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Question: Does the panel think that metformin will be the aspirin of the 21st century?
Norman Evans: Certainly in America, where metformin has not been widely used until recently and is not available generically, it is fast becoming one of the most widely prescribed drugs.
Sue Cradock: The challenge is that it causes some side effects in some people so I don’t think it will be taken up by everyone.
Michael Kirby: In the metformin studies, exercise and diet did rather better than metformin, so patients may take the pill as the easy option but in fact they can do themselves more good by dieting and exercise.
Martin Cowie: I would make a general comment. If you ask a medical student how to treat a condition they will immediately give you a list of drugs. A lot of people coming through nursing college, medical school, and pharmacy school think that modern medicine is all about drugs. Yet medicines are one part of a very much more complex whole. We would do well to invest a little more in communication and understanding where patients come from when they talk about their health.
Question: I am a mother and as a cardiac nurse I feel that I know a lot about healthy diets. My children have packed lunches for school and I try hard to make them healthy, but I still feel I am giving my children far too much salt. I know the government is putting pressure on the food industry to reduce salt but I don’t think it is fast enough.
Sue Cradock: The challenge is around schools and I think that leads back to the issue about having a whole system approach and a strategy around obesity and chronic disease that engages local education authorities and so on. That is where PCTs need to be driving some of their work. While we in health should be raising the issues we should be engaging other people in helping treat or manage some of those issues. But I think also that some of the messages are not clear.
Stanton Newman: We shouldn’t underestimate the complexity of the message. If you look at the behaviour of people taking statins, one of the questions is the nature of their diet. Many of them may be led to believe that they do not have to worry about their diet any more. They say “I don’t have to worry about this any more it’s been done for me by this magic bullet”.
Barbara Myers: Yet there is a paradox there in that people don’t like to take tablets and pills, so they should take responsibility for their own lifestyle.
Stanton Newman: We should not talk about patients as if they are homogeneous. People have different beliefs about medication and about diet, and that’s what drives their behaviour. It’s the heterogeneity of the group of people that we all have to treat that is important. If we use one model and think it is going to apply to everybody we will get ourselves into trouble.
Question: The transnational companies tried to block the World Health Organization when it said no more than 10% of the diet should be from sugar. What does the panel think we should do to change our culture when transnational companies put huge pressure on health professionals not to speak out?
Martin Cowie: This probably won’t be a popular opinion but I think we have to get health in balance. For many people, particularly when they are young, health is not their priority in life. Their priority often is making money, having a career, having fun, particularly as teenagers. I would not like us to become health fascists, decreeing what is right and what people should eat and what they should drink, etc. I accept that a lot of the choices society has made recently are not for long term health benefit. But I think we have to be seen as part of society helping with these issues, we have to persuade people rather than legislate as to how people should live their lives.
Stanton Newman: There is an interesting point about advertising and cigarettes. If you look at the data prior to 1980 the biggest change in cigarette smoking occurred through tax increases. The fiscal imperative is quite a powerful one in terms of persuading people not to do certain kinds of things.
Question: If diabetes is in control, blood pressure is in control and so on, should we tail off the medicines to cut the cost to the NHS?
Norman Evans: Some pharmacologists have suggested that in hypertension you can taper off the medication but there is no evidence that stopping medication in diabetes has any benefits at all. I certainly wouldn’t advocate that just to save costs. I would argue that probably the most cost effective part of the NHS at the moment might well be the drugs bill. You have to look at disease management rather than medicines management—the problem is that we can cost the drugs element, where we can’t measure the cost of nursing care and everything else.
At the moment we have a particular problem with cancer medication and the costs of cancer drugs. But cancer drugs account for 9% of total cost of cancer care and yet we are hounding the manufacturers to produce evidence, outcome data and so on. I think the pharmaceutical element in care is cost effective.
Question: Is there any evidence to suggest that the statins, fibrates, and bile acid sequestrants actually dissolve deposited cholesterol or lipids in the vessel wall? Also, one of the major risk factors is the misuse of alcohol in causing cardiovascular disease, whereas no such risk is reported with the use of cannabis. Would the panel recommend cannabis bars as opposed to pubs?
Stanton Newman: All I can say is that the widespread and controlled use of alcohol is very different from the widespread and uncontrolled use of cannabis. We actually do not know very well what the long term effects of cannabis are and it might also depend on the way you take it.
Michael Kirby: I think there have been some post mortem studies conducted on young people in America that have shown definite brain damage caused by the use of cannabis. I am quite convinced that two glasses of red wine is a good thing. There are several plaque regression studies showing benefit with statins and I think one of the important actions of statins is stabilising unstable plaque. Unstable angina is often due to instability of the plaque and can be stabilised with the early use of a statin.
Question: We heard how in the ASCOT study the patients have a beautifully well controlled blood pressure. They all seem to walk in and don’t have to wait, and they get a cup of tea at the end of it. If I was to able run my practice like that, that would be the case. Is there any point in having research in ivory towers that cannot be applied into primary care?
Anne McKerracher: When the patients first came to us their mean blood pressure level was 164/95 mm Hg and that was before they were provided with the tea. We are lucky to be able to offer this service. This is not the reason for improved blood pressure control. Strict adherence to target levels, non-pharmacological advice and our focus on cardiovascular disease play an essential part.
Michael Kirby: We were also an ASCOT center, we didn’t give the patients a cup of tea and a biscuit, and we also got our patients down to target.
Martin Cowie: Your comment relates to both the scientific validity of what we are told from the clinical trials, which is not under dispute—it is a very robust way of assessing a hypothesis—and to the external generalisability of that information. That is a challenge and is where implementation—how we translate the benefit from the clinical trials into clinical practice—is very important. Neil Campbell showed us some of the robust health services type research but that is only just in its infancy at the moment.
Question: To make significant impact we need to create win:win situations—wins for our patients but also wins for the people who are making the changes. I am not convinced that the new GMS contract is going to do that from a clinical viewpoint. I think there will be significant changes initially but that GPs and nurses will then find there is a population of patients they can’t reach or who have natural disease progression and can’t actually make significant changes. In a few years time when we have all our secondary prevention clinics and primary prevention clinics, we are left with a resistant pocket of patients. What would the panel’s approach be to targeting those people?
Martin Cowie: Your choice of language—“resistant patients”—once again gets to the attitude of the health professional to the patient. The patient probably doesn’t consider himself or herself to be “resistant” and I think there is no point getting into that mindset. We try our best to apply the evidence within the resources we have. But there is no point beating ourselves up that we are not perfect. Just be realistic about what we can achieve and work hard towards that end.
Sue Cradock: The words “heartsink patient” often come out when we run workshops. When we actually look at that it is actually the person that is not doing as they are told. I agree we have to think about these people differently. But they are making the decisions that are right for them at the time. The role for someone like me is to ask what we could do to help because there are a lot of people struggling. I have yet to meet someone that I can’t offer something too.
Neil Campbell: There is a group of patients who don’t come at all. In our secondary prevention clinics we get about 80% who come and 20% who don’t come at all. They are an extremely difficult group to reach—you will see them on average at least once a year, probably more than that opportunistically, but I find it desperately difficult to get through even a small proportion of the secondary prevention agenda in the last minute or two of a 7.5 minute consultation. So I think we do our best opportunistically and that’s about as much as we can do.
Stanton Newman: In the end there is always going to be a group of patients who will not take our advice, and indeed that is up to them: they make choices about lifestyle, they make choices about what they wish to do and they might actually think that what we are advising them is not particularly good for them and their choice of lifestyle. But to turn it on its head is interesting: at what point do we consider we have been successful? What we are saying is we don’t think we are doing enough now, we think we can do more and better. I think that it is going to take a lot of effort and thought for us to reach where we want to be.
Michael Kirby: We have run a lot of health promotion initiatives over the past 15 years and in each group we have looked at we have managed to get about 67– 69% of people to take part. The others choose not to. That is their right.
Anne McKerracher: I agree that all we can do is offer advice. It is up to the patients whether they want to take it or not. You might offer advice for four years and all of a sudden something might hit, so it is worth going on with it.
Question: We know there are health benefits with reducing blood pressure, cholesterol and HbA1C and each movement downwards results in a health gain benefit. Should the GMS contract not be rewarding a movement of the practice population towards those targets rather than setting an absolute target of, for example, 80% at HbA1c 7%?
Michael Kirby: That would be very difficult to achieve. The problem with HbA1C, as we know from the UKPDS data, is that people will remorselessly go the other way. So there will be a certain advantage in diagnosing as many new patients with diabetes as possible as they are easier to keep down at a lower level. In terms of working out payment it is obviously easier to have a single cut-off point. I think the new contract is difficult enough to work out payments for as it is—to do graduated payments would be more difficult.
Question: I work in the acute setting where patients have obviously survived the event and we start secondary prevention. Patients then go home on their treatment having been told they will be on it for the foreseeable future. But in many cases their GPs are saying no. How can we bridge this primary/secondary care divide so that we have seamless care?
Martin Cowie: Communication is the key here, making sure the information follows the patient. Some areas are successful in actually having a more integrated approach from primary and secondary care. Primary care trusts and their local hospital trusts have a responsibility to develop a consistent approach to disease management. I think we are moving towards that and I hope we are getting better, but it is a real difficulty. But it does make the patient more comfortable if everybody is singing from the same hymn sheet.
Michael Kirby: Part of the problem is that prescribing incentive schemes have deterred GPs from prescribing drugs for a long time and old habits die hard. But I agree with Martin that integrated care pathways are the answer. We do need an agreed approach for any one individual patient, and the patient’s journey from home into hospital and from hospital back to home needs to be coordinated centrally. The PCTs are in a good position to do that and I think they need to start with a few diseases and do it well. CHD is a good example. We are getting better and there has been a great improvement in communication certainly between our acute trust and GPs in the past year. Most of our patients now come out on a cocktail of drugs that gets transferred straight on to the repeat prescribing list.
Sue Cradock: If you inform your population, your patients, about what is good treatment and then have a discussion with them about how to overcome the barriers that they might face in the surgery, then they may be the people who will get the prescriptions.
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