Margaret McCartney's Blog, page 8

The Guardian, the Times, the Herald; there are probably more newspapers who have carried full pages adverts for Lifeline Screening over the last few years.

This company offers screening tests – that is, tests on people who are completely well. If you have symptoms, the situation is very different. Screening sounds logical – picking up small or potential problems before they develop into disease. Sadly, the logic doesn’t often bear out in real life. There are many reasons why this is so, but one of the most compelling is that it’s very hard to know which are the abnormalities that will cause problems. The truth is that when we look for problems in perfectly well people, we find them – cysts, narrowing of vessels, enlarged vessels, odd looking bumps or lumps in internal organs. But which ones will cause problems? Which will never cause you any bother? And if treatment is offered, will this be more likely to do you harm than leaving it alone?

A huge amount of effort has gone into trying to work out which are the screening tests worth doing, and which ones cause more harm, overall, than good. The UK National Screening Committee is charged with continually assessing the evidence and making judgements based on the facts.

In 2009, complaints about Lifeline Screening adverts were not upheld by the ASA, which I was very disappointed about, especially considering that as a GP, I had many first hand concerns about the information people were being given. Last year I complained again. I thought Lifeline Screening overemphasised the benefits, didn’t say what was already available on the NHS, and and didn’t give fair information about the pros and cons, especially about aortic screening. I wrote about my concerns regarding Lifeline, as well as some other similar companies, in the BMJ. Lifeline didn’t respond. I and several other doctors complained to the General Medical Council about the medical director, DrJohn Coltart. They did not investigate primarily because we did not produce evidence of direct patient harm.

Professor of neurology, Charles Warlow, went to a Lifeline Screening session and wrote about it in the BMJ. He wrote “This was just screening, nothing more and nothing less, done for profit – with the results to be dumped in my lap within 21 working days and for my GP to sort out the emotional and physical consequences of any abnormality, true or false, even though she didn’t request the tests…..Why is this nonsense tolerated or allowed? Where is the audit of these screening outfits? Where is the partnership with patients?”

Consultant neurologist David Nicholl, who also complained about Lifeline wrote in the BMJ: “ Carotid doppler is an extremely useful test for those patients who present with symptoms which are suggestive of carotid territory TIA (transient ischaemic attack). It is an utter waste of money and resources to screen a patient who has no symptoms. Indeed the claims of companies such as Lifeline are, in my opinion, extremely misleading”.

The 2011 complaint was eventually upheld by the ASA in 2012. However, on the basis of the new advert – running in the Herald this week – it is every bit as unfair, biased, alarmist and misleading as the last three years. I have attempted to annotate some of the advert in the link above. The points made by the ASA were:

- it was agreed that it was not possible to offer absolute peace of mind

-Lifeline would now work with the Committee of Advertising Practice to rework the adverts so that they were not misleading.

-it would not be acceptable for Lifeline Screening to claim that they could prevent 80% of strokes

-the ASA decided that it was okay for Lifeline NOT to say that aortic aneurysm screening was already available (in an audited, evidenced fashion) on the NHS

Because Lifeline agreed to this without ASA Council involvement, an adjudication was not published. There are several notes of the ‘informally resolved‘ cases.

Yet there are still huge problems with the adverts, as I’ve annotated above. We know, for example that screening carotid arteries for narrowings in well people is a waste of time – and is actually overall BAD for people – see here: “benefit is limited by a low overall prevalence of treatable disease in the general asymptomatic population and harms from treatment.” On osteoporosis screening, “there is insufficient evidence of the effectiveness of treating low-risk populations”.

The bottom line is that Lifeline Screening appear to have the ASA’s approval to continue to run alarmist, misleading and unfair adverts. In the NHS, quite rightly, doctors are very concerned about shared decision making- in other words, losing the paternalistic plinth and sharing uncertainty and choices with patients. This is a very good thing. But it is imperative that people are given fair evidence – not scaremongering or overselling the tests on offer.

If you do want advice about what to for your health, I think it’s quite straightforward.

Don’t smoke,

Don’t drink excessively

Eat a variety of foods, mainly plants

Keep to a reasonable weight

Do exercise you like

Meet people, do things you enjoy, including work

and if you have any symptoms, see your doctor promptly.

It looks as though these adverts will continue with the ASA’s blessing. It is distressing for GPs to meet patients who have spent over £100 on tests they don’t need, with money that could have been used for many other things which were more likely to benefit them. I don’t know what to do, apart from hoping for a broader public debate about the problems of overdiagnosis and overtreatment, of which screening pays a major part.

If you want to read more about screening, there is Sense about Science’s booklet (which I helped with) (and my book, The Patient Paradox, which is cheaper from the publishers (or even cheaper on Kindle).

View more on Margaret McCartney's website »

Like • 0 comments • flag

Published on July 22, 2012 10:49

Inside Health – the Self Care campaigns

These are the references I used for tonight’s Radio 4 Inside Health http://www.bbc.co.uk/programmes/b019dl1b

http://www.independent.co.uk/life-style/health-and-families/health-news/im-worried-about-my-dandruff-and-other-gripes-gps-are-sick-of-hearing-7936430.html

http://www.pagb.co.uk/publications/pdfs/Minorailmentsresearch09.pdf

http://www.selfcareforum.org/wp-content/uploads/2011/07/chhosewellsummercampaignpressrelease.pdf

http://www.selfcareforum.org/

http://www.pagb.co.uk/media/responses.html

http://www.selfcareforum.org/wp-content/uploads/2011/07/chhosewellsummercampaignpressrelease.pdf

This is the very biased survey.

https://www.surveymonkey.com/s.aspx?sm=7MOnHTVGuEuNN2dkaCK%2fzQ%3d%3d

http://www.southofengland.nhs.uk/2012/07/12/51-million-unnecessary-gp-visits-nhs-investigate-why/

http://www.telegraph.co.uk/health/healthnews/9392184/Millions-see-GP-for-stuffy-noses-and-dandruff-in-waste-of-appointments-survey.html

View more on Margaret McCartney's website »

Like • 0 comments • flag

Published on July 17, 2012 13:00

Inside Health

references for tonight.

Mike Richards and the ’3 week cough’ awareness campaign discussion

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2361660/

http://www.bmj.com/content/339/bmj.b3094.full

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2361660/?tool=pubmed

This may also be of interest, which is an article about the (lack of) evidence for the 3 week cough campaign;

http://www.pulsetoday.co.uk/main-content/-/article_display_list/14033555/wake-up-to-perils-of-awareness, with references

NHS Cough 2012

Department of Health. Lung Cancer Awareness Campaign cluster briefing slide pack. 2012

Athey V, Suckling R, Tod A et al. Early diagnosis of lung cancer: evaluation of a community-based social marketing intervention. Thorax 2012;67:412-7

Hamilton W, Peters T, Round A et al. What are the clinical features of lung cancer before the diagnosis is made? A population-based case-control study. Thorax2005;60:1059-65

Ford A, Forman D, Moayyedi P et al. Cough in the community: a cross sectional survey and the relationship to gastrointestinal symptoms. Thorax 2006;61:975-9

Stapley S, Sharp D and Hamilton W. Negative chest X-rays in primary care patients with lung cancer. Br J Gen Pract 2006;56:570-3

The other piece on Inside Health was about the lovely blog here with Dr Martin Brunet where he tells about the Infection Control Nurse, the Care Quality Commission and his train set. The CQC statement is here , the press release is cut and pasted below, and the train set stays.

9 July 2012

Infection control advice to practices

Statement from Yong Tan, Infection Control Lead Nurse at NHS Surrey:

“It’s really important the NHS has good infection control measures in place because this helps reduce the risk of bugs being passed on from one person to another.

“We make regular visits to GP practices and other healthcare sites to check they are meeting the necessary requirements, which includes having the appropriate infection control practices.

“Following a recent visit to Biscombe Medical Centre, we recommended some steps the practice could take to further strengthen the measures they already have in place. This included a recommendation to reduce the volume of children’s toys they have in the centre.

“It’s great for children to have something to play with as it can help them feel more at ease. However, they do carry risk of infection and therefore need to be cleaned every day.

“With this in mind, we suggested the practice may want to have fewer toys so they can keep them clean more easily. As it was only a recommendation, it is of course for the practice to choose whether or not to make any changes.”

- E N D S -

View more on Margaret McCartney's website »

Like • 0 comments • flag

Published on July 10, 2012 15:12

Who’s the expert?

Following on from twitter discussion.

I am a GP; I qualified in 1994. I spend two or three hours a week reading and learning new things about evidence and medical practice. I encounter at least one problem daily that I think I should go and find out more about. I have passed lots of exams, have letters after my name, am often asked to give talks about medical things, I teach students, and I would still never think of calling myself an ‘expert’.

Part of this is the nature of general practice – some people say ‘expert generalist’; I just say GP. ’Expert’ to me implies that I am better than others; my dictionary says ‘having a thorough knowledge’. Of medicine, I don’t know if that is realistic. There is danger in presuming that one’s knowledge is complete; and arrogant danger in assuming that I know everything. I try my best. Sometimes I get things wrong; we all do; my hope is that I own up, make best amends, and use that experience usefully. Because I know that I don’t know everything, I know that I need to check back, think, talk to colleagues. I am a working GP, same as other GPs, trying to do my best with what’s available.

I am on my patients’ side. That is to say; my automatic default is that I am advocating for the person who is my patient. This will mean that I do my best to get a helpful diagnosis, sometimes to avoid diagnosis, to share uncertainty, to discuss the limits of medicine or the dilemmas we face. This will also mean that I will sometimes decline to do things which are harmful or dishonest; such as extended prescriptions for dangerous and unneeded medication, or sign sick lines which I can’t justify.

Often, this is not just a 10 minute appointment. More often, it’s a relationship over time. So a decision might, on reflection, change; more information might be later gathered; further issues might appear to be explored or ignored. I am on my patients’ side. Whose else could I be on?

The rise of the ‘expert’ patient changes this.

For decades, patients have organised themselves into groups where information can be shared, support and knowledge offered, and where they have been able to request health professionals address their concerns or wants of discussion. I am aware of many, usually small, charities and patient groups who have fulfilled these needs locally and extremely well. The agenda has been created and designed by patients, they have been in control, and they have been able to talk and directly influence healthcare staff. Not all patients have wanted to be involved centrally or peripherally with other people who have similar illnesses. Some people have wanted to be told by their doctors what they should do; some people want to examine each decision possible in minute detail.

That’s all fine. It’s more than fine – I should be adaptable enough to maintain basic standards of informed consent while ensuring that people get the right amount of information. It’s my job, it’s what I love, it’s what I still feel I have a vocation to do.

But when I read the text of the ‘expert patient‘ programme, I am filled with dismay. It offers people the chance to ‘take control of your health’ in a six week course. I am not sure that anyone can really offer an intervention promising control over our health. This course, rather than being run by people with the same condition (so unlike the support from a charity or group for say MS or diabetes) is run by people with any of many long term conditions, and is run to a Department of Health protocol. There is no teaching of things that might be useful, for example, how to interpret media claims about ‘breakthroughs’, and much of the teaching – for example, relaxation skills – are often being run already for free by local services. The inference from the DoH is of health consumerism, where people as patients should be able to push harder for and consumerism only really works if there is to be shopping around. So we have one aim

greater flexibility and choice in accessing services, for example through the nurse-led telephone
service (NHS Direct), Walk-in Centres and the NHS website;

Hilda Bastian puts it very well

“Who will be left sitting and waiting, with little time left for them, while others are getting all their questions answered, and getting double medical advice for each decision? Whether you look at it from the point of view of the have-nots, the timid, or an overburdened practitioner, my fear is that some of this might not be fair.”

In other words; the least articulate, the least demanding, and possibly the most vulnerable will end up worse off.

I am worried, deeply worried, that the consumerism masquerading as ‘expertise’ is really only there to make patients into customers. Customers can choose and shop around and demand; they can also be fired by businesspeople who see them as drains on time and resources. (We have seen this already; some GPs, in the post-NHS Act have ‘let go’ patients in nursing homes because of high workload to financial reward). A professional relationship is something different; a duty of care; and primarily, of course, of making the care of my patient my first concern – and advocating for that person to the best of my ability.

If we really wanted to get closer to that – and why is can often seem to some people (some of whom have replied on twitter) that doctors are not on the patients side – it is necessary to look at the influences on the consultation. Doctors are seen by the government to offer quality based on ticking lots of boxes; smears, blood pressures, advice to stop smoking. If you are pretty well and don’t have a lot of health care needs, it might be easy to fit these in. (Whether it is right is another matter.) But if you are ill, if you have issues you want to discuss, if you need to be listened to: these needs are competing with the need of the practice to demonstrate ‘quality’ ticking of boxes. The patient’s agenda looses out. It’s almost criminal. It has threatened professionalism. I think it has broached it. It distresses me.

More than ever, urgently, as the NHS Bill comes home to roost, we need patients and doctors on the same side. We need to make sure that our shared priorities – not the GP contracts’ – are the ones we listen to. We do not need to be made enemies, playing pointless games of who has the greater ability to be ‘expert’. Patients need to help doctors regain their professionalism in the face of government pressures – the contract, choose and book, the electronic patient record – which detract from what we it is that the patient really wants to talk about.

More than ever, we need doctors and patients to be on the same side.

View more on Margaret McCartney's website »

Like • 0 comments • flag

Published on July 10, 2012 14:49

The CQC does not want toys to be thrown out

Delicious statement from the CQC

- see twitter for context. More tomorrow hopefully on Inside Health.

‘Rumours that practices will have to throw out toys from their waiting rooms have no basis in fact. This and other rumours such as carpets and soft furnishings in waiting rooms will have to be removed due to infection issues control are absolutely false. These are matters that are not likely to cause the CQC any concern, or lead to non-compliance with the essential standards of quality and safety. The Commission is aware that some PCTs have been saying this to practices and would encourage any one who has encountered this behaviour pass that information on to the CQC who will advise the PCT their advice is wrong.’

View more on Margaret McCartney's website »

Like • 0 comments • flag

Published on July 09, 2012 04:14