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(1) Selling smaller packs of painkillers slashes suicide risk

(2) Study questions whether NICE is delivering the goods

(3) Will email consultations improve patient care?

Online First
(1) Selling smaller packs of painkillers slashes suicide risk
http://bmj.bmjjournals.com/cgi/reprint/bmj.38253.572581.7C

(UK legislation on analgesic packs: before and after study of long term effect on poisonings)

Selling paracetamol and other painkillers in smaller pack sizes has slashed rates of suicide and damage to the liver from paracetamol poisoning, concludes a study on bmj.com this week.

Suicides from overdoses of paracetamol or aspirin dropped nearly a quarter in the three years following new legislation in 1998, which cut pack sizes and limited how many tablets a retailer was allowed to sell.

The researchers also found that numbers of tablets taken in non-fatal overdoses of aspirin and paracetamol fell significantly after the legislation. As a result admissions to liver units for paracetamol poisoning, and numbers of related liver transplants also dropped heavily - down by nearly a third (30%) in the four years after the laws came into force.

Researchers analysed rates of suicides and non-fatal overdoses from paracetamol, salicylates (aspirin) and ibuprofen across the UK between 1993 and 2003. While overdosing from paracetamol and salicylates - both covered by the new laws - decreased, patterns of overdosing from ibuprofen, which was not targeted in the legislation, remained roughly the same.

Although smaller pack sizes do not prevent someone from buying multiple packs from various retailers, many of those who overdose do so impulsively - using tablets to hand in the home, say the authors.

Smaller pack sizes will prevent deaths, say the authors. Their research provides a persuasive argument to reduce pack sizes still further, they conclude.

Contact:
Sue Simkin, senior researcher, Centre for Suicide Research, University of Oxford Department of Psychiatry,Warneford Hospital, Oxford, UK Email: sue.simkin{at}psych.ox.ac.uk

(2) Study questions whether NICE is delivering the goods

(What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews)
http://bmj.com/cgi/content/full/329/7473/999

(Commentary: Is NICE delivering the goods?)
http://bmj.com/cgi/content/full/329/7473/1003

Implementation of guidance issued by the National Institute for Clinical Excellence (NICE) has been mixed, according to a study in this week's BMJ.

Researchers assessed the response of the NHS to 12 pieces of NICE guidance reflecting a range of drugs, devices, and procedures, different care settings and cost consequences.

Some clinical practice changed in line with NICE guidance. For example, prescribing of taxanes for cancer and orlistat for obesity grew rapidly after NICE guidance had been published.

Uptake of drugs for Alzheimer's disease and guidance for the removal of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance.

No change was apparent in surgical procedures and use of medical devices, such as hearing aids, hip replacements, hernia repair and colorectal cancer surgery.

The adoption of guidance seems more likely when there is strong professional support, a stable and convincing evidence base and adequate funding, say the authors. Healthcare organisations should also be encouraged to set up formal mechanisms for handling guidance, they conclude.

NICE has recently woken up to the potential problems regarding the implementation of its guidance in the NHS by appointing an "implementation tsar," writes Professor Nick Freemantle in an accompanying commentary.

Achieving real change in clinical practice is clearly a necessary part of the remit of NICE, Without this vital step, the resources currently used to support the NICE enterprise would be better spent on care of patients. So, rather than give up on the task of modernising the way the NHS uses healthcare interventions, we should look at a variety of ways to make NICE more effective, he concludes.

Contacts:
Paper: Professor Trevor Sheldon, Department of Health Sciences, University of York, UK Tel: +44 (0)1904 321 300 Email: tas5{at}york.ac.uk

Commentary: Nick Freemantle, Professor of Clinical Epidemiology and Biostatistics, University of Birmingham, UK Tel: +44 (0)121 414 7943 Email: n.freemantle{at}bham.ac.uk

(3) Will email consultations improve patient care?

(Letters: Email consultations in health care)
http://bmj.com/cgi/content/full/329/7473/1046-a

Making email communication part of routine medical practice may have unforseen consequences for the NHS, warns a doctor in a letter to this week's BMJ.

Responding to data drawn largely from the United States, showing demand to be mainly patient led, Geoff Wong argues that what Americans want may not be what UK patients want.

The policy goal of the NHS is generally accepted as equal access, based on need, he writes. Poor and elderly people are the most needy and the least likely to use the internet. Using email for communication may offer choice but probably at the expense of access.

He believes that full research into the impact of a new technology is needed before any steps are taken to adopt it as the norm.

"Give the patient a choice," urges IT expert John Charnock in a second letter.

All government departments, including the NHS, are required to offer their services both electronically and using traditional methods. The technology is available today, and it is inexpensive. The only way to measure its effectiveness is to pilot it, he writes.

Contacts:
Geoff Wong, General Practitioner Principal, Daleham Gardens Surgery, London, UK Email: geoffrey.wong{at}nhs.net

John Charnock, Director, Marple Limited, Rainhill, Merseyside, UK Email: john{at}marple.co.uk

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