Dr Spence, writing in the British Medical Journal this week, informs us that digital rectal examination is now bad medicine because it is unpleasant, invasive, and has unknown specificity/sensitivity (1). Rectal examination now joins a list of other recently publicised clinical examinations that would appear to be of little clinical significance such as pelvic, breast and testicular examinations during some medicals (2,3).  What Dr Spence forgets is that the other tests he is suggesting are just as invasive, unpleasant and although they may have  a known specificity and sensitivity still are unpleasant and can cause potentially unnecessary harm ie. Colonoscopy and mammography for instance. An example of a failed rectal examination that recently comes to mind was of a 45year old man with a learning disability who was admitted for colonoscopy for unexplained diarrhoea. He had been referred to and seen by a Consultant who ordered the investigation without performing a rectal examination. Bowel prep and a digital examination prior to the colonoscopy resulted in a bed-full of faeces. Diagnosis - overflow incontinence which if he had been examined properly at the initial presentation would not have resulted in this wasted referral. There are other cases that I could describe that highlight the wasted opportunity of a rectal examination. Clinical medicine is based on the premise of a good history and examination before further tests are considered. The reverse appears to be now creeping into medicine. This demeans the clinical examination as well as deskilling physicians. This simple test like the others does not take long, is cheap, can lead to a diagnosis but importantly gives the patient the knowledge that they have been listened to and examined, a now increasing forgotten consideration.

Announced on news today that any woman can get the morning after pill free of charge from a chemist. The positive side of the argument is that this will reduce unwanted pregnancies. I am sure that several pregnancies will be avoided but there are several problems with this namely

• Women will use this as their only form of contraception with its consequences
• Probably will see a rise in STD’s
• Woman don’t realise that it is not 100% proof- counselling on the rise for inevitable terminations
• Costs the NHS money not only for the drug but also the dispensing fee for this service by the chemist which I am sure will not be cheap 
• Anything free has no value and durex sales will fall

Why can’t women take some responsibility and also the men for having unprotected sex. If a woman is adamant she wants unprotected sex thats fine but if she wants the morning after pill let her buy it. The cost is miniscule ie a charge of £3 to £5  is not unreasonable and can be achieved if the drug companies stopped adding phenomenal charges on top of its manufacturing costs. It makes women take note of the cost, may stop them using the pill as a freebie, saves the NHS money and stops whacking fees being charged for its dispensing. Everyone wins.

Is this too difficult for this Government and their medical advisors to grasp or am I losing the plot?

Researchers have recently stated that QUOF targets for GP’s have made no discernible difference to improving care and outcomes for patients with hypertension. The total amount of money spent on the QUOF programme is £1.8 billion pounds.

This statement led me to look at premature death from heart disease in Kent. Since 2000 Kent  was used as the preliminary blueprint for the QUOF programme and financial incentives were given to GP’s to achieve targets for hypertension , heart disease, diabetes mellitus and stroke ie. increased screening and use of aspirin and statins to treat those at high risk of these diseases. Then the QUOF targets followed in 2005. Therefore Kent has been tackling premature heart disease since 2000 and after 11 years we should have seen a reduction in deaths compared to the rest of the country with this long lead in time. This was predicted and stated vociferously in the press on multiple occasions when the programme was drawn up. If you now look at the graphs for premature death from heart disease  in Kent compared to the rest of the country there has been no deviation from a parallel line drawn for the rest of the country. Yes Kent does have lower premature death from heart disease but this was apparent pre- 2000 and has since shown no signs of becoming even lower to the rest of the country.

This raises serious questions about what we are spending money on and whether it has any cost benefit whatsoever. The biggest improvement in stopping premature heart disease is for the population to stop smoking. The fall in deaths seen in Kent and the rest of the country can be clearly attributed to a reduction in smoking in the graphs seen.

The Government would be better served taxing cigarettes to the hilt and stopping QUOF payments. We would have so much more money tackling improving the quality of life of patients say with arthritis or other chronic disease problems. 

Well Gov what do you say?

There is an article in GP news asking how are GP’s going to help fund homeopathy in Primary Care in this era of financial cuts and states that 1 in 3 PCT’s are still funding homeopathy.

This whole issue is a nonsense. I have tried the use of homeopathy to treat patients in the past having undertaken a year of training at the Homeopathic Hospital. At most I obtained a  placebo type response and usually only in patients who have subjective symptoms such as tiredness, PMT and others which are difficult to measure. Even when  patients were referred to the Homeopathic Hospitals the medical improvement was non-existent. So personally and with other studies showing it does not work how can we continue to fund this treatment? Thre is no scientific evidence to substantiate its mode of action and certainly no placebo controlled clinical trials showing its benefit.

If patients want homeopathic treatment those GP’s who want to prescribe it can issue a private prescription with minimal cost to the patient. Those wanting homeopathic treatment for chronic conditions can like all other patients have to fund it themselves like patients do for other therapies such as osteopathy. chiropractic and reflexology.

There is nothing to debate on this issue.

Continuity of care in General Practice has always been one of the reasons for having a GP who knows you and takes care of you. Most definitions ofcontinuity of care talk of uninterrupted health care for a condition from the time of first contact–eg, to the point of resolution or long-term maintenance.
What was surprising to read in the Kent LMC newsletter January 2011 was of an article by an LMC representative that brings the whole concept of continuity of care into question. The article talks of hospitals requesting GP’s to undertake MRSA swab testing as part of a pre-operative assessment. The GP in question feels that this is not his responsibility in that although he has referred the patient for surgery he should not undertake this procedure and that it should be done by the hospital concerned. I can see his point to some extent in that if we were to do this we may end up taking bloods etc pre-operatively. Where his argument starts to fall apart is when the hospital requesting these swabs may be many miles away ie in London as opposed to a local hospital in Kent. His argument goes that the patient should travel to London at both great expense and time to have these swabs done. However 10 minutes is the total amount of time should this be done by his Practice Nurse and that includes writing the forms and labelling the swabs. Please also remember that this is easily a Practice Nurse type job for which the GP receives subsidies for her wages from the NHS.
The impression by the LMC Rep was “I want payment for this or don’t ask” despite the fact that his patient maybe massively inconvenienced by this decision.
I work as an Independent Doctor and any requests I have received I have personally fulfilled at NO EXPENSE to the patient and I hope I have upheld my definition of what continuity of care really means.
Is the Kent LMC position on this going to change?

Publication recently in GP news quotes the following

Among other concerns, it also found that continuity of care has worsened, with just over a quarter of patients able to see their preferred doctor at the worst performing practices.

Recently two patients have attended this surgery for second opinions and have left me wondering what the QUOF targets are really for and who benefits.

The first patient was an elderly man who had been having recurrent bouts as he puts it of bronchitis and was now receiving his fourth course of antibiotics. To cut the story short examination showed that his inhaler technique was poor having also said he had never been taught how to use it. Secondly it was apparent he had asthma on his reversibility testing (had never been told this)and was not taking his preventer inhalers at all and only when he felt like it. He had been seen on 4 occasions to get the antibiotics. This practice had achieved 100% points for all disease categories yet this practice had no idea on how to treat this type of patient.

Another patient presented at a medical with hypertension and proteinuria 3+ on dipstick. He was sent back to his GP for treatment. Several months  later he had to reattend for a further medical and his BP was raised again 158/98 and 3+ protein on dipstick. Further investigations showed he was passing 3gms protein / 24 hrs. He was told by his GP he did not need to treatment for  his BP and he just had a bit of protein in his urine and not to worry. What happened to making a diagnosis of possible nephropathy and getting treatment with an ACE inhibitor to prevent further damage to his kidneys by keeping his BP down. Also what happened to the fact that is is well known microalbuminuria is a risk factor for heart disease never mind the fact this patient had overt proteinuria.

These two recent cases make me wonder whether QUOF is of any benefit and whether it stops GP’s thinking especially the last case where if the patient had been a diabetic he would have been treated completely differently- or would he have been? 

Steroid injections,such as depomedrone, are given to joints to reduce pain and inflammation particularly in patients with rheumatoid or osteoarthritis and even gout. Previously it has been assumed that if these injections are given too often that the joint gets worn away more quickly and may need to be replaced with an artificial joint. Good news is that a study in 2006 into this problem seems to suggest that patients given up to 3 injections into a joint in a year do not appear to wear their joint away any quicker than those not having the steroid injections.

This is good news for patients as I believe this type of treatment is effective, quicker acting and much safer in helping joint pain and inflammation than the use of non steroidal anti-inlammatory drugs such as diclofenac and ibuprofen, which can cause gastric bleeding and counteract drugs used for lowering blood pressure.

So why do GP’s keep telling their patients you can only have two steroid injections to your joint per year? Is this so that they do not have to perform or refer them for this procedure? Any other suggestions? 

Many patients with sciatica that is not responding to therapy such as physiotherapy are offered an epidural steroid injection into the back to not only help their pain but also prevent surgery. 
Does it work? The simple answer is NO unfortunately.
Over 200 patients with sciatica not resonding to therapy were divided into 2 groups those that had an epidural with steroid and those that just had a salt injection. Atat 3 weeks post injection only 13% of patients in the steroid group had responded as opposed to 4% in the salt injection group. When you analysed the patients from 3 months onwards there was no difference between them. The more worrying thingwas that at 1 year only 33% or 1 in 3 patients were 75% better in either group.

What does this mean. I have never understood how a steroid injection can relieve sciatica when the disc prolapse is obviously pressing on the nerve. I have also never understood why surgeons do not operate early on these patients when with keyhole surgery you can obtain  complete relief of pain from  sciatica in 90% patients..
What this study shows is that unless you begin to get relief from sciatica within 3- 6 months then it is unlikely you will get any further improvemennt in pain relief and maybe we ought to be more forceful in saying to both Neurosurgeons and Orthopoedic Surgeons  to get keyholing on my back and stop sticking needles into my spine!

In Kent all the Orthpoedic surgeons seem to continue to offer patients epidurals and nerve blocking injections even in patients with spinal canal stenosis. All this does is put the patients quality of life on hold for many months than need to.This also has major implications to both employers and those that are self-employed who are being cheated of pain relief which would enable them to get back to work.