GP patients have to be seen

The NHS has been in the news a lot recently. Big changes are afoot, and about time too. While I am very aware that it is blasphemy to say so, the NHS no longer works well in many areas, and needs to change. It's a constantly evolving being and the way it is managed needs to evolve along with it. Unfortunately this hasn't happened.

I think some of the new proposals are very sensible. Surely if anyone is going to know where money is most needed and best spent it is the GPs on the front line? I hope this plan works and I welcome it.

There is another idea being touted, however, that I don't think is sensible. In fact, it makes me very concerned indeed. The Government is planning to offer patients email consultations with GPs. People will be able to directly email their GP through a new Communicator tool, part of the secure personal health organiser website originally set up to allow patients to view their records online. Remember what a disaster the NHS IT system was to set up? Doesn't bode well, does it?

It's a move the Government claims will improve access to primary care. The word to pick up on is "access". It may well be improving access but it is certainly not improving care. It may possibly work for issuing repeat prescriptions to those with chronic but well managed conditions, or getting results from home test kits such as blood sugar or BP, to update records, but beyond this? No chance.

There is a very good reason why tradition has dictated that doctors bother to see their patients in person, to talk to them, ask them salient questions and maybe even lay on a hand. It's because patients are not generally very good at telling you what is wrong with them. They need help, and it is not always what they say that gives you the answer. Being able to see them, to read their body language and hear the tone of their voice are vital parts in diagnosis. I'll give you an example: chest pain. "Dear doc, I have pain in my chest, comes and goes, maybe a bit goes to my left arm as well. Should I be worried?"

Chest pain can have many causes, heart attack being one, acid reflux another, but it could also be a simple chest infection or even depression manifesting as a pain. Never could this be worked out from an email without either much back-and-forth correspondence (taking up at least as much time as a face-to- face consultation) or a very informed, educated and impartial patient relating the exact relevant symptoms correctly. It won't happen.

I have had good personal experience of this long before any pilot schemes were tried out. Since my TV shows have aired I have been inundated on a regular basis with emails from people all over the world wanting help, advice and diagnoses. I can confidently say that few are easily or quickly answerable, and few give enough information for any sort of useful reply to be given other than "Better go and see your doctor".

Given that the public is spending £2 billion a week on the health service I think it a very sad state of affairs for medicine if a face-to-face appointment with a GP becomes not a right but a luxury.

Cash for eggs: there are so many issues

Fertility and its management is always an emotive subject that polarises opinion. The views of the public are currently being sought on surrogacy - in the spotlight again following Nicole Kidman's announcement that her second daughter was carried this way - as well as the use of donor eggs and sperm to enable infertile couples to have a baby. More ethical issues are being explored, including whether close relatives should donate eggs or sperm to each other, and if it is acceptable for a baby to be born, through egg donation, to a woman who is also its grandmother.

The debate follows a high court ruling that may have opened the way for surrogate mothers to be paid, a practice which had been banned. If the public concede, then women could be set to receive thousands of pounds for donating their eggs. Currently, British clinics are banned from paying for eggs and sperm directly but can pay up to £250 in expenses - which hasn't exactly filled potential donors with a desire to go through with the process of donation.

The problem with the "cash for eggs" proposal will not be with the well-meaning majority but the unscrupulous few, who will lure in women by making egg donation seem like an easy way to earn money - without any explanation of what actually is involved. Worrying, too, is the possibility of "designer genes" being offered to couples prepared to pay exorbitant fees for the perfect combination of brains and beauty; the higher your exam marks and the better your bone structure, the more your eggs could be worth.

I'm not sure money is the main issue, however. While it's mainly the small amount of cash currently offered to donors that has been blamed for the shortage of eggs, I suspect a greater problem is the recent change in UK law which requires the identity of sperm or egg donors to be revealed to their children - the idea of a load of "surprise" children showing up years after donation undoubtedly puts off many would-be donors.

Maybe the issue is being looked at from the wrong angle, in London at least. The stats for maternal age show that in the UK London has the lowest number of births per 1,000 women aged 25 to 29, and the highest birth rate for women aged 35 to 39. This implies London women are leaving pregnancy until much later, a known risk for fertility issues and the need for donor eggs or even surrogacy. Many have argued that more should be done to cure infertility and to encourage women to have children when they are young and their eggs are still in good condition, instead of worrying about turning body parts into tradable commodities.

Flu is a threat but simple measures can keep it at bay

Last year I wrote rather scathingly about the panic surrounding the predicted flu epidemic that never was. This year I'm going to be more cautious as I feel things have changed. Flu is back but this time it affects a new demographic of hitherto unaffected people, which could have profound implications on our future approach to managing flu.

The number of flu victims has been rising steadily, which isn't unusual, but these victims are mainly professional, young middle-aged and middle-class, which is. What is worrying some virologists is the newly proposed theory that these current unlikely flu victims are stricken down because last year's flu jab may have made them more vulnerable to this year's attack by the H1N1 swine flu virus.

As it has been estimated that a serious outbreak of flu could kill 65,000 people in Britain and, according to one study, could knock out nearly 40 per cent of all health professionals — doctors, nurses and paramedics — in the first 10 days then this theory, if true, is a disaster. Already swine flu is spreading faster in the UK than in Europe, and the figures are likely to climb even more steeply now that we are back at school and work and mingling with each other again.

But we have had vaccine scare stories frequently in the past and few have been legitimate. In fact many have been very damaging, like the MMR scare.

This is still very much a theory, totally unproven, so I would advise everyone, whatever age or state of health, still to have a flu jab this year, as it will help reduce the chances of a pandemic that could kill far more than the vaccine will ever adversely affect.

This year I have also seen more chest infections in my clinic, always with the same story: “It started off as a bit of a cold, then developed into something much worse, doctor.” Viral illnesses and flu can be common precursors to pneumonias so getting your flu jab will help stop this. Not smoking, a healthy diet, and getting plenty of exercise and rest will too. If you seem to be regularly affected ask your GP about pneumococcal pneumonia vaccine. It's effective in 80 per cent of healthy adults and helps high-risk groups lower their odds of getting pneumonia.

Finally, given the chances of catching flu this year seem so much greater, consider taking antiviral drugs if you do get ill. The side effects can be dreadful but they can make illness milder and last for a shorter duration.

The sound solution for breast cancer

We have long known that breasts change with age. It is a perfectly natural process but one that women have been fighting for generations. Gravity always wins in the end, particularly over women with large boobs who have had several pregnancies. Joggers can suffer particularly badly. But whilst this age related sagging might not be desirable from an aesthetic point of view, it does have a very useful property from a medical one. The older you get, the less dense your boobs get and the easier it is to image them for lumps. This is the reason why we don’t offer mammograms to young women. Currently on the NHS screening is offered from the age of 47, and this is not just to do with money. It really is more effective after this age. Young boobs just don’t x-ray well. But now the results of new studies show another property of breast density, but this one is not so good. There is increasing evidence that density is a key factor in breast cancer. Women with more tissue than fat in their breasts are up to five times more at risk because they have more cells. Those involved in the research have suggested that all women should be advised of their breast density, and all should be offered ultrasound scans, to pick up tumours that mammography may have missed. The theory is that denser breasts hide their lumps from x-rays, but may reveal them to ultrasound. Of course since this information has been released the usual loud clamouring has started, demanding that the already overstretched NHS offers this extra screening test to all women.
Our current screening program is great. Mammography lowers breast cancer mortality by 15% to 20%. But if ultrasound can further improve this then surely it should be added to the program too? The problem is that it is very operator dependent, and in multiple trials comparing the accuracy of mammography plus ultrasound to that of mammography alone in women with denser breasts who were at high risk for breast cancer, the addition of ultrasound to mammography did result in detection of additional cases of cancer, but at the expense of a roughly fourfold increase in false-positives. This means that four times as many women would have to undergo an invasive biopsy procedure that they do not need if this method of screening was introduced. This would cause a level of anxiety that may be acceptable in a high-risk population, but certainly would not be in lower-risk patients. An unobtainable number of extra man-hours would also be needed to cope with the increased counselling involved.
Neither can ultrasound consistently detect certain early signs of cancer such as tiny deposits of calcium in the breast that cannot be felt but can be seen on a conventional mammogram. Nor does it have good spatial resolution like mammography, and therefore cannot provide as much detail as a mammogram image.
What is not being publicised is the fact that the combination of mammography and ultrasound still missed one out of every five cancers. So ultrasound is certainly not a silver bullet for breast cancer screening and shouldn’t be hailed as such. Perhaps rather than shouting that women are being denied ‘life saving cancer tests’ we should be a little more measured in our approach and look for ways to improve the uptake of mammography itself. Still too many women do not attend. Also, ensuring all screening programs offer digital imaging, which is more accurate still, may be a better use of time and money, and will avoid creating a cohort of worried and confused women.

Breaking the migraine barrier

New research looking into the causes of migraines has produced what may be one of the most important and useful medical findings of the century. Scientists have found a gene that regulates how pain is felt in the brain, a gene that can be turned up or down. Called TRESK, the gene controls the sensitivity of pain nerves in the brain and it is thought that migraine sufferers may have a fault in their gene, causing the extreme sensitivity to light, noise and touch experienced during a migraine.

It’s an exciting discovery as it may lead to the creation of a new generation of drugs that can simply turn up the threshold at which the body feels pain making migraines a thing of the past. It not just migraines that will benefit however, as it could potentially lead to a new form of painkiller being developed as well. As the gene is susceptible to being switched on and off with drugs it means that it could be altered to increase the threshold to such an extent it eliminates the feeling of pain altogether.
Migraines cause a considerable burden to sufferers and their work. In the UK around 18 per cent of women and 8 per cent of men get migraines resulting in the loss of more than 25 million working days a year. The World Health Organisation has named migraine as a leading cause of disability worldwide and it has been estimated to be the most costly neurological disorder in Europe.

Sadly migraines are often very badly managed by the medical profession, many of whom still continue to promote ideas like its cheese, or chocolate that cause migraines. Actually the situation is more complex, and it is necessary for more than one trigger to be present, possible more than 48 hours before the onset of headache, in order to cross the threshold that leads to an attack. Contrary to popular belief migraines are not caused by food allergy either, and no specific antigen-antibody reaction has ever been identified although certain foods may be one of a complex of triggers. Actually, missing meals (resulting in a drop in blood sugar) and dehydration are far more important triggers. Changes in sleep pattern, hormonal changes, head and neck pains and stress are all other culprits. Very little time is spent explaining and helping to identify these interacting triggers and existing treatments are often not taken early enough. There is currently no cure for migraines but many different treatments are available which can be effective if used correctly. The problem is that it can require quite a bit of personal experimenting with different types and combinations of medicines before the most effective one is found. Even simple painkillers can work well, but many people only take painkillers when their headache becomes very bad. This is usually too late for any benefit to be felt.


My top 5 tips if your migraines are poorly controlled are:

1) Identify prodromal symptoms like changes in mood or behaviour to help identify as early as possible when a migraine may be imminent.
2) Keep a diary of all the details of what you were doing for the few days before an attack to help you better understand them.
3) Identify your specific triggers and gradually cut them from your life, if possible.
4) Take treatment early –by identifying the warning signs this should usually be possible.
5) Always carry treatment with you and ideally a little food and drink too.

If you feel your migraines are not under control then ask your GP for a referral to a specialist migraine clinic for further advice.

Teen Sexual Health

As a sexual health doctor the recent visit of the Pope made me angry for an obvious number of reasons. In rebellion I want to announce that the 26th September this year is World Contraception Day and we should all mark it. It’s not a day I expect many to have ever heard of, and it is perhaps considered a little too Hallmark for some, but given the statistic that approximately a third of the 205 million pregnancies that occur each year worldwide are unplanned, the need for such a day can be clearly seen. To mark the event a multi-national survey looking at attitudes towards contraception has been undertaken. The results are depressing although pretty unsurprising. They highlight a significant disconnect between what young people know they should be doing for contraception, and what they are actually doing in their day to day lives. It also shows that highly unreliable contraceptive methods, such as the ‘withdrawal method’ are still being viewed as effective by almost a third of young people. Perhaps most depressing of all is the news that that the highest reported rates of STIs are found among young people aged between 15 and 24. Nearly half report that they prioritize personal hygiene, including showering, waxing and applying perfume, above contraception, and teens in the UK reported that the reason why they failed to use condoms was because they were often too drunk to remember.
Straight from the school of the bleeding obvious, this apparently earth-shattering revelation that the appalling STI and pregnancy rates amongst UK teenagers maybe linked to the significant increase in binge drinking observed over the last few years has grabbed headlines but I find it truly hard to believe that no one has made this observation before. Experts quite rightly describe the findings as alarming, but disagree over whether the solution lies in providing more contraception or better efforts to rein in binge drinking. I think improving sex education would be a better starting place, by including more focus on relationships, feelings, emotions, confidence and respect. The British media could also do a lot to help, by stopping its prudish campaign of being deliberately and mischievously resolved to undermine any sexual health/education initiative aimed at helping young people and their parents. I can but dream. I personally find the results alarming because sadly I cannot now see a truly effective solution actually being implemented. The problem is that until the government addresses its ludicrously hypocritical drug and alcohol laws things are only likely to get worse. Making legal (and, let’s be honest, frankly encouraging the use of) the one drug that causes considerable self-destructive behaviour and affects judgement in the way that alcohol does is absurd. It gives such a confused message to our young people that I weep for the future. Yes, alcohol is responsible for many a condomless encounter because that is the one property of alcohol that we most embrace –its ability to make us relax and forget. Teens are no more going to stop drinking than the Catholic Church is going to repeal some of its insane views on sex and contraception.

Losing our Doctors

In my day being a junior doctor sucked. I had a miserable time, was bullied by an evil female surgeon with a chip on her shoulder and permanently felt like a zombie due to a ridiculous work rota. I’m not sure I actually learned anything for the first year or so other than the fact that this really wasn’t the working life that I wanted or hoped for. I got out and sought an alternative. Essentially we were slaves, used as 24-hour phlebotomists, secretaries, and robot-like IV cannulators by consultants who were completely disinterested in training us. We looked for any opportunity to rise as quickly as we could through the archaic feudal system or get out altogether. Unfortunately those opportunities were few and far between.
Very little attempt was made to rectify this until the EU working time directive, which was introduced into the NHS last summer, forced hands. Designed to improve the work-life balance of junior doctors it limits the working week to 48 hours. Understandably many rejoiced until the realities set in: the situation now is just as farcical as it ever was. Juniors are asked to lie about the number of hours worked to ensure trusts are compliant with the directive, or made to ‘voluntarily’ opt out of the directive when signing their contracts. Hospitals have been forced to shake up their rota systems, leaving junior doctors to work the majority of night shifts and weekends, meaning that although they were indeed working fewer hours, they were missing most of their important teaching and training sessions. Of recent medics who wanted to carry on and specialise, 22 per cent were turned down by hospitals because they lacked skills or experience –a fault of their working rotas. Junior doctors that I talk too now tell me that the only way to get work done is to sneak back into the hospital when everyone else has gone home, avoiding the managers policing the working hours. They are being made to work intense shifts doing work that should be delegated to people who are less well trained in what is a gross misuse of highly skilled staff and will lead to a dearth of properly trained specialists in the future.
So it really doesn’t come as any surprise at all that latest figures show nearly a quarter of junior doctors drop out of their NHS training in England after two years. To be fair, not all are lost from medicine as some take gap years or move to other parts of the NHS to work, but many head abroad to work in Australia, New Zealand and other parts of the world where they can enjoy a better working life. All I can say is ‘clever them.’
Hospitals are clearly struggling to cope with the introduction of the 48-hour week and are running understaffed rotas where juniors have to work on thinned-down teams with no specialist guidance. Hospitals need to look more closely at how they organise their rotas and how to reduce much of the unnecessary bureaucracy and menial work that takes up so much of the junior doctor’s time.
Until the problem is sorted doctors will continue to leave. And who can blame them?

Egg Donors should volunteer for the right reasons

The government's fertility regulator has announced that it is considering lifting the UK ban on selling eggs and sperm to try to ease the shortage that they say is driving thousands of couples to go to foreign fertility clinics. It claims it’s decision is based on allegations that clinics in countries like Hungary, the Czech Republic and Slovenia, popular with couples unable to conceive naturally, routinely ignore safety guidelines. Women attending there have multiple embryos implanted into the womb to increase the chance of a pregnancy occurring, but unfortunately this also increases the likelihood of multiple births, and so to the health risks to both mother and baby.
Currently, British clinics are banned from paying for eggs and sperm directly, but can pay up to £250 in expenses which hasn’t exactly filled potential donors with an enthusiastic desire to go through with the complicated process of donation. Several different alternative options are now being explored from simply doubling this sum, to copying the system in Spain, where women are paid €900 for each cycle of eggs. The regulatory body is also examining an alternative option: to allow women to be paid many thousands of pounds, enticing them with considerable lump sums, as happens in the USA.
All this makes me rather uncomfortable. There is something intrinsically wrong with a ‘cash for body parts’ situation. Families of organ donors do not benefit financially from their deceased relative’s decision to donate, and blood donors don’t get paid either. I feel that so too should egg and sperm donations be done for altruistic (or egotistic) reasons and not for large wads of cash. I am well aware of the counter arguments; egg donation is far more invasive than giving blood and so deserves some sort of compensation for the time and risks involved. Women need to have their cycles synchronised with the matched recipient and then undergo a two-week course of hormone injections, daily blood tests and ultrasounds until they have produced several ripe follicles. Harvesting those follicles then involves a minor operative procedure, time off work is inevitable and complications can occur. But look at the situation in the USA, where cutting-edge reproductive technologies and infertile couples are providing young women with thousands of dollars for their eggs. Tempting adverts can be seen in college newspapers making donating eggs seem like an easy way to earn money and help meet the demands of rising costs, without any explanation of what actually is involved. More worryingly are the reports that the excess of young women wanting to exchange their eggs for cash is creating a cohort of doctors who are exploiting the desperation of childless couples by offering a ‘designer genes’ service for couples prepared to pay exorbitant fees for the perfect combination of brains and beauty. The higher your exam marks and the better your bone structure, the more your eggs are worth. This terrifies me as it is nothing more than a sordid form of eugenics, selecting those characteristics deemed desirable by society and selecting out those, like homosexuality and being ginger, that aren’t. A genetic underclass will be created of those whose attributes do not meet the high expectations of the prospective parents.
Getting pregnant and having a baby is not an absolute right, as so many women seem to think. Nor is choosing the type of child that you have. Donating your eggs to help others should be a noble, selfless and altruistic act, having total control over the phenotype of your baby is certainly not. It’s selfish and a gross violation of the laws of nature.

Same sex wards can work

Our great leaders are about to announce their rather ambitious plan to put an end to mixed sex wards in hospitals. It’s certainly not the first time this desire has been voiced. Tony Blair called for their abolition in 1996, when Labour was still in opposition, saying it should not be beyond "the collective wit" of ministers to achieve. 14 years on and it clearly was. Its successful implementation has been a goal that has eluded ministers for years.
As with many of the government’s ideas this one seems rather attractive on paper, but as soon as the practicalities of achieving it across the board are considered, it shows itself to be an unrealistic aspiration. Many of our hospitals are old Victorian buildings that would require extensive renovations in order for them to comply. These are unlikely to occur since we are living in a time of massive public service cutbacks and a pre-existing shortfall of hospital beds. I do understand the feelings of anxiety, exposure and vulnerability that mixed sex wards may create, to say nothing of those dreadful ‘backless’ hospital gowns that leave little to the imagination. If it is indeed the case that patients are left uncovered in front of patients of the opposite sex then it seems to me that a simpler and more urgently needed solution would be to improve the training and discipline of nurses and doctors on such wards, perhaps by bringing back the concept of ‘Matron’. These dragons may have been feared by all, and certainly struck terror into the heart of every junior doctor who crossed them, but boy did they get things done properly.
Rather bizarrely the government makes much of the apparent indignity of the sexes having to share bathrooms. I’m not really sure why this should be such a problem -surely there are bigger and more pressing health issue that need tackling than whether Mrs Jones prefers to find the loo seat left down when she pays a visit? As is so often the case it’s not only the idea that is questionable, but also the way in which ministers attempt to enforce their ideas. NHS trusts will be warned that they will face fines if they do not get rid of their remaining mixed sex wards by the end of the year. Just what an already cash strapped trust needs when trying to implement a change that will require a considerable increase in spending to achieve.
Just how necessary are these proposed changes? In a recent survey of 150 patients admitted to a variety of different wards 24 per cent said that they had no preference as to the type of ward they went on, and 57 per cent actually preferred mixed sex wards; their reasons being that they felt it created a more normal atmosphere and better reflected the outside world. The concept of segregating the sexes stemmed in part from the data that in the community young men commit most violent crime, and women were said to report feeling vulnerable on mixed wards. But in an institutional or hospital setting research has found a very different picture. There, women have equal rates of episodes of violence, there was considerable spread in age range, and that age and gender failed to predict assaultiveness. I cant help feeling that all this is a bit of a sly distracter however; same-sex wards may be nice to have, but must come secondary to safe clinical care and good medical outcomes. Assessing your hospitals worth by how comfortable you stay was, as you would a hotel, is most definitely flawed. Patient satisfaction and consumer choice are all very well politically, but isn’t therapeutic benefit the one main issue on which health care planners should focus? What effect will same-sex wards have on therapeutic outcome? I’m not sure anyone actually knows the answer. Yet.

Time to stop milking it?

As the government desperately scans through it’s extensive list of expenditures looking for areas in which it can make cuts, the spotlight fell on the ‘free milk for kids’ scheme. Scrapping it could save around £60m per year, and yet almost as soon as it was suggested publicly, No 10 hastily released a statement saying the scheme would remain. But the damage has already been done and the usual militants are stepping in, shrieking with outrage that such a proposal could even have crossed anyone’s mind.
Yet if you suppress the initial knee jerk reaction and look at the science behind it one can see that it’s actually a perfectly sensible, even advisable idea. The scheme is the only remaining part of what was known as the Welfare Food Scheme, first introduced in 1940 to protect pregnant women and young children against wartime food shortages, but now, in this time of gross nutritional excess, is an outdated and unnecessary idea. Indeed scientific evidence is amassing that suggests regular consumption of milk may be bad for you, by not only by causing some diseases but also by failing to prevent others for which it has traditionally been seen as a panacea.
Experts now say that after the first year of life children require no milk of any type. The former director of paediatrics at Johns Hopkins School of Medicine estimated that half of all iron deficiency in US infants results from cows' milk-induced intestinal bleeding. He proposed that infants drink so much milk (which is very low in iron) that they have little appetite left for foods containing iron; at the same time, by inducing gastrointestinal bleeding, milk causes iron loss. The same certainly applies to British infants too.
Cow's milk is simply just that: for cows. Man is the only animal that drinks milk into adulthood. It’s higher in sugar than humans need, and although high in calcium, only around 30% of it is available for use by the body, as compared to 60-70% for fruits, grains, legumes, nuts, roots, seeds, and vegetables.
There is also a theory that a protein found in milk mimics closely a protein found on the insulin producing cells of the body. If the body develops an allergic reaction to this milk protein then it is also stimulated to destroy the insulin cells through an autoimmune attack, a possible cause of diabetes.
The pro-milk lobby will scream ‘osteoporosis’ in their defence. But whilst milk is often sited as being key in the development and maintenance of strong bones, even this has now been questioned. When looked at globally it can be seen that the countries with the highest rates of osteoporosis, also have the highest consumption rates of milk and dairy products –it does make you think. Milk proteins contain phosphorous and sulphur compounds that acidify the blood. In order to correct this acidity, the body actually draws calcium from the bones, weakening them.
Instead of recommending multiple servings of dairy to ward off the dreaded osteoporosis, we would probably do better to advise women, and especially teenage girls, to take more exercise. A 15-year study published in the BMJ found that exercise may be the best protection against hip fractures, and that a reduced intake of dietary calcium does not seem to be a risk factor.
So perhaps it really is time to re-evaluate this dinosaur of a tradition and ask ourselves the question: is providing our kids with free milk actually doing more harm that good? Current evidence suggests that it might be.