Deputising Services and Out of Hours Care
Patients are more satisfied with the out of hours care provided by their own practice doctors (70.7%) rather than deputising services (61.8%) according to a study in the BMJ (BMJ [1997] 314:190-3). The outcome of the visit (24 to 120 hours later) did not appear to differ between the two groups. The difference in satisfaction levels may reflect an increased delay in the time taken to visit by the deputies.
Crisis in London's Mental Health Services
1997 saw the advent of a new King's Fund report on London's psychiatric services. The report entitled London's Mental Health, states:
US: HMO Gagging Clauses illegal
Health Maintenance Organisations that restrict doctors from discussing treatment options with Medicare beneficiaries are acting illegally. So said the US Dept. of Health and Human Services. This set a federal precedent and bypassed Congressional and Senate hearings. A few health maintenance organisations have removed gagging clauses in reaction to negative publicity.
New plans for UK General Practice
The UK Department of Health published a new white paper about the future of General Practice in 1997.
Among it's recommendations were:
This latter diversion will be seen as controversial by hard pressed hospital and community Trusts already struggling to implement the Government's underfunded Care Progreamme Approach.
Moderate alcohol consumption and mortality
Chinese epidemiological research has demonstrated the benefits of mild to moderate alcohol consumption. The paper, published in the BMJ (1997; 314: 18-23) investigated the risk of death associated with various patterns of alcohol intake. 18,244 men aged 45-64 years were enrolled in this prospective study. Against lifelong non-drinkers, those who consumed 1-14 drinks a week had a 19% reduction in overall mortality. Those who drank 28 or fewer drinks a week had a 36% reduction in death from ischaemic heart disease (but there was no effect on death from stroke). However heavy drinking was associated with increased rates of gastrointestinal tract, cirrhosis and stroke. The reduced mortality effects of low consumption were not confined to wine.
Psychiatry On-Line Antipsychotic Survey.
http://www.priory.com/journals/survneur.htm
Out of 100 doctors randomly drawn from the first weeks of the continuing survey... Their top 5 preferences for the initial antipsychotic given to suspected cases of schizophrenia was as follows:
If you are a psychiatrist/physician registered with Psychiatry On-Line who hasn't voted yet, please do consider visiting the site soon. We also have a survey into antihypertensives.
In March 1996 the British Government was reeling from the political impact of a world-wide ban on exported British Beef. Between May 1990 and 1996 there were ten cases of Creutzfeldt-Jakob disease reported in people under the age of 42 to the UK Spongiform Encephalopathy Advisory Committee (SEAC). More cases were reported in March 1996. The best estimates of the expected incidence of cases between 1990 and 1996 vary between 1.26 and 6.3. However, a critical factor in determining whether the incidence of CJD is rising (which might indicate transmission of BSE to humans) is the validity of the epidemiological assumptions regarding the prior incidence of CJD. Such epidemiological assumptions have previously proved to be ill-founded, as in the case of HIV epidemiology. Predicting the likely future incidence of any human variant of BSE is again fraught with difficulty. Options to stem any possibility of the spread of a variant have included culling the entire British herd, age specific random selection and slaughter of cattle depending on their brain pathology, culling all cattle born before 1990, killing the calves of affected cattle, and killing all herds with any affected members (in case of lateral transmission).
As a response to the crisis the British consumer has largely abandoned buying British beef. Burger chains such as McDonalds's and Burger King are sourcing their beef from outside the UK. However, BSE is not confined to the UK. Cases of BSE have certainly appeared in other countries - including Switzerland. We would be interested to know of public health policies in other countries regarding BSE, scrapie and other prion-related brain pathologies.
The Drug Intervention Log published in early 1996 was enthusiastically received by readers and within weeks of publication was adopted in several hospital audit programs.
The publishers look forward to further feedback to establish mean scores for physicians' DIL factors according to differing practices and professions. This and the Side Effect Registry are two ways in which we hope to enhance global interaction and co-operation with respect to medical care.
The care in the community initiative, and the focusing of psychiatric services on psychosis (see above item) has imposed greater burdens on UK general practitioners. The new 1990 contract and the internal market have imposed targets and bureaucratic requirements previously undreamt of. Medical students and junior doctors in the UK are voting with their feet and General Practice is very much losing out in terms of medical manpower. Between 1988 and 1994 there was a 15% fall in the number of general practice trainees. The British Medical Association last week published a report which blamed these factors together with a rise in the proportion of women in medicine and a widespread desire to have a less than full time commitment to medicine.
The report Medical workforce made a number or recommendations including an urgent review of the numbers of student doctors in UK medical schools, a reversal of community care, and additional resources to encourage recruitment.
A new anti influenza drug, GG-167, produced by Glaxo Wellcome, will have phase II trials resumed as a result of the increase of cases during the winter of 1995-1996. GG-167 works by preventing the 'flu virus spreading round the body by blocking the enzyme which releases it rather than by killing the virus directly. In theory this should enable the body's immune system to deal with the infection before it becomes widespread. It is expected that the drug will be produced as a spray or as nasal drops. Glaxo Wellcome hope to receive approval from the regulators in 1997.
New compounds, developed by Khepri Pharmaceuticals, have shown
reduction in joint inflamation and damage in arthritis in
preliminary results. The new proto-drugs are vinyl sulphones
which have been taken from design to preclinical test in 10
months by using computer modelling. They act selectively on
protease enzymes such as cruzain, cathespins and capains. The
compounds act on the enzymes by interacting with the target site
through hydrogen bonding (J.T. Palmer et
al Journal of Medical Chemistry, 1995, 38,
3193). The researchers hope that the specificity of
these vinyl sulphones, along with their stability will remove
most of the concerns raised by potentially toxic or highly
reactive compounds which have been reported as drug candidates
before.
The San Fransisco company is now looking for collaborative
research to take their latest drug candidates further.
The British government has recently launched a trial of a new
computerised drug advice system for primary care doctors. It is
part of the research and development project PRODIGY, aimed at
improving the effectiveness of GP prescribing.
Over 120 practices in around 60 Family Health Service Authorities
(FHSAs) in the UK will be participating during the six month
trial.
The system, expected to be relevant for around 95% of
consultations will offer advice on the different drugs that can
be offered.
A number of software companies have agreed to take part in the
trials and have developed their software to give the requested
advice.
The NHS Executivehas been discussing with software suppliers the
need to design systems which provide therapeutic advice and
guidance during consultations. It appears that the participating
companies have been taking note.
The trial was launched by health minister Gerry Malone who said:
"Prodigy is an important developments which,by offering a best practice quide at the touch of a button, could have a major impact in improving the quality and cost-effectiveness of GP prescribing.
A similar system has been tested in the Netherlands and has been shown to provide valuable support in one of the most complex areas of their work. Once the trial is completed we will evaluate it carefully
If we decide to make the system available nationally, its use will be at the discretion of the GP"
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