From the News Desk of Jeanne Hambleton

Source Pulse Daily
Posted 14 July 2014 | By Christina Kenny

GPs in Cambridge have been warned against sending patients to A&E, after one of the country’s most renowned teaching hospitals announced that it had been placed on black alert.

Cambridge University Hospitals wrote to GPs, ambulance services and four other nearby hospitals on 10 July to warn them that Addenbrooke’s Hospital was facing ‘severe’ capacity issues.

GPs have been asked to consider whether patients they would usually send to A&E can instead be assessed through an ambulatory care service and all referrals must now first be discussed with an on-call doctor, the hospital said.

The hospital has been on black alert, which indicates the highest possible level of capacity crisis, since early July.

It had been placed on the black alert several times in recent years – for 190 days in 2012-13 alone. Though figures for 2013-14 are not yet available, it is understood that they are expected to rise.

The letter, seen by Pulse, said that the trust was experiencing ‘severe’ capacity issues across all areas.

CUH’s on call director, Amanda Kahn, wrote: ‘We have planned admissions on hold. We have contingency areas open.

“We are no longer able to place patients from the Emergency Department. We have critical staffing levels.

She added: “If you do phone GP liaison to refer a patient, please be proactive to considering whether your patient can be assessed on EAU3 (ambulatory care) rather than simply sent to the Emergency Department.”

FEED BACK FROM GPs or Readers of Pulse Daily

1. It would seem referring a patient to A&E is not a simple task so GPs it seems do not take this lightly. It seems GPs do not like it any more than we do as patients.

2. So a hospital with current, and multiple past, capacity problems wants GPs not to refer to AEU. Sorry my stock of medical goodwill ran out many, many years ago and if my patient needs to go the AEU they go. End of discussion. Why has the hospital not solved their capacity problems? Just why should GPs help those who would not help themselves?

3. Admitting a patient, or sending them to A&E is not an easy thing to do. The patient does not like it unless obviously necessary. They know they will be seen by a nurse after 1 minute and them be in a corridor for 3 hours and 59 minutes before admission. It will also take me at least 15 minutes on the phone, quite apart from arranging ambulance and letter. Does anyone in secondary care really feel admissions are an easy option? What are we going to do with patients that need admitting – leave them at home?

The same alert thing happens with our local hospital. They built the hospital they could afford under PFI, so it is too small and the car parking is very expensive. Everyone told them it would be too small and yes, surprise; it is. Our local population did not go younger, and chronic illness did not become less of a burden. Now we get regular letters with “red alert” “purple alert” etc. We get them so often, they go in the round filing bin immediately, unless I get really miffed which is when I send them back a fax. “dear hospital our practice is on black alert with bells on and red stars. Please do not discharge any of our patients as our surgery has now reached full capacity”. I am certain my missive will be treated with as much consideration as it deserves.

4. It is just a matter of funding and staff patient ratios. That is all. A hundred more inquiries will not solve anything till we can compare like with like. How many beds. consultants, junior doctors, nurses per 1000 patients ?

5. Our local hospital had black alerts last year, then they turned into rainbow alerts with spots on it, as they had hours of waits for ambulances to drop off new patients! Demand management from the DOH is the only way to stop the flood of folk turning up to A&E with coughs and sore throats, drunks need to be fined for wasting NHS time.

6. Close the doors to A&E for minor non accident and non emergency care – simple decommission them so they aren’t paid to see it. See how soon it is all sent back to where it belongs. Coughs and colds – even in small children belong at home in bed with parental care and Calpol.


Nice Pushes Through Decision To Widen Statin Treatment To Millions More Healthy People

From the News Desk of Jeanne Hambleton
Source Pulse Daily
Posted 21 July 2014 By Caroline Price

NICE advisors have stuck to their decision to halve the risk threshold for primary prevention of cardiovascular disease to 10%, despite calls from the BMA and other clinical experts to drop the proposal because of concerns it will lead to over-treatment.

The final guidance on lipid modification published today could potentially put millions more people on statins and has been criticised by the GPC as having ‘insufficient evidence’ for GPs to have confidence in the recommendation.

NICE has strengthened recommendations on lifestyle changes that should be tried before starting patients on a statin, saying GPs should offer statin treatment ‘if lifestyle modification is ineffective or inappropriate’.

But the final guidance is otherwise largely unchanged from the original draft publication announced in February this year, despite months of controversy.

The major new recommendations are to use the QRISK2 tool exclusively to formally risk assess adult patients up to the age of 84, and to offer high-intensity statin treatment with atorvastatin to patients with a 10-year risk of 10% or higher.

The guidelines state: ‘Before offering statin treatment for primary prevention, discuss the benefits of lifestyle modification and optimise the management of all other modifiable cardiovascular disease risk factors if possible.

If lifestyle modification is ineffective or inappropriate offer statin treatment after risk assessment.

‘Offer atorvastatin 20mg for the primary prevention of cardiovascular disease to people who have a 10% or greater risk of developing cardiovascular disease. Estimate the level of risk using the QRISK2 assessment tool.’

Guidelines group chair Dr Anthony Wierzbicki, honorary reader at Guy’s and St Thomas’ Hospital, told Pulse that BMA concerns over the evidence base for statin treatment at the 10% threshold were baseless.

Speaking to Pulse, Dr Wierzbicki said: ‘The evidence is clearly there and even at the relatively conservative risk threshold of 10% for “hard” cardiovascular outcomes, we still show this [approach] is going to be “event-effective” in terms of the best use of resources in the NHS, and it is also cost-effective in terms of how much money we would have to spend in the NHS to deliver those outcomes.’

Dr Wierzbicki added: ‘There is actually very good disclosure on safety data on statin trials. We used a huge meta-analysis of all the phase three data comprising over 300,000 patients – this is all statins, at all doses – published within the last year, which is an enormous trial database of the randomised trials against placebo.’

‘We also have data from registries – although it is always of more limited quality – and prescribing data from various countries, on the rates of side effects and these are really quite low.’

NICE advisors also dismissed the GPC’s objection that GPs would be overwhelmed by the huge increase in appointments needed to manage more patients on statins, arguing that the new recommendations have vastly simplified the approach to managing treatment with lipid-lowering therapy.

Dr Wierzbicki said: ‘We have actually taken a lot of notice of that – and what we’ve done with this guideline is simplified the protocols.’

But the GPC hit back, re-stating its concerns that NICE is ignoring the potential increased risks of harm from statin use and over-estimating the benefits from the evidence so far.

In a collective statement, GPC members wrote: ‘The GPC believe that there is insufficient evidence of significant overall benefit to low-risk individuals to allow GPs to have confidence in the recommendation to reduce the risk threshold for prescribing cholesterol lowering drugs, and that doing so might distort health spending priorities.’

Dr Martin Brunet, a GP in Guilford, Surrey, who has campaigned on over-treatment issues, told Pulse he was ‘extremely disappointed’ that the guidelines group had not given GPs more room to give patients choice on whether to start a statin.

Dr Brunet said: ‘It is so disappointing to see the lack of emphasis on patient preference in the key points summary. There is mention that a lower dose of statin might be used in patients with established cardiovascular disease on the grounds of patient preference, but there is nothing about patient preference in the area of the key recommendation with regards to a CVD risk of 10%.’

Dr Brunet also questioned the push to treat patients with CKD stage 3 with statins.

He said: ‘They now advise not to use any risk stratification, but just to start a statin in all patients with CKD. This will include a huge number of older women who are otherwise well and have what many would consider to be normally ageing kidneys.’

‘For me this is a very significant shift in favour of more treatment.’


One GP commented “In our society , those with the best knowledge of what is happening are those who are furthest from seeing the world as it is. “ 1984 , George Orwell

Another GP said:
(1) the implication on us is , of course, more statin ‘offer’ but offer does not necessarily mean ‘offer taken’ or ‘offer tolerated’

(2) have to engage your patient and ensure that they understand fully the meaning of 10% CVD risk as well as the concept of benefit against risk. We are not living in a perfect world, my dear academic colleagues

(3) we still need a proper and sensible debate about the exact incidence and prevalence of adverse reactions/side effects , 5-10% or 10-15%? That has to be an official information given to our patients.

(4) I would predict the Read Code ‘Adverse reaction to statin prophylaxis’ and equivalents will have to be used more. In fact, also document whether the quality of life of the patient is impaired by statin or not, bearing in mind it means differently in different age group.

(5) Time , of course , more appointments, you know what I am going to say anyway.

(6) Remember shared decision with your patients is a task based on democracy , not some autocratic parenting in this Stalinisation, sorry I mean Statinisation.

Personal comment

As a fibromyalgia patient, when I was offered statins for high cholesterol and read the side effects, it meant living with a constant fibromyalgia flare. I could see no benefit in that and found other natural means of reducing my high cholesterol. Back soon Jeanne

About jeanne hambleton

Journalist-wordsmith, former reporter, columnist, film critic, editor, Town Clerk and then fibromite and eventer with 5 conferences done and dusted. Interested in all health and well being issues, passionate about research to find a cure and cause for fibromyalgia. Member LinkedIn. Worked for 4 years with FMA UK as Regional Coordinator for SW and SE,and Chair for FMS SAS the Sussex and Surrey FM umbrella charity and Chair Folly Pogs Fibromyalgia Research UK - finding funding for our "cause for a cure" and President and co ordinator of National FM Conferences. Just finished last national annual Fibromyalgia Conference Weekend. This was another success with speakers from the States . Next year's conference in Chichester Park Hotel, West Sussex, will be April 24/27 2015 and bookings are coming in from those who raved about the event every year. I am very busy but happy to produce articles for publication. News Editor of FMS Global News on line but a bit behind due to conference. A workaholic beyond redemption! The future - who knows? Open to offers with payment. Versatile and looking for a regular paid column - you call the tune and I will play the pipes.
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