Editors' Blog

February 2008 - Posts

• When in England, do as the French do... Drink half bottles

  Another week and another miracle solution proposed to tackle binge drinking in England. This time it's not about price it's about quantity. A doctor is calling on supermarkets to make half bottles of wine more available (and cheaper of course) in order to discourage people buying regular large 75cl bottles. Apparently it's simply "too tempting to finish the bottle there and then". According to Dr Trish Groves, deputy editor of the BMJ, the English drinking culture can be tackled by reducing alcohol portions in the same way super-size meals are being discarded to fight obesity. What sounds like a very simplistic idea could have a positive impact although it might not be able to resolve the problem on its own, in my view. As soon as the first half-bottle gets empty the guilt of opening a second one would be rapidly wiped by the comforting pretext that it's only a small bottle after all.  On the other hand, it is true that in other European countries, in particular in France, wine can be bought almost anywhere in half bottle, carafe, and small jug (pichet). Do French have fewer problems with binge drinking? I'd like to hear your thoughts on this... Dr Groves' call comes just a week after the British Medical Association last week said the government should take action and control cheap alcohol offers in supermarkets and bars. "Come on Tesco, Sainsbury's, Waitrose, Morrisons and all - help us out. Cheers" writes Dr Groves. Let's hope supermarkets will hear the message. Posted Feb 29 2008, 11:55 AM by Emilie Reymond with no comments

• Do they really want conveyor belt health?

  Today is one of those days I’d love to be a cartoonist. I would then provide you with a simple image to show my reaction to some of the National Audit Office’s (NAO) report on the GMS contract. Amongst the criticism of the deal and the DoH’s failure to ensure value for money, the NAO points to what it describes as a ‘fall in GP productivity’ of 2.5% per year. It bases this calculation of the fact that GPs, having dropped out-of-hours, are working a mere 52 hours a week and are therefore seeing fewer patients while their income has increased. If you take this simplistic measure, of course GP productivity would fall under the contract – it was designed to give them a pay rise and reduce the hours worked. However, this is a poor measure of productivity. If we were examining a factory we would also consider the outcome of the changes. In other words was it now producing more or better quality goods in the time worked? The NAO measure fails to take into account how GP time is used. It doesn’t address the health outcomes, the savings to other parts of the NHS if conditions such as CHD or diabetes are dealt with early, nor the types of conditions seen. It also fails to consider whether there has been a change in patients seen – ie are the right patients been seen? Perhaps to impress the NAO in the future GPs should adopt a new approach. So now imagine that cartoon I failed to draw: patients on a conveyor belt through the surgery as GPs automatically hand out antibiotic and statin scrips as they roll by. Posted Feb 28 2008, 03:31 AM by Bronagh Miskelly with no comments Filed under: GMS contract

• Using the internet to beat DoH propaganda

  When you read that DoH staff have been amending the Wikipedia entries for the department and its ministers on a twice-daily basis for the past two years (The Observer), you realise that the goalposts have moved in the propaganda game. In fact, you could say that the participants are now playing rugby rather than football. For example, if you type ‘M&S’ in to Google today, you will not only find the website of our beloved Marks & Spencer, but probably the website of a trade union campaign to highlight where and how the company’s food is produced.  This type of campaigning has been popular among web-savvy pressure groups and is now being taken on by more established organisations. The DoH has, of course, been playing dirty with general practice in recent months, manipulating the public image of GPs and forcing through changes to the GMS contract. This government is a highly effective manager of information - and misinformation - in the political arena and if the medical profession is going to compete then its representatives have no choice but to embrace the marketing techniques of the internet. Here’s one suggestion: every national and local media outlet now has its own website, most of them with the capacity for readers to comment online. If the BMA was to organise its network of representatives around the UK, so that every media outlet was monitored by a doctor, there would never be an anti-GP story appearing without an explanation or rebuttal from a member of the profession. This may seem like overkill but would actually not take a huge amount of time. Medical politics is becoming an ever-more complex game and the stakes are high. You have to be in it, to win it.   Posted Feb 27 2008, 04:37 AM by Colin Cooper with 1 comment(s)

• Binge drinking, the BMA and lifestyle advice

  The BMA is embroiled in a ‘binge-drink row’, according to a number of Sunday papers. Apparently the association, which last week called for the government to take tougher action on the availability of cheap alcohol, recently applied for a licensing extension to allow its bar to remain open until 1am. But the move prompted complaints from local neighbours, who were apparently concerned about ‘drunken antics’ at the BMA’s headquarters. According to reports, residents in the area had complained of guests ‘urinating’ outside nearby properties, ‘frolicking’ on scaffolding outside the building and generally ‘causing disturbances’ in the early hours. It is very tempting to imagine various doctors from the association causing a ruckus in the street and frolicking on scaffolding (whatever that involves) after consuming vast quantities of booze. However, apparently the licensing extension is primarily for when the headquarters is hired out for events and private parties and the suggestion is that it is behaviour on these occasions that residents object to. The Sunday Times suggested that the association had opened itself up to accusations of hypocrisy considering its stance on binge drinking. I'm not sure about this, but the story did get me thinking about the whole issue of health professionals as role models. A number of initiatives over the years have urged nurses to lead by example, particularly when it comes to smoking. In 2005 the RCN launched a huge campaign to help nurses to quit and in the run-up to a ‘smoke free’ England nurses were again targeted. Can nurses or doctors who smoke provide believable smoking cessation advice? They probably can, but whatever they say would be seriously undermined if their patient caught them having a sneaky fag in the car park afterwards. Of course, health professionals who have personal experience of, for example, smoking and weight problems may be the ideal person to help patients with similar issues. They will be empathetic, be able to discuss any difficulties in a very real way and really engage with the patient. The issue of whether health professionals should lead by example is not necessarily clear cut, but many feel it is important. I don’t doubt for a second that, in the future, we will see more and more campaigns encouraging nurses, doctors and other health professionals to live healthier lifestyles. I’d be interested to hear what you think. Should health professionals be paragons of virtue? Or is it unrealistic to expect them to lead by example?   Posted Feb 26 2008, 10:58 AM by Emma Bower with no comments

• DoH shamed into recruiting 4,000 extra midwives

  It’s so nice to see a government department being stung in to action by a chastening report from one of its own bodies. Last month the Healthcare Commission criticised NHS trusts for failing to provide maternity services of a sufficient standard. The government had previously rejected complaints from the Royal College of Midwives that there were too few midwives to fulfil the promises made in Labour’s 2005 election manifesto. But the commission’s report seems to have convinced health ministers that action is needed – hence a new drive to recruit 4,000 extra midwives by 2012. Of course, this doesn’t mean that the problem is solved. The midwives still have to be recruited and who knows how much fiddling will be done with the figures over the next four years – remember the community matrons target? But it’s refreshing that the DoH does seem to have respect for at least one of the institutions influencing UK healthcare, and long may the commission continue to be a thorn in the side of overbearing governments. (Of course I may be completely wrong about this so please let me know…)   Posted Feb 25 2008, 10:03 AM by Colin Cooper with no comments

• Binge drinking on top of the agenda… again

  It's the news of the week: the government is making its umpteenth attempt to tackle binge drinking in England. The objective this time is to limit the sale of cheap booze and the issue is backed by the highly mediatised report on alcohol consumption released this week by the BMA.   But it seems all a bit contradictory to me; did the government not implement a 24-hour drinking law just over a year ago? It was supposed to limit the damage but now the new licensing system which allows any pub or bar to serve alcohol all night is being blamed for contributing to the public health problem. And it is indeed quite a serious one. According to the latest figures from the BMA, alcohol kills more in a month than heroin does in a year and the number of children needing medical treatment after binge drinking has soared by nearly 40 per cent in just six years. So charities and government bodies are trying to find new solutions - as it becomes clear that the ones they have come up with until now have made no difference - and this time they are targeting people's financial capacity. Let's ban happy hours, two-for-one booze offers, supermarket price cuts, and increase tax on alcohol, shall we? Don't get me wrong, I am certainly not supporting binge drinking but I just can't help but picture a typical Friday night when I go to a dinner party and make a quick stop by the corner shop where I usually have to fork out £10 fto get decent bottle of wine... I am not sure higher prices would stop me buying it but it would certainly alter my good mood for the 30 minutes it takes me to get to my friends' house. Am I the only one who fears making alcohol almost unaffordable might have the effect the price increase on cigarettes had? People will not reduce their consumption but will save the pennies on other goods - usually food or other essentials - in order to afford their booze. And who will the big winners be then? Not consumers but supermarkets of course. Tesco has already announced it was ready to discuss with the government about possible legislation on pricing and promotions - i.e., put their prices up. No kidding... Of course Tesco's bosses are well aware it would be commercial suicide to be the only ones to increase prices. And legally, supermarkets are not allowed to team up to put up prices so they are just waiting for the government to 'take action'.  I'll have another glass of wine while I wait… Posted Feb 22 2008, 07:23 PM by Emilie Reymond with no comments

• Johnson tipped to replace Castro

  Following the revelations that health secretary Alan Johnson probably modelled his no-nonsense approach to primary care on the style of England football manager Fabio Capello, it is now thought to be entirely possible that Johnson is being lined up to take over from Fidel Castro as the official dictator of Cuba. The facts are: 1 Johnson has the perfect background as a former postman, union supremo and self-confessed ‘bit of a Mod’. 2 He has a no-nonsense style. 3 DoH officials once went on a fact-finding mission to Cuba. 4 He has a no-nonsense style. This is good news for practices because there is more trouble ahead for primary care if Johnson hears that the recovery of stroke patients can be aided by music. It will only be a matter of time before he starts hurling cups of tea around surgery waiting rooms, demanding that all practices give all patients the choice of listening to music of their choice, at their time of choosing, with the hot drink of their choice. If practices fail to provide music, Johnson’s own Desert Island Discs selection will be imposed. Incidentally, looking back on Johnson’s disc choices in October, it is now clear that he was making a whole raft of covert references to his future plans. Drive in Saturday obviously refers to the extended hours debate, while Friday on my Mind is Johnson dreaming of when he’ll be able to ring up his local surgery at the last minute and book a non-urgent appointment for the weekend. His choice of You Little Fool is a blatant sideswipe at the chairman of the GPC, while Beneath the Sun completes his selection with a nod to his future role in bringing choice to the people of Cuba. Posted Feb 21 2008, 09:09 AM by Colin Cooper with no comments

• Not just an NHS trolley dash

  Attending a debate last night on whether competition was ‘the solution to the NHS’s problems’, I started to worry if anyone was clear on what they were arguing over. No one had clearly defined what was meant by ‘competition’ or what participants were competing for. The standard line from the pro-competition lobby is that ‘competition will make providers up their game’. But what are the incentives and what are the measures? In business competition is often seen as making the most money or having the most customers. But in other sorts of competition the goals are different. Sport is the greatest example of competition we have but we don’t judge Arsenal’s success on the amount the club takes at the turnstile or decide the Olympic long jump medal on who raised the most sponsorship. So what are providers in health competing for – the best health outcomes, patient throughput, earnings, value for money, smallest drug spend? A speaker at the debate mentioned a hospital where MRSA rates dropped once wards were told they were in competition with each other ‘because no one wanted to come last’. But those staff weren’t competing for a contract or a higher budget, they were competing not to be worst. As another speaker said, perhaps we are asking the wrong question. If competition is to offer a solution to NHS woes, we first need to decide what type of competition we are looking for. Just because ‘competition worked in the telecoms industry’ does not mean a free market health provision will have better patient outcomes. The NHS needs a properly designed ‘market' if competition is to be anything more than a trolley dash for the most profitable services. Posted Feb 20 2008, 06:41 PM by Bronagh Miskelly with no comments

• What's the point of the poll?

  The Times columnist David Aaronovitch is someone who manages to be unceasingly controversial no matter what topic he puts his pen to. But while he occasionally spouts copy verging on the ludricous, he is more often than not devastatingly accurate. So it was with some trepidation that I approached his column today, noting the headline: 'Ignore the doctors. Polyclinics are the future'. He had been examining the Darzi plans and thinking them rather good. Then he turned to the BMA for a second opinion. What he heard first was an argument to save the 'generalist' and 'holistic' role of GPs, which he interpreted as a plea to preserve 'inexpert' care. What he and his family needed was better access to specialists, he said. Then he rubbished the arguments for continuity of care, saying that quality was more important, and he battered the doctor who had complained about the new 'dial-a-pizza' attitude to healthcare. His response was: 'when did illness stop being 24 hour?'. And so it went on. Now, some bits of this column were undoubtedly ludicrous, but what struck me about much of his rant was that it was so easy to pick apart the BMA's arguments for preserving general practice. We have seen in recent weeks how expertly the DoH outmanoeuvred the profession's representatives on extended hours. Ministers don't bother trying to win over public opinion - they win over the media and let them do the work. The BMA's poll of GPs this week now seems an expensive irrelevance at a time when the association needs to be devastatingly accurate with its media strategy. Posted Feb 19 2008, 06:06 PM by Colin Cooper with no comments

• Can the DoH 'modernise' nursing careers?

  When readers of Independent Nurse receive their copies of this week’s issue they will see a story about responses to the DoH’s consultation on its framework for nursing careers and the NMC’s consultation on the future of pre-registration education. At the time we went to press (last Thursday) we only had responses from Unite/CPHVA and the Queen’s Nursing Institute (QNI), on which we based the magazine’s story. However, on Friday morning we received the response from Unison and this morning we got hold of the RCN’s response. As is often the way, magazine deadlines don’t always suit the news – which is why it is good that we can now provide daily news updates on Healthcare Republic. A fully updated version of this story can be found here. In terms of post-registration careers, most of the responses are concerned that the framework will not translate well into practice – particularly the idea of five career pathways. All of them seem to find the plans confusing. The RCN is worried that the pathways do not work for nurses in general practice, Unite/CPHVA is concerned they do not support the specialist practitioner qualification and both, along with the QNI, do not believe the framework adequately addresses the future of advanced practice – particularly the future of the advanced generalist nurse. These are very real concerns about whether the changes envisaged by Modernising Nursing Careers work for those in primary care. Considering the government is currently planning on moving a huge amount of NHS services out of hospitals and into the community it is quite astounding that this should be the case. The responses also said that many of the ideas put forward by the consultation were too vague, or provided little information about how they could work in reality. And there was concern about whether there will be any funding or support to roll out what will be a huge change across the service. There are some thorny issues that still need to be addressed by those working on the Modernising Nursing Careers initiative, but there are already alarm bells ringing about the DoH’s ability to deliver such a massive shift.  Posted Feb 18 2008, 11:59 AM by Emma Bower with no comments

• Valentine's Day hangover

  I don't know about you but I am glad Valentine's Day is over. Nowadays, it feels a bit like an excuse to fill the commercial gap between Christmas and Easter and I am just exhausted by the whole thing - well I was more than happy when 50 tulips were delivered to my office yesterday, but that's not the point. While I was recovering from this somewhat forced romance binge, looking for some Valentine's Day-related anecdotes - and I did come across a few - I found something that could prove really useful for the special day next year. A US-based website called inSPOT gives the opportunity to people with a recently-diagnosed STI to inform former sex partners about their disease via virtual Valentine's Day cards... Apparently, people are more comfortable bringing up taboo subjects online. Well I guess it also helps that the e-sender can choose to remain anonymous. The system is pretty straightforward, you pick your city (only available in the US at the moment), then the e-card you would like to send - this ranges from a simple "I am so sorry" note to an humorous "I got screwed while screwing, you might have too" - add a short message (good luck?), enter the lucky recipients' email addresses and press send. It might seem a bit direct but if you think that increasing diagnoses of STIs and record HIV prevalence make these the fastest growing health conditions in England, any solution to tackle this issue is welcome. Although good progress has been made in terms of access to sexual health services in the past few years, according to a recent report published by the FPA (Family Planning Association), the number of people living with HIV in the UK is about 70,000, one third of whom do not know they are infected. Based on current trends, around 100,000 people will be infected with HIV by the end of 2010, compared to 30,000 in 2000. On top of that, there have been significant increases in STI diagnoses in GUM clinics since the the publication of the national sexual health and HIV strategy seven years ago. I admit the e-cards are not the most romantic way of telling ex-lovers the bad news but perhaps they'll get the message and will be grateful in the long term... Well, at least it's eco-friendly, it has a purpose - it could save lives - and is definitely less cheesy than a standard Valentine's Day card, isn't it? Well until you receive one... Posted Feb 15 2008, 07:51 PM by Emilie Reymond with no comments Filed under: sexual health

• Cosmetic surgery loses its lustre

  When we put together the survey to research GP views on cosmetic surgery, the question about patients dissatisfied with their outcomes was something of an afterthought. The survey had been a response to the rapidly growing numbers of procedures taking place in the UK, and concerns from cosmetic surgeons that potential patients were not consulting their GP before seeking surgery. But of course the aspect picked up by the national media was the fact that 61 per cent of GPs had seen dissatisfied patients. The calls to our office from TV and radio researchers were requests for ‘horror stories’ – the sort of thing where people went in for an eye lift and came out with three legs. In a way this was good, because any coverage of cosmetic surgery as a medical procedure that carries risk is, in my book, a bonus. The big problem with this branch of medicine at the moment is that those most likely to seek surgical enhancement are not seeing it as a medical procedure. To them it’s just another beauty treatment. And it’s now commonplace for procedures such as breast augmentation to be given as a special present, such as for a 21st birthday. And although in our survey GPs reported increasing numbers of consultations prior to surgery, they are probably only a small percentage compared to the numbers who did not seek their advice. Indeed, a survey by Which? showed that few people considering cosmetic surgery would think to consult their GP beforehand. Instead they would turn to magazines, the internet, or friends and family. Maybe this is because they are embarrassed, or maybe they don’t think their GP will know anything about cosmetic surgery, or maybe they simply do not see it as a medical issue. So they go for surgery with high expectations, are dissatisfied with the results, and then go to see their GP… Posted Feb 14 2008, 06:39 PM by Colin Cooper with no comments

• Paying for convenience

  We've all done it. Sat at home waiting for a delivery, the gasman or whatever. And as I do it today, I have been thinking about being a consumer. The iPod generation has been brought up demanding instant gratification and while not tolerate an NHS that does not deliver says Bernard Ribeiro, president of the Royal College of Surgeons in his foreword 'Quite Like Heaven? - Options for the NHS in a consumer age', a report from the think tank Civitas. He argues that younger adults lack the post-war generation's patience and experience of hardship which helped shape the NHS. What struck me about his ideas is that although the demands placed on healthcare are driven by consumer expectations, they are not applied consistently. Take everyone's favourite topic, extended hours. The drivers of this apparent demand for longer surgery hours are commuters and those who say ‘they can't take time off work to see the doctor'. Yet there are plenty of other ‘services' that only happen during the day. For example, it can be nigh on impossible to have a fridge or a sofa delivered outside normal working hours. And getting a timed appointment for something like having a gas boiler serviced - no it's always sometime between 8am and 2pm, assuming someone turns up at all. So how do the ‘I can't take time off work...' types manage these trials - they can't all have stay-at-home spouses.   Of course some companies will offer a weekend or named day delivery - for a charge. A charge that many are only too happy to pay in exchange for convenience. For that matter large supermarkets vary the cost of their home delivery services depending on the demand for slots - so it can be more expensive in the evening or at weekends. And quite frankly I'd pay not to be stuck in waiting for a 'some time between 8am and 2pm appointment' today. Which inevitably leads to the question: if the government wants primary care to be more like a consumer-focused business, why not allow GPs to charge for pre-booked evening and weekend appointments? Posted Feb 13 2008, 07:02 PM by Bronagh Miskelly with 1 comment(s) Filed under: extended hours, charging patients

• Nurses and staff ignored in extended hours battle

  There is a group of primary care providers who have been largely overlooked in the media battle that’s been fought over extending surgery hours. I’m referring to practice staff – the thousands of managers, receptionists, cleaners etc who will be affected by the changes being forced through by the government. And, now I think of it, primary care nurses have also been kept out of the picture. This is not coincidence. While GPs may be acutely aware of the impact of these changes on the organisation of their whole practices, the government has managed to focus attention purely on the ‘fat cat’ family doctors. Ministers and their spinners have successfully demonised GPs over the past year, gradually building up resentment in the media over the terms of their contracts. Now we see the pay-off, in that despite a lot of hot air from the GPC and BMA, the profession’s representatives have caved in at the first opportunity, afraid (as usual) of bad publicity. But could the publicity have been any worse? Anyway, as practices start to realise that they will have to implement some form of extended hours in about six weeks’ time, they will need to answer the difficult questions about which staff will be required to work when, and who will want to, or be able to, do the extra hours. Many of the practice staff that ministers have so far ignored, will no doubt have serious concerns about the damage to their own working and home lives, and HR issues will become a major headache as the practical reality of extended hours dawns at practices across the country. But for DoH officials it’s just another ill-informed, poorly thought-out policy, ruthlessly implemented without any concern for the lives or morale of NHS staff. In short, just another day at the office.   Posted Feb 12 2008, 10:22 AM by Colin Cooper with 1 comment(s) Filed under: extended hours

• Why Britain is a 'Prozac nation'

  More than 31 million prescriptions for antidepressants were issued in England in 2006 after an almost continuous rise over the last 10 years. Are we turning into a nation of ‘pill poppers’? Liberal Democrat leader Nick Clegg certainly thinks so. Last week he prompted a debate on the state of mental healthcare by claiming that Britain was a ‘Prozac nation’ and services were failing the public. He believes trusts must ensure people have quicker access to counselling and psychotherapy and says his party would guarantee treatment within 13 weeks. On average people wait seven months to access talking therapies, according to research by the Lib Dems. Perhaps it is no wonder that so many antidepressants are prescribed – clinicians must feel they have to do something to help patients in the interim. However, there are some signs of a shift away from medication. A survey of 200 English GPs by the Mental Health Foundation found that 22 per cent suggest exercise to help people with milder forms of depression, compared to just 5 per cent in a similar survey three years ago. They survey also found that there is a wider belief by GPs that exercise therapy can help in depression. The real problem is that depression and mental health problems are becoming increasingly widespread. The Office for National Statistics says that between 8 and 12 per cent of the population experience depression in any year. Mental health services are crying out for extra resources and staff – they simply cannot meet this level of demand. MPs are quick to criticise prescribing levels, but if health professionals are to issue less scrips they must have an alternative to offer patients. If politicians are serious about tackling ‘over prescribing’, improving access to talking therapies and providing more exercise on referral schemes should be their top priority. And the only way to do that is by ensuring adequate funding reaches frontline services. Posted Feb 11 2008, 11:06 AM by Emma Bower with 1 comment(s)