The Crippen Diaries 2007 (20)

Not quite Emergency Ward 10

Monday 14th May

Stress at home this week as we start the first day of AS levels and GCSEs.

A glass of orange juice and a brief look at The Times. GPs are front page news again. This time we are accused of filling up the customers with Prozac, inappropriately and unnecessarily. Well, that is the implication anyway.

Paul Farmer, chief executive of Mind, said:

“Doctors are guilty of a knee-jerk reaction in prescribing pills, which are commonly long-term prescriptions and have well-known issues with side-effects. The mindset of GPs will have to change so that they consider counselling and other forms of therapy as a frontline treatment.” (The Times)

That’s great, Paul. We will send everyone for counselling, for “Talking Therapy”, and then for an all expenses paid holiday in the Caribbean. We are as likely to get the latter as the former. My practice no longer has routine access to therapists, they were taken away. Government cuts, don’t you know. We have poor psychiatric services generally and a CMHT staffed by amateurs many of whom do not know what they are doing.

Add on to that the increasing public expectation that there should be a “pill” for everything ever increasing consumer demand for Prozac, and you have a receipe for disaster.

It is not just GPs. Hospital doctors dole out SSRIs with gay abandon too, and many nurse specialists think that anyone with an upset – particular a bereavement – should be on medication.

Far too much of this junk is prescribed. My practice, for what it’s worth, is one of the lowest prescribers of the stuff in the county. We try to avoid it. Easy to say. You may not believe me. Suit yourself.

Driving into work, I listen to the Radio 4 Today programme. Hamish whats-his-name from the BMA is being given a hard time by Naughtie. Same old stuff. GPs are idle, are providing a lousy service and are ripping of the NHS. Time they did some work to justify there obscenely high salaries.

I arrive at the Health Centre. One of the receptionists hands me a copy of the PMJ. She does this to annoy me. She knows my views on it.

Brown to tackle £100,000 a year GPs over pay and hours

Gordon Brown is heading for a showdown with family doctors over their six-figure salaries. He will tell them to bring back proper out-of-hours care or effectively take a pay cut. GPs will be ordered to see patients in the evenings and at weekends to justify their bumper salaries - which have risen to an average of more than £100,000 in the last few years. A source close to Mr Brown insisted the GPs' contract would not be 'torn up'. Instead, he said, the existing deal would be modified to divert money away from those who do not provide out-of-hours care towards those who do.

I suppose I should try not to get angry about statements in the PMJ.

“GPs will be ordered…” “bumper salaries…” “the GPs’ contract would be…modified to divert money away from those who do not provide “out-of-hours” care towards those who do.”

So, a quarter of the QoF money will be taken away and given back to the GPs who start doing out of hours work again. Gordon may be in for a surprise. Providing an out of hours’ emergency service is one thing. Providing a walk in service for people who want their athlete’s foot treated on Sunday afternoon is quite another.

Brown needs a rabble-rousing soft target, and it seems we have got the job. The misconceptions abound and will be perpetuated. It is the same nonsense as the criticisms of the consultants who are now portrayed as doing less work for more money. I cannot be bothered to argue any more. Even some of the junior hospital doctors, who you would think would know better, seem to be jumping on the bandwagon.

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The first patient is David, a 78 year old with prostate cancer. He had radical radiotherapy and currently his PSA is less than two. So far, so good. However, he has residual radiation cystitis and proctitis and so spends most of his life in and out of the lavatory. He also has ischaemic heart disease and COPD. The angina is well under control, but his exercise tolerance is poor because he is short of breath. His medication needs careful juggling and frequent review. Try taking diuretics when you have radiation cystitis. David is frightened by prostate cancer. He knows it can go to the bones. His staging bone scan was negative but he is particularly frightened of bone cancer because his wife died last year of myeloma, which affected her bones.
So, apart from all his physical ailments, David is bereaved. He is thoroughly fed up. To make matters worse, he has just had a letter from DVLA in Swansea which encloses a complicated form asking a variety of questions about his illnesses. If he loses his driving licence he will have real difficulties, so he wants me to help him fill in the form.

Clearly a small dose of Prozac will sort him out.

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Tuesday 15th May

The first patient limped in and was grumpy. He had strained his back lifting a heavy tea-chest into his van. He saw one of my partners three days ago, the day after the injury. From the notes he had been properly assessed and given both appropriate advice and appropriate analgesia.

He was not worse, but he was no better. I had nothing to offer. He just needed more time, which is what I told him. And no, I was not “going to give him something else”. I did not have anything else to give him.

Expectations are too high.

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I spend a long time with a 22 year old girl who came in with bronchitis. She has mild asthma. Her peak flow was fine, she was taking her inhalers but unfortunately she was also taking between 20 and 30 cigarettes a day. Some smokers are not receptive to advice. She was. We discussed various psychological strategies. She decided to use nicotine chewing gum rather than patches. I think the gum is vastly superior but it is still only a crutch, an adjunct. You have to want to stop. I arranged to see her again next month.

When she had gone I filled in the new Government QoF smoking template. Lots of reasonable bits of data, like how many cigarettes a day, and then finally a question as to whether I had “referred her to a smoking adviser.”

The template does not contemplate the possibility that I might give her advice on stopping smoking. Actually, though I say it myself, I am good at it. See the Crippen “Stop smoking in 28 days” programme.

I have had a lot of success with it.

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Thursday 17th May

Nicholas is an alcoholic.

He is now in his mid-fifties and is in steady employment working as an administrator in a software company. In his early thirties he nearly drank himself to death. His life was saved not by the NHS but by Alcoholic’s Anonymous. He has been dry ever since, with two lapses. The first lapse was twelve years ago. The second lapse was three weeks ago.

He stopped going to AA about ten years ago, which is a shame. But he felt that they were no longer right for him. He is a non-smoker and could not find a non-smoking group. Also, over the years and despite all they have done for him he began to find their approach a little too evangelical. And so, after his last lapse, he asked if I would arrange for him to have some support from the Alcohol Unit of the local psychiatric department.

By the time he came to see me, he had already stopped drinking again. He looked rough, and his gamma GT was over four hundred. When Nicholas drinks, he drinks. He had thrown away his BP medication and his cholesterol tablets and so, aside from the alcohol problems, he needed a medical “sort out”.

He is back on the straight and narrow now. His gamma GT is back in double figures, and falling, and his BP is back to normal.

He is an interesting man. We have talked at some length about why he lapsed, and how he felt about the lapse and how he felt when he was drinking. And he has been covering this ground as well at the alcohol group. One of the other members of the group was an Irish alcoholic, who we will call Seamus. Nicholas and Seamus have struck up a friendship.

Last week, Seamus turned up to the group ten minutes late. He had not been late before. When he sat down, it was clear that he had been drinking. He was not paralytic, but his speech was slurred, and he smelt of alcohol. When challenged by the group facilitator he admitted he had been drinking. He was asked to leave immediately. He had broken his contract. You are only allowed to attend the group if you are sober.

WTF is that about, doc, asked Nicholas. It is easy for us all to sit and chat when we are sober. But we need help when we crack and start drinking. That is when we are really fragile. If AA had not taken me in, drunk, dishevelled, dirty and desperate twenty years ago, I would not be alive today.

I don’t have an answer. I think the word “resources” comes into this somewhere. It is more cost efficient to help those who are helping themselves.

Nicholas will not be going to the alcohol group again. He is going to put up with the cigarette smoke and return to AA. And he is going to take Seamus with him.