4. Matthew Parris uproar: GPs are archaic, we can leave it all to others and the specialists. An example from my work

17/06/2012

I have invited Matthew Parris to come and see what goes on in my working day (see link below). I reflected on his article, published yesterday, as I rode my bicycle in this morning. I was prompted to write this in answer to his wrong-headed opinion piece.

I arrived at work this morning (Sunday) to catch up on loose ends (of which there are many). Sitting on my desk, in front of my keyboard, was a bottle of tablets (dispensed by the hospital that had recently discharged her): methotrexate 10mg, with instructions to take two weekly. I had left this on my desk to remind me to send in a service alert to the hospital.

The problem is this (I am writing this for the intelligent layperson): methotrexate is a drug given to patients with severe rheumatoid arthritis. It is very effective but it is also potentially dangerous. It reduces the immune system, but if it reduces the immune system too much, it can kill the patient. There have been deaths due to wrong dosages of methotrexate being given to patients, or the patients not getting regular (monthly) blood tests to check their immune status and missing warning signs. The other thing that can be confusing is that there is no fixed dose of methotrexate, it varies from patient to patient.

Methotrexate tablets come in two sizes, 2.5mg and 10mg. A few years ago, in response to a national alert and at the behest of our local prescribing advisers, GPs in Tower Hamlets carried out audits of their methotrexate prescribing. As a result, we instituted a number of systems so as to reduce the risks. One of those changes was to stop prescribing 10mg entirely so as not to avoid potential confusion and mistakes. Less confusing for the patients and carers, less confusing for the prescribers, less risk of making inadvertent drastic changes to medication.

So: an elderly patient with rheumatoid arthritis was discharged from hospital last week (she had been admitted for another reason). I saw her 2 days ago for review. We went over her medication. Her daughter explained that the hospital had suggested decreasing her methotrexate dose from 4 to 2 tablets, as they thought the methotrexate might be causing the problem for which she was admitted. But when I checked the discharge summary (which lists the medication), it listed methotrexate 10mg tablets, take 2 weekly. As stated above, we never prescribe 10mg tablets. The hospital had made a mistake: they thought they were reducing her medication when in fact they were doubling it (her usual dose is 4 tablets of 2.5mg, which is 10mg). Now a doubling of a patient’s methotrexate can have fatal consequences, so clearly this is a problem. (I asked the daughter to bring in the actual bottle, which she did; it contained methotrexate 10mg tablets; it is sitting in front of me).

I rang the hospital pharmacist to check. I said I thought it was policy not to prescribe 10mg tablets. She was unaware of this. She agreed that a serious prescribing error had occurred and she was going to raise an incident.

I need to pursue this by alerting the hospital, and my GP colleagues. There certainly is a GP policy, is the hospital aware of it? Should the hospital policy change? And so on.

Now, the reason I have outlined this particular incident is because this error was discovered by me, her GP, who has known her for years. I do her repeats (receptionists do not generate the methotrexate prescriptions, only a GP can); I make sure she has had her blood tests before I issue another month of her medication. For her, and a number of other patients like her. Did the hospital doctors looking after her understand about methotrexate?

As GPs we are generalists, we are also coordinators. Sometimes I feel like an air traffic controller, with many planes in the air. There used to be general physicians, and general surgeons, but no longer. GPs are the last generalists. Yes, we have to keep updated. Is this possible? Yes, it is, but it takes time and encouragement and a supportive environment. We don’t need to know how the latest thing about cochlear implants because the specialists deal with that sort of detail. What the public, commentators, Department of Health, politicians need to understand is that GPs are specialists in general practice and that this is a real specialty, with lots of levels of complexity. It takes intelligence, creativity, problem solving, teamwork, passion, time, commitment to do this job well.

Can you do without this job? You can try, but I think you’d find you would have to re-invent the GP.

Yes, it may be that there are GPs and GP practices which perform poorly and which need to improve their standards. That is an important issue and needs addressing in an intelligent way.

*

My invitation to Matthew Parris   Click here


3. Matthew Parris uproar: if family doctors did not exist would we need to invent them?

17/06/2012

My GP colleague Pete Deveson offered consolation yesterday to a distraught colleague, saying that ‘our evidence trumps his prejudice’, with a link to an interview with the late Barbara Starfield.

Well worth reading, thank you Pete.


2. Matthew Parris uproar: summary and excerpts from his article

17/06/2012

Having bought and read the article, and having it in front of my, I will summarise the main points (I don’t thing I’m breaking the law here):

If family doctors did not exist, we would not need to invent them
Next week family doctors are about to strike (yes, he does use the word strike)
We pay GPs more than airline pilots, but they are really just glorified gatekeepers: a portal to specialist medical care
GPs have receptionists, so the NHS uses GPs as its receptionists.
Question: are we paying too much for these receptionists?
We really don’t need to pay these GPs all this money to deal with coughs and colds; we can just get rid of the middle man, and use a variety of lower grade professionals (community pharmacists, nurses, receptionists, maybe ‘an American idea’ physician’s assistants) to route the patients to the specialists.
Gone is the time when the GP could have a grasp of the whole of medicine and its advances; they cannot keep up
The concept of the personal doctor is dying, about to be extinct
Referral rates are rising and ‘in some practices’ they are reaching 50%
‘It’s nice if you mechanic knows you and your car but, on the whole, if a tyre needs changing there’s much to be said for going straight to a tyre centre.’

I will end by quoting the last 2 paragraphs and hope Rupert does not mind:

“Nurse-led primary care, too, is plainly on its way and expanding fast, with (the research is clear) excellent results. Walk-in and appointment clinics are becoming more common, especially evening clinics. Sexually transmitted disease, family planning, coughs and colds, eye, ear nose and throat … in all these fields specialist practices staffed by nurses and pooled doctors, rather than personal GPs, are where we’re going.

“The only question is how fast. Let’s hope next Thursday’s strike prompts us to speed this thinking up. Decades ago, at the bookshop Foyles, you had to get a little chitty from a person in a booth before you could get your purchase. One day we’ll remember the GP surgery in the same way, with the same amusement that the archaic practice lingered so long.”

*

Matthew Parris has a flowing prose, and the texture of the article is far better than I have reproduced. However, the content and basic message is as outlined.

When I looked at the online article an hour ago, there were over 200 comments. The latest one read:

As I was meandering through a completely unrelated medical story and its background I came across Wittgenstein’s 7th Proposition that I thought is perfect for Mr Parris’s peroration:

whereof we cannot speak, thereof one must be silent


1. Matthew Parris uproar: what if you can’t see behind the paywall?

17/06/2012

People on Twitter yesterday will have seen consternation from some quarters on an article by Matthew Parris published in the Times yesterday. The link will have taken you to the paywall; those without a subscription were/are unable to read the article and judge for themselves.

This poses an interesting question. At some level people feel we should be able to see this article, for free. But of course, not so long ago, when I was a young man, newspapers all cost something. With the advent of the internet, quality online newspapers still charged (in my memory), and then became free. And then our friend Rupert Murdoch decided to charge us to view his merchandise. So there we are today.

To solve the problem at a personal level, I went out yesterday and bought the print version and lugged it home. I found the offending article, cut it out, and placed the rest in the recycling box. I read the article, was initially incensed, and then wrote Mr Parris a letter (see links below). I then thought I needed to write a ‘Letter to the Editor’. I went online, and then of course I was confronted with the paywall. I tried to find a way to just send them an email, but could not find a way to do it (I nearly sent my ‘Letter to the Editor’ to the Editor of Time magazine; just about to click ‘submit’ when I realised it was the wrong periodical). Needs must, I bought an online subscription (details below), and sent my letter.

So what can you do to view this article?

You can go through the bins in your neighbourhood if you live in that sort of neighbourhood.

You can ring a friend, if you have that sort of friend, and get him/her to read it over the phone.

You can view part of the article via a photograph on Twitter, but you might get a sore neck.

If your moral compass will stretch that far, you can take out a subscription to the online Times. I took out the minimal pack I could; you pay £1 for the first month, and then £2 per week from then on. What they don’t make entirely clear upfront (yes, of course, it’s there somewhere in the fine print a few clicks away) is that you will be locked into paying the weekly rate for 52 weeks. Now the good news is that if in the first month you decide this is not for you, you can ring them up and cancel the subscription. And this is what I intend to do.

I am going to post a summary of the article to give you some sense of the content. Maybe it will wet your appetite enough to pay £1 as described above, or to go through the bins.

*

My invitation to Matthew Parris    Click here