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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Rethinking primary care’s gatekeeper role Geva Greenfield, Kimberley Foley, Azeem Majeed. 354:doi 10.1136/bmj.i4803

Cardiovascular diseases are first in patient morbidity and mortality, especially in the Western World.
As expected, periodic primary prevention screening health checks exploring cardiovascular risk occupy a large part of GP clinical time and effort.
This UK study adds evidence to the known concept that screening health checks are ineffective, costly, and counterproductive. [2][3][4]
In a recent analysis of all available studies, cancer screening has never been shown to “save lives”. [1]
Thus, GP primary screening against both the first and the second most common causes of patient morbidity and mortality, proved ineffective.
Medical errors are the third leading cause of death in the Western World, certainly avoided if nannying visits to general practitioners/family doctors are drastically reduced.
GPs even fail to follow simple cancer prevention guidelines. [14]
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death, but since smoking and air pollution are its most common risk factors, nagging visits to GPs don't help avoiding this disease.
Even a third of adults with previous diagnosis of asthma and chronically treated, never had the disease. [13]
Motor vehicle and firearm accidents are the fifth leading cause of death, but, understandably, they are not preventable by GP visits.
Suicides and self-harm traumatisms are the sixth leading cause of death, but GPs could not reduce them [6], probably because recent evidence reveals that administered antidepressants actually increase suicide risks by 2-5 times. [7][8][9][10][11]
Health checks do not even manage to identify and treat pre-diabetic patients. [12]
Family doctor extensive H1N1 vaccinations do not offer protection against influenza related hospital admissions. [15]
Visits to GPs do not diagnose dementia earlier. [18]
NSAIDs offer no clinical benefit for spinal pain, a systematic review and meta-analysis reveals. [16]
Non-drug therapies should be first line treatment for low back pain, according to US guidance to clinicians. [17]
Concluding, frequent visits and health checks to family doctors do not seem to reduce specific morbidities and mortalities from the seven most frequent diseases that afflict patients.
After these embarrassing findings, policy strategists must rethink primary care’s gatekeeper role.
References
[1] http://www.bmj.com/content/352/bmj.h6080
[2] http://www.bmj.com/content/355/bmj.i5994
[3] http://www.bmj.com/content/345/bmj.e7191
[4] http://www.bmj.com/content/349/bmj.g4983
[5] http://www.bmj.com/content/353/bmj.i2139
[6] http://www.bmj.com/content/355/bmj.i6761
[7] http://journals.sagepub.com/doi/pdf/10.1177/0141076816666805
[8] http://www.bmj.com/content/348/bmj.g3510
[9] http://www.bmj.com/content/352/bmj.i65
[10] http://nordic.cochrane.org/sites/nordic.cochrane.org/files/public/upload...
[11] http://www.bmj.com/content/355/bmj.i6103
[12] http://www.bmj.com/content/356/bmj.i6538
[13] http://www.bmj.com/content/356/bmj.j282
[14] http://www.bmj.com/content/356/bmj.j772
[15] http://www.bmj.com/content/344/bmj.d7901
[16] https://www.ncbi.nlm.nih.gov/pubmed/28153830
[17] http://www.bmj.com/content/356/bmj.j840
[18] http://www.bmj.com/content/356/bmj.j1300

Competing interests: No competing interests

15 March 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Thessaloniki, Greece
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Re: Mental health: patients and service in crisis Jacqui Wise. 356:doi 10.1136/bmj.j1141

The rate of detention under the Mental Health Act steadily rises, patients complain that self referral to mental health services is difficult and police and A&E feel overwhelmed with those with mental health problems. Meanwhile care of those with complex mental health conditions is often chaotic and GPs complain referral to services can be difficult and bureaucratic.

In my opinion the organisation of mental health services needs a review and some of the received wisdom about these services should to be challenged. In particular the widespread reliance on home treatment teams to care for those regarded as “at risk of admission" to inpatient care should be reconsidered.

Such teams usually insist on a formal referral from another professional (who themselves have conducted an assessment) before home treatment can be provided. This delay and bureaucratic barrier can cause the difficulties GPs, the police and A&E report. The teams often fail to provide consistent treatment, where continuity of carer is paramount, and this can lead to breakdown in therapeutic relationships, chaotic care and sometimes detention in hospital.

In my opinion we should instead prioritise GP based mental health services. Every practice should have an allocated nurse practitioners or community nurses who can provide expert and consistent treatment and good communication with the practice. Every area should have a walk in self referral “crisis clinic” to provide prompt easy assess to those in mental health crisis, (and the police and general practice) so that treatment can be started quickly and admission to hospital can be averted.

Services should emphasise continuity of care, good communication and ease of access. Home treatment teams sometimes don’t.

Competing interests: No competing interests

15 March 2017
Keith E Dudleston
Retired Consultant Psychiatrist
Modbury, Devon
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Re: Reporting attrition in randomised controlled trials Jo C Dumville, David J Torgerson, Catherine E Hewitt. 332:doi 10.1136/bmj.332.7547.969

Hi,
My name is Ronak and I am a researcher in Canada. I recently went through the article titled "Reporting attrition in randomised controlled trials" and had a query. I tried to contact the author but got a response that the email does not exist. Here is my communication:

In the section titled "Effects of attrition" there is a line which states
Schulz and Grimes argue that loss to follow-up of 5% or lower is usually of little concern, whereas a loss of 20% or greater means that readers should be concerned about the possibility of bias; losses between 5% and 20% may still be a source of bias.3

Here the reference is made to 3 which is

Fergusson D, Aaron SD, Guyatt G, Hebert P. Post-randomisation exclusions: the intention to treat principle and excluding patients from analysis. BMJ 2002;325: 652-4. [PMC free article] [PubMed]

My query is that me and my team are unable to find what Schulz and Grimes have said. Would you please clarify this matter or have we missed something?"

Here are the article details:
BMJ. 2006 Apr 22; 332(7547): 969–971.
doi: 10.1136/bmj.332.7547.969

Thanks.

Competing interests: No competing interests

15 March 2017
Ronak Brahmbhatt
Physician-Researcher
-
-
Canada
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Re: Emergency care and resuscitation plans David Pitcher, Zoe Fritz, Madeleine Wang, Juliet A Spiller. 356:doi 10.1136/bmj.j876

The comment by Michael Stone (http://www.bmj.com/content/356/bmj.j876/rr) upon this article could be read as suggesting that the ReSPECT process does not comply with the provisions of the Mental Capacity Act 2005. Having been involved in providing informal legal input to the Working Group during the course of the development of the process and the form, and for reasons that I elaborate in more detail in a post upon my website, available at http://www.mentalcapacitylawandpolicy.org.uk/respect-a-new-approach-to-a..., I would suggest that the process complies with both the provisions of the MCA 2005 and also the requirements imposed by Article 8 ECHR.

I do not underestimate the extent of the changes that will be required to implement and embed the process, but it is in my view an important step towards refocusing discussions and care planning towards the perspective of the patient.

Competing interests: No competing interests

15 March 2017
Alex Ruck Keene
Barrister
39 Essex Chambers, London, WC2A 1DD
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Re: Removal of all ovarian tissue versus conserving ovarian tissue at time of hysterectomy in premenopausal patients with benign disease: study using routine data and data linkage Jemma Mytton, Felicity Evison, Peter J Chilton, Richard J Lilford. 356:doi 10.1136/bmj.j372

We agree with the points made by Savvas and colleagues. We too suspect that oestrogen has a protective effect against heart disease – and said so in our discussion. We have also speculated that the increased heart attack rate observed with oestrogen replacement therapy in the trials mentioned, might have been because the hormone replacement therapy (HRT) was started many years after the menopause in most women in these studies.

We were thus a little surprised and disappointed to have our study described as ‘flawed’. The writers do not point to a design flaw, save that we did not have data on use of HRT. But we had already mentioned this was a limitation of our study – the study simply was not designed to find out whether HRT could obviate the increased risk of heart disease associated with ovary removal. The writers conflate a study limitation with a flawed study.

Competing interests: No competing interests

15 March 2017
Richard J Lilford
Chair in Public Health
Jemma Mytton, Felicity Evison (University Hospitals Birmingham), Peter J Chilton (Warwick Business School)
University of Warwick
Coventry, CV4 7AL
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Re: Industry links with patient organisations Jeremy Taylor, Simon Denegri. 356:doi 10.1136/bmj.j1251

"Insanity: doing the same thing over and over again and expecting different results." Albert Einstein

Taylor and Denegri’s pledge for pharmaceutical industry funding of patient organisations deserved comment (1)

First, positive myths such as “Industry plays a valid and important role in the provision of medical education” and that “Medical representatives can be a useful resource for healthcare professionals” are still alive despite the robust evidence of the contrary.(2) Therefore, Taylor and Denegri’s naivety is excusable. Taylor and Denegri should: a) understand that industry’s first goal (whatever his business is) is and will always be to create value for its shareholders; b) look at the civil and criminal records of the pharmaceutical industry. (3) In my opinion, no spoon is long enough to sup with the devil.

Second, patient advocacy is not a gift. Independence is not only about funding but also about skills. Basic skills are prerequisites for advocating, they include medicine (public health, pharmacology, psychology, clinical trials methodology …) but also strategic planning, communication … Moreover, public outcry can be counterproductive, such as unduly precluding the use of safe alternatives.(4) AIDS activists developed such skills, better than many professionals and, without financing from the drug industry. That is why they produced new paradigms and why they succeeded.(5)

A charity should not be registered among patient organizations if accepting external funding, as healthcare professionals should not when participating to taskforces. But no problem if a company gave funds to a national charity, not specific to a disease, granting her support thorough a transparent bidding process.

1 Taylor J, Denegri S. Industry links with patient organisations. A healthy relationship is possible if based on integrity, independence, accountability, and transparency. BMJ 2017;356:j1251

2 Braillon A, Bewley S, Herxheimer A et al. Marketing versus evidence-based medicine. Lancet 2012;380:340

3 Braillon A. Drug industry is now biggest defrauder of US government. BMJ. 2012 Jan 10;344:d8219.

4 Tracy EE, Bortoletto P. The role of social networks, medical-legal climate, and patient advocacy on surgical options: A new era. Obstet Gynecol. 2016;127:758-62.

5 Cairney R. In back alleys near Vancouver's AIDS conference, the disease was gaining ground. CMAJ 1996;155:1160-3.

Competing interests: No competing interests

15 March 2017
alain braillon
senior consultant
University Hospital. 80000 Amiens. France
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Re: David Oliver: Why shouldn’t nurses be graduates? David Oliver. 356:doi 10.1136/bmj.j863

I am grateful for all the comments so far and for the considerable online interest in the article, which seems to have touched a nerve.

Ms Pearson of the Telegraph tweeted me yesterday to say that my use of the word "reactionary" was "lazy". In my experience, opinion columnists working in mainstream media never appreciate being criticised, not least by someone like me who only dabbles in journalism.

She told me that her views were in fact those of many readers and voters and that instead of "reactionary" they were "sensible and fair."

These views (see reference 1 and 2 in my column) also include scrapping NHS translation services (because patients should either learn to speak English or bring a friend) and expending time and cost chasing the estimated £300m maximum (less than 0.3% of the NHS budget and much not recoverable anyway) on health tourism.

Given the evidence that graduate nurses make care safer, I will stick by my choice of language.

Meanwhile, although most comments have been supportive, any defence of degree-level nursing (which by the way isn't even an issue any more in most countries the NHS recruits nurses from any more than women going out to work or being able to vote is an issue) is always accompanied by nurses who trained via the old route becoming very defensive.

The line (and I have received a few emails and tweets of this nature) is always "I trained the old way and didn't have a degree and I hope I delivered excellent care and so did my colleagues."

I can't say this often enough or loudly enough. Just because we now think it's a good idea for nurses to have degrees, just as pharmacists and allied health professionals do, that does NOT mean we are disparaging nurses who trained in the pre-degree era or attacking their values.

It is conflating two separate issues and doesn't help.

By analogy there are some first rate teachers who never went to teacher training college and some excellent NHS managers who started before anyone had invented the NHS management training scheme or degrees in health management.

That does not mean we shouldn't have formal teacher training qualifications or developmental programmes for NHS managers.

David Oliver

Competing interests: No competing interests

15 March 2017
David Oliver
Consultant Physician
Berkshire
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54
Re: Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis Laurence C Baker, Sean Mackey, et al. 356:doi 10.1136/bmj.j760

This is good to read a research article on "Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis" [1].
The harmful drug interaction of benzodiazepines and opioids is depressed respiration and increased sedation. This is related to additive actions of both the drugs, benzodiazepines slow down the central nervous system.
FDA is requiring boxed warnings on all opioid analgesic and benzodiazepine and also warn patients of the potential dangers of combined use of opioids and benzodiazepines [2,3].
Health care provider should not forget the "Pharmacology principles" in therapy, that play the role in patients care.

Regards,
Dr Rajiv Kumar
Faculty, Dept. of Pharmacology,
Government Medical College & Hospital Chandigarh-160030, India.
References:
1. BMJ 2017;356:j760
2. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm518697.htm
3. https://www.fda.gov/Drugs/DrugSafety/ucm518473.htm

Competing interests: No competing interests

15 March 2017
Dr.Rajiv Kumar
Faculty
Dept. of Pharmacology, Government Medical College & Hospital Chandigarh 160030. India.
DRrajiv.08@gmail.com
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69
Re: My mum’s care means that decisions not to resuscitate must now be discussed with patients Kate Masters. 356:doi 10.1136/bmj.j1084

I have not been able to read Kate's article, because it is subscription. But Kate's response (15 March) to Sarah C Vaughan's question, allows me to comment.

I sent an e-mail to Kate, on 7 March, and I told her that I had read the court ruling, and had commented on the ruling in a rapid response (ref 1):

‘I have read the Tracey ruling - it was complicated, and 'rather muddled in terms of certainty about what had happened'. But one possible interpretation, as I read the ruling, is that Mrs Tracey was willing to discuss CPR but only if her family were present during the discussions, and as the relationship between the clinicians and the family had broken down, the clinicians did not want to hold discussions with the family present.’

Judging from what Kate has written in her response, I was not far off the truth when I suspected that: 'The DNACPR then became a battle ground. First they kept on at mum about it, alone, and scared her'.

I think the main thing we should be learning from Kate's experience - apart from 'clinicians must talk to patients and/or family and friends' - is that 'All the doctors wanted to talk about was the form. All we wanted to talk about was mum'. Professionals tend to become 'immersed in the process/record' but relatives do not - we relatives 'want common sense behaviour', not adherence to protocols which sometimes make no sense in the situation. This is definitely true for end-of-life at home, which I bang on about, where 'the NHS' keeps trying to improve things by means of 'protocols and records' whereas I insist that instead we need an approach of 'get the patient, GP, family carers and district nurses to keep talking to each other, then tell people such as 999 paramedics to ask the family why they were called, and what can they do to help' (ref 2). I wrote in ref 2 'the 999 Services are currently working to guidelines and protocols which tell them to ‘look at the records made by the GP’ instead of asking the family carer who called 999 to explain the situation' which seems to be very similar to Kate's 'All the doctors wanted to talk about was the form. All we wanted to talk about was mum'.

If people such as Kate Masters were not speaking out, these issues would not be highlighted. And if they are not highlighted, they will be addressed either too slowly, or else not at all.

Ref 1 http://www.bmj.com/content/350/bmj.h2640/rr-0

Ref 2 http://www.bmj.com/content/355/bmj.i5705/rr-15

Competing interests: No competing interests

15 March 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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Re: David Oliver: Why shouldn’t nurses be graduates? David Oliver. 356:doi 10.1136/bmj.j863

This view may be widespread in sections of the general population due to an ongoing misconception or lack of knowledge about the modern Nursing profession. Healthcare in general is not well served by realistic representations in the media (think Casualty and numerous other TV dramas), albeit with more shows letting people peek behind the curtain (the BBC's fantastic 'Hospital' and 24 Hours in A&E spring to mind).

Unfortunately, the view that degree requirements for registered Nurses are a bad thing is also unfortunately present within the profession. I personally experienced negative attitudes towards time spent in university as a student and having begun a PhD in a Nursing department I was asked by a colleague why I wanted to stop being a Nurse.

This view seems unique to Nursing, seemingly being the only profession which doesn't value it's own academic achievement. I can only hope over time that this will change. Having all registered Nurses now qualifying with degrees may accelerate this change and studies showing the benefit of a degree educated workforce are always welcome(1).

(1) Aiken, LH et al (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet 383:9931

Competing interests: No competing interests

15 March 2017
William P Ball
Staff Nurse and PhD Student
Edinburgh Napier University
School of Health and Social Care, Sighthill Campus, Edinburgh, EH11 4BN
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