Who is the Blame for AE overcrowding ?

The health secretary Jeremy Hunt blames general practitioners (GPs) for the overcrowding crisis in UK emergency departments,1 because GPs gave up responsibility for out of hours care in 2004. Is this fair? Before 2004, GPs had 24 hour responsibility for patient care. General practice has always been hard work, but demand and expectation were increasing unsustainably in the 1990s. Middle aged GPs (without the protection of junior staff) were often up through the night yet working the next day. Compared with hospital colleagues, the pay and status were poor. GPs were hugely undervalued. General practice was in crisis, with talk of widespread professional burnout.⇑

As a consequence GPs started forming local cooperatives, sharing the burden of out of hours care. For many doctors, being on call just three or four sessions a month was a revolution in working, and eased the pressure. This model was inexpensive, worked well, and care was provided by locally accountable doctors. And many of us took pride in not referring patients to hospital, temporising until the patients were seen by their own GPs the next day.

But the Labour government offered to take all out of hours responsibility away from GPs. It introduced NHS Direct, offering telephone advice, and vetting out of hours requests for GPs. The intent was to reduce demand and costs. But telephone advice is fraught. NHS Direct became institutionally risk averse, addicted to clumsy clinical algorithms that often dispatched unnecessary ambulances. Access to GPs out of hours became bureaucratic, with distant call handlers and call backs taking hours. Many patients simply bypassed this mess and went straight to hospital emergency departments. NHS Direct’s costs spiralled.2

As for out of hours consultations, initially it was older, experienced GPs who continued to provide care, but eventually they stopped. Fewer younger GPs had the experience or mindset to work out of hours. Facing a recruitment crisis, GPs were shipped in at great expense from outside the area, this policy filling Daily Mail polemics. And doctors are never blamed for doing too much, so inexperienced and disconnected doctors have a much lower threshold for sending patients to hospital. Continuity, localism, and experience were lost. Lastly, society became more anxious about health, fuelled by the media peddling fear. These are the foundations of the overcrowding in emergency care.

How do we fix it? Keep it simple. Locate emergency departments in primary care centres, and make out of hours primary care available on a walk in basis. Pay GPs to take back out of hours telephone triage, and keep some morning slots open so that out of hours demand can be deferred. Monitor this. Finally, insist that emergency staff rotate through general practice, because overinvestigation in emergency care adds huge pressure on resources. Nobody wins in a blame game.

Bad Medicine: Diabetic Medication

Type 2 diabetes is a modern plague largely brought on by lifestyle and is considered a progressive, non-reversible condition. The polypharmacy of chronic disease is the drug industry’s lottery win, and no more so than in diabetes, with new drugs and the increasing use of analogue insulin in type 2 diabetes worth tens of billions of pounds worldwide.1 ⇑

The drug industry’s business plan for diabetes follows a familiar pattern:

(1) Conduct questionable research and control the original data.
(2) Schmooze the politicians, health regulators, and patient groups to suggest undertreatment and need for “urgent action.”
(3) Recruit tame diabetologists, massage them with cash, and get them to present at marketing events that masquerade as postgraduate education.
(4) Pay doctors to switch to newer drugs in dubious international postmarketing “trials.”2
(5) Seek endorsement from the National Institute for Health and Care Excellence to bully doctors to treat diabetes aggressively with drugs.3
And so the complexities of diabetes are reduced to simply lowering blood sugar.

What is the annual cost of pursuing this reductionist, drug based approach? In the past decade, spending on insulin in the UK has risen 300%, to £311m4 (€356m; $463m), and on oral diabetic drugs 400%, to £277m. And have you ever wondered why companies generously give away glucose meters? Test strips are a £166m market, the value of which has risen 300% in 15 years.4 Factor in staff time (when not attending more educational updates sponsored by the drug industry) and the patient and family’s time, and you have a great but expensive business.

But do analogue insulins, new diabetic drugs, and self monitoring of blood glucose improve outcomes? Does even tight glycaemic control make a difference? No data on mortality or morbidity exist for the new therapeutics.5 6 7 8 9 10 11 Likewise intensive glycaemic control is not superior with respect to mortality and cardiovascular disease.12 So billions of pounds are being spent chasing a ghostly surrogate endpoint: low blood sugar. Worse, there is evidence that these new drugs cause harm. Rosiglitazone has already been withdrawn; pioglitazone has been linked to bladder cancer; and exenatide and sitagliptin double the risk of acute pancreatitis.13 14 All this is an example of the scientific illusion that is so called evidence based medicine, where research is just mechanically reclaimed statistics pulped into junk educational nuggets—mere marketing by another name.

There remains another fundamental question. Can diabetes be reversed or cured by weight loss? A small, well designed study of 11 patients irrefutably showed that it can.15 And clinical effect is more important than any statistically significant yet clinically undetectable effect that a huge study funded by the drug industry might find. The therapeutic approach in diabetes is upside down. Incredibly, spending on diabetes drugs could employ 40 000 personal trainers. The complicity of doctors and lack of dissent against the drug model of diabetes care is bad medicine.

References
↵Cohen D, Carter P. How small changes led to big profits for insulin manufacturers. BMJ2010;341:c7139.FREE Full Text
↵Gale EA. Post-marketing studies of new insulins: sales or science? BMJ2012;344:e3974. FREE Full Text
↵National Institute for Health and Care Excellence (NICE). Blood-glucose-lowering therapy for type 2 diabetes. April 2013. http://pathways.nice.org.uk/pathways/diabetes#path=view%3A/pathways/diabetes/blood-glucose-lowering-therapy-for-type-2-diabetes.xml&content=view-node%3Anodes-considering-triple-therapy.
↵Health and Social Care Information Centre. Prescription Cost Analysis—England, 2012. April 2013. www.hscic.gov.uk/catalogue/PUB10610.
↵Davidson MB. Counterpoint: self-monitoring of blood glucose in type 2 diabetic patients not receiving insulin: a waste of money. Diabetes Care2005;28:1531-3.FREE Full Text
↵Horvath K, Jeitler K, Berghold A, Ebrahim SH, Gratzer TW, Plank J, et al. Long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus. Cochrane Database Syst Rev2007;2:CD005613.Medline
↵Van de Laar FA, Lucassen PL, Akkermans RP, Van de Lisdonk EH, Rutten GE, Van Weel C. Alpha-glucosidase inhibitors for type 2 diabetes mellitus. Cochrane Database Syst Rev2005;2:CD003639.Medline
↵Shyangdan DS, Royle P, Clar C, Sharma P, Waugh N, Snaith A. Glucagon-like peptide analogues for type 2 diabetes mellitus. Cochrane Database Syst Rev2011;10:CD006423.Medline
↵Black C, Donnelly P, McIntyre L, Royle PL, Shepherd JP, Thomas S. Meglitinide analogues for type 2 diabetes mellitus. Cochrane Database Syst Rev2007;2:CD004654.Medline
↵Richter B, Bandeira-Echtler E, Bergerhoff K, Clar C, Ebrahim SH. Rosiglitazone for type 2 diabetes mellitus. Cochrane Database Syst Rev2007;3:CD006063.Medline
↵Ooi CP, Loke SC. Colesevelam for type 2 diabetes mellitus. Cochrane Database Syst Rev2012;12:CD009361.Medline
↵Hemmingsen B, Lund SS, Gluud C, Vaag A, Almdal T, Hemmingsen C, et al. Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 diabetes mellitus. Cochrane Database Syst Rev2011;6:CD008143. Medline
↵British National Formulary (BNF). www.bnf.org/bnf/index.htm.
↵Singh S, Chang HY, Richards TM, Weiner JP, Clark JM, Segal JB. Glucagonlike peptide 1-based therapies and risk of hospitalization for acute pancreatitis in type 2 diabetes mellitus: a population-based matched case-control study. JAMA Intern Med2013;173:534-9.Medline
↵Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia2011;54:2506-14.CrossRefMedlineWeb of Science
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The Doctor Won't See You Now ! The Problem of cancelled appointments

Time is money, and no more so than in medicine, with the NHS spending £40bn a year on wages.1 So we complain about the 10% of patients who did not attend at hospital clinics, wasting our precious and expensive time. Some doctors even take it as a personal affront. We have policies for these DNAs, and we send out angry letters, talk of fining patients or sometimes of removing them from practice lists, and complain to the newspapers about the wasted millions.2

Yet DNAs happen for many reasons: a wrong address or an inability to cancel the appointment because of busy or unanswered hospital telephone lines, for example. Also, with a unexplainable 10-fold variation in referral rates between doctors,3 patients often simply do not understand why they have been referred in the first place.

We doctors naturally see problems from only our own perspective, but there is another narrative to hospital appointments. Patients complain about poorly organised, chaotic clinics; waiting for hours; lost case records; and never seeing senior staff or the same doctor twice. And then there are cancelled clinics. Anecdote suggests this is common, and evidence from Northern Ireland indicates a rate of about 10%,4 similar to that for DNAs. As for DNAs, cancelled appointments represent wasted clinical time that the NHS never gets back. But unlike DNAs, cancelled appointments involve higher costs, with time consuming administrative rescheduling and the cost of posting millions of letters. Then there are ambulances and patients’ transport to rearrange.

We should not underestimate the inconvenience to patients and their families, many of whom will have taken time off work, waiting months only to find their appointment unapologetically cancelled and delayed. This reflects badly on the NHS, with slow service made worse. And with a 5% annual growth in outpatient referrals the current pressures seem unsustainable.3 Lastly, the private sector is desperate to find fault and expose inefficiencies to usurp NHS services.

We cannot control DNAs, but we can do more to control cancelled appointments. (Writing about the many unnecessary soft “return appointments,” which comprise two thirds of appointments, would fill another column.) The most common reasons given for cancellation are “consultant unavailable” and “consultant cancelled appointment,” and often there is no explanation.4 Cancelled clinic rates are too high, unacceptably inconvenient to patients, and hugely inefficient yet the topic is hugely under-researched. Why?

Margaret Thatchers Medical Legacy

Rats on the streets during the bin collectors’ strike, the Green Goddesses, wildcat strikes, flying pickets, the closed shop, block votes, “one out all out,” restrictive work practices, double digit inflation, a three day week, and a winter of discontent. The 1970s in Britain were a time of national crisis, with undemocratic and out of control trade unions.

The Conservatives won the 1979 election: working class people had voted for change. The Thatcher government crushed the unions’ power, but the price was broken communities, public disorder, and mass unemployment. The industrialised north and Scotland paid the heaviest price, while the south east and London experienced economic renewal. Margaret Thatcher was a saviour to some, a political savage to others; this was her divisive legacy. Thatcherism set off a cascade of consequences: the current deregulation of the NHS is simply her unfinished free market business.

There is another Thatcherite legacy—worklessness. During the 1980s and 1990s, unskilled middle aged men were haemorrhaged from heavy industry, with no hope of work in the new service based economy. So general practitioners were encouraged to redefine the unemployed as “sick” to get the unemployment figures down. We colluded, because this meant some improvement in meagre benefits for patients. So this worklessness doubled between 1985 and 1995, to more than two and a half million people, but varied hugely by region. Today in areas of Glasgow, 17% of the working age population is deemed too sick to work, eight times more than in Hampshire.1 (These figures do not include people officially deemed unemployed.) This huge difference can be explained only as a social phenomenon; it cannot reflect true variation in disease or disability.

Worklessness is a modern medical scourge. With 1.8 million children living in workless households,2 it is associated with poor child development and schooling, behavioural issues, unhappiness, and increased risk of being a NEET (“not in education, employment, or training”) at age 18.3 For adults, worklessness is bound to poverty and premature death.4 It is worklessness that has created the chasm of inequality, leaving millions of children in poverty. These are society’s new precariat, and society’s elite are unwilling or unable to tackle this pernicious sickness. But welfare reform must happen, whatever the lobbying, protests, and conflict.

Welfare reform is not about paying down the national debt but about saving the mental and physical welfare of millions of marginalised people. And today there is a public consensus for change.5 We must break the cycle of worklessness. This will take Thatcherite conviction, steely leadership to see it through, a willingness to be disliked, and even historically to be considered divisive. Worklessness and welfare are a national crisis, and reform must not be for turning.

Immigrant Song

My family landed in a closed rural Scottish community in the 1970s, in Afghan coat and beads, something truly alien, the first of the English “white settlers.” I know something of immigration, something of the hostility and mistrust it generates. Humanity has two equal but opposite forces—to strive to conform and to strive to be different. So the outsider is to be feared and welcomed in equal measure.
Immigration is again rising up the political agenda. The truth is that immigration does put pressure on public services, housing, health, education, and employment. And these pressures land squarely on the most deprived in society. Yet immigration is an abstract concept to the middle class, which is personally untouched by its negative consequences. Immigration is a real problem, with real potential for conflict and resentment. There is a need for real debate about resources.
But immigration has a much more fundamental, profound, and long term impact.
Glasgow, like every postindustrialised northern city, is a place to leave. And hundreds of thousands of people fled in the 1970s, 80s, and 90s, never looking back, and leaving a scale and complexity of social problems that is difficult to articulate. Although the rest of the country and the economy roared on, the northern cities were stagnant, our forgotten untouchables trapped in a prison of housing schemes, benefits, drink, drugs, and violence. Inner city youths were either knocked up or banged up. Men and women of an underclass were cast as just “chavs” and “neds” to the majority, under a national social segregation policy based on class. Britain’s single greatest social issue has been the subject of mere political tokenism and ignored by successive governments of all colours. Despair was the only game in town, with medicine left sweeping up the body parts of hopelessness.
But in recent times the UK has sucked in immigrants, even into places like Glasgow. People without choice, economic migrants or asylum seekers, have been forced into concrete social housing and failing inner city schools to live among the marginalised. And like previous waves of immigration it is changing the psyche of our depressed cities.
Immigrants often have strong values and culture and are hard working, driven, and focused on education. Their children do well at school. Immigrants are agents of change, offering something that political initiatives do not: change from within. The current abrasions from immigration will heal. And immigration’s real gift is not economic but what it offers our poor—hope.

Why Doctors Must Do House Calls !

Like many doctors of a certain generation, I’ve made many thousands of house calls. I’ve been barked at by poodles, rottweilers, pit bulls, and chihuahuas. Taken lifts full of graffiti, vomit, urine, and Buckie wine bottles. Walked up blacked out stairwells using the torch of my auriscope to guide me, with the crunch of used syringes under foot. Met countless fresh faced police officers and seen death in every manifestation. And announced death to screams, cries, sobs, and hysterical laughter. Detained patients under the Mental Health Act at 3 am. Stood on blood, pus, and excrement soaked nylon carpets. Conducted mouth to mouth resuscitation. Driven in the middle of the night through rain, snow, and wind. Suppressed my fear and steadied my hand to inject penicillin while watching the rash of meningococcal septicaemia. Assessed neurotic, psychotic, myopic, sociopathic, and alcoholic patients in the comfort of their own homes. All with no lone worker status and no risk assessment.

I’ve been pushed to the edge professionally, emotionally, and physically. I’ve done what I could, and I did my best. No Dr Kildare or ER, but real hand to hand medical combat chaos. House calls gave me insight and made me a doctor in practice, not just on paper.

But house calls are losing favour. Practices sometimes refuse them, and the once common regular visits made to older people are long gone. Domiciliary visits by consultants seem all but extinct. House calls are considered inefficient and even risky on health and safety grounds. Increasingly we see patients only on our own consulting room turf, sanitised and controlled. Doctors seem to live separate, distant, parallel lives, with a decreasing knowledge of the communities we serve. Yet you learn so much from house calls. You see how people live and the practical problems they face; you meet families, neighbours, and home helps. You get to understand the limitations of healthcare in the context of people’s social situations. You glean something of patients’ personal lives from family photos, music, and pictures. But most of all, doctors learn to cope.

The aspiration to deliver “holistic care,” with an understanding of people’s psychological, physical, social, and spiritual needs, is mere lip serve without home visits. And the goal for more patients to die at home, to limit hospital admissions, and to improve communication is not achievable without a willingness to see patients at home. The house visit is at the heart of medicine, with doctors seen and connected to the area. While we waste billions on pointless health service initiatives that seem like a good idea in distant medical war rooms, we miss the obvious. We should encourage and support doctors to visit patients in their homes. This is simple, effective, important yet undervalued medical care.

CoCodamol Addiction -Bad Medicine

The UK Home Office has recently highlighted the sharp rise in prescribing, misuse, and deaths linked to tramadol.1 We’ve known tramadol as a problem in general practice for years. And death from prescription drugs is but the merest tip of an addiction iceberg, with at least 800 other misusers for every death, according to US data.2 The UK has been slow to acknowledge misuse of prescription drugs, a problem described as an epidemic in the US, where prescribed opioids kill 15 000 people a year2 and misuse of prescription drugs is as big a problem as illegal drugs and alcohol.

We have another, far bigger potential problem than tramadol: codeine combined with paracetamol—co-codamol. A parliamentary report in 2009 highlighted addiction to low strength co-codamol sold over the counter.3 The report called for more awareness, control, and education. Yet since this report, use has increased further, with a doubling of co-codamol prescriptions in a decade.4 Prescribed co-codamol is stronger and is dispensed in much larger pack sizes than that sold over the counter. Indeed, doctors prescribe five times as much total codeine than is bought over the counter.4 5

I witness addictive behaviours, especially with co-codamol 30/500 (30 mg codeine phosphate and 500 mg paracetamol per tablet), with patients massively exceeding the recommended dose, taking many tablets as a single dose, and sourcing prescriptions from relatives. Patients can be aggressive and defensive if questioned and experience classic physical and psychological opioid withdrawal. Patients risk fulminant liver failure from unintentional paracetamol poisoning. The medical indication for co-codamol was a long forgotten, vague, musculoskeletal pain. Yet repeat prescriptions of co-codamol are churned out monthly on repeat prescribing systems, out of the sight and consciousness of doctors. Co-codamol—a legal, seemingly safe, and legitimate addiction—has an atypical dependent population: young women. This may be simple anecdote lacking in evidence, but the internet rattles with accounts of co-codamol addiction. There are also huge anomalies in prescribing, with a fivefold difference in prescribing rates by region, unexplainable by disease rates.6

Doctors have been encouraged to use opioids in non-malignant pain syndromes, told that, if used therapeutically, opioids do not cause addiction. This is not true. Co-codamol addiction is grossly under-reported because official statistics relate to referrals to addiction services. General practitioners do not refer patients with co-codamol dependency to addiction teams. The true scale of the problem is reflected in a UK website for codeine dependence, which has counted more than three million visitors since 2007.7 We need some urgent research, action, and honesty. Doctors and patients are in denial about the scale of unaddressed addiction to co-codamol. This is very bad medicine.

Notes
Cite this as: BMJ 2013;346:f1821

Footnotes
Provenance and peer review: Commissioned; externally peer reviewed.

Follow Des Spence on Twitter @des_spence1

References
↵ACMD Advisory Council on the Misuse of Drugs. ACMD consideration of tramadol. Home Office, 2013. www.homeoffice.gov.uk/publications/agencies-public-bodies/acmd1/advice-tramadol.
↵Centers for Disease Control and Prevention. Policy impact: prescription painkiller overdoses. CDC, 2012. www.cdc.gov/homeandrecreationalsafety/rxbrief/.
↵All-Party Parliamentary Drugs Misuse Group. An inquiry into physical dependence and addiction to prescription and over-the-counter medication. 2007-2008 parliamentary session. www.drugscope.org.uk/Resources/Drugscope/Documents/PDF/Appgotcreport.pdf.
↵NHS Information Centre. Prescription Cost Analysis—England 2011. www.ic.nhs.uk/searchcatalogue?productid=5461&q=%22Prescription+Cost+Analysis%22+&topics=0%2fPrescribing&sort=Relevance&size=10&page=1#top.
↵PAGB Proprietary Association of Great Britain. OTC medicines and addiction. PAGB, 2012. www.pagb.co.uk/factsheets/codeine.html.
↵NHS National Treatment Agency for Substance Misuse. Addiction to medicine: an investigation into the configuration and commissioning of treatment services to support those who develop problems with prescription-only or over-the-counter medicine. www.nta.nhs.uk/uploads/addictiontomedicinesmay2011a.pdf.
↵Codeinefree: Raising awareness of codeine and dihydrocodeine dependency. www.codeinefree.me.uk/.