I do sympathise, my dad’s spent a career trying to get IT to work in the NHS, and when I worked as a rep I did my fair share of chasing pointless targets, which frankly got in the way debating the evidence providing a valued servive etc. etc. I ultimately left big pharma for these reasons.

My point about the QOF was it did pay GP’s a lot of money, so it seems reasonable ask to profession to investigate, scientifically, its effects. i’m sure he knew this would introduce bias into his sample, that was always going to happen, but some research here is better than nothing.

my wider point however is we’ve come to a point with social medicine where people have to admit some of the resource (especially pharma’s budgets) need to be focused better. There is some Science in Management, even if first principals are much fuzzier and you only have to read Marmots Whitehall study to realise how effective it could be.

The equality trust studies are really good, and point to the fact, scientifically, that if people really want to help they should create a fairer society. I also suspect many MP’s feel the same. Just as I’ve met many very good Dr’s in the NHS. What’s needed though is better, management and research of this, much more than on the clinical side, which gets a disproportionate amount of resource. Unfortunately MP’s never talk about this, or bring up rationing for that matter!

However for treating cough, I’d grant medcine some cash money to have a real look at short term mucolytic use, then some more to look at their antioxidant properties in the long term for COPD. I’d want to save some for looking at patient self management though!

1. Nobody has yet mentioned packaging. I (happily) use a generic proton pump inhibitor, but the brands seem to change with almost every prescription renewal, and each new brand comes with a different type of packaging, never offering anywhere near the ease, convenience and small overall size of the branded drug. Because generic companies are in business to keep costs to rock bottom it seems to me they don’t care about such issues; a pity.

2. Concerning the very issue of colds and sore throats in Ben’s original post. I now know of two instances (both anecdotal, so obviously with limited direct value) in which someone with a serious streptococcal infection following an initial mild sore throat was held off from proper investigation and treatment until their symptoms had reached an extremely serious level because GPs had been convinced it is almost always unnecessary to prescribe antibiotics for throat symptoms. With every sensible message there always comes the risk that the point will be taken in too black-and-white a fashion by those unable to reason well.

www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2961208-3/abstract

Bit of a catch 22, then: how do you balance the seemingly large chance of a relatively minor adverse reaction (ie poorer immune response) against a small risk of a major reaction (especially when, though a very unpleasant thing to witness in a child, a febrile convulsion itself seldom does any lasting harm.)

No, I don’t know what the answer is, I simply raise the dilemma for debate!

“Doctors commonly prescribe treatments, even when they know they’re not effective, because in the face of assertive patients, demanding a specific treatment, many will choose an easy life.”

Guy is right – we get bombarded with questionnaires, surveys, requests for letters confirming that they have been having to take their sick parrot to the vet and all sorts, on a daily basis. This is on top of the tasks of actually trying to care for our patients and wrestling with all that the modern NHS places in the way of that aim, like the IT system.

To be honest, 50 quid for a survey would hardly merit a glance from me unless I thought it was a really worthwhile project, in which case I would try very hard to do it for nothing – and have done. Unfortunately the more common scenario is of carrying the survey around with me for ages with good intentions until I realise that it is now so far overdue that it is pointless completing it.

I freely admit that I have had some nice things, and some very useful things, from the pharmaceutical industry (now only a fraction of what was on offer even 10 years ago), but what I get mostly from them is a headache from trying to work out which information from them can be trusted and which needs to be treated with great suspicion. We do not, in fact, swallow every announcement from the drug industry as gospel, years of dealing with government and health authority diktats is excellent practice for that approach.

Inter alia, this means that I think you should inform your friend that he should be very doubtful as to whether his responses are actually representative of GP opinion, or only that self-selected subset who Are swayed by such inducements. Certainly, a former colleague of mine would probably have done so, and I would hate to think that his attitudes and opinions were in any way a reflection of my own, any more than I follow the current media line that the most corrupt of the current crop of MPs is representative of the whole lot.

Let me know when you get a distribution deal and I will be first in line. I’ll take the labels off and pepsi challenge that stuff with Calpol and Boots paracetamol suspension. Actually that’s a good idea, we could market placebos for popular OTC medications like cough syrups and painkillers and allow people to do their own controlled trials on their kids! Of course, they’d need kids of similar ages and they’d all have to get ill together, but I think it’s a goer

I was just thinking about extending the idea to homeopathy but how would you ever develop a reliable placebo? Surely all water has a memory of something? What if a tiny bit was the active ingredient you were testing? Your placebo would be super strong instead of inactive!!! Perhaps the homeopathy people are right, randomised controlled trials on this stuff is just too dangerous, it’s too easy to OD…

What actually happened was he wrote to 200+ GP’s asking for about half an hour do a semi-structured interview regarding the QOF.(Again I should blog earlier in the day!) He was researching a PhD into P4P in healthcare management. About 5 bothered to write/email/call back saying ok. He ended up having to spend about £2k of research money getting his data.

I accept that GP’s are self-employeed, work long hours, their time is money, and most of them do try and give back, (some regions better than other). However I would have hoped that the profession would accept that the QOF is already payment enough!

So that leaves the question if £100 per hr is ever justified, here or at any other time really, including with footballers! The link provides some interesting reasearch into this, and it is peer reviewed.

www.equalitytrust.org.uk/why/evidence/physical-health

No he didn’t! GP’s are self-employed business people who generally work 50 hour weeks. If someone sends them a short questionnaire about the Quality and Outcomes Framework (QOF), then they will probably spend a few minute and reply to it.

If people send a big 6 page A4 questionnaire that takes half an hour then they probably won’t. It’s paying for time. It’s a market decision that your friend made to increase his response rate to something done in their own free time. People’s time has a value you know!

Interesting GP studies are few and far between, because there’s not much money to study them with, I know I’m lookin into doing a PhD!(Incidentally there’s also not much data collected coz a lot of em are effectively private business men and not properly integrated into the NHS)

I was recently told by a professor of public management roughly 99% of NHS research funding goes on more clinical stuff and only 1% to management. I’ve not checked the figures but if they’re correct then if thats not a scientific conflict of intrest story I dont know what is. Again it’s about opportunity cost and ROI.

Incidentely a researcher recently told me he had to pay £50 quid a time to get GP’s to answer a questionnaire about the QAF. Your right Ben we are a nation obsessed with pills and healthcare of all sorts really, but its certainly not just pharma that makes all the money from it!

Re: CALPOL

I have always wanted to sell a children’s medicine called PLACEBO, that parent could give to their children for minor ailments. It just needs to be that bright pink colour with a foul strawberry flavour. I am sure that parents everywhere would love it!!

@ Martin Young

Ethical Drug Companies vs. Generics? I think you’ll find that most actives are made in China – whether from Big Pharma or Generic companies often in the same factory.

DrJG – I accept your point about patient confusion, although with the proliferation of one-stop dispensing, supervised self-administration, and the variety of environments which hospital pharmacies supply today the idea that hospital practice is irrelevant to the community situation is perhaps not absolute. But the letter to the Times expressly covered issues of generic bioinequivalence, and I argue that 30+ years of hospital experience shows that this can be overstated. And what’s more, the group responsible for the letter have produced a whole raft of arguments in their longer consultation response which would apply equally well to generic prescribing, so what’s the deal?

Administration errors in hospitals and care homes have as you say been widely studied, and the causes are multifactorial. However in all of the reports the only influence of generic medication highlighted is the problem of house-style packaging which fails to distinguish, say, HonestJohn Generic’s bumetanide from its levothyroxine, for example. And packaging is hardly an issue specific to generic substitution.

Of course we have had some poorly-made generics; Kent Pharmaceuticals’ mid-1980s flucloxacillin syrup is a painful memory for example. But these are the exceptiion. And given that the proposals will exclude certain medications, and that an exemption for the prescriber will be provided, what has really changed from generic prescribing?

Can’t remember where, but not long ago I saw an interesting item, though it barely classed as serious research. They took a team of rugby players, all of whom, on questioning, claimed that generic Ibuprofen was just as effective as the branded version. They then tested the effect of a generic by timing how long they could keep their arms in a bucket of ice, before and after the ibuprofen. As expected, they managed longer after the drug.
They then repeated the test some while later, but with branded ibuprofen, same dose. They found a bigger improvement after dosing with this, despite the subjects’ stated beliefs on generic vs branded drug.
What does it all mean? Dunno, but I certainly found it interesting and would be interested to see if it is reproducible.