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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: David Oliver: Towards a GP consensus on the future of UK general practice David Oliver. 357:doi 10.1136/bmj.j2949

David Oliver rightly notes there is no clear direction for change in general practice.

The small practice model is being made redundant, possibly for largely politically motivated reasons. However much this model gives good value (in terms of doctor effort), responsiveness and continuity (for patient care), it also may no longer fit modern health technology. Just as everyone wants their local district general hospital and A&E at the end of their garden, sub specialisms, expertise and availability of expensive equipment mean bigger, centralised hospitals are necessary for care. Maybe now we need to relinquish the idea that one GP can offer care for 2000 patients from cradle to grave. Actually, a specialist nurse can look after your chronic disease much better. A specialist team would keep you well and in the community once if you are older, frail and approaching the end of your life.

Out of hours needs to be linked to patient records and to surgeries. Referrals and investigations can usefully be taken forward during 8-8, 7 day appointments. Bigger practices or groups are needed to achieve this. This is the model we are being asked to, or told to, embrace as part of our democratic, political process.

Holding on to small practices and small hospitals maybe keeping our health care in the 20th century, with, for example, high infant mortality rates and low cancer detection rates when compared to our European compatriots.

New models of care combining primary with community or secondary care seem to be thought of as fringe ideas. However, this is not only where we are headed, with new Trusts to be negotiated and in place by 2020 but also key to abandoning the internal market. The purchaser-provider split is under exposed, neither discussed within our journals, among ourselves or as part of an electoral or political debate. It is very expensive, in terms of management and information costs and destructive, for instance to specialists or hospitals taking an overview of the population's health.

The reason there is no consensus among my primary care colleagues is clear to me. Most GPs earn around the rates of pay of a train driver; £60,000 for a 4 day week (driver) or a 32 hour, 2 day in surgery week (partner) or a 3-3.5 day, salaried GP, 35-hour week These GPs would happily hand in undated resignations, for instance. However, CCGs provide many GPs and practices with an inordinate additional income. My pension suggests I brought £200,000 extra into my practice for a 2 session a month post lasting two and a half years. These CCG post GPs would neither want to give up the internal market, combine primary and community care or have any reason to want to give up their job-for-life as a small/medium sized practice partner. The conservative coalition in the government before last have pulled a very clever divide-and-rule move, which only our LMCs seem to have acknowledged.

Clearly primary care is failing, both our patients and us, the staff working within it.Vested interest is holding us back. A clear direction, or a generalised and helpful acceptance of the direction being offered, would be one big step forward for us as well as our patients. It might also bring us more respect for doing a better job among our acute sector colleagues, such as David Oliver..

Sarah Evans
Salaried GP, Bedfordshire
(previously a partner in Hertfordshire)

Competing interests: No competing interests

24 June 2017
Sarah C Evans
salaried GP
126 Castle Hill Rd LU6 1QG
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Re: Benchmarking life expectancy and cancer mortality: global comparison with cardiovascular disease 1981-2010 Samir Soneji, Isabelle Soerjomataram, et al. 357:doi 10.1136/bmj.j2765

Again we see extra-ordinarily sophisticated analyses of the major causes of death of humans, using piled-high medical assumptions about causes. Yet, although evolutionary data on human 'survive-thrive' physiology and metabolism is known, it is eschewed. CVD rates soared after men had been 'working in' factories and wars (where they also were encouraged to smoke heavily) that were overwhelmed with industrial toxins. Cancers rates also rose (in the famous chimney sweeps) in the highly exposed, but more slowly. The other characteristic, apart from human chemical pollution, was that fresh food quality in poor city industry workers and families was dreadful, and phytochemical intake, nearly non-existent.
However, PARTICULARLY for humans, as a very sophisticated energy conservation mechanism, a surprisingly wide range and high volume of micronutrient dense foods are required for optimal health. Due to migration and nomadism, humans have come to occupy very different environments, so food types are now extremely varied. These micronutrients, largely phytonutrients, provide modulation of cell protection systems for uniquely energy-efficient metabolism, and high level immune function and cell repair. If this system is functional, it also provides a good detoxifying system of many natural chemicals - better than most organisms. This allows potentially long and healthy life-spans. Humans have devised and come to depend on complex cultures of food gathering and preparation. These traditions are passed down generations and across groups, to allow humans to survive, and hopefully thrive.
In the 1960's after Rachael Carson's Silent Spring and the US Surgeon general warned that smoking caused cancer, frankly, mid-term toxic chemicals were controlled more effectively and CVD rates dropped precipitously in Western countries. Cancer development rates never dropped, only survival, due to rescue, and some curative, hi-tech treatments, became longer.
Now overall, there are thousands of 'unknown if safe', persistent industrial chemicals released. Food on average is bred to not produce their own secondary 'self-defence' chemicals, and is ever more refined, especially, along with the worst of the industrial pollutants in lower HDI countries.
Current governments have given up and are letting the conglomerates pick off the the planet's resources. This is in a rush to commodify resources before world-wide manifestations of pollution (a rare word these days), manifest as climate and ocean change, affect even the industrial giant CEO's.
Thus we see obvious contamination by fracking chemicals EVEN of human drinking water ways in poorer ares of high HDI countries, and bee kill off by cancer causing chemicals. The rest of us are more or less subtlety exposed the whole time to our chemical, Anthropocene environment.
Get out of your industrial labs, do real evo-bio-research and turn arable land under high-input monocultures back into clean mixed smart eco-farms. The cost of repair of our (and the Earth's) health by this type of food production will be way less that all cancer, CVD, 'obesity' and/or chronic disease, medical devices and drugs, and their research. Real food helps with the body's environmental chemical management. It's never too late to change - until the Earth's life is gone.
McGill, A. T. (2014). Past and future corollaries of theories on causes of metabolic syndrome and obesity related co-morbidities part 2: a composite unifying theory review of human-specific co-adaptations to brain energy consumption. Archives of Public Health, 72(1), 31. doi:10.1186/2049-3258-72-31

Competing interests: No competing interests

23 June 2017
Anne-Thea McGill
GP and Obesity Researcher
​​School of Health & Human Sciences, Southern Cross University
Lismore Campus, Military Road, East Lismore, NSW 2480, Australia
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Re: Physical activity, cognitive decline, and risk of dementia: 28 year follow-up of Whitehall II cohort study Alexis Elbaz, Mika Kivimäki, Archana Singh-Manoux, et al. 357:doi 10.1136/bmj.j2709

As a participant in Whitehall II study since 1985, I'm glad to see that useful research is being published after 32 years, and there have been plenty of others of course. I'm disappointed that none of us were involved in this piece of work. And I'm not entirely sure that I fully understand the conclusion, when I was always led to believe that it's not possible to prove a negative.

Competing interests: No competing interests

23 June 2017
John G Gooderham
locum lollipop lady
none
none
Billinghsurst
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51
Re: Listening to patients is not enough Daniel Sokol. 357:doi 10.1136/bmj.j2670

This is an excellent essay with great teaching value.

I have looked for years for the purported Osler quote: "Listen to the patient. He will tell you the diagnosis," but have never found it. I think it is apocryphal. Still, it is a "keeper" whoever said it.

In Cushing's biography of Osler there is an anecdote on how he dealt with errors:

P. 253 on Osler as a pathologist doing autopsies

“Once in a ward class there was a big colored man whom he demonstrated as showing all the classical symptoms of croupous pneumonia. The man came to autopsy later. He had no pneumonia, but a chest full of fluid. Dr. Osler seemed delighted, sent especially for all those in his ward class, showed them what a mistake he had made, how it might have been avoided and how careful they should be not to repeat it. In 30 years of practice since then…I remember that case.

If we could only share our mistakes in this way!

Competing interests: No competing interests

23 June 2017
David Elpern
Physician
Williamstown, MA 01267 USA
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Re: Self help approach to graded exercise may help chronic fatigue syndrome Susan Mayor. 357:doi 10.1136/bmj.j3057

Susan Mayor states that the GETSET trial shows that graded exercise therapy can improve fatigue and physical functioning. Due to weaknesses in the trial design, it is not actually possible to distinguish biased self-reporting ("placebo effect") from genuine improvement. Indeed, we know from previous studies that GET and CBT don't lead to improvement on objective measures of health and functioning in CFS: their effect is most consistent with a small transient placebo effect. That this study was funded and is being taken seriously is very worrying.

Competing interests: No competing interests

23 June 2017
Anton Mayer
-
-
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Re: Grenfell Tower fire: why we cannot ignore the political determinants of health Martin McKee. 357:doi 10.1136/bmj.j2966

Hello,

I read the articles on Political Determinants of health with interest. Political Determinants of Health have been reigning supreme since time immemorial. When there were no democracies there were monarchies. Each leader had a desire to conquer others, resulting in untold misery to the general public. Main sufferers in this play of power were always the poor and those incapable of escaping with the assistance of wealth, bribery etc. etc.

The Bhopal Gas tragedy in India is a glaring example of the self interest of the greed of industrialists and incompetence of the political will. Thousands have suffered for decades as a consequence. Things will improve only when all aspects of Public health are given their due importance by those in power, whether they have financial power or administrative power. However, the general public should also be educated sufficiently to be persistent in raising their voices and not give in to apathy.

With regards,

Nalini Tandon

Competing interests: No competing interests

23 June 2017
Nalini Tandon
retired medical Doctor
None
Vienna VA USA
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44
Re: Listening to patients is not enough Daniel Sokol. 357:doi 10.1136/bmj.j2670

This decision seems somewhat bizarre. In particular, I question the argument that if a consultant would have asked the question then so should the SHO – and even consultants may be a bit forgetful at 5am..

Eliciting a history and asking the right open ended questions is as much an acquired art and skill as a taught discipline, although not determining the presenting symptom is fairly basic. Asking why did the patient present is sometimes irrelevant to the ultimate or underlying diagnosis but is still relevant to the patient as it may, at its most basic level, require treatment in its own right. The “by the way” as the patient is leaving may reveal the real problem. Surely whoever admits the patient to the emergency department has the obligation to record the reason for attendance and to pass on this information? Could this, in this instance, have been recorded as vomiting - and would this have affected the legal judgement? In that case the relevant question might well have been “Do you have any other concerns? “, rather than the one of asking “Why are you here?” or “What brought you to the department?”. The first sounding somewhat confrontational, the second opening the way for misunderstandings. It seems probable that the legal bills facing the NHS will continue to escalate.

Competing interests: No competing interests

23 June 2017
Simon Kenwright
Rtd Physician
Stowting
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38
Re: Give a voice to the voiceless Kamran Abbasi. 357:doi 10.1136/bmj.j2996

Success is a mess. It's a zero-sum game in which winners are heroes, but losers are zeros. The winners strut and summit, while the losers stutter and plummet. But since winners are losers rescued by luck and pluck, winners should share their success with losers, because charity and parity are the only real success.


Competing interests: No competing interests

23 June 2017
Hugh Mann
Physician
Retired
New York, NY, USA
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Re: Self help approach to graded exercise may help chronic fatigue syndrome Susan Mayor. 357:doi 10.1136/bmj.j3057

The title is somewhat ambitious.
The number reporting 'much better', or 'very much better' is around 13% better in the treatment group than the control group. 'May help a small minority of chronic fatigue sufferers'.

Despite the trial being ended for well over a year now, the 12 month recovery rate is not published.
This was null, for example in PACE.

This trial had no objective measurements at all, and relied on self-reports.
The trial material claimed this was a positive intervention - to not have a positive effect on the self-reports would be very, very odd.

I note Wechsler et al's [3] work on Asthma and placebo response where even faced with continuing airway restriction, patients reported getting 'better' after sham treatment, when they were unchanged. [2] Actiometers or some other actual measurement beyond questionnaires is needed.
Convincing patients to self-report an improved condition on a questionaire is not an improvement if that is all you have done! The above study fails to convince that is not all they have done.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154208/
The outcome was switched after sight of the data. Note the comment "before any outcome data were formally examined." [1]

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4917732/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154208/
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154208/

I am a patient with CFS. I am often bedbound, following trivial exercise (washing up).
The reasons I am bedbound is not due to cardiovascular or muscular insufficiency or avoiding exercise. I do not have Delayed Onset Muscle Soreness in the days afterwards. I have severe cognitive effects (n-back/... performance plummets). I have significantly reduced one-time maximal grip strength. Normal exercise response does not cause pain in the whole body following exercise of one muscle group, or the host of other symptoms.

Competing interests: No competing interests

23 June 2017
Ian Stirling
Medically retired
Star, Fife, Scotland
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69
Re: Wendy Burn: On Ilkley Moor with cats . 357:doi 10.1136/bmj.j2714

When asked if she supports doctor assisted suicide, Wendy Burn answers 'But could I kill anyone? I don't think so'.

Campaigns in UK to legalise doctors enabling sane suffering terminally ill people to commit suicide do not involve the doctor killing the patient but rather providing the wherewithal for the patient to act at a time and place of their own chosing..

Many of the medical notables interviewed for BMJ Confidential sadly show they just have not thought about the subject or followed the successes in other countries.

Do doctors have a duty to ease suffering? They should show an understanding of this matter and can then make a truly informed choice - hopefully putting the interests of the patient first.

Doctors could learn more from Health Professionals for Assisted Dying.

Competing interests: No competing interests

23 June 2017
christopher j burns-cox
Physician
North Bristol NHS Trust
Wotton-under-Edge
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