onal support, refuge, and police liaison. Court orders are obtainable quickly, and may be t he only way to stop men going near previous victims. 206 They may also require someone to l eave home, or let the victim return home. They are not long-term solutions, but can save li fe. In the UK, Law Centers give access to legal protection: to \201 nd the nearest, phone 0207 387 8570 \200\224or the patient \200\231s solicitor may be available. The police may also need calling. Prevention Lack of full-time employment is a leading predictor of who is going to get abused, 207 but simply saying \200\234Go out and get a job \200\235 rarely h elps. See also Child abuse, p146. Parent \200\223child interaction therapy (PCIT)1 is one v alidated way of reducing family violence. 208 This off ers practical help in rec- ognizing antecedent events which tend to trigger violence. 1 Through a one-way mirror, the therapist watches parents interact with the child. The parent wears a device in the ear to receive h elp & real-time feedback from the therapist next door. 514 e r a c y r a m i r P 515 Sustainability, and alternative/holistic medicine We need to know about alternative medicin e to understand our patients \200\231 - undeclared distress, which use of these treatments is so often a sign of. We can also advise on the safety of various therapies. We must also learn from therapists about patient-centered care, and the sustainability of healthcare. Th is entails systems of interacting methods to restore and optimize health that have an ecolo gical foundation, that are environmentally, economically and socially viable inde \201 nit ely, and that function harmoniously both with the human body and our wider environment, and that do not result in unfair or disproportionate impact on any ecosystem. Alliance for Nat ural Health www.anh-europe.org Some alternative therapies are the orthodoxies of a diff erent time (eg herb- alism) or pla ce (the Ayurvedic medicine of India), some are mainly diagnostic (iridology), some therapeu tic (aromatherapy). Some doctors are suspicious of unorthodox medicine, and feel that its p ractitioners should not be \200\230let loose \200\231 on patients. But in many places the law is that, however unorthodox a practi- tioner may be, he or she cannot be convicted of u nethical practice in the ab- sence of clear harm. Many people ( 5 million/yr in the UK) con sult alternative practitioners, often as a supplement to orthodox treatment. Some will feel unable to tell their doctor about trips to alternative therapists, unless asked. e r a c y r a m i r P Modern medicine is criticized for sacri \201 cing humanity to technology, and with little bene \201 t for many people. In contrast to the orthodox doctor, alter- native therapists is seen as taking time to listen, laying on hands rather than instruments, and giving medic ines free (not always!) from side eff ects. Acupuncture: Can treat many ailments; increasin gly used in orthodox prac- tice for pain relief, control of nausea and treatment of addicti on. For these, endorphin release provides a scienti \201 c rationale. Homeopathy: is based on the idea that \200\230like cures like \200\231, and that remedies are improved ( \200 \230potentiated \200\231) by increasing dilution. Randomized trials show no greater effi ca cy than placebo, or suggest real (small) bene \201 ts, eg in asthma. Manipulative therapie s (osteopathy; chiropracty) are widely used and may help musculoskeletal and other problems , eg asthma. Yoga: This is an ancient Indian discipline with physical, mental, and spiritua l components which aims to achieve a state of spiritual insight and tranquility. Randomized trials show that yoga can produce worthwhile bene \201 t. 209 Clinical ecology: Starting from the fact that atmospheric pollutants, toxins, and xenobiotic chemicals (from other org anisms) are known to be harmful, a system is built up around techniques (using intradermal injections) for pro- voking and neutralizing symptoms related to foods. Holism: Holism enta ils a broad view: of the patient as a person, of the role of the therapist, of the therapie s used. The patient \200\231s autonomy is encouraged through involvement in decisions, and nurturing of self-reliance. \200\207Specialism doesn \200\231t exclude holism: nephrologis ts can be as holistic as naturopaths. As shown on p478, most models of the GP consultation are based on a patient- centered holistic approach. Compare the sequence \200\230bronchiti s \200\203antibiotic \200\231 with \200\230bronchitis \200\203smoker \200\203stressed \200 \203redundancy-counseling \200\203?antibiotic \200\231. \200\235Doctor, can I use alternat ive therapy for HRT? \200\235 One answer might be: \200\234Ex- tracts from red clover (Tri folium pratense), soybean (Glycine max) and black cohosh (Cimicifuga racemosa; eg 8mg of st andardized extract PO/24h) are of- ten used. Some trials support their use, 210,211 but the se are active agents that might have the same SEs as HRT. Finding out might cost millions . You could try them, and you might well be lucky. \200\207Beware advertising in \202 uen ces. \200\235 212 Integrative medicine: This is a patient-centered, interdisciplinary, non- hierar- chical mix of conventional and complementary solutions to case management of patien ts with complex problems, eg chronic low back or neck pain. 213 Living dangerously Life can only be understood backwards, but it must be lived forwards. Ye ars ago a patient had a seminoma successfully treated, and in the year that follow-up stopp ed, he had a myocardial infarction, followed by a good recov- ery. But the patient became m orbid, self-centered, and depressed, perhaps because of the dawning appreciation of his mor tality, his residual breathless- ness, and his inability to do carpentry. His GP tried hard to cheer him up and rehabilitate him by encouraging exercise, sex, a positive self-image, and alter- native hobbies. Rehabilitation was working when he began to develop head- aches and kept asking forlornly whether these were a sign that his cancer had spread to his brain . There were no signs to suggest this. His GP knew that there was a chance that the tumor w as resurfacing, but judged that start- ing a pointless chain of investigations would be dis astrous to the patient \200\231s mental health. So instead of arranging CT scans the GP int erpreted the forlorn questions \200\234You are only asking questions like this because you are in a nega- tive frame of mind \200\235, and the patient and his GP developed strate gies to avoid negative cognitions. The headaches improved, and the pressure to investigate was resisted, and a state of augmented trust was established between the patient and his GP : a marvelous asset in an uncertain, litigious world. 516 (S ren Kierkegaard) e r a c Friedrich Nietzsche 1886 Beyond Good and Evil; aphorisms 220 \200\223226 Home visits Glory or drudge? We hate home visits while in consulting rooms and acting up to images of the busy GP who must dispense precious time in miserly but fair aliquots. But wh en we are doing home visits, we love them. We are less often interrupted, and the possibili ties of practicing holistically are much en- hanced. We see the family in their own context , and new diagnoses and treat- ment options tumble out of cupboards, bathrooms and larders as we wonder about lost corridors hoping for inspiration or a cup of tea. One colleague mai n- tains that no home visit is complete without going through the bins on the way out: \200\234what we discard tells us more about ourselves than what we keep \200\235. This is p robably taking garbology too far, but the point is well-made. \200\207Home visits are grea tly valued by patients, and are a good way to avoid 999 calls. 214 Night visit with Nietzsc he 215 (What follows will seem hard to follow in cer- tain moods, but give yourself time in your profession and you will come across many mysterious motivations which will trump any hereinafter enacted.) y r a m i r P In a small car on an open road, I am heading to a sick child, aged 10. Ni- etzsche is sitti ng beside me, it seems, and muttering in the dark: \200\234Why bother with all this medici ne? It gives you no pleasure, and I see you feel no compas- sion. Be a free spirit like me! Let me to say to you: \200\230You are entangled in an un- yielding snare and straightjack et of duties and cannot get free. \200\231 You think you are making a sacri \201 ce to a n oble cause. But listen: \200\230Anyone who has truly of- fered a sacri \201 ce knows he w anted something for it and got it \200\224perhaps some- thing of himself in return for some thing of himself \200\224that he gave up something here in order to have more there, perhap s just to be more, or at least to feel as if he were more \200\231. \200\235 I drive on, obediently strapped to my straightjacket of duties. Then, on my right, I see, b etween the shadows of two houses, a huge moon, rising between them, low and red. It \200 \231s far too big to believe, but I know I have seen this once before \200\224aged 10 \200 \224a huge harvest moon rising over the river Cherwell. Ni- etzsche cannot see it. He \200 \231s too high. But I \200\231m slumped over the wheel; I can see it just as it was a few d ecades ago. I wax. I wane. Ideals come and go, and will return. I do my night visit in a st range calm, sailing on my Sea of Tranquility. On my way back I look for my moon, to show it to Nietzsche. But Nietzsche has gone, and the moon is shining on someone else \200\231s night visit. Your night visit perhaps? I will we ar your straightjacket and you can wear mine. I \200\231ve got my moonlight inside me now; enough for a few more decades, I wonder? 517 Minor illness GPs may not want to spend much time on minor conditions, but this may become unavoidable if he issues a prescription each time (rather pointless if all the patient want ed was reassurance). This reinforces attendance, as a proportion of patients will come to a ssume that a prescription is neces- sary. GPs rate 14% of their consultations as being for minor illness (mild gastroenteritis, upper respiratory problems, presumed viral infections , \202 u, and childhood rashes). 216 In some studies, 80% are likely to receive a pre- sc ription (but this number may be falling), and >10% are asked to return for a further consul tation. Why does this great investment of time and money occur? Desire to please, genuine c oncern, defensive medicine, prescribing as a way to end a consultation, and therapeutic unc ertainty all play a part. (Minor for whom ?) e r a c y r a m i r P Positive correlations with low prescribing rates include a young doctor, practicing in affl uent areas and long consultation times. Patients in social classes I and II are more likel y to get a home visit for minor ailments than those in other social classes. Membership of the Royal College of General Practitioners does not in \202 uence prescribing rates. 217 N ot everyone wants to reduce prescribing, but advice is available for those who do. \200 E ncourage belief in one \200\231s own health and innate powers of recuperation. \200 Using a self-care manual explaining about minor illness. 218 \200 Using self-medication (eg pa racetamol for fever). \200 Using the larder (eg lemon and honey for sore throats). \200 Using time (eg pink ear drums \200\224follow-up if symptoms worsen). \200 Using deferred prescribing \200\234He \200\231ll get over it, I predict, in a few days; but here is a pr escription if I am wrong: it \200\231s good for him to learn to deal with these infections himself, but if this doesn \200\231t happen, this is plan B. \200\235 The use of Cates plot s (nntonline.net/visualrx/examples) is one way (with a nice visual im- pact) for communicat ing NNTs to interested patients and colleagues. These smiley-faced plots can be a bit simpl istic, eg the one for antibiotic prescrib- ing for otitis media (NNT \211\21020) omits quan tifying rare but serious complica- tions (mastoiditis, p544). \200 Using pharmacists, 219 or granny (a more experienced member of the family). \200 Pre-empting requests for antib iotics (eg for sore throat): \200\234I \200\231ll need to exam- ine your throat to see if you need an antibiotic, but \201 rst let me ask you some questions \200 From what you s ay, it sounds as if you are going to get over this on your own, but let me have a look to s ee. \200\235 [GP inspects to exclude a quinsy.] \200\234Yes, I think you \200\231ll get ov er this on your own. Is that all right? \200\235 Empowering patients Any illness, minor or otherwise, is an opportunity to empower patients. Use the time to enable patients to improve their ability to: \200 Cope with life and to understand their illness. \200 Cope with speci \201 c illnesses. \200 Feel able to kee p themselves healthy. \200 Feel con \201 dent on handling health issues. \200 Be con \201 dent about the ability to help themselves. We know that time spent this way improves p atient satisfaction and clinical outcome 220 (although simply extending consultation times in the hope that this will happen is not enough). 37 This may be better than delegating min or illness to nurse-led triage clinics \200\224which have no continuity of care as well as run- ning the risk of increasing demand and augmenting medicalization of human events. 23,2 4,221 In some communities attendance for minor illness is falling, except in older males of low educational status. 38 Also, drug costs are falling in Eng- land in primary care ( 8. 81 billion in 2011 VS 8.83 billion in 2010). 222 Are you ready for emergencies and on call? Equipment: Airway; stethoscope; auroscope; ophth almoscope; patella ham- mer; scalpel; BP device; FeverScan (or similar, for T ; no mercu ry); pulse oxime- ter; dipstix/capillary glucose; needles; syringes; gloves/KY jelly ; ant iseptic \202 uid; sutures; specimen bottles/forms; sharps tin. Some drugs to have: see TA BLE. 518 Drugs for your black bag (keep in date! \200\224contents depend on local needs) Oral/topica l agents IM/IV agents \200 Pain killers; antibiotics \200 Ceftriaxone \200 Prednisolo ne (soluble) \200 Cyclimorph ; naloxone \200 Lofepramine or SSRI \200 Prochlorperazi ne \200 Ranitidine or similar \200 Furosemide/bumetanide \200 Aspirin 75 & 300mg \200 Atropine; adrenaline \200 Paracetamol mixture \200 Chlorphenamine \200 Rehydrat ion sachets \200 Benzylpenicillin (IM) \200 Inhalers; GTN spray \200 Water for inject ions \200 Buccal midazolam (p208) \200 Enemas/suppositories* \200 Glucagon \200 Fus idic acid viscous \200 50% glucose \200 Haloperidol Administrative items \200 Mental Health Act forms \200 Headed notepaper etc \200 Phon e N : chemists, ambu- lance, police, hospitals etc \200 Certi \201 cates; nurse forms a uthorizing drugs for IV pumps; prescriptions \200 Book to record batch numbers for ampoules and narcotic use 223 \200 Prescriptions; temporary resident and othe r forms e r a c eyedrops Glucogel glucose gel \200 Diazepam temazepam *Suppositories: diclofenac 100mg (for re nal colic); paracetamol 60 or 125mg for vomiting feverish children. y r a m i r P For the pocket Phone (charged!). Try a smart-phone device eg incorporat- ing this book, OHC M (we declare an interest!) & BNF; see Dr Companion (Med- Hand ) andoup.co.uk/academic/med icine/handbooks/pda. NB: the trouble with relying on books is that there is no room for mor e than one in a bag, and the danger is that if you keep them in your car, they are not to h and for easy reference. No-one wants to get to the top of a block of \202 ats only to hav e to descend to see if X interacts with Y or to \201 nd out the incubation time for scarl et fever. Permanently on Internet access means that as well as loaded books, every- thing e lse is available too, eg decision support and access to patients \200\231 notes \200\224 eg web EMIS/NHS spine/records; decision support. For the car Maps, torches, nebulizer, spare batteries, speculum, de \201 brillator, ECG, dressings, peak \202 ow meter; O2, sat nav, chauff eur. For the mind We have a duty to be fully conscious and reasonably healthy. Take opportunities to sleep before and after night duties. We know that on- call night work ind uces sleep debt with prolonged impairment of awake ac- tivities, sleep quality, and perform ance. Not working the following day after an on-call night only allows for partial recovery of sleep quality to begin. 224 We have all been in the position of visiting patients who are less sick than we are \200 \224and we tend to carry on until we drop (see p689). This is bad for us and bad for patien ts. If you are sick, and no locum is to hand, phone your local Primary Care Organization or out-of-hours co-operative. Open surgeries: riding the chaos With many simultanous demands, and the waiting room \201 lling up faster and faster with insoluble problems, panic may strike unless we get into the mood of our juggler (p466 \201 g 1). On his forehead is sta mped I am here for you. The easier but doomed alternative is Keep the pa- tients at bay at any cost \200\224the stereotype of the unapproachable doctor behind a glass wall. To thrive in tumultuous open surgeries, don \200\231t hide behind anything: ride the torrent. Most o f your pa- tients will understand what you are trying to do, and will somehow support you. Fig 1. Riding the chaos \200 519 Prescribing and compliance/concordance On any day 60% of people take drugs, only half of w hich are prescribed. The others are sold over the counter (OTC). The commonest OTCs are ana lgesics, cough medicines, and vitamins; for prescribed drugs the common groups are CNS and cardiovascular drugs, and antibiotics. On average, 6 \200\2237 NHS prescrip- tions are issu ed/person/year (21 in Italy and 11 in France). GPs account for 75% of NHS annual prescribing costs ( 10% of the total cost of the NHS), al though many of these \200\230GP drugs \200\231 will have been initiated in hospital. The c ost of these prescriptions has rises faster than in \202 ation and is 300,000/GP/year. Positive correlations with low prescribing include a young doctor, practicing in an affl ue nt area, and longer consultation times (is extra time is spent explaining about minor illne ss (p517) may be given, so that ex- pectation for a prescription is replaced by belief in o ne \200\231s own health). Formularies aim is to make prescribing more cost-eff ective, by c ompiling an agreed list of favored drugs. This voluntary restriction can work in tandem wit h compulsory NHS restricted lists, and lead to substantial savings (eg 18%). Developing for mularies at individual practice level has been recommended, but this is time-consuming and may be better achieved by adapting an exist- ing formulary. ScripSwitch is an alternative, using software to \202 ag up more cost-eff ective solutions, which can be swapped in with one click if the GP so desires (eg valaciclovir \200\203aciclovir). The problem of denying GPs drug choice leading increase referral to secondary care 225 is obviated by this method . Dispensing doctors Where there is no chemist \200\231s shop (eg rural areas) UK GPs are p aid to dispense to their patients. Their annual prescribing rate can be as low as 70% of th eir non-dispensing fellow GPs. Compliance (Does the patient take the medicine?) \200\207Th ere is no point in be- ing a brilliant diagnostician if nobody can be persuaded to take you r treat- ments. Even in life-threatening conditions, compliance is a major problem occurrin g in up to 56% of patients (eg adolescents with acute lymphatic leu- kaemia). The following are associated with increased compliance. \200 Being able to identify with a personal do ctor. \200 Patient \200\231s overall satisfaction with the doctor. \200 Simple therapeu tic regimens. \200 Written information (use short words \200\224Flesch formula >70, OHCM p3). \200 Longer consultation times or prescribing on home visits. \200 Prescribing in association with giving health education. \200 Continuity of care, coupled with belief in effi cacy of the treatment. \200 Short waiting time for appointments. \200 The encoura gement of self-monitoring by the patient. Monitoring compliance: Monitoring plasma drug lev els is the most reliable way of doing this, but it is cheaper to ask patients to return wit h their tablets, so that you can count them (or to count during a phone contact) 226 \200 \224or, better still, establish a basis of trust so that the patient can check for him- or herself. \201\201Compliance or concordance? Compliance suggests that you know best and pat ients who lapse are foolish. But it is known that adapting GP advice to their needs leads t o fewer side eff ects, eg GI bleeding: your prescription may read \200\230ibuprofen 400mg/ 8h \200\231, but the patient may, sensibly, only take the drug when his joints are bad. Don \200\231t think of this as the patient failing to do some- thing. It is you who have faile d to reach a shared understanding of the pros and cons of drug-taking. Concordance denotes more than this: think of it as a lib- erating concept, promoting egalitarianism in medicine . \200\207There is no healthier ideal. 227 Are you nodding in the direction of concordance while still covertly be- lieving in compliance? Then let us put the boot on the other foot and await the time you are monitored for compliance with some marvelous guidelines: we pre dict that concordance will now seem more rational and desirable! e r a c y r a m i r P Healing Since Neolithic times, healing has had a central place in our culture, and is recog nized as \200\230mor bettir and mor precious pan any medicyne \200\231 (OED V 152.1). Rece ntly medicines have improved greatly, so that the role of doctors as the purveyor of medici nes has eclipsed their more ancient roles. We all recognize the limits of our role as presc ribers, and we would all like to heal more and en- gage in repetitive tasks less often. But what, we might ask, is healing? How is it diff erent for from curing? Healing is, at one l evel, something mysterious that happens to wounds, see p731. 520 On another level, healing involves transforming through communication: a kind of hands-on h ypnosis. We can cure with scalpels and needles, but these are not instruments of communicat ion. Here is an example of healing (an all too rare event in our own practice). On a rainy February evening, after a long surgery, I visited a stooped man at the fag-end of life, wit h something the matter with his lung. \200\234I suppose it \200\231s rotting, like the res t of me \200\224it \200\231s gradu- ally dying. \200\235 I reply: \200\234Do you think you \200\231re dying? \200\235 \200\234Aren \200\231t we all? \200\235 \200\234Green and dyi ng \200\235 I reply for some reason, half remembering a poem by Dylan Thomas (Fern Hill). T he patient looks mysti \201 ed: he thinks he misheard, and asks me to repeat. \200\234Gre en and dying \200\235 I say, feeling stupid. There is a pause, and then he rises to his ful l height, puff s out his chest, and completes, in a magni \201 cent bar- itone, the lines: \200\234 \200 Time held me green and dying, though I sang in my chains like the sea. \200\235 bigeye.com/fernhill.htm By chance I had revealed a new meaning to a favorite poem of his which perhaps he thought was about childhood, not the rigors of his old age. Both ou r eyes shone more brightly as we passed to the more prosaic aspects of the visit. This illu strates the nature of heal- ing: its unpredictability, its ability to allow us to rise to o ur full height, to sing, rather than mumble, and how externally nothing may be changed by h ealing, just our internal landscape, transformed and illuminated. It also shows how healing depends on communication, and is bound up with art. Healing may be mysterious, but it is n ot rare. We have so often kissed the grazed knees of our daughters that we expect the heali ng balm of kisses to wear out, but, while they are young, it never will, because children k now how to receive \200\224but not how to doubt, and the kiss is the paradigm of healing: c ontact between two humans, wordless service of the lips. e r a c y r a m i r P Our central task of sifting of symptoms, deciding what is wrong, and pre- scribing treatmen t are all tasks which, according to the editor of the Lancet are destined for delegation to microchips. 228 This implies that our chief role will be as healers and teachers. Meta-ana lyzes of randomized healing trials (prayer, mental/spiritual healing, therapeutic touching) bear this out to some extent: 57% of randomized trials show a positive eff ect. 228 There will always be some way to go before healing, the central ideal of medicine, becomes its central activity. After all, the last thing any of us wants during appendicitis, is a p oet or a healer \200\224but last things will always retain their power to set us thinking. We should also be able to combine healing paradigms with mechanical neuropsychological appr oaches to consultations. This is the aim of spiritually orientated group therapy.1 The healing eff ect of laughter and tears are never far away in signi \201 cant consultati ons, as the latent becomes manifest: as one patient said \200\234There had been latent fee lings bottled inside me for years; after every teary session I felt better \200\235. 229 It \200\231s too glib to say what \200\231s broken gets mended, but tears can liquefy somethi ng in the soul that can then resolve itself, helped by the hugs that tears induce. 230 1 Group prayer, yoga breathing, and spiritual readings with severely ill women can improve mood, aff ect, motivation, interpersonal bonding, and sense of self, and can succeed in rea ching patients and promoting recovery in new ways. 231 This page intentionally left blank Social matters Unemployment in families UK data show a link between child deaths and unempl oyment, lower social class and overcrowding. Babies whose fathers are employed are heavier at birth (by 150g) than unemployed fathers \200\231 babies, after adjusting for other facto rs. Accidents and infection are more rife among children of the unemployed compared with se lected controls, and their mothers may be more prone to depression. As unemployment rises, so does child abuse. Other factors identi \201 ed with this rise are marital discord, debt , and parents \200\231 lack of self-esteem, as aff ected families reveal: \200\234When he lost his job he went bonkers. He changed completely. He became depressed and snappy. Frustr ated. \200\235 Marital breakdown heads the list of problems of women with neuro- sis, comin g 2nd (to job diffi culties) in men, and is a leading factor in >60% of suicide attempts. I n the USA, divorced men have the highest mortality. The greater incidence of cardiac deaths is in young divorced males. Being divorced and a non-smoker is nearly as dangerous as smok ing a pack a day and stay- ing married. Marital harmony (eg cuddling) protects from cardiac death, as shown in one prospective study of 10,000 Israeli hearts. Parental behaviors pred icting problematic marriages among off spring included jealousy, being domineering, getting angry easily, being critical, moody, or taciturn. 232 UK social security bene \201 ts For England, see dss.gov.uk/lifeevent/bene \201 ts. The Disability Rights Handbook, 36e, 2012 explains how the Personal independ- ence payment (PIP) is replacing the disability living allowance (DLA). Statements of \201 tness for work (Med3)UK says how long a person is off work for. Self-certi \201 cation occurs during the 1st 7 days of illness. If a patient as ks for a sick note during this period, it has to be private and is chargeable. The GP can i ndicate whether modi \201 cation to the workplace or amended duties would allow work to ta ke place; a phased return to work can also be speci \201 ed. 522 e r a c y r a m i r P Med3s can only be backdated when based on a previous assessment. An as- sessment is de \201 ned as the date you either had a face-to-face or phone con- sultation or considered a report from another doctor or professional. GPs can issue a Statement on or after this date , but not before. If a patient asks for medical evidence to cover a backdated period for wh ich there has not been a previous assessment a GP cannot issue a Med3 for the backdated per iod but in the comments box he can advise that the patient was not \201 t for work for an earlier period (if he has evidence to justify this advice). Why are further reports (IB113/ESA113) sometimes needed from a GP? Peo- ple suff ering from speci \201 ed severe disabilities may be treated as incapable of work without being teste d. So UK Jobcentres take steps to identify such people before applying the Personal Capabil ity Assessment (Incapacity Ben- e \201 t) or Work Capability Assessment (Employment and Su pport Allowance). GPs help by giving a precise diagnosis and factual clinical details where a per- son may have a severe condition that, under Regulations, allows them to be treated as incapable of work without needing to undergo a bene \201 t-related examination. Advise people with more than one job to submit the statement to their main employer, who ca n note the details of the advice you have given. They can dwp.gov.uk/docs/ \201 tnote-gp-g uide.pdf then present the form to their 2nd employer. 523 Social class and inequalities in health With the introduction of the British NHS, with its ideal of each according to need and equal access we assumed that diff erences in the health of diff erent social classes would go. The reverse has happened!233 The Black Report: Inequalities in Health National Service Frameworks (eg NSFs for heart disease, diabetes, mental health, and older people) aim to redress inequalities, but increase inequalities (rich people make more use o f new resources). This is compounded by the fact that the South-East is becoming ever riche r while in some of our great Northern cities over 50% of households are \200\230breadline poor \200\231. 234 Joseph Rowntree Foundation 2007 p53 genes and the locus and post-codes o f poverty How does poverty cause ill-health? In breast cancer, relapse is more likely in de prived post- codes, where smoking, drinking and an unhealthy diet make p53 mutations more l ikely, 235 so its cancer-protecting protein is less abundant (see p649). The big way to rem ove health inequality is to \200\201smoking in poorer people. And if some wealthy people q uit too, so what? So health inequalities don \200\231t matter as long as overall health is improving? Not quite. Justice matters too. It is the lack of justice which led to the NHS \200\224which would have been the best inven- tion of the 20th century, if only it had remo ved inequalities. e r a c y r a m i r P UK Registrar General \200\231s scale of 5 social or occupational classes eg lawyer, doctor, accountant Class I eg teacher, nurse, manager Class II eg typist, shop assistant Class III N Class IIIM eg miner, bus-driver, cook eg farmworker, bus-conductor Class IV eg cleaner, l aborer Class V Professional Intermediate Skilled non-manual Skilled manual Partly skilled (manual) Unskill ed manual ! r e g n o l m e e s y l n i a t r e c \200\207Poor people living in North London (eg Tottenham Green) live 17yrs less than rich people (in Chelsea); their life expectancy (71yrs) is < that in Ec- uador, China and Beliz e (none has a national health service!). 236 Mortality rates are higher in social class V v s class I: In stillbirths, perinatal deaths, infant deaths, deaths in men aged 15 \200\2236 4 and women aged 20 \200\22359 this factor is 1.8, 2, 2.1, 2, and 1.95. Ditto for lung canc er (SMR1=1.98), heart disease (1.3) and stroke (1.9). Melanoma and Hodgkin \200\231s diseas e are exceptions. l l i w e f i l r i e h t : e r u s a e l p Eff ects of social class and geography are hard to tease apart: in the UK, city dwellers \200\231 mortality rates are 22% (95% con \201 dence interval: 19% \200\22325%) higher th an those in the most rural areas (especially for lung cancer and respiratory disease \200 \224and pollution is a likely cause of this). 237 y l n o s \200\231 e n o e m o s Within occupations the eff ect of social class is seen in a \200\230purer \200\231 way tha n when groups of many occupations are compared: in a study of >17,000 Whitehall civil serva nts there was a >3-fold diff erence in mortality from all causes of death (except genitouri nary disease) comparing those in high grades with those in low grades. Similarly in the arm y, there is a 5-fold dif- ference in mortality from heart disease between highest and lowes t ranks. d e v o m e r e v a h We know that illness makes us descend the social scale, but this eff ect is probably not bi g enough to account for the observed diff erences between classes. It is more likely that t he diff erences are due to smoking behavior, education, diet,2 poverty, stress, and overcro wding. Cognitive ability can partly explain socio-economic inequalities in health ( \200 \230intelligent people look after themselves \200\231 \200\224has some truth). Note that sm oking is 3-fold more com- mon in nurses than in doctors 238 and cognitive factors must play some part in this. This need not imply pessimism about attempts to break the chain that li nks socio-economic status and cognitive ability with health. During some life stages, envir onmental factors may be able to in \202 uence cognitive skills. Interventions can be targe ted in order to optimize these eff ects. 239 y a m u o y g n i k o m s g n i v o m e r y B 1 The SMR (standard mortality ratio) is the ratio of mortality rates in one class compared with the aver- age for the whole population. The whole population has an SMR of 1.00. 2 Low earners consume only a bit less wholemeal bread and more sugary drinks, processed meat and sugar than average, eg 2.5 portions of fresh fruit and vegetables, compared with the avera ge of 2.8. 240 Purchasers and providers Two sets of contrasting principles 1a He who pays the piper, calls the tune. 1b Priceless therapeutic assets cannot be bought or sold: compassion, conti- nui ty of care, and commitment. 2a My job is to spend, spend, spend, until all my patients are healthy. 2b The job of the Treasury is to squeeze, squeeze, squeeze, until all spending is within government targets. (The clarity of this dichotomy becomes turbid when the doctor is asked to do the squeezing.) 524 Never just ask how good a structure is without also asking how good it is at transforming i tself: that which cannot transform, dies. The UK National Health Service is the largest emp loyer in the Western world and for years the search has been on to \201 nd ways to contro l and transform this dear, mighty thing. The purchaser \200\223provider split is the most p owerful lever yet developed for this purpose. Purchasers commission care by drawing up cont racts with compet- ing providers, who deliver the care. The better the provider delivers se condary care (do not pause to ask what \200\230better \200\231 means: speculation on this point might ruin the argument) the more likely they are to get the contract next year. The catch is that all the extra eff ort the provider makes to out-perform a contract this year will probably be taken for granted next year. The same may hold true if purchasing is used for the imposition of guidelines ( \200\230evidence-based purchasing \200\231). What has be en created is a treadmill which goes faster and faster, while taking less and less account of individual patients \200\231 and doctors \200\231 legitimate but varying needs. Unless t he market is rigged, natural selection ensures that the \201 ttest and fastest providers survive. Patients and taxpay- ers bene \201 t \200\224until the point where cynicism and e xhaustion set in. There is no evidence that once the purchaser \200\223provider path is cho sen, then cynicism and exhaustion inevitably follow, and there is evidence at local level t hat bene \201 ts accrue, and services become more tuned to consumers \200\231 desires. (Co nsumers are not infallible judges of what constitutes health \200\224but they are the best judges we have.) \200\207If the State runs both supply (money from general taxa- tion) and demand (control of waiting lists etc), the rules of the market cannot operate and effi cie ncy is hard to achieve \200\224which is why NHS trusts are being freed from central NHS con trol. Controlling change from on top: an historical example from maternity: 1 Government se ts up an expert group (mothers, midwives, ministers, obste- tricians, and general practitio ners \200\224these are jokers in the pack, because they are simultaneously consumers, purch asers and providers). e r a c y r a m i r P 2 Issuing of objectives and indicators of success \200\224eg by 5 years: Women should have a named midwife to ensure continuity of care. \200 Women should be able to choose their place of delivery. Aim to achieve the outcome that she believes is best for her baby and herself. \200 \211 75% of women should know the person who is to deliver t hem in labor. \200 Midwives should have direct access to some beds in all maternity units. \200 \211 30% of women should have a midwife as the lead professional. 3 Fanfare phase: the group \200\231s attractive-looking report is issued (at great ex- pens e to taxpayers) to all groups and personnel involved (except mothers). 4 Lack of \201 nan ce is blamed when no improvements are detected at 5 years. 5 Later, the units are marked fo r closure and the cycle of hope, rising expecta- tions followed by despair and cynicism bec omes complete as the consulta- tion exercise proves to be a derisory exercise in making glo ssy reports. 241 Anatomy of change Ideals (woman-centered care) \200\203Speci \201 c polic y objective (all women to have the chance to discuss their care) \200\203Purchasers \200 \231 action point (set up maternity services liaison committee with lay chairperson) \200 \203Providers \200\231 action point (provide link-workers, and advocacy schemes for women w hose \201 rst language is not English). This type of activity may or may not lead to incr eased accountability and quality of services. 242 525 Referral statistics There is great variability in individual GPs \200\231 referral statisti cs, which leads purveyors of government strategy to the error of saying \200\234Why is the re a 4-fold diff erence in referral rates between GPs? Such variation is insupport- able; s ome doctors must be referring too much \200 \200\235 An advance is made when this issue i s reframed as: \200\234There is information contained in this variability \200\235. This i nformation can guide service development. 243