If general practice fails, the whole NHS fails | Kailash Chand

Anyone who has visited their GP recently will be aware of the pressures: the struggle to get an appointment, the difficulty of seeing the same GP more than once, the rush to get you out of the door for the next patient.

The crisis in general practice is unprecedented. The health secretary, Jeremy Hunt, fails to understand the seriousness of the situation facing general practice in England.

There are now 8,000 GP practices in England – one in 20 has disappeared since 2010. The rate of loss of local surgeries has increased. There has been a fivefold rise in the number of GP surgeries approaching senior NHS managers for advice about shutting their doors or merging with nearby practices. Furthermore, a freedom of information request by Pulse magazine revealed 58 practices closed in 2016, with a further 34 shutting because of mergers.

The failure to acknowledge the crisis facing GP services – an under-resourced, over-stretched shell of their former self, struggling to keep pace with patient demand despite the efforts of their staff – could finish off the general practice, “the jewel in the crown of the NHS”, in next few years for good. Hunt never tires of saying GPs are central to his vision for the NHS. But the gap between policy rhetoric and reality has never been starker.

The NHS has the most stressed GPs by western standards, as a result of relentless workloads, endless bureaucracy and the shortest time spent with patients. We have been squeezing the lemon for all sorts of healthcare needs for years. But it is getting to the stage where there is nothing left to squeeze.

The government is asking GP practices to provide more services, including many involving the transfer of hospital care into the community, without the resources required to successfully deliver them. And now, NHS England wants 12 hours a day, seven days a week opening in general practice.

There are not enough GPs to cover current working hours. The colleges want 10,000 more GPs to service the present demand. The promise of 5,000 new GPs not only ignores the fact that the pressures of the profession are putting medical graduates off joining, but also that it takes a good eight to 10 years to train. Practically, it’s not possible to pull so many GPs out of the hat.

Despite all this, Hunt talks of more care in primary care, more access, initiatives and ideas – ignoring the workforce crisis, a funding disaster and the committed GPs facing burnout. General practice’s share of the NHS budget has fallen progressively in the past decade, from a high of 11% in 2006 to less than 8.5% now. Many practices will see further reductions over the next three years, forcing further closures. A combined financial and staffing crisis could cause chaos in primary care for years and ultimately kill off general practice for good.

The root cause of the crisis is this unprecedented combination of rising patient demand and declining resources. Practice incomes have been frozen for several years and this has led to real net incomes dropping by more than 20% since the introduction of the GP contract in 2004. Practices are being brought to their knees by this unprecedented fall in money for primary care and rising demand for GP services. Primary care is imploding faster than people realise and patients are already bearing the brunt of the problem.

General practice is the bedrock of many NHS services and the gatekeeper to the rest. We can either confront the realities facing practices and make plans now to meet growing challenges – or we can bury our heads in the sand and watch this key part of the health service slide into terminal decline.If general practice fails, the whole NHS fails.

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If general practice fails, the whole NHS fails | Kailash Chand

Statins advice to GPs is a victory for vested interests more than evidence | Kailash Chand

Statins could be prescribed to more men and women, with a smaller sized risk of heart condition, right after the NHS medicines watchdog lowered the bar for prescriptions.

Good (the National Institute for Overall health and Care Excellence) has issued advice that proposes lowering the cardiovascular primary prevention chance threshold – the degree of danger at which statins can be prescribed – from 20% to 10%.

Several believe that such advice would not have the self-confidence of the pros charged with its implementation. In Could a nationwide conference of general practitioners passed a unanimous movement calling for Good to recommend such adjustments only on the basis of a complete disclosure of trial information. This was followed in June by an unprecedented open letter to Wonderful from a variety of senior medical doctors and academics expressing four major areas of concern: medicating wholesome folks non-disclosed side-result information relying on market-funded statins trials and conflicts of curiosity within Good.

Nice is basing this advice on an examination of market-sponsored trials that might have exaggerated benefits whilst under-reporting harm. Most statins data is presented employing relative chance, which inflates benefit. For example, the heart safety review claimed a forty% reduction in mortality from cardiovascular disease, but the reduction in overall mortality was .3% per yr.

Concomitantly, the side-result information has been declared commercially out of bounds, leaving medics and individuals unable to evaluate the cost-advantage of these drugs.

I have been a GP for more than thirty years and prescribed statins with little concern, right up until I took statins myself for in excess of two years. I developed side-results like myalgia, backache and rest disturbance. I stopped taking statins and my signs and symptoms largely disappeared.

An intervention trial evaluating rosuvastatin unveiled that one particular in one hundred females taking a statin risked building type 2 diabetes at one.9 years. For these individuals the chance of contracting diabetes is roughly the same as the likelihood of keeping away from a non-fatal heart attack. For individuals with a minimal danger of cardiovascular illness, 130 men and women require to get statins for a 12 months to avoid just one undesired overall health outcome.

Wonderful describes itself as follows: “We offer independent, authoritative and proof-based advice on the most successful methods to avoid, diagnose and deal with ailment and unwell health …”

The health care occupation should hence assume Great to base its findings on full data disclosure and independently evaluated cost-benefit of statins. Nevertheless, it transpires that eight out of twelve people on the Wonderful guideline improvement group have ties to the drug organizations, and Wonderful is recommending this guideline on the basis of the Cholesterol Therapy Trialists Collaboration drug-business-funded trials. Nice simply asserting that is independent seems unconvincing.

At existing, it is estimated that about 7 million individuals in the United kingdom consider statins. If Great guidance is followed the number could enhance by numerous million. The evidence for the benefit in major prevention – ie preventing cardiovascular condition in men and women who do not have any diagnosed cardiovascular ailment – is weak.

Three-quarters of people having a 1st heart assault, for instance, have standard cholesterol amounts. According to the Planet Well being Organisation, 80% of cardiovascular illness is caused by smoking, inactivity, an unhealthy diet regime, and other way of life variables. Statins give the illusion of protection to numerous individuals who would be significantly much better served by merely strolling more and staying away from processed food.

Excellent medicine ought to usually be proof based and offered to the correct patient at the proper time. Statins have an important position in patients who have an current heart illness or have had a heart assault. Sufferers should be wary of these guidelines, and engage in meaningful dialogue with their medical doctor, just before deciding regardless of whether or not to medicate. If growing numbers of folks without having heart condition consider statins it will be a victory for vested interests more than proof.

Statins advice to GPs is a victory for vested interests more than evidence | Kailash Chand

Charging for crutches is the initial unpleasant phase in direction of dismantling the NHS | Kailash Chand

‘The reason people are issued with these devices is because there is a clinical need for them; it is not a nice luxury they could do without.’ Photograph: DNY59/Getty

There is little doubt that the NHS is under huge strain from a period of sustained austerity. In this difficult economic climate it is not surprising that local NHS bodies across the country are having to make difficult choices in agonising circumstances – but we must not allow this to compromise the founding principles which have sustained our health services since its creation.

South Warwickshire clinical commissioning group (CCGs) is clearly facing serious financial issues, caused by the government’s failure to recognise that the NHS is struggling to cope with rising patient demand, especially from our ageing society. It is the lack of understanding of these pressures that is causing CCGs like South Warickshire to look at plans like alternative income streams.

Unfortunately in that case consideration now appears to being given to introducing charging for essential medical equipment such as walking sticks, knee braces and wrist splints. Let us be under no illusion that this is a trivial proposal, or something that will not affect patients. The reason people are issued with these devices is because there is a clear clinical need for them from the patient’s perspective; it is not a nice added luxury they could do without, it is a key part of reducing pain and improving a patient’s life. As such this is a small part of the wider ideology that has made our health service so cherished by British people: if you need help with your health you get it, free of charge, regardless of your background, wealth or status in society.

By putting in place a system of charging for any form of treatment you are eroding and damaging that key principle. The fact is that, with any charge, there are people who will be able to afford these items and those who will not. In this case, many older, frail people, and those on low incomes with small budgets, will be faced with a choice as to whether they pay for devices they badly need or keep the money back to pay for essentials, like keeping their house warm or putting food on the table.

As a consequence we will be opening up a huge gap between the haves and have-nots in the NHS. We will be returning to a dark, terrible period before the second world war when the quality of your health depended on the size of your bank balance. This was an era that as a society we firmly closed the door on – we do not now need to reopen that door by stealth.

From a practical point of view, another economic argument arises that undermines any plan to introduce charges. If people are discouraged by charges for getting essential equipment, then their health will invariable be compromised as their wellbeing will worsen. This will result in patients needing more admissions to hospital, visits to the GP and so on. In the long term, this measure will therefore end up costing the NHS more money and waste further time, exacerbating the very problem that the charging is supposed to solve.

No one should be against CCGs and others making sure every penny is spent wisely. But we cannot and must not set ourselves down a path that devalues our cherished health system, and starts the process of splintering the delivering care based solely on how much money people have in their bank account.

Charging for crutches is the initial unpleasant phase in direction of dismantling the NHS | Kailash Chand