Exclusive The RCGP is to consult its members on whether the college should support a parliamentary bill that

would change the law on assisted dying for terminally ill patients.

The move could lead to the college becoming the first medical college or body to support assisted dying.

The consultation, to be announced tomorrow, follows a letter to The Times newspaper today from a dozen senior

doctors supporting a change in the law over the issue.

The letter, from 12 former leaders of medical royal colleges was prompted by the Assisted Dying Bill tabled in the

House of Lords by Lord Falconer of Thoroton, the former Lord Chancellor.

The bill aims to give a small group of very advanced terminally ill patients whose suffering is not adequately

alleviated by palliative care the choice to legally end their lives if they wish to.

Although no medical royal colleges or bodies currently support assisted dying - with many opposed to it - the

RCGP says it will now ask its members whether it should support a change in the law and that it will release full

details tomorrow.

Professor Gerada said that doctors had a right to hold a view on whether they should help someone to die but

argued that medical royal colleges should adopt a neutral stance on the issue and let society decide.

The letter published today from doctors including Sir Terence English, past president of the Royal College of

Surgeons, Dame Margaret Turner Warwick, former president of the Royal College of Physicians and Dame Fiona

Caldicott, past president of the Royal College of Psychiatrists says: ‘We believe that there is a strong case for the

legalisation of assisted dying for terminally ill mentally competent adults’.

’We hope that the debate among legislators and the public will focus on the central issue. This is whether a small

group of very advanced terminally ill patients should be allowed this degree of control over the end of their life.’

NHS England has told its local area teams to prepare a plan by the end of the month to tackle waiting times in

A&E departments, including how primary care and other services can ease the rising pressure on emergency

services.

NHS chiefs also said today that they will publish a plan over the next week about how they will support local

commissioners and when they will intervene if a CCG is failing to control demand for urgent care services.

The move comes after a political row over waiting times at A&E departments, with Jeremy Hunt blaming ‘poor

primary care provision’ for a rise in A&E attendances since the 2004 GP contract allowed GPs to opt out of out-

of-hours care provision.

Earlier this month, the Labour Party published figures that showed the NHS had missed the national four-hour

A&E wait target every week for six months.

At a board meeting today, NHS England interim chief operating officer Dame Barbara Hakin said she will ask

local area teams to work with CCGs and local government to put together a full plan for how urgent care should

be managed in their local area to reduce waiting times for patients in A&E, involving primary care as well as NHS

111 services.

She said: ‘I will be asking our area team directors to take responsibility for a plan for their local area… and to put

together a full plan by the end of the month.’

‘They will take repsonsibility to make sure patients don’t wait an unreasonable time.’

NHS England chief executive Sir David Nicholson said NHS England will also launch two ‘interventions’ to

ensure continued good care for patients locally next week.

One will be the ‘whole systems plans’ for urgent care, while the other will outline how NHS England will work to

‘develop and support’ CCGs as well as when it is approporate for NHS England to intervene to ensure patients

receive good care locally.

He said : ‘We know there are real pressures on social care, primary care, hospitals… We have been working to

support A&E services and in the last week we have seen some improvement to services but this is a whole

systems issue.’

He said: ‘We will next week publish two interventions. The whole system plans that we expect to be put

together… so that we can begin to see improvements. This is a very important intervention. We will also publish

[a plan for] how to develop and support CCGs, and how to intervene when it is appropriate.’

The board meeting also saw NHS England approving its future plan for NHS 111, which will include an external

review to learn lessons from the failings of the rollout as well as as an internal look at how the service should be

taken forward including whether it has ‘got the scope right’ and if there is ‘a good balance’ between clinical and

non-clinical call handling.

Dame Barbara said: ‘NHS 111 services have been undeniably unacceptable in some places but it is really

important that we remember that in most places it has worked very well.’

She added: ‘Our ambition continues to be that over the next few months we will have 111 available everywhere.’

But the RCGP has called today for better support for NHS 111 to help it properly direct patients to the most

appropriate form of care.

RCGP chair Dr Clare Gerada said: ‘It is extremely worrying that there is still so much uncertainty around the

delivery and reliability of the advice provided by NHS 111 in some areas.

‘We are also concerned that patients are losing confidence in the new service before it is even fully up and

running. We call on NHS England to provide more reassurance about its effectiveness and ability to deliver the

necessary standards of care for all patients using the service, right across England.

The inquiry led by Robert Francis QC into the horror story that was the Mid Staffordshire scandal sent

shockwaves through the medical profession as well as the rest of society.

Doctors have been criticised for not being ready enough to question the system when things go wrong.

Mr Francis himself singled out local GPs for only raising ‘substantive’ complaints once the investigation had

already been set up.

And with GPs now in the commissioning driving seat, the onus appears to increasingly be on general practice to

stop the next Mid Staffs before it happens.

But are GPs really in a position to police quality across the wider NHS?

A Pulse survey of 343 GPs suggests even when the profession does raise concerns about the quality or safety of

hospital care, they are too often ignored. Some 40% of the GPs who responded had raised concerns about care

with their local hospital in the past 12 months alone.

But of those who had raised concerns, almost a third (31%) said their information was not listened to or, where

appropriate, acted on, while a similar number (30%) said they do not know if their complaint was acted upon.

Among the issues the GPs reported were medication delays, discharge errors and high rates of readmissions

after premature discharge.

Patient ‘shouted at’
 

One GP from Birmingham, who says their patient was shouted at and then refused admission to A&E at their local

foundation trust, despite needing urgent care, says: ‘It turned out the patient was in terminal renal failure and our

registrar had every right to send him in.

‘The patient eventually went to another hospital and ended up in intensive care.

‘The consultant sent a letter back saying it would be investigated in the hospital and it should not happen again

but we have heard nothing since – it was just to protect themselves.’

Dr Mary Hawking, who recently retired after over 30 years as a GP in Bedfordshire, said she had raised many

concerns stemming from the poor quality of discharge from hospitals.

She says: ‘The problem is, you send off a complaint and it gets completely lost. I’ve tried various tactics, sending

it to the chief executive [of the trust], to the PCT, trying to get the official channels involved and nothing at all

happens.’

A duty of candour
 

Problems of this kind are not new.

Last year, Pulse revealed a similar high level of concern among GPs about standards of care at local hospitals,

with one GP in seven claiming that one or more of the departments at their local hospital was ‘dangerously

substandard’.

But the Francis Inquiry has concentrated minds on the role of GPs in ensuring quality of hospital care.

One of its central recommendations was that GPs should play an active role in monitoring hospital care and have

systems to identify ‘patterns of concern’.

At the time of the publication of the report, Prime Minister David Cameron backed the recommendation, calling for

GPs to be ‘more enquiring’ about what happens to their patients in hospital.

Ministers have said that they want all providers to have a ‘duty of candour’ over their mistakes but have not

clarified how this will apply to practices.

The Government is introducing chief inspectors for hospitals and care homes – and considering the equivalent

for primary care – but it is not clear how this will prevent the ‘next Mid Staffs’ that is predicted by some

commentators.

Dr Grant Ingrams, a GP in Coventry, says: ‘There is still a question over what duty is going to be placed on GPs. If

it is to notify whoever we believe is the appropriate person each and every time we find a problem and to actively

monitor patients when they are in hospital, we can’t do it.

We don’t have the resources.’

A spokesperson for NHS England says it ‘strongly supports’ the recommendation that GPs should take a greater

role in monitoring the quality of their patients’ hospital care.

She says: ‘The introduction of clinical commissioning groups provides an unprecedented opportunity for GPs

and GP practices to work together more collaboratively and systematically in sharing intelligence about quality of

care for their patients.’

RCGP chair Professor Clare Gerada says there must be better systems for GPs to ‘feed back patient concerns

about hospital care’, but she draws the line at the profession having formal responsibility for what goes on in

secondary care.

She says: ‘Patients and their GPs need to be confident that they will receive good and safe care in hospital.

[But]

we do need to be clear about where the boundaries lie in terms of the GP’s role here.

‘GPs should not ultimately be responsible for the standards of care in hospitals but it is important that any

concerns GPs have are raised, to help hospitals improve patient care.’

The GPC agrees, saying CCGs should assume the responsibility for collecting data and making it easier for

practices to raise concerns.

Dr Chaand Nagpaul, GPC negotiator, says: ‘Individual practices should certainly be able to relay feedback, but we

need to be realistic about the extent to which GP practices can provide information about hospitals – we can’t

assume GPs hold all the keys to assessing hospital performance.

‘I think this a role for CCGs – they should be facilitating the processes to allow practices to raise concerns as part

of their commissioning function.

‘In my area we have a “service alert” form. The GP practice sends that to the CCG so even for a single event, if

many practices notice the same problem it helps to identify trends and take action on service issues.’

CCGs take action
 

There are signs that CCGs are getting the message.

The CCGs that have taken over the Staffordshire area say they are looking closely at how they can monitor their

providers more closely.

Andrew Donald, chief officer for Stafford and Surrounds and Cannock Chase CCGs, says: ‘We’re Mid Staffs, we

have to be exemplars for the new system.’

He adds: ‘We have a fairly structured way of getting feedback.

There’s an information sheet that we ask people to complete and send through, and if there’s a problem with an

acute trust there’s a GP advice line that directs into Mid Staffs.

This has been well established for three years now.

‘We’re also asking GPs to get their patients to keep diaries to write about their experiences as they go through the

system.

We have had discussions on Francis – about GPs not abdicating responsibility for their patients once they have

left the surgery.

It’s about saying, “how do we follow patients through?”.

‘The idea of having patient diaries could be a good way of doing that – creating opportunities for patients to give

feedback as they’re going through the process.’

Dr Michael Dixon, interim president of NHS Clinical Commissioners, says CCGs will be ‘morally obliged’ to act on

the concerns of GPs.

He adds: ‘I think CCGs will want to put resource towards this, because this is part of improving and redesigning

services.

This will not only involve totting up the problems but also the solutions as well – which probably pay for the job in

terms of saving resources for the future.

‘I think there may be short-term benefits – if patients receive atrocious care I can see CCGs not paying the bill,

putting a service on hold or on probation.

‘What we’re stymied by at the moment is the complete paralysis of the past, where if a patient had a bad deal, all

the payments had been made in the past through payment by results.

This is exactly the sort of re-engineering that CCGs are going to need to do; if you get
 

a shoddy service, you don’t pay for it.’

One complicating factor for GPs in this new era of openness could be the CCGs themselves, however.

Last month a Pulse investigation revealed that hundreds of GPs have been obliged to sign up to ‘gagging

clauses’ under their CCG constitutions.

While GPs have historically been free to speak publicly and to the media about their local NHS, from 1 April more

than 200 practices across five CCGs – NHS Newbury and District, NHS Sutton, NHS Dorset, NHS Thurrock and

NHS Windsor, Ascot and Maidenhead – have been prevented from making any ‘public statement’ about CCG

matters without prior written approval. Members of the governing bodies of five further CCGs are bound by similar

clauses.

Such clauses do not remove GPs’ ability to blow the whistle on specific concerns about patient safety, and CCG

leaders have defended the move, insisting it is simply to ensure a ‘consistent view’ on local services.

But critics have attacked the clauses as unacceptable, with the GPC warning that ‘in the post-Francis world,

practices should not be restrained or put under any pressure with regards to not voicing concerns’.

A key plank of the reforms was to shift power and influence into GPs’ hands, but it seems GPs will need to keep

fighting on all fronts to make sure their voices are heard

GPs have a duty to raise concerns with their own employer or with external providers under the GMC Good

Medical Practice guidance.

Their overriding ethical responsibility means they have an obligation to take action if they think that patient safety,

dignity or comfort has been seriously compromised. GPs should not enter into a contract that prevents or

restricts them from raising concerns about patient safety. 

The GMC’s supplementary guidance Raising and acting on concerns about patient safety (2012) explains how to

take action and what to do if the concerns are not acted on, or are not acted on properly. Paragraphs 7 and 8

explain the duty to raise concerns as follows:

‘All doctors have a duty to raise concerns where they believe that patient safety or care is being compromised by

the practice of colleagues or the systems, policies and procedures in the organisations in which they work. They

must also encourage and support a culture in which staff can raise concerns openly and safely.

‘You must not enter into contracts or agreements with your employing or contracting body that seek to prevent you

from or restrict you in raising concerns about patient safety. Contracts or agreements are void if they intend to stop

an employee from making a protected disclosure.’

Most GPs will have very constructive working relationships with colleagues in secondary care and will be able to

resolve any concerns informally in a prompt and satisfactory way.

Where there is a systemic or significant patient safety concern then it is appropriate to go to someone higher up

in the organisation who has operational oversight and will be able to delegate responsibility for investigating the

concerns to the right person and take the necessary action. 

Where serious patient safety concerns are identified, the stages described below will help ensure that they are

raised in a prompt, proportionate way.

Stage 1

1. Report concerns immediately – do not delay as you are not in a position to put the matter right yourself.
2. This may be by telephone initially, but put your concerns in writing to the trust’s medical director or other appropriate officer to ensure that they are accurately summarised and reported
3. Keep a clear record of concerns, the steps you have taken and all correspondence
4. Expect a prompt investigation and a written response from the trust explaining what was found and any action taken to rectify the problem
5. If no response or an unsatisfactory response is received, consider escalating complaint further – see Stage 2.

Stage 2

1. Escalate the complaint within the trust. Contact the trust’s chief executive, including all details and correspondence
2. Also consider informing commissioners. Speak to your CCG board, CSU or NHS England local area team medical director
3. If no response or an unsatisfactory response is received, consider escalating complaint further by raising the matter with the relevant regulator – see Stage 3.

Stage 3

1. If you have not been able to raise the issue locally with the responsible person because they are part of the problem, or where your concerns have been dismissed without good cause and where there remains an immediate and serious risk to patients then your duty is to raise the matter with the regulator (e.g. GMC or CQC) who may have responsibility to act.
2. If you are unsure get advice from your medical defence organisation, BMA/LMC, professional bodies, the NHS Whistleblowing helpline (http://wbhelpline.org.uk/) or Public Concern at Work (a charity that provides free, confidential legal advice)

Stage 4

1. In exceptional circumstances, where the stages above have been followed but you believe that patients remain at risk of harm, you may consider whether to make your concerns public
2. You should get advice from your medical defence organisation or other bodies mentioned in stage 3 before taking such action, and refer to GMC guidance on making concerns public. This guidance says that this is justified provided the concern is formed in good faith and you must be scrupulous in protecting patient confidentiality
3. Don’t disclose confidential information and manage the process carefully. Consider making a single disclosure of essential information to one media organisation you can trust

Dr Michael Devlin is head of advisory services at the Medical Defence Union

Exclusive GP faith in the Conservative Party has plummeted over their health reforms, with only 12% of the

profession saying it is the political party they trust most to manage the NHS.

The Pulse survey of 364 GPs showed Labour was the most trusted on the NHS, with 28% backing the party on

managing the health service. Only 12% backed the Conservative Party, 8% each backed the Green Party and the

Lib Dems, and 6% said UKIP.

By far the largest percentage (35%) thought no party was trustworthy when it came to managing the NHS.

This margin was also translated to GP voting intentions, with 26% saying they would vote for Labour in the next

election and 19% of GPs saying they would vote Conservative.

On the eve of local elections across the country, around 10% of GPs plan to vote for each of the Green Party and

UKIP.

Some 8% said they would vote Liberal Democrat and 4% for a range of other parties including the Scottish

Nationalists, Plaid Cymru, the British National Party, the National Health Action Party and the Monster Raving

Loony Party.

The 255 GP partners who responded were more distrustful of all the main political parties than their colleagues as

a whole, with 36% saying they would not trust any party with the NHS.

The 47 salaried GPs who responded were more likely to vote Labour (44%) and to trust Labour with the health

service (42%) than were other types of GPs.

A Pulse poll in 2009 found fewer than one in ten GPs now planned to vote Labour in the next general election,

with support for the Conservatives at more than 50%.

A similar poll in 2010 found just 15% would vote Labour, and only 17% prefer Labour’s health policies, compared

with 53% who planned to vote Conservative and 30% who supported their health policies.

Dr Robert Morley, executive director Birmingham LMC, said: ‘Trust in this Government has fallen because it is the

current Government and it has shafted us.

Just like the previous Government shafted us, and the just like the next Government will shaft us.

‘It is to do with everything they are doing, through the GP contract, the NHS reforms… they are politicians and

they act to their own ends. We have a job to do which is to look after patients, while their job is to get votes.’

Family Doctor Association chair Dr Peter Swinyard, a GP in Swindon, illustrated GPs’ disillusionment’ with the

political reforms of the NHS.

He said: ‘Politicians don’t run the NHS, they meddle in it. The last politician who tried to do something useful with

the NHS was Andrew Lansley and look where that got him.’

Dr Paul Charlson, a GP and former chair and now head of policy for Conservative Health, said he was ‘not

desperately surprised’ that GPs were cynical over the Government’s handling of the NHS.

He said: ‘I find it a bit disingenuous and disappointing that we spent a lot of time thinking about how to get GPs

involved in running the NHS and so many of them don’t appear to be up for it.’

Dr Richard Vautrey, GPC deputy chair said: ‘The changes in the past two to three years build on those introduced

under previous governments, so all parties are complicit in the changes. And because of the coalition, those GPs

who hoped the Liberal Democrats would bring a new take on things have not been proved right.’

Dr Catti Moss, a GP in Guilsborough, Northamptonshire, said she would vote Green in the next election. She said:

‘The problem is I’ve been a GP since 1982 and I’ve worked through five major reorganisations. All of us can see

the problems but the constant temptation to reorganise gets us into a cycle where the system gets changed but

people don’t benefit.’

Jamie Reed, Labour’s shadow health minister, said: ‘This is a damning indictment of David Cameron’s NHS

betrayal.

‘GPs repeatedly warned the Prime Minister over his chaotic NHS re-organisation and decision to force GP

commissioners to put every contract out to tender, but he ploughed on regardless. Doctors are now abandoning

him in droves – showing a complete lack of faith in the Tories’ handling of the NHS.’

A Conservative spokesperson said: ‘The Conservative Party is putting patients at the heart of the NHS, working

to ensure that the quality of care is as good as the quality treatment, and protecting the NHS budget.’

GP practices have ‘untapped potential’ and should take a more ‘proactive approach’ to improving the health of

their patients, an NAPC-commissioned report says.

The report, carried out by the Nuffield Trust on behalf of the NAPC, said that GPs need to go beyond curing

immediate illness and should proactively prevent ill-health.

It said interventions from the health services could help educate patients on the leading risk factors for illness and

disability, which include hypertension, tobacco, alcohol misuse, high body mass index and low physical activity

to prevent ill health.

GPs, with their registered lists of patients and neighbouring practices with whom collaborations could be

organised, have ‘untapped potential’ to take a more active role in improving health and preventing illness, it said.

The report drew on current research, analysed routine data taken from a notional general practice of 10,000

patients to identify potential actions to improve community health and interviewed GPs and practice managers

currently developing and testing new approaches to population health management with the NAPC.

The report said: ‘General practices, with its registered list of patients, has untapped potential to engage in a more

proactive approach to improving the health and wellbeing of the local population. Such a focus is essential if the

NHS is to meet the challenges of responding to the rising rates of chronic illness at all ages of the population,

during a time of financial austerity.

‘There are already examples of GP-led practices engaging in work to improve access, outreach and management

of both their chronically ill patients and those who are still healthy.’

Stroke and cardiovascular disease are top of the list of conditions underlying emergency admissions, and while

many are appropriate, others may have been avoidable through better preventative care, it said.

It added that significant number of patients would not attend the practice once over the course of a year, therefore

GPs will need to devise ways of reaching out to those registered but not regularly attending, in order to

understand their lifestyle risks.

The report’s final recommendation was that the NHS should encourage CCGs to fund GP lead roles in population

health, in order to create enthusiastic leaders who will articulate a vision of proactive general practice.

However, the report also found there were barriers to GPs taking on a more proactive role. It admitted that many

GPs do not accept that population health is their responsibility, and they lack the training and skills to use public

health data and techniques.

There are also fears the current reforms will distance the NHS from wider public health efforts coordinated by

Public Health England, when public health professionals have not worked closely with general practice in the

past. The report called on the DH to assess whether public health officials are building the required relationships

with CCGs and GPs.

Another barrier is that the financial pressure on NHS England may result in CCGs focusing on meeting short-term

goals resulting in quick financial wins (such as reducing elective or emergency admissions) rather than investing

in preventative initiatives which can take years to change results, it said.

Ms Ruth Thorlby, Nuffield Trust Senior Research Fellow and author of the report said: ‘Many people have called

for general practices to take a more proactive approach to population health in recent decades. We found that in

this report for the NAPC that there is enthusiasm in general practice to make this vision real: at seems to be

important is to allow local practices to define what this means for themselves, alongside identifying and

supporting a cadre of GPs and other primary care staff to act as leaders

‘The immediate financial pressure on the NHS must not squeeze out investment in more prevention initiatives,

which can often take several years to come to fruition.

‘In theory, NHS England and Monitor should enable flexibility in pricing and contractual systems, which could

support innovation between general practice and other providers, and tilt the financial system away from the

acute sector. However this means creating space for general practice to innovate as providers and not being

inhibited by concerns about conflicts of interest.’

9.30am

After dropping my younger daughter at school I set off on my bicycle to Freedom from Torture’s office in Finsbury

Park.

Cycling is often the quickest way to get around London plus it’s cheap and good exercise.

I started volunteering at the human rights organisation in 1995, ten years after it was founded, when it was the

Medical Foundation for the Care of Victims of Torture. I work here two days per week and the rest of the week I

work as a GP with people who are homeless and vulnerably housed.

At Freedom from Torture I work as one of the lead doctors in the Medico Legal Reports Team. Freedom from

Torture’s doctors, the majority of whom are volunteers, have an important role in assessing the health of survivors

of torture.

Those in my team write medico-legal reports (MLRs), documenting medical evidence of a person’s physical and

psychological torture.

The reports are commissioned by legal representatives and are submitted as expert reports – to the Home Office,

for first instance asylum decisions, or to the Tribunal, for appeal cases – to help their case for protection in the UK.

The account of torture is assessed in accordance with international guidelines set out in the Istanbul Protocol,

asserting the consistency of the evidence with the individual’s account of torture.

10.00

I catch up with our administrative team who provide excellent support, obtaining and processing important

documents and importantly sending the finished reports to lawyers.

Our multi-disciplinary team also includes lawyers, so we have a rich mixture of expertise.

10.30

I catch up with the other doctors and legal colleagues and discuss any challenging cases and urgent deadlines of

an imminent court hearing 

11.00

All our MLRs are independently checked by a medical specialist reviewer, of which I am one, and also by a legal

specialist.

Each report takes about an hour to review – I need to check that no relevant details have been omitted

13.30

I chair a monthly meeting for doctors where we discuss clinical and administrative issues arising from the work,

workload and anything that the doctors wish to raise.

It’s also a good opportunity to catch up with each other.

14.00

I’m meeting my mentee who is a GP from London who started working here six months ago.  

As the work is so different from what doctors have done before we offer all new doctors a mentor who works with

them 1-2-1 and offers guidance and support. All the doctors who work here are driven by a passion to help and

support people who have experienced trauma that most people would find impossible to comprehend.

A few years ago I set up peer support groups which meet monthly so doctors can meet to discuss the challenges

of the work, exchange thoughts and ideas and gain support.

The issues discussed with mentors and peers are practical and emotional, as the work doctors do here can be

highly stressful.

A doctor will typically see a patient for three, two hour assessments – though these can be longer, where they

document the account of torture in detail.

This involves noting down a full history of their ill-treatment, which may include beating, burns or rape.

Physical scars are assessed and other injuries such as badly healed fractures, lacerations, burns, damaged

ligaments, or chronic bone infections, including where they are on the body, are meticulously recorded.

They also document evidence of severe psychological problems.

This is why we allow such a lot of time.

It is important that the patient does not feel hurried or pressurised and they can disclose at their own pace - it’s

crucial we build trust with patients so they feel able to reveal even the most distressing things that happened to

them.

Many clients require interpreters and we have a skilled team with whom we work.

To enable patients to get the best care and support we may refer them to Freedom from Torture’s clinicians who

can provide them with the long-term psychological help and support they may need.

Doctors also liaise with a patient’s GP, (if given consent to do so) which is an important part of the work. As a GP

myself I am fully aware of the pressures which many GPs work under – lack of time, lack of continuity and poor

access to interpreters. A letter from one of our doctors here can be extremely helpful for a GP who may not even be

aware of a patient’s history of torture.

15.30

I meet with a colleague for her appraisal. Many of our doctors are retired or have a portfolio career, and may

therefore not have an NHS appraisal.

We have our own Responsible Officer and can therefore offer appraisals and revalidation for any of our doctors

who need this.

18.30

I head home.

My daughters are home from school and college and my husband cooks dinner as he’s home before me (I’ll be

doing some cooking at weekends).

He’s a fantastic support for me – he works as an imaging assistant in hospital. In the evening I’ll help my daughter

with school work and do a bit of reading to stay on top of the latest research.

Our department works with Freedom from Torture’s policy and external affairs team where our MLRs form the

basis of our research reports, which aims to hold torturing states to account.

Our most recent report on torture in Iran was based on evidence from the MLRs we produced for Iranian patients.

The UN Special Rapporteur on Iran, Dr Ahmed Shaheed, drew on, and included, our research in the report he presented to the UN Human Rights Council in March.

Our MLR team is commissioned to write about 600 reports a year and we’re currently looking for more volunteers

in London, Manchester and Birmingham. Volunteers work a varying amount of time - the minimum required is a

session (at least four hours) per week or fortnight.

The work can be intensely stressful, as you’re dealing with such extreme accounts of brutality.

The doctors we recruit are suitably qualified and are trained in the methods of documentation of torture.

We’re currently looking for volunteer doctors who are looking for the challenge of working here and the

extraordinary help you can provide to survivors of torture - you can see the job descriptions

GPs have become ‘agents of state privatisation’ in a development that threatens the integrity of the whole

profession, says the GPC in the most strongly worded attack it has issued on the Goverment’s reforms so far.

The motion says CCG membership means GPs have become ‘integral agents of state rationing, cost control and

privatisation’ which ‘seriously threatens’ the trust between GPs and their patients, and poses a risk to the integrity

of NHS general practice.

The GPC added that there were significant obstacles in the way of GPs implementing the recommendations of the

Francis report as they will be under pressure from their CCGs to stay within budgets.

The news comes after Pulse revealed that two practices were forced to join their CCG by NHS England against

their wishes, in a move which the GP leaders said flew in the face of the idea that the NHS reforms put more power

into GPs hands.

Hundreds of GPs have also been asked to sign legal agreements in the form of CCG constitutions which prevent

them from speaking in public about anything related to their CCG.

The motion was passed at yesterday’s GPC meeting. Dr Richard Vautrey, deputy chair of the GPC, said: ‘It is

highlighting the difficulty in which GPs are placed because of their position as being both members of the CCGs

and the desire and professional responsibility to provide a service to their patients.’

Dr Chaand Nagpaul added: ‘This motion is describing concerns about how things may pan out. The idea of

membership is a misnomer - in normal membership, you have a choice about whether you want to be a member.

‘The Government speaks of membership as some sort of club where members are all in agreement. But actually

GPs have been forced into it… it forces GPs to be bound by the rules of those organisations even when they

explicitly dissent from the view of the organisation.’

A spokesperson for the Department of Health said: ‘Decisions on treatments should be made by clinicians, based

on what is most clinically appropriate for the patient.

‘Far from putting GPs at odds with the interests of their patients, the changes we have made to the health service

will ensure that it is clinicians who take these decisions in future, based on clinical evidence and in the interests of

patients.’

• 

  Press Association - Some 24 per cent of nurses told researchers they had been warned against whistleblowing

1. Use numerical and verbal rating scales to assess pain in older people

Assessment of pain is always challenging, but the range of pain assessment tools that have been validated in

the literature is improving.

Use of verbal descriptors – such as ‘none’, ‘mild’, ‘moderate’, ‘severe’ -and numerical rating scales are well

documented as being appropriate for the older population.

Guidelines for the assessment of pain in the older population are being updated this year by the British Pain

Society and British Geriatric Society.

2. Use the Abbey or Doloplus scale in patients with dementia

The Abbey or Doloplus are tools which are useful for assessing patients with reduced levels of cognitive ability

or communication difficulties, such as those with dementia.

These scales are gaining more evidence in a variety of settings.

3. Don’t overlook pharmacological treatment options because of concerns about potential side effects

Advancing age should not be a barrier to considering pharmacological treatment options for pain -

Having said this, there are surprisingly few studies examining the use of analgesics in older people specifically.

Generally, younger populations have been used and the results then extrapolated to older people -

this can be problematic because of the physiological changes in aging and the impact of comorbidities.

Consider lower initial doses and titrate more slowly than you may in younger patients to minimise side effects.

4. Try paracetamol first line

Paracetamol is the first-line pharmacological treatment for persistent pain in older people, particularly for

musculoskeletal pain as it has good efficacy and relatively few side effects.

Before considering alternatives, recommend regular use.

5. Be cautious with NSAIDs

NSAIDs must be used with caution in older people, and for the shortest duration at the lowest dose. A PPI

should be coprescribed and the patient should be closely monitored for renal and cardiovascular side effects,

and drug or disease interactions.

6. Be aware that tricyclics and anti-epileptic drugs are often poorly tolerated by older people

For neuropathic pain, drugs used such as tricyclic antidepressants and anti-epileptic drugs do have

demonstrated efficacy, but tolerability and adverse effects limit their use with older people.

7. Consider interventional therapies, especially in patients with localised or regional chronic pain

Pain in the older population tends to affect the knees, hip and back.

When pharmacological treatments are ineffective or not tolerated, interventional therapies should be

considered, especially in patients with chronic pain. Intra-articular corticosteroids are recommended in

osteoarthritis of the knee although there is no evidence for their efficacy in other joints in older people.

Facet joint interventions may be beneficial for both cervical and lumbar pain.

There is some evidence for epidural steroid injections in patients with spinal stenosis, but this is not strong

enough to support their use in radicular pain or sciatica.

8. Psychological interventions may be used as an adjunct to medication

Psychological factors often influence how patients respond to, and cope with, pain.

Psychological interventions can help to modify beliefs and attitudes.

Few studies have focused on older adults but cognitive behavioural therapy may be effective in decreasing

chronic pain, improving disability and mood. 

9. Aim to customise exercise programmes to the patient’s needs and capabilities

Evidence supports the use of exercise programmes that comprise strengthening, flexibility and endurance

activities.

They increase physical activity, improve function and pain.

The choice of exercise depends on patient preference and programmes should be customised to individual

capacity and need.

There are lots of options, including progressive resistance exercise, walking, water-based exercise, and

adaptations of tai-chi and yoga.

10. Consider complementary therapies in patients with osteoarthritis or musculoskeletal pain

Complementary therapy, for example acupuncture, transcutaneous electrical nerve stimulation, and massage,

should be considered - although the evidence is limited. 

Acupuncture applied singularly or in combination with other modalities reduced pain and improves quality of

life in patients with osteoarthritis.

Percutaneous electrical nerve stimulation combined with physiotherapy reduces pain and self-reported

disability for up to three months.

Similarly, conventional TENS and massage can be used for relief of musculoskeletal pain.

Dr Aza Abdulla is a consultant physician with a specialist interest in elderly care at South London Healthcare

Trust.

He participated in the production of the upcoming national guidelines on management of pain in older people.

This article was written with help from Professor Pat Schofield, professor of nursing at the University of

Greenwich and Professor Roger Knaggs, associate professor in clinical pharmacy practice at the University of

Nottingham.

See the Age and Ageing website for a copy of the guideline on the management of pain in older people produced

by the British Geriatrics Society and the British Pain Society.

Reference

Schofield P (ed) et al Guidelines for the management of pain in older adults. March 2013. Age and Ageing.

The health secretary has vowed to ‘change GPs minds’ over the value of diagnosing dementia earlier, by

tasking the Department of Health to improve the services offered by the NHS.

Jeremy Hunt said some GPs think diagnosing dementia is ‘pointless’ and that it will not make a difference, but

that this is a ‘misconception’ that he wants to change.

Taking questions on health in the House of Commons yesterday, Mr Hunt was asked by Mark Menzies,

Conservative MP for Fylde, what steps he is taking to support GPs in achieving his ambitious targets for

dementia diagnosis.

He responded: ‘There is a misconception amongst some GPs that a dementia diagnosis is pointless and can’t

make a difference when we know that in fact the correct medicines can help between one-in-three and one-in-

four of people who have the condition.’

However he also conceded that there is currently a lack of support available for patients who have received a

dementia diagnosis.

Mr Hunt added: ‘But some GPs also have a point when they are concerned that it is very, very difficult to access

good services for people who have dementia.

‘So the way that we will change GPs’ minds is for them to appreciate that something will change if someone

gets a dementia diagnosis and that is the big challenge that this ministerial team has set the Department.’

He said a key priority to achieve in England, learning from good practice in for example Scotland, is to have a

‘proper integrated care plan’.

‘I don’t think any GPs think that diagnosis is pointless but that we should leave to the patient to decide when is

the right time for diagnosis. I am glad that he has conceded that there is a lack of support available for patients

receiving a diagnosis.

‘I also welcome what he says about medication helping between one-in-three and one-in-four dementia patients

because I don’t dispute that.

Earlier he said it could stave off symptoms for several years.

That I disagree with.

1. The primary purpose of medical records is to document all matters related to the health of a patient and to

ensure continuity of care.

Whilst you should write with a medical audience in mind you should be prepared to

share and explain the content with patients.

1. Medical records should be clear, accurate and legible. Although abbreviations are used commonly, you should take care to use them only where their meaning is unambiguous and unlikely to cause offence.
2. Patients have the right, under the Data Protection Act, to ask for factual inaccuracies in the record to be rectified or deleted and such requests may become more common with online access. You should only comply with a request if you are satisfied that it is valid, although it is rare to delete an entry in its entirety. Any disputed entries can be annotated with the patient’s view.
3. Practitioners should be cautious when recording particularly sensitive information such as child protection issues. Only information related to the individual patient should be available, whilst protecting third parties’ confidentiality.
4. Doctors must ensure that information which may cause serious harm to the mental or physical health of the patient or third parties is limited from access, if possible.

Dr Pallavi Bradshaw is a medicolegal adviser at the Medical Protection Society

Exclusive Hundreds of GP practices are blocked from voicing concerns over NHS care in their area under their

CCG constitutions, despite the Government’s declarations that ‘gagging’ clauses are now unacceptable in the

health service after the Francis Inquiry.

Legal agreements covering more than 200 practices from 1 April include clauses that prevent GP members from

speaking about the CCG’s work without prior approval from the board.

The GPC said that it was ‘inappropriate’ that the clauses were inconsistent with the legal ‘duty of candour’

placed on health professionals after the publication of the Francis Inquiry into failures of care at Mid

Staffordshire NHS Foundation Trust.

Pulse first reported the gagging of GP practices last year in two CCGs in a move that marked a shift in the

independent status of GP practices, who are currently able to speak publically and to the media about PCT business.

Since then, Pulse has learnt NHS Newbury and District, NHS Sutton, NHS Dorset, NHS Thurrock and NHS

Windsor, Ascot and Maidenhead CCGs have all retained a clause in their constitutions that prevents member

practices from speaking out on CCG matters without getting prior approval from CCG leaders.

A further five CCGs have clauses that prevent those on the governing body from speaking out to voice concerns.

Four CCGs – Hull, Northumberland, Kingston and Oldham - that did have gagging clauses in their draft

constititions have since removed them, with one saying that they did not want to prevent their members from

speaking out ‘on issues of concern to them’.

The clause for Newbury & District, which covers 11 practices, and Windsor, Ascot & Maidenhead, which covers

20 practices, states: ‘No member will make or permit the making of any press release or other public statement

concerning the CCG without the prior written approval of the [operational leadership team].’

In Sutton (29 practices), Dorset (103) and Thurrock (36), the clause reads: ‘None of the members or members of

the Governing Body shall make or permit or authorise the making of any press release or other public statement

or disclosure concerning the group or any of the members or members of the governing body without the prior

consent in writing of the governing body.’

The clauses are very similar to a controversial Londonwide LMCs draft constitution published in 2011, which

chief executive Dr Michelle Drage said at the time would strengthen governance and decision-making

processes.

But the GPC said that the clauses were unnacceptable. Dr Chaand Nagpaul, a GPC negotiator, said: ‘In the post-

Francis world, practices should not be restrained or put under any pressure with regards to not voicing

concerns especially given they could be held culpable as members of a commissioning organisation.

‘One of the key Francis recommendations is that GPs need to be aware of the quality of care provided to

patients, including in hospital services, and there is a duty on individual GPs to express and report concerns. It

is inappropriate for CCG constitutions to curtail this clear recommendation.’

Dr Brian Balmer, chair of Essex LMC, said: ‘There is a big difference between setting out the corporate

responsibilities for board members and telling everyone they are not allowed to say anything as members of the

CCG. If it is to apply to member practices, how are they going to enforce it? Are they going to tell people they will have to leave CCGs? It’s daft.’

The chair of NHS Newbury and District CCG, Dr Abid Irfan, defended their constitution, saying that they had met

today to discuss it and had decided to keep the clause because it was a ‘helpful guideline’.

He said: ‘Everyone recognised that it was a way to support GPs and practices - there was no feeling that anyone

was being “gagged”. If there was any serious issue that an individual GP felt strongly about then they would

naturally be free to speak out.’

Dr Adrian Hayter, CCG chair designate at NHS Windsor Ascot & Maidenhead CCG, said the clauses were

designed to so the views of individual GPs and the CCG were not confused. 

He said: ‘We have no Machiavellian plan to not allow free speech and indeed we encourage this in our GP

community. It is however important for the public to have a consistent view from their local NHS Commissioning

organisation for the shape of their local services.’

A spokesperson for NHS Oldham CCG explained that they had removed the clause in their constitution banning

members from speaking out: ‘It was never the intention to “gag” our members. The revised constitution better

reflects our long standing position that we recognise our members duty to speak out on issues of concern to

them’.

A spokesperson for NHS Sutton CCG said they ‘actively encourage’ their members to escalate any concerns or

issues about patient safety and none had raised concern about that particular clause. NHS Dorset CCG

reitterated the CCG’s position that the clause would only be applied to ‘statements of a confidential nature’ and

insisted they were not trying to stop GPs speaking to the media ‘in general’.

But a DH spokesperson said CCG constitutions were not intended to gag their members and that they were

committed to transparency in the health service.

He said: ‘We would not expect CCG constitutions to prevent individuals from raising concerns or speaking out

in the public interest.

‘They are intended to set out the operating arrangements of the CCG, to ensure that all members work in

partnership with the governing body on any public messages.’

A spokesperson for NHS England said: ‘CCGs are independent statutory organisations, and their constitutions

have been developed as a means of achieving consensus between member practices on their organisational

behaviours. Most CCGs have included provisions within their constitutions to ensure their organisations speak

with a single, united voice, in order to secure maximum public understanding of the CCGs and their work.’

Exclusive Almost half of GPs have brought forward their retirement plans compared with five years ago, as

worsening morale and rising workload takes its toll on the profession, a Pulse survey shows.

The survey of 364 GPs found 43% are looking to retire earlier than they intended five years ago, with the average

GP intending to down tools at age 61 years.

Only 19% of GPs predicted they would continue in the profession beyond 64 years, despite the Government

reforms to pensions meaning some junior doctors would be forced to work until 68 to get their pension.

The GPC warned this was a trend that would add to the current GP shortages in some areas, and it follows

LMCs saying in January that half of GPs are considering quitting general practice due to the Government’s

planned contract changes.

Respondents to the Pulse survey said they had made the decision as general practice was reaching ‘crisis

point’, with pay freezes, spiralling QOF work and the Government’s pensions reforms pushing them to quit earlier.

Of the GPs who responded to the survey, 30% said they planned to retire at 55 to 59 years, 44% at 60 to 64 years

and 12% at 65 to 70 years. Some 5% said they would continue working as a GP past 70 years.

Some 43% said they had decided to retire earlier than they had planned five years ago, 48% said their retirement

plans remained unchanged from five years ago, and 9% said they were unsure.

GPC chair Dr Laurence Buckman said rising early retirement rates would worsen the rising workforce crisis in

the profession revealed by Pulse last month, with GP vacancy rates quadrupling in the past two years.

Dr Buckman said it was an ‘inevitable corollary’ of the way the Government had treated the profession.

He told Pulse: ‘The contractual changes and the pressure of work related to that, the inability to earn a living, the

changes to GP pensions and the capping of pensions more generally, as well as revalidation. Between all of

those, there are now a lot of reasons why GPs will consider premature retirement.

‘There will be less GPs as a result.’

Dr Nigel Watson, chair of the GPC commissioning and service development subcommittee and chief executive

of Wessex LMCs, said earlier retirement of older GPs would undermine the profession.

He said: ‘I have practices with three or four doctors going soon and so the younger GPs will have to take on the

responsibilities of partnership, and they’ll struggle.

‘The exodus is quite significant. In any year you’ll always have a cohort of GPs that have done their time, but the

feel that’s different this year. The decision to leave is with regret- but they can’t work like this anymore.’

He said: ‘I think more than anything what is influencing me to plan to retire early is how the GP contract has

been steadily eroded ever since its introduction. What is such a shame is that I still enjoy trying to do a decent

job for the patient in front of me.’

Dr Jyotsana Patel, a GP in Wembley, north west London, said he would retire in six weeks due to the strains on

his health.

He told Pulse: ‘The reason is the seamless amounts of work that has been dumped on me, without thought of

capacity for that sort of increase.

‘I am pleased I can turn my life around finally and save my health and sanity.’

Dr Sally Dowler, a GP in Tottenham, north London, said the rising de-professionalisation of GPs was behind her

decision to quit general practice earlier than planned.

She said: ‘Scrips, monitoring, doing hospital ‘errands’ as per their letters, medical reports, sitting on committees

and constant need to prove that my skills and knowledge are good enough - despite no hint of evidence to the

contrary - is getting quite demoralising.

Patients have the right to ask their GP to correct any factual errors they see in their medical records,

according to the new NHS Constitution.

In the Government’s response to its consultation on the NHS Constitution, they re-asserted patients’ right to

access their health records, and added that they have the right to ‘have any factual inaccuracies corrected’.

The accompanying handbook clarified that this did not give the patient the right to change a clinical opinion

and that if a GP disagreed there was an error then the patient’s disagreement should be written into their notes.

The news follows comments made by Dame Fiona Caldicott, who is leading the Government’s information

governance review. Last November she said patients should be able to amend errors in their records, but

should not be able to change their medical histories.

The changes to the NHS Constitution come as the Government began to implement its target for GP

practices to offer patients access to full patient records, appointment booking and test results by 2015, with

a new DES beginning this year.

The handbook said: ‘You have the right to have any factual inaccuracies corrected. Ask your health

professional about amending your records if you believe they contain a factual error.’

It added: ‘There is no obligation to amend professional opinion, however sometimes it is difficult to

distinguish between fact and opinion. Where you and the health professional cannot agree on whether the

information in question is accurate you can ask that a statement is included to set out that the accuracy of

the information is disputed by you.’

They added that they removed a statement which said that health records ‘will always be used to manage

your treatment in your best interest’ as this could sound ‘paternalistic’.

The handbook clarified that there are only a few exceptions where patients should be denied access to their

records, such as where the information includes details about another person, or where the information may

be harmful, for example, where serious mental illness means the patient may be a risk to themselves

Parents in Wales have been urged to take their children to their GP to get the MMR jab, if they have not had it yet,

after the number of cases in an outbreak centred on Swansea soared to 432.

Cases have doubled in the past three weeks, up from just over 200 at the beginning of March, with 116 cases

reported in the past week alone, Public Health Wales reported.

The latest figures have heightened concerns that unvaccinated children are increasingly likely to come into

contact with the virus. Cases are expected to continue to rise for some time yet and could reach 1,000 by the end

of April.

Dr Marion Lyons, director of health protection at Public Health Wales, said: ‘Measles is now spreading at an

alarming rate across areas of Wales.

Worryingly there are still tens of thousands of susceptible children across Wales, yet our weekly monitoring of

vaccination rates shows only a slight increase in numbers receiving MMR jabs.

‘If the numbers of parents bringing their children for MMR jabs does not dramatically increase, measles will

continue to spread and quickly reach levels last seen in the outbreak in Dublin in 1999/2000.

In that outbreak over 1,200 children were infected and three died.’

Our genetic hand of cards

Each of us is born with a genetic hand of cards passed down from our parents.

This is called our genome and is made of three billion pieces of code made of just chemical letters: A, C, T and G.

A single nucleotide polymorphism is a single letter difference in DNA between individuals.

We each have millions of variations and most of these seem benign. This study looked at more than 100,000 common differences found in at least one in 10 people.

By comparing cancer patients with healthy controls the scientists could identify genetic spelling mistakes that occurred repeatedly in the cancer group.

Forty nine new single nucleotide polymorphisms (Snps) were found associated with breast cancer, bringing the total identified to 76.

For prostate cancer, 23 new markers were found, bringing the total to 78. And for ovarian cancer, eight new regions were found, bringing the total to 12.

There should be routine psychiatric screening in pregnant women so that treatment can begin earlier and post-

partum depression can be averted, say researchers.

The study

Women who had given birth in the maternity ward at Magee-Women’s Hospital were visited on the ward and

offered screening by phone at four to six weeks post-partum.

All women who were reached by phone and who had screen-positive findings, defined as an Edinburgh

Postnatal Depression Score of 10 or more, were offered a home visit evaluation for psychiatric diagnostic

assessment. A total of 10,000 women underwent phone screening, with 826 of the 1,396 screened positive

accepting a home visit.

The findings

Episode onset was most frequent in the post-partum period, with 40.1% of the 826 women visited experiencing

a depressive episode in the first four weeks after giving birth.

33.4% experienced an episode during pregnancy and 26.5% before pregnancy.

The most common primary diagnoses in visited women were unipolar disorders, with 68.5% having at least one

unipolar episode. 22.6% experienced bipolar disorder and 5.6% an anxiety disorder.

What does it mean for GPs?

The US researchers concluded that ‘these data suggest consideration of screening during pregnancy to

identify psychiatric disorders and intervene earlier in the episode course.’

They added that a ‘comprehensive screening and diagnostic characterisation coupled with diagnosis-specific

intervention strategies might reduce maternal disability, improve function and avert a new generation risk.’

GPs face a new statutory ‘duty of candour’ to report treatment or care that they believe has caused death or

serious injury, says the Department of Health in its official response to the public inquiry into the failures of care

at Mid Staffordshire NHS Foundation Trust.

The duty will apply to all all providers registered with the CQC, but the Department of Health said it would look at

how how broadly the duty should apply.

Health secretary Jeremy Hunt also said they would explore whether to introduce a new ‘chief inspector of

primary care’ to sit alongside chief inspectors for hospitals and care homes, which would act as ‘whistleblower

in chief’ for the NHS.

But it stopped short of recommending an Ofsted-style quality rating for indivividual GPs - with ratings of

’inadequate’ to ‘outstanding’ - but the measure will be intrdoduced for hospitals and care homes.

Mr Hunt said the ratings could not be entirely ruled out for GPs in the future.

The DH document said: ‘A spirit of candour will be critical to ensuring that problems are identified quickly and

dealt with promptly. Openness is a key element of healthy organisational cultures in health.’

It added that while such a contractual duty already exists, it intends to go further and make this a statutory duty.

The document added: ‘We intend to go further and introduce a statutory duty of candour on health and care

providers to inform people if they believe treatment or care has caused death or serious injury, and to provide

an explanation.

We will need to carefully consider the scope of this duty on all providers.’

It comes as the DH also published its revised version of the NHS Constitution today but it said further changes

are likely to be consulted on in light of Francis later in the year.

Other actions that may come to be of relevance to GP practices include making nurses subject to revalidation;

the CQC adopting a new peer-review model for assessments that will take into account whether patients are

being listened to and are treated with dignity and respect; as well as the DH asking the GMC to tighten and

speed up its procedures dealing with breaches of conduct.

Mr Hunt said: ‘The health and care system must change.

We cannot merely tinker around the edges - we need a radical overhaul with high quality care and compassion

at its heart.

‘Today I am setting out an initial response to Robert Francis’ recommendations.

But this is just the start to a fundamental change to the system.’

GPC deputy chair Dr Richard Vautrey said that the development was ‘concerning’ as GPs already had a

professional responsibility to be open and honest and engage their patients.

He said: ‘To actually impose a statutory responsibility actually risks, paradoxically, the situation being made

less transparent because of a fear of litigation affecting your livelihood.

It may actually make it harder rather than making it easier.

‘So there is the potential for a lot of unintended consequences as a result of this and we are not really sure this

is the best way to proceed. We want a change in culture of the NHS without a fear of criminalisation in the

process.’

He also cautioned against the prospect of a chief inspector of primary care: ‘We already have significant

regulation with GMC, CQC looking at quality of primary care.

I think we are yet to be convinced that it would do anything other than duplicate what is already there.’

Dr Michael Devlin, head of advisory services at the Medical Defence Union, said: ‘We note that the Government

is planning to introduce a statutory duty of candour for providers of care to NHS patients and that it would

apply only in cases where there is serious injury or death.

At the moment, there are too many unanswered questions such as whether/how it would apply to primary care

and how serious injury would be defined.’

‘We see no need for a statutory duty of candour because GPs are already under an ethical duty to tell patients

as soon as anything goes wrong, irrespective of whether it is ‘serious’ or not.

So far as we know GPs are already fully aware of and comply with that professional duty to be open and honest

if something goes wrong.’

Dr Stephanie Bown, director of policy and communications at the Medical Protection Society, added: ‘MPS has

long held the view that while you can mandate disclosure, legislation cannot deliver the attributes of high

quality and open communication such as empathy, sincerity, and comprehensiveness.

A culture change is what is needed.’

‘We will be further highlighting to Government that despite the understandable appeal of a legislated duty, this

will not achieve the objective of effective open communication.

The risk of any legislation is creating a ‘tick-box’ mentality, which does not support the intensely sensitive,

personalised and patient-centred conversations that should happen with patients and their families when

something has gone wrong.’

When I heard Professor Clare Gerada and Dr Margaret McCartney on the Today programme discussing the news

that three quarters of GPs ‘administer placebos once a week’, I was surprised.

I am not sure I have never knowingly prescribed a placebo.

I might have been persuaded by a patient to prescribe something I wasn’t 100% sure about – but that’s shared

decision-making in practice. I am concerned about deceit of medicine at many levels.

I can understand why some GPs are tempted to prescribe when they think it may not be effective. It’s quick, and

it gets patients out of the door faster than you could with an honest conversation, or at least it does for that

consultation, but it also encourages help seeking behaviour and repeat attendances.

But at my surgery – where this week we triage 115 patients on the phone one morning – if we gave every patient

a face-to-face consultation then we’d never give everyone the time they need. Most of the solutions to patients’

problems can be found in their history, and many of the problems they bring to GPs can be solved through

information, reassurance, advice about self-care or over the counter treatment.

Strictly speaking, any treatment a patient doesn’t need is a placebo – examinations included. For instance, I

would resist performing a chest examination in a child just because the mother wants me to do one. 

If there is no clinical indication such as suspicion of pneumonia because of other features (such as chest pain,

high fever, unwell, breathlessness), then I really don’t need to listen to the chest.

To do so without an explanation as to why it is unnecessary would be deceitful. 

When you take time to explain why it is not helpful, then most parents are happy.

You give them confidence to know when to be worried, and most of all when not to be.

For the same reason most GPs would instinctively decline to prescribe an antibiotic, a viral URTI doesn’t need

me to listen to them breathing.

However, it still needs me to understand their concerns, inform, reassure, advice and most importantly empower

to self assess and self care.

The ‘magical stethoscope’ myth

Placebos take power away from the patient and give power to the doctor.

We begin to see magical treatments and examinations – the stethoscope that can hear a virus, or the antibiotic

that can cure all infections. But this myth hurts everyone.

The sooner patients realise and doctors admit the limitations of medicine, the sooner we will get the demand for

NHS services back on track.

I have said before that the NHS is a paternalistic institution. Like all professions, medicine is a myth-builder which

relies on its own jargon and tools of the trade to keep a bit of mystique.

But the time has come to be open and honest about what medicine can offer, and what it can’t.

We have so much opportunity now for patients to self-care, for everything from self-limiting respiratory infections

to diabetes and hypertension, and it’s a big missed opportunity.

GPs are key patient educators, and the solution to demand is by admitting that sometimes it’s more effective if

we don’t intervene.

I myself have a long-term condition and just this morning, emailed my GP and consultant a few questions about

my treatment while I travelled down to London on the train.

Doing that was more time- and cost-effective than booking an appointment, and although I admit that I probably

get a bit of ‘special treatment’ because I myself am a GP, there are a couple of doctors at my surgery who use

email to communicate with their patients.

The NHS has been incredibly slow at adopting new ways of communication.

We should always come clean with the public and our patients. To any GP who would defend placebo treatments

and examination I would ask, why can’t we have an open and honest conversation with patients?

It’s my belief that it’s a doctor’s duty to be honest and open with patients, and that means cutting down on our

use of anything with a placebo effect, examinations and treatments alike, it is a short-term solution and frankly a

bit of a cop-out.

Dr Steve Laitner is the clinical lead for the Department of Health-funded programme on shared decision-making, and a GP in St Albans.

The study

Some 155 patients aged 25 to 70 years with sleep apnoea were randomised to receive either management in

primary care or in a specialised sleep centre.

All patients were deemed to have a high diagnostic likelihood of moderate to severe sleep apnoea, defined as a

score of five or more on a four-item screening questionnaire and an overnight 3% oxygen desaturation index of

at least 16 events per hour.

Primary care management consisted of advice on managing continuous positive airway pressure (CPAP)-related

adverse effects, encouragement to maintain adherence and education about lifestyle changes to improve sleep

apnoea.

Specialist centres also had a patient’s overnight oximetry trace and further investigations if necessary.

The findings

Mean Epworth Sleepiness Scale (ESS) scores for the primary care group improved from 12.8 to 7.0 after six

months, and in the specialist group from 12.5 to 7.0.

The adjusted difference in the mean change in ESS score was not significant between the two groups.

Improvements were also present in both groups for the Functional

Outcomes of Sleep Questionnaire, but there was no significant difference between the two groups for the change

from baseline to six months.

The estimated costs per patient for primary care were £1,217, compared with £2,052

in the specialised care group.

What does it mean for GPs?

The Australian authors concluded that ‘with adequate training of primary care physicians and practice nurses

and with appropriate funding models to support an ambulatory strategy,

primary care management of obstructive sleep apnoea has the potential to improve patient access to sleep

services.’

JAMA 2013, available online 13 March

GPs will be expected to double the percentage of adults with type 2 diabetes who achieve NICE-recommended

blood glucose, blood pressure and cholesterol levels in five years, under new targets set by the Government.

The Government said more should be done by GPs to make sure that risk factors were controlled in diabetes and

set a target for 40% of patients with diabetes to be within NICE-recommended levels, which is double the current rate of 19.8% by 2018.

It also recommends a dramatic increase in the proportion of patients with diabetes being given nine basic care

processes annually - such as foot checks and microalbuminuria tests - from 50% to 80% by 2018, possibly by

bundling the QOF indicators together.

Pulse revealed last year that ministers had written to NICE to ask it to explore the practicality of raising QOF

thresholds and creating a ‘composite’ indicator in QOF for diabetes worth over £5,000.

The targets were revealed in a response from the Treasury to a report published by the House of Commons

Public Accounts Committee that was very critical of GP management of diabetes last year.

The PAC said too few patients were achieving the recommended levels for blood pressure, cholesterol and

diabetes and called for QOF indicators to be bundled.

In its response, the Treasury said: ‘It will never be appropriate for every person with diabetes to be within the

recommended outcomes ranges defined by NICE, which are set for the UK population as a whole. The specific

proportion cannot be defined, particularly for glucose control.

‘However, the department agrees that more can be done to increase the proportion of people with diabetes

achieving the recommended levels for blood glucose, blood pressure and cholesterol.’

The Treasury said it recommended changes to QOF, although this would be up to NICE’s assessment of whether

to bundle indicators and the NHS Commissioning Board.

It said: ‘The current payment system is not driving the required outcomes. GPs are paid for each individual test

they carry out rather than being rewarded for ensuring all nine tests are delivered.’

The QOF revisions – especially relating to microalbuminuria testing and the DM13 indicator – are expected to help

achieve ‘universal’ annual coverage for the nine basic diabetes care processes, the Treasury added.

‘The Government does not consider it is appropriate for the department or the NHS Commissioning Board to

mandate which individuals should provide specific elements of care,’ it said.

Dr Bill Beeby, chair of the GPC’s clinical and prescribing subcommittee said the targets set by the Treasury were

unrealistic as they depended on patients attending appointments and acting on the medical advice they were given.

He said: ‘One of the main reasons why things are often out of control in diabetes is because patients just don’t

listen to medical advice.

‘The QOF was never designed to achieve the things the Treasury is suggesting. The concept that it is all about

incentives and that we GPs will chase these things down until the last man standing is quite erroneous. If a

patient does not come in for a test there’s only so many times you can phone them.