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Minutes 2013-2014

8th October 2013 Professor Marilyn James  ‘When Scrooge met Santa Claus’

2nd October 2013 Dr Ian Shand  Presidential Address ‘Playing the Game and other Metaphors’        

12th November 2013   Dr Clare Gerada.  ‘Women and Leaders’
26th November 2013 in the Derby Medical School‘NHS Reform- have we left it too late?’Dr James Kingsland OBE

10th December 2013 Dr Adrian Dunbar.’‘Chronic pain, fibromyalgia, mud baths and vigorous exercise. 
7th January 2014 Dr Anne Thomson, ‘Wheezles and Sneezles’.

21st January 2014 – Theo Raynor, Professor of Pharmacy Practice, University of Leeds – ‘The benefits outweigh the risks – who says?’

Tuesday 4th February 2014 – Dr Nick Spencer, Consultant Radiologist and Lead Clinician for Cancer at Mid Yorkshire Hospitals NHS Trust – ‘Access or Accuracy, MRI or MDT? or Chaos Theory: A Radiology Reflection!’

Tuesday 25th February 2014 – Dr Colm O’Mahony, Consultant in GUM, Countess of Chester Hospital and media star! – ‘The Trouble with Sex’

 

Tuesday 11th March 2014 – Open meeting – Dr Phil Jones, Consultant Physician in Elderly Medicine, Aberystwyth and award winning semi-professional photographer – ‘A very patient wife’

 

Tuesday 25th March 2014 – Dr James Shand – hopefully a brand new consultant interventional cardiologist – ‘Dad, I want to be a Plumber’

 

Tuesday 8th April 2014 – AGM and then – Dr Liv O’Connell and Mr Peter Cull, GP and A&E consultant respectively –  ‘Medicine in Malawi – a different kind of provision pressure’

 

 

8th October 2013 Professor Marilyn James  ‘When Scrooge met Santa Claus’

Apologies from; Dr Paul Cartwright, Mr John Hodgkins, Dr David Bullock, Dr Wendy Scott and Dr Gerry Bryant

We were welcomed by locum Vice president, Dr David Young. He introduced the new president for this year, Dr Ian Shand, who was warmly welcomed.

The minutes of the speakers of the 19th of March were read by the junior secretary and agreed.

It was noted that 3 members have died: Dr Jack Charlton, Mr David Thomas and Dr Harry Morrow-Brown. We held a minutes silence in their memory.

We welcomed two new members- GPs from The Osmaston practice, Dr Bhanit Patel and Dr Toral Patel. They were proposed by Dr Ian Shand and seconded by Dr Chris Warner.

Dr Ian Shand then introduced the evening’s speaker, Professor Marilyn James who is professor of the Economics of Health and Social Policy at the University of Nottingham. She has many years of experience as an applied health economist and has a good track record of securing funding. Notable projects include ‘the cost benefit analysis of diabetic retinopathy screening’ and educational interventions to reduce NHS spending.

Professor James delivered a talk entitled ‘When Scrooge met Santa Claus’

Professor James outlined the basic dilemmas involved in balancing the books in delivering health care. There is a tendency for us ‘to want it all and want it now’ but we lack the resources. And what we do have needs to be shared fairly and used wisely.

It takes more than Drs to run the NHS and accountants do not have all the answers. We need health economists to look at all the options in a balanced way and to marry the costs and benefits.

In the past data was poor, historical events and opinions counted more than evidence.

But now, there is a growth in innovations, evidence based health care, a growing population and growing expectations. Health economists are being called on more and more to look at value for money in terms of benefits delivered and resources used.

They do this by defining and quantifying cost benefits, applying decision techniques and applying economic evaluation tools. Clinical outcomes are sometimes standard measures and sometimes Quality of Life indices.

EQ5D is an economist’s tool used to assess the whole well being of an intervention. It’s favoured by NICE i.e. it gives credibility for funding.

Health economists do not have all the answers, they can only inform decision making. They are involved in research trials, decisions, policy making and introduce clarity of thinking.

Evaluation takes information from all sorts of sources and Professor James acknowledges that there are sometimes badly designed trial and statistics to contend with.

Professor James then gave us some examples of how she had been involved in some NHS projects. These included Diabetic retinopathy screening, steroid injection versus physiotherapy for shoulder pain, education intervention to reduce pathology test requests in primary care and collecting data to challenge entrenched spending patterns.

There were many questions from the floor.

A vote of thanks was given by Dr Sally Archer and we all applauded what had been a most interesting and stimulating talk.

35 members and guest signed the registers.

2nd October 2013 Dr Ian Shand  Presidential Address ‘Playing the Game and other Metaphors’

Apologies were received from; Mr Iftikhar, Brian Hands, Nicola Brain, AR Nicholson and J Nicholson.

The death of Dr Blackwall was noted and marked by a minute’s silence.

We then had a collection for the Royal Medical Benevolent Fund.

The previous meetings minutes were read and agreed.

Dr Wendy Scott then introduced Ian Shand who is the incoming president of the society this year. Dr Shand is a senior partner at the Osmaston Road surgery. Wendy had great pleasure in handing over the president’s medal and introducing Ian to the audience.

Dr Shand entitled his address

Dr Shand reflected on his last 30 years in General Practice. He has sometimes been frustrated and amused by what drives people and what ’the rules’ are. Individuals and organisations have been observed to ‘play these games’. They may be innocent, manipulative or wrong or frankly criminal.

Dr Shand then illustrated his observations by giving us examples;

Patients- they may have hidden agendas or not be honest – this may relate to financial gain – i.e. claiming for an RTA or Child benefit. Frequent users of the service ‘cry wolf’ and make it difficult for Drs to unravel the truth.

Doctors can game play by selecting patients, prebooking easy reviews instead of seeing new more challenging patients, or passing work to OOH at the end of the day.

Nurses have been observed calling the Dr excessively for ‘silly things’ to cover themselves.

Politicians want 8am-8pm, 7 day cover. Is this an opening gambit to try and get Gps to settle for something slightly less?

Pharmacists appear to be milking the system when they take control of the repeat prescription and over dispense unwanted drugs to patients – thus gaining a dispensing fee and taking reimbursements for unused drugs.

PCT managers – there seems to be a high turnover with little action taken.

Dr Shand also listed insurance companies, employers, HMG –[Government], pharmaceutical companies , academia and the press for pursuing their own agendas  for personal and financial gain. So often as GPs we are caught in the crossfire, always being an advocate for the patient and guarding precious resources.

Dr Shand has personally taken a stand against some wrongs he has seen over the years and been instrumental in getting a ‘Hair Loss Clinic’ using treatment with no evidence – shut down.  He also testified against a pharmacist who was committing fraud.

Dr Shand finished by listing a few metaphors which he finds useful in daily practice.

Piece of string question

Take the blinkers off

Catch 22

80/20 rule

It’s ok to be ‘good enough’

GOK- this has its own read code!

Dr Shand thanked us for listening – I found it a wonderful insight into the scope and problems in GP today, and appreciated his pearls of wisdom. We all applauded what had been an enlightening and informative address.

 

46 members signed the registers

12th November 2013   Dr Clare Gerada.  ‘Women and Leaders’ Apologies from; Dr Wendy Scott, Mr S Iftikhar, Dr Philip Lacey, Mr Mark Sibbering. The minutes were read and agreed. The prize for the best GEM student was awarded to Emma Stewart. Julie Carson the first awarded best GEM student was also present.The collection for the Royal Medical Benevolent Fund raised £604. And the proceeds from the tombola at the DMS dinner raised £300.

Dr Shand then introduced Dr Clare Gerada. She was warmly welcomed and delivered a talk entitled ‘Women and Leaders’

Clare Gerada (born 1959) is a London-based GP and is Chair of the Council of the Royal College of General Practitioners for three years from November 2010. She is the college’s first female Chair for 50 years, the previous female Chair having been Dr Annis Gillie.

*Dr Gerada was born in Nigeria although her father came from Malta, and she grew up in Peterborough, England, where her father was a GP. She qualified in medicine at University College, London in 1982 and then trained in psychiatry.

She started work in general practice in Lambeth, London, in 1992, after working at the Maudsley Hospital, London, on substance abuse. She was awarded an MBE in 2000 “for service to medicine and to drug mis-users”. She has also been Director of Primary Care for the National Clinical Governance Team and Senior Medical Advisor to the Department of Health, and is Medical Director of the NHS Practitioner Health Programme, which provides confidential medical advice for doctors and dentists.

She is one of the partners in the Hurley Group, an NHS organisation which runs a number of GP practices and walk-in centers across London.

Dr Gerada cites her main interests of work as being around mental health and substance misuse and has spent over her professional career leading the development of primary care substance (alcohol, drugs) services in England.

She is married with children to the psychiatrist Professor Sir Simon Wessely

In February 2013 she was assessed as one of the 100 most powerful women in the United Kingdom by Woman’s Hour on BBC Radio 4.

In September 2013 she was voted by readers of the Evening Standard as one of the top 1000 influential Londoners.*

Dr Gerada is the most prominent female Dr in the press.

She reflected on the last 3 years post she has held. She described it as a rollercoaster and a learning process. Dr Gerada recalled her childhood and upbringing which encouraged her to be independent and outspoken; qualities she has brought to the post. To be successful she considers that one has to work hard, stick by your values and have a good support network. She also believes in being kind to others.

Her address was kept deliberately short so there was a lot of time for questions, and there were many.

They covered such items as the provider purchaser split, the out of hours blame game, the excessive workload in GP,  the loss of independent contractor status, the short fall of GPs, social media, balance of the sexes in the workforce, the medical school selection process and recruitment problems.

As a profession she believes we need to stand up for the poor the needy and the vulnerable, and that we must never lose sight of this in our thinking or values.

A vote of thanks was given by Dr Eisenberg.

58 Members, Guests and Students signed the register.

26th November 2013 in the Derby Medical School‘NHS Reform- have we left it too late?’Dr James Kingsland OBE

 

Apologies;  none. The minutes of the last meeting were read and agreed. A new member Dr Helen Lever – a GP from Hilton was proposed by Dr Ian Shand and seconded by Dr Eisenberg. Dr Shand then introduced Dr James Kingsland OBE who gave us a talk entitled ‘NHS Reform- have we left it too late?’

Dr Kingsland is a fellow graduate with Dr Shand from Leeds Medical School.

James is the Senior Partner in a nationally renowned, award winning General Practice in the North West of England.
He now devotes half time in clinical practice and half time in national advisory roles and for company boards. He was the National Clinical Lead for the English Department of Health’s implementation programs for Clinical Commissioning from April 2009 to April 2013, firstly for Practice Based Commissioning and latterly for the NHS Clinical Commissioning Community. In this role he was also the Primary Care Lead on the DH Board of the National Clinical Directors.
He continues as the clinical lead for the National Primary Care Network, extending the work he developed in his most recent DH role. James has a wealth of experience in General Practice, medical education and medical politics.
He has regularly worked as a GP advisor to Ministers, Government and the Department of Health, as well as being a member of the DH National Leadership Network and now part of the NHS Top Leaders program. He also serves on the NICE Commissioning Steering Group, the Care Quality Commission’s Stakeholder Committee and Dr Foster Ethics Committee.
He is a GP trainer for 20 and undergraduate tutor for the medical schools of Liverpool and University College London.
He is the resident doctor for BBC Radio Merseyside and regularly provides expert advice on national television. He is an established national and internationally renowned speaker.*

There have been dramatic changes in the NHS. But reform does not mean restructuring. We need to see transformational change. We now have a whole new range of organisations trying to shape the NHS.

The vision is for ‘a patient centered NHS, led by clinicians’ – this was met by a wry smile from the audience, hardly a novel concept!

Dr Kingsland gave a brief recent history of changes which have tried to stop the budget from mushrooming. In 1990 the Fundholding model was the first attempt to align a clinical decision with a budget. This carried on for 7 yrs. It was possible to measure outcomes against spending activity.

This was aiming to change behaviors at a clinical practice level. We, as clinicians, cannot divorce ourselves from clinical decisions.

However life expectancy is increasing; there are higher expectations, new drugs and technologies are expensive. But, these pressures have been around for years.

In 1997 fundholding stopped [some think too soon].This was to address under resourcing and long waiting lists.

The investment program tripled money to the NHS to £100 billion. The 18 week target was born and access to a doctor within 48 hours was the norm. This however led to a mushrooming of management, which Andrew Lansley has decided to get rid of.

To keep the budget the same we have to increase productivity by 4.5% per year. We want to keep GP access free, but some public debate has to be entered into regarding some charges. This could be in the form of charging for DNAs, increasing the prescription charge or charging for hospital food.

We now have practice based commissioning.

Where will this reform fall down? Dr Kingsland is of the firm belief that leadership is not about a name or a position but transformation where in the consultation there is a shared decision between the Doctor and the Patient. It is a style of practice.

When restructuring occurs instead of reform then this is a problem. Also we need the tools to do the job. Data and budgets need to be at the correct level so good decisions can be made. If the CCG just looks like a slimmed down version of the PCT then we have missed the point.

An example of this is; how are NHS England and CCG’s going use this new structure to tackle the problems of unwarranted variation service, duplication of service and wastage of money?

It cost roughly £25 to see a GP .If the patient goes to the Walk in Centre [WIC] it’s roughly £38-40. The patient is often directed to the GP, thus duplicating the service and wasting money. New care pathways and work forces will need to match this vision.

Many questions were taken from the floor. They included information about the WIC service; how a safe and effective out of hours service can be provided; how to stop organisations protecting their budgets at the expense of others, and not in the interests of the patient; what to do about procurement and wastage; addressing risk averse behaviour and merging of primary and secondary care budgets.

Mr Steve Milner gave a vote of thanks and we all applauded what had been a most stimulating talk.

*Adapted from the ‘linked in’ profile

30 Members and Guests signed the registers.

‘Chronic pain, fibromyalgia, mud baths and vigorous exercise. Dr Adrian Dunbar.’ The Minutes of the Meeting of the Derby Medical Society Held in the Derby Medical School 10th December 2013

 

Dr Shand had the pleasure of introducing an old colleague from Leeds medical school; Dr Adrian Dunbar. Dr Dunbar is GP with special interest in musculoskeletal medicine and chronic pain management. He has been editor of ‘Synovium’ an educational publication for Arthritis Research UK.

He delivered a talk entitled ‘Chronic pain, fibromyalgia, mud baths and vigorous exercise.’

Dr Dunbar opened his talk with the question ‘is fibromyalgia anything special?’ In his opinion it is another term for chronic pain syndrome.

There are new guidelines recently published by the Canadian fraternity on management of fibromyalgia.

Currently it is defined as 4 months plus of pain, axial and peripheral and 11/18 sore spots. It also has an element of fatigue, sleep and mood can be disturbed and there may be variable somatic symptoms. It is a condition to be recognised and managed in primary care.

It is not a soft tissue disorder. It is a disorder of neural processing. Patients should not be referred to rheumatology.

The prevalence is 4.7% in 30-50 year olds female:male ratio is 7:1. It occurs in 20% of rheumatology OP attendees. The prevalence may be higher, up to 8% and ratio may be closer 1:1. It is a biopsychosocial problem, and as such the medical model fails.

Dr Dunbar illustrated typical management problems with 2 case studies.

Chronic pain ‘something must be done’, ‘I’ve read the latest research and want to try…’ TATT, aches all over.

In all cases we must explore mood and physical symptoms and out rule other underlying diseases by performing pertinent tests.

Chronic pain is a genuine physical sensation. It is persistent and not amenable to treatment with specific remedies. The medical model does not work and neither do drugs. It is a syndrome in which pain and disability are modified by physical, psychological and social factors.

Acute pain has a protective function and is self limiting. In contrast chronic pain offers no protective factor, it degrades health and functioning. This leads to weight gain and increased cancer risk.

Chronic pain markers are; sleep disturbance, fatigue , low mood, anxiety, PTSD, avoidance behaviour activity cycling, perpetual cause seeking and obsessive type cognitive disorder.

If the medical model is applied it leads to futile investigations, fear, high health costs and lives lived in limbo.

Another question; ’Is a fibromyalgia diagnosis helpful?’

It is a disorder of pain processing and is a genuine problem. There is no cure. Treatment is multimodal and rehabilitative. CBT, graduated exercise and some medications may help .Do not attribute to a single cause. In some cases mud baths have proven effective. Many treatments show promise but are, in fact, fairly ineffective.

Increasing doses of opiates are ineffective and harmful. Try instead to address expectations, empower the patient, foster sleep hygiene, advise exercise, not rest and do discuss the latest research and refer for multidisciplinary pain management.

Dr Dunbar runs BMJ Master Classes on this subject. He can be contacted on adrian.dunbar@btopenworld.com

A vote of thanks was given by Dr John Charlton, and we all applauded what had been and interesting and helpful talk.

 

34 members and guests signed the register.

7th January 2014 Dr Anne Thomson, ‘Wheezles and Sneezles’.

 

Dr Shand wished us all Happy New Year.

The minutes of the meeting of the 10th December 2013 were read and approved.

Dr Shand then had the pleasure of introducing Dr Anne Thomson, recently retired Clinical Director of the Oxford Children’s Hospital.

Dr Thomson qualified at Aberdeen and studied paediatrics at Guys in London. She made her way through the ranks- being a registrar in Derby [recalling her time at the North Street site of the Children’s Hospital] then working at Charing Cross; a lecturer at Leicester and then as consultant at Oxford[1989] where she was a paediatric respiratory specialist. She evolved a service which was a tertiary referral centre specialising in cystic fibrosis and brittle asthma.

Her talk was entitled ‘Wheezles and Sneezles’.

Human Rhinovirus C is the commonest cause of acute wheezing in children presenting to hospital.

HRV is a potent inducer of childhood asthma and is compounded by RSV. Infections in these children are worse if they are atopic.

The origins of asthma are 1. Genetic. 2. In utero exposure to allergens, and 3. Post natal: smoking, allergens and viral agents.

Pet allergy is difficult to manage as patients and their families are very attached to their pets.

Non atopics can also wheeze, this is caused by viruses and small airways calibre. All infections are compounded by smoking.

What is the treatment for viral induced wheeze? There is little evidence for antivirals, bronchodilators and steroids. Montelukast has been shown to reduce wheezing in some if taken for 7 days at the onset of the URTI. It has also been in prophylactic management at the start of the school term when URTIs are more common. Up to 50% of children wheeze at some point in their lives but it is not asthma. It’s important not to forget that there are other causes of respiratory symptoms in children.

The prognosis of cystic fibrosis {CF} is much improved due to advances in nutrition, treatment of infections and specialist care in CF centres. More than 50% of the CF population are adults now.

Screening is not foolproof and if a child has recurrent respiratory problems then reconsider the diagnosis.

Regarding childhood infections; MMR, whooping cough, HIB and invasive pneumococcal infections are rare thanks to immunisation as and the advent of Prevenar B. The meningococcal C vaccine has proven very effective. There is an equally effective vaccine against the B strain now, but this is not widely available as it is currently not thought to be cost effective. Called ‘Bexsero’ it’s only available privately and Dr Thomson advises parents to get their child immunised. There is also a vaccine for ACWY for those travelling to the Middle East and Africa.

Rotavirus vaccination has reduced the hospital admissions for gastroenteritis by 80%.

It’s safer than ever to be a child in our society but more and more children are attending A&E and being admitted for short stays. The peak presentation is between 4-9pm. It’s to do with less availability if GP s at this time, less experienced GPs, confusion for the public where and when to get advice and the hospital acts like a huge beacon. The 4 hr incentive means that patients know they will get seen reasonably quickly.

Dr Thomson believes that education is the way forward and the use of social media and Apps to advise on the management of self limiting conditions would help parents. Also the training of GPs has become rather narrow so that paeds is not required or can only be done for a short time.

Dr Thomson suggests a large combined OOH centre with a primary care filter first. Also there should be a financial drive to make CCGs act.

There were many questions from the floor.

A vote of thanks was given by Dr Paddy Kinsella, and we all applauded what had been a most interesting talk and discussion.

Dr Shand reminded us about the elective bursaries which are to be announced at the next meeting on the 21 st January 2014.

 

38 guests and members signed the registers.

Tuesday 21st January 2014 – Theo Raynor, Professor of Pharmacy Practice, University of Leeds – ‘The benefits outweigh the risks – who says?’

Dr Shand welcomed members and visitors.

The minutes from the meeting of the 7th January were read and agreed.

Dr Shand then had the pleasure of introducing a friend and colleague from Leeds, Prof Theo Raynor.

Theo Raynor researches how medicines are used in primary care, notably the effective provision of consumer medicines information. This is the written and spoken information people get with their medicines. He works at research, practice and policy level in the UK, US and Australia.

Theo spent 20 years in hospital pharmacy, combining practice with research and teaching, before moving into academia in 1996.

He became the inaugural Professor of Pharmacy Practice at the University of Leeds in 2000, where he has a highly active practice research programme. This work is complemented by the company which he co-founded, Luto Research Ltd, which spun out of the University in 2009. Theo remains an academic advisor to the company.

Theo was appointed in 2010 to the Royal Pharmaceutical Society ‘Expert Advisory Panel on Pharmaceutical Science’.  In a video commissioned by the Royal Pharmaceutical Society, Theo describes his research and its focus on making an impact on helping people take their medicines safely and effectively: http://vimeo.com/21478616. *

Prof Raynor started by asking how do we best present risk /benefit information to patients about the medicines they take? He gave examples of leaflets he had seen which boasted that the benefits of taking medicines outweighed any risk!

We want patients to be more involved in their health care choices, but there are many barriers and rules which apply to getting this information across. For a start many adults do not have good reading skills, and it’s amazing how many different interpretations there are for diagrams and pictures. Medicine labels in 1978 were very basic and open to misinterpretation i.e. 6 hourly may mean three or four times per day depending on how you interpret it. Also some instructions are irrelevant or open to misinterpretation. For example the word ’Avoid’ and the word ‘whilst’ are not easily understood. In 1984 Distalgiesic was one of the first medicines to have an information leaflet within the package. This was due to the problem of patients mixing it with alcohol, with often fatal consequences. The instruction was ‘Avoid alcohol whilst taking this medicine’. Since then there has been an attempt to standardize information on leaflets. Medicines are approved at EU level and are covered by EU medicines law. Since 1999 all medicines have to have a leaflet in the packet containing the SPC[summary of product characteristics], written by the manufacturer and it must be clear and understandable.

In 2005 there was an EU directive which stated that these leaflets had to be tested by the public, called ‘user testing’. This is the main thing that LUTO research is involved with. This was initially seen as a hoop jumping exercise by the drug companies, but they have been surprised when patients do not understand their leaflets.  Consequently the leaflets have been redesigned to be more user friendly, containing bullet points and useful information.

The research has brought out many common points; namely patients want written and spoken information, they want to balance the benefits and harms of taking a medicine. Leaflets are too negative, containing a long list of side effects. In relation to harm or side effects ‘very common’ is perceived to be up to 80% when in fact the manufacturer means >10%. Similarly low risk is never perceived as less than 1% by the public when in fact it can be 0.01%.It is better to describe events as natural frequencies i.e. 1:100.

Benefits are listed by giving a descriptive review of what the drug does. Numerical data can put this into perspective, i.e. If 100 people with this condition took the drug for 2 years it would reduce the number of MIs by 3 and strokes by 2. Some patients are surprised by the data and are adamant the numbers are too low. There was a wide range of responses to this data. The general public is not good at understanding absolute or relative risk. Patients did want information and to be taken seriously and to take responsibility.  Information can be presented in different ways and there is a big prescriber influence. A useful tool is NNT [numbers needed to treat]. Prof Raynor considers that this is very close to the information that a patient might need to make a decision. www.thennt.com/

Prof Raynor went onto illustrate some of his points by talking about the Polypill.[ amlodipine, simvastatin, losarten and hydrochlorthalidone] It has no funding for a license and can be bought online. The trial data is poor, it medicalises well people, there is lack of long term data and the NNT was poor. It costs £84 for 3m supply.

There were many questions from the floor.

Dr Alan Meakin gave a vote of thanks. We all applauded what had been a most interesting and thought provoking talk.

Dr Shand then announced the medical student elective bursaries which had been judged by Steve Milner and his wife. The monies of £250  each were awarded to; Sarah Humphries, who is going to Samoa, and Lauren Taylor who is going to Vanuatu. They will be invited to give presentations about their elective later in the year.

The next meeting is on the 4th of February when Dr Nick Spencer will be talking about radiology.

We were reminded about the summer meet. This will be held on 28th June and will include a visit to a vineyard at Renishaw Hall with wine tasting and tea afterwards.

*Taken from medhealth.leeds.ac.uk/profile/1100/376/dk_theo_raynor

28 members and guests signed the registers

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