Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The excesses of "Evidence Based Medicine"
- David J Young (9 March 2003)
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Addressing multiple morbidity can use the same evidence-base as the need for organised multi-sectora
- Simant G Westley (14 March 2003)
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Multiple authorship poses its own difficulties
- James N Hardy (21 March 2003)
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David J Young, GP Principal/Primary CareTutor 10.Chapel St Spondon Derby DE2 7RJ
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I concur with the unease about polypharmacy. Consultants with narrower interests simply bolt on their particular care package if the patient is referred in their direction. Dare I suggest that the General Practitioner is THE specialist in "multiple morbidity" which can often include Persistent Unexplained Physical Symptoms and some degree of somatisation. Could it be incumbent on us to edit the leviathan of the modern prescription WITHOUT recourse to our bewildered hospital colleagues? Are we ready to admit that the dangers of polypharmacy usually outweigh the small absolute benefits of each drug? Half our patients will not manage to comply in any case, perhaps they are the safer. Competing interests: None declared |
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Simant G Westley, Public Health Scientist, Welsh National Public Health Service c/o IMSCAR, Wheldon Building, University of Wales, Bangor, Gwynedd LL57 2UW
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Bravo! Wright, Smeeth and Heath’s recommendations are supported by my experience in community development, disability welfare rights and population needs assessment, service review and multi-agency strategic planning. Most service weaknesses identified have concerned multiple morbidity (in learning disability, mental health, physical and sensory disability, stroke, diabetes and CHD) and systems that were adequate to address multiple needs. In addition, many people with multiple morbidity do not turn first to the NHS – alcohol and illegal drugs provide self-medication as illustrated below. Men whose early family life is disrupted often leave school with poor literacy and social skills. They enter the forces, building trades or petty crime. They gain trades and parental responsibilities, but, unless literacy and confidence to ‘fit in’ improves, can only achieve good incomes in the black economy. While young and active they can tolerate the effects of the smoking, alcohol and drugs they self-prescribe to prevent experiencing emotions, but these gradually erode health and capacity to plan, provide, relate or parent. Eventually a physical or emotional injury prevents sufficient exercise to effectively eliminate these toxins. Multiple morbidity follows: respiratory disease, hypertension, diabetes, chronic pain, depression, arthritis, poor digestion and further substance abuse, and the community loses experienced tradesmen. If they have not paid tax or stamps, they remain outlaws for fear of a tax bill, and continue to self-medicate with alcohol etc. Only when their health and circumstances are considerably worse, can they be persuaded to seek help and register as disabled. Men with this profile contribute significantly to premature male mortality, broken homes, emergency admissions and poor CVD outcomes. SureStart is supporting children at risk of becoming this type of adult, but Wright, Smeeth and Heath’s recommendations could help prevent and effectively treat the multiple morbidity of earlier generations’ childhood casualties. Grade 1 evidence exists for the benefit of organised multi- disciplinary care in stroke, CHD and diabetes, even though the precise components of care are less well validated. Organised, integrated, and multi-sectoral working are the necessary and interdependent components, just as simultaneous strengthening of individuals, communities, services and policies are needed to effectively tackle inequalities. Competing interests: None declared |
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James N Hardy, GP principal Bethnal Green Health Centre, 60 Florida Street, London E2 6LL
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Dear Editor, In their leading article Wright, Smeeth and Heath correctly refocus our attention on the inextricable links between poverty and poor health (1). Their piece rather anxiously introduces a new term to describe these health problems, "multiple morbidities". This is a biomedical construction if ever I heard one, a public health obfuscation. It's not that I disagree; it is more that the multiple authorship fails to drive home the key points in a fragmented article. The irony (and I'm sure it is not lost on the authors) is that multiple authorship has inadvertently subverted the clarity of the work. To expand; the issue is not that primary care lacks specialist credentials, or that secondary care has become too specialised. It is rather that communication across the interfaces continues to be absurdly primitive. Part of this is a reflection of inadequate manpower, poor management and an antdiluvian records system; some is a question of attitude, especially amongst inexperienced, simply ignorant or poorly led secondary care teams. Increased undergraduate training in primary care, already underway, has begun to redress the knowledge gap. Further endeavours to include compulsory six-month primary care posts in post-graduate training are to be welcomed. Most of all we need more health care personnel and up-to-date unified record systems that will deliver speedy and effective communication across all interfaces. If these caveats are acted upon, the authors need have no fear. We can safely return to the nineteenth century care model where the community -based physician would involve a surgical technician if required. These days of course, we have many more technicians with whom we can explore the multiple morbidities of our patients. Competing interests: None declared |
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