate doctors must:

“Demonstrate awareness that many patients use complementary and alternative therapies, and awareness of the existence and range of these therapies, why patients use them, and how this might affect other types of treatment that patients are receiving.”

That can be interpreted pretty widely and the study was an email survey sent to the deans of all medical schools in the UK. These explored the current CAM content of the syllabi and issues around the level of satisfaction among students and staff with the current content. The paper on BMJ Open prints most of the various responses but it doesn’t seek to analyse them qualitatively in any formal way. Overall, 18 out of the 31 medical schools responded and all of them taught CAM to some degree (as per GMC requirements). Six of the responses indicated that CAM was taught formally and it was most frequently studied as part of a student selected component.

However, the author does suggest that there are ‘problematic approaches to CAM in a minority of survey responses’. He highlights that often CAM education is being delivered by practitioners or academics with a specific interest. The author suggests this is a ‘form of indoctrination’ and potentially of significant ethical concern. I imagine CAM practitioners would think that it is entirely normal that specialists talk about their own fields but I would suggest that the author has a point. For example, I for one might be more inclined to treat advice regarding proton pump inhibitors with more scepticism if it were presented by Big Pharma compared with a gastroenterologist. In my experience gastroenterologists don’t hold deep-rooted beliefs about what interventions are effective without a substantial body of evidence. I’m not sure the same can be said of many practitioners of complementary medicine.

I have my own reservations that those practitioners with a deep vested interest and personal commitment to their therapy will give a balanced view of the evidence-lite interventions of CAM.

Smith, K. (2011). Factors influencing the inclusion of complementary and alternative medicine (CAM) in undergraduate medical education BMJ Open DOI: 10.1136/bmjopen-2011-000074

The GP business model – a delicate balance

I can remember Andrew Lansley making the case at the last RCGP conference that one of the reasons that GPs are ideally placed to be intimately linked to commissioning was because of their independent status within the NHS.

The GP business model is frequently misunderstood. Most GPs are independent contractors who work in their own self-contained partnerships, employing staff and often owning their own premises. GPs have a great deal of independence in how they run their business but many wouldn’t be viable if they weren’t shackled to the NHS. They are not true free-marketeers by any stretch of the imagination. Most GPs have never really been involved in competition and they have enjoyed the privileged position of being in a business that is, collectively, too big to fail. A recent opinion article in Pulse written by Dr Paul Charlson (a Tory) pushes the case for opening up competition and claims that GPs ‘conveniently ignore they are private practices’. He, like many others advocating competition, conveniently ignores the current limitations on the GP business model.

Another article in Pulse suggesting ways GPs might seek to increase their practice list size also highlights the problem. One of the biggest factors in a practice’s income is the size of its list of patients. Therefore, getting more patients may seem like a great idea. Of course, it takes about two seconds to work out that this a zero-sum game. There are no extra people to register and no spares just sitting around waiting to be swept up by a diligent GP. The bottom line is that if one practice takes more patients then it does so entirely at the expense of a neighbouring practice that will lose the income.

The RCGP has been opposed to a relaxation of the rules on practice boundaries. A lot of patients find this irksome – particular commuting types who are rarely in their home areas within working hours. Many GPs will oppose practice boundary abolition out of naked self-interest as maintaining the practice boundary system retains their position of provider privilege. However, the restrictions around practice boundaries have provided a financial safety net for general practice and is one of the factors that helps to ensure a universal service.

The private practice status of the typical GP business is an awkward tension held together by the need to provide that universal service while allowing local flexibility. It isn’t a true blue, devil-take-the-hindmost competitive world and there are good reasons for that. Practices do make a profit but in most cases it is a modest one that pays GPs and their staff a reasonable salary. Most practices can’t make a significant profit above this but the quid pro quo is that they are unlikely to go bust. Don’t be persuaded by the straw man argument that GPs are already private providers and the NHS reforms are a natural development.

We only need to pull a few small threads to unravel the whole fabric of our primary care.

Nothing about me without me – Mat Southwell

One of the highlights of the RCGP/SMMGP Conference last week was Mat Southwell’s talk ‘Nothing About Me Without Me’. There were a number of nuggets in there and his comments on the derisory and often tokenistic nature of service user involvement hit home for lots of folk in the audience (and not just the service users).

The speech is entitled “Nothing About Me Without Me” in acknowledgement of INPUD’s (International Network of People who Use Drugs) founding statement “Nothing About Us Without Us”. In the speech Matthew explores meaningful participation from his time running a participative drug services in the national health service for ten years through his work as a drug user activist and most recent engagement in the UNAIDS Programme Coordinating Board. He explores the nature of meaningful participation from clinical practice, through staffing and onto engagement in management and policy fora. He draws on reflections and illustrations from his time as health service manager and professional head of service, his time leading the UK drug user movements engagement with the NTA and his current work with the United Nations, to illustrate his argument.

It often helps if you are prepared to be a little bit sweary and his direct criticism of the NTA was refreshingly honest in a world of bland political manoeuvring. I’d recommend you catch Mat in person if you can.

SMMGP Network 31

The excellent SMMGP Network 31 has been out for a week or two now. There is some good stuff on the implications of the new Drug Strategy, the impact of stigma, gambling services and, amongst other things, the usual pragmatic clinical advice via Dr Fixit.

You can download it at the SMMGP website or read it courtesy of those clever people at Issuu and their gizmo above.