News from Nowhere 88 July 2020

Digital doctors

On-line consultations in general practice take the pressure off practitioners and have changed general practice for the better. This is becoming conventional wisdom, but some evidence suggests otherwise. According to a modelling study from the University of Liverpool, digital-first consultations are likely to increase general practice workload unless two conditions are met. Digital consultations must be shorter than conventional face-to-face consultations, and a higher proportion of patients must be managed without a subsequent consultation – something that is not observed in most published studies. In the Bristol modelling study (based on the best available evidence), digital-first access models using online, telephone, or video consultations seem likely to increase general practitioner workload by 25%, 3%, and 31%, respectively. So instead of waiting several days to see your GP in person, you may wait several days for a digital consultation.

Source:  Salisbury C,  Murphy M, Duncan P The Impact of Digital-First Consultations on Workload in General Practice: Modelling Study  J Med Internet Res 2020;22(6): e18203

What price PPE?

The Health Services Journal has sketched out the costs of Personal Protective Equipment purchased by the NHS, using data from Liverpool University Hospitals Foundation Trust.  This Trust spent £3.3m on PPE during April, mainly for face masks and gowns. 225,000 FFP2 facemasks were bought for an average price of £4.90, which is almost 10 times higher than the 50p value assigned to the same facemasks when received from NHS England. Around 114,000 IIR facemasks were bought for an average price of 86p, compared to the 20p value assigned to the NHSE stock, and around 392,000 gowns were bought for an average price of £4, compared to a 50p valuation. The costs seem to fit with other Trusts’ expenditure, where managers confronted by staff deaths and junior doctors ready to walk out would pay high prices. Some of the price differences may not be profiteering, because transport costs were included and air freight is very expensive whilst cheaper options by sea or rail take four to eight weeks. News from Nowhere thinks this story supports the idea of bringing PPE production (rather than procurement) in-house.

Source: HSJ Daily Insight  The protection price-tag  2nd July 2020

Cytokine Storm as science and spectacle

When Covid-19 overwhelms the body’s defences it induces a ‘Cytokine Storm’, a final barrage of immune system chemistry that may itself damage the body.  This storm is a crisis of huge proportions that we can easily understand and visualise – think of the sandstorm that leaves Matt Damon isolated on a hostile planet in ‘The Martian’, or the storm of orbiting junk that destroys a space station in ‘Gravity’. 

Except it doesn’t happen like that. Cytokine Storms do occur in Severe Acute Respiratory Syndrome (SARS), but seemingly not in Covid-19, where overproduction of the cytokine family of defences does not seem to take place. This may matter a lot, because treatment for a condition that you don’t have seems unlikely to help and may inadvertently do further harm. Symbolically, the Cytokine Storm is a powerful image of immense danger. Those who weather the storm and survive are clapped out of hospitals by appreciative staff, whose risk-taking with their own health is applauded in turn by an appreciative public in a Thursday evening ritual. We should not forget Rudolph Klein’s description of the NHS as fuelled by dramaturgy, nor Anton Obholzer’s bid to rename the NHS the “National Keep Death At Bay Service”. The science is one thing, the spectacle is another.

Source: Sinha P, Matthay M, Calfee CS Is a “Cytonkine Storm” relevant to Covid-19?  JAMA online June 30th 2020

Catharsis

In May (issue 86) News from Nowhere noted angry views of the British Medical Association in the correspondence to the Health Services Journal. Our innocent comment struck raw nerves. Here’s a prime example.   “I can tell you that with GPs dominating the BMA landscape and agenda and with the power of the Local Medical Committees, I have long since believed that GPs are the most overworked, demoralised, put up on, underfunded, understaffed doctor workforce group in the NHS….. And they do seem to have higher rates of attrition than most hospital docs. I have also noted that they are far, far better than us hospital doctors at blocking change (e.g. the Care Home aspects of new contract). I think it takes a fellow GP to say anything critical. Criticising the BMA, GPs or LMCs would be a suicide mission (for a hospital doctor). Where I do get cross is after years of hospital docs doing down general practice, these GPs now routinely slag us off “oh you just over-investigate people and admit too many and we would do a much better job with them”. I will steer well clear of criticising GPs but not when they start with that kind of crap…

A distorted lens

This year the Health Services Research UK annual conference was (of course) on-line and free, making it accessible to more of our moles than usual. Lots of interesting stories were told, but one in particular caught News from Nowhere’s attention. Talking therapies are posed as good and friendly alternatives to the use of anti-depressant or anxiety-reducing medication – chemical coshes that add physical side–effects to psychological distress. This small qualitative study examined adverse outcomes from psychological therapy. Some therapy users experienced profound and enduring negative consequences including hopelessness, emergence of new- symptoms, interpersonal problems, self-harm and suicidal ideation. Service users often felt pathologised, misunderstood, and unheard. Therapists, on the other hand, found it difficult to identify these effects, struggled with the associated risks and experienced internal dissonance. All of these responses contributed to a ‘distorted lens’, which seemed to prevent the detection of harm. It is one small study and should be interpreted cautiously, but next time you hear arguments for expanding talking therapies bear it in mind.

Source: Lavanya Thana, Tim Weaver & Mike Crawford   Behind the veil of silence: understanding adverse outcomes of psychotherapy  https://hsruk.org/conference-2020/presentations/complexities-quality/complexities-quality-full-abstract

The great and the good

What is going on in the Royal College of Physicians? Professor Andrew Elder resigned as President of the Royal College of Physicians in Edinburgh, soon after being elected. There is talk of problems with the Membership examination (essential for progress in medical training), rivalry between the London and Edinburgh Colleges, and potential conflicts of interest. The Colleges are not receiving income from Membership examinations or from conferences and letting of space for events, so there is a reason to worry. Trustees are involved, as are auditors. No doubt the truth will emerge eventually, but this must be an unwelcome distraction from efforts to contain Covid-19. 

Read more News from Nowhere and articles on the NHS in ERA 3 at http://www.healthmatters.org.uk/

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