APOLOGIES once again to our international readership, but the focus this month, once again, starts with domestic matters. It's about the change in the infant immunisation schedule, from triple plus Hib and oral polio to the five-in-one injection. By the time the September BJGP comes out it will be old news, but at the time of writing it's very fresh in the memory. On page 727 Neville Goodman discusses the inept management of the announcement. The sequence of leak, press chase, Department of Health (DoH) rejection of scare stories, followed a few days later by the arrival of the Chief Medical Officer's official letter to GPs gave us all a few innocent laughs at the expense of the Department. There was the added advantage that those of us who had been following the news didn't need to read the CMO's letter. Goodman puts it down to the DoH having no alternative strategy in place.
But wait a moment. This change must have been planned for more than a year. The people responsible for the change will have looked at the evidence, had meetings, consulted those already using the new system, had more meetings, consulted suppliers and agreed contracts. Yet the plan was released to outsiders -- doctors and nurses as well as all the people with children being immunised -- a few weeks before the change takes place. Even the RCGP's official spokesman for immunisation heard nothing before receiving the letter just before the story was leaked (by somebody else, he assures me). This is not a controversial change, and is easy to explain to anyone, but it was planned with a degree of secrecy more appropriate to a surprise attack on enemy territory. Why didn't the DoH take us all into its confidence when it first started considering the change? I can think of only two reasons. The first reason is that they may have felt that as soon as the possible change was announced some parents would delay immunising their children until the new scheme came in. This might be a concern, but most parents still want to protect their children and would understand the need to continue with a marginally inferior programme while considering and planning for an improvement. The second reason is that nobody ever considered consulting the public and the professions because that is simply not the way that government works in the UK. If this change had been in the public domain for the past year, there would have been no leak, no press story and no embarrassment; where everything is open there is no scope for leaks. In the immediate aftermath of the leak, when press activity was at its height, at least one journalist repeated what has now become a cliché, that nobody trusts the government on scientific matters any more. But what is revealed by this story is the more depressing truth that the government doesn't trust the public and professions enough to involve them in such discussions at an early stage.
The obvious rejoinder is that doctors have, at least until quite recently, been equally unwilling to trust their patients. But genuine efforts are being made to increase patients' involvement. On page 667 there is a trial of giving patients an audiotape of their consultation, in the hope of increasing the sense of partnership between doctors and patients. While many found the tapes useful, and heard things they had missed in the consultation, there weren't major changes to patients' anxieties or adherence to medical advice. A trial designed to test the value of eliciting patients' concerns concluded that it did increase satisfaction, but at the cost of some additional consulting time (page 663). The leader on page 651 argues that the extra time is a small price to pay. Finally, a study from Nijmegen supports the arguments for seeing your own personal doctor (page 693). We do need to know if seeing your own doctor increases your chances of a patient-centred consultation. Then, just before we all get carried away by euphoria, Mike Fitzpatrick applies his usual cold sponge; too much false equality between patient and doctor may eat away at our authority until we become wholly ineffective (page 715).
In this month's ‘Recent advances in primary care’, dealing with cardiovascular disease (page 695), one figure is astonishing. Under the new contract, GPs in the UK are rushing around throwing statins at anything that moves. The estimates of effectiveness are based on Framingham data, which overestimate the current UK risks by 57%. This ought to be another area where we should be working out how to have sensible patient-centred medicine with shared decision making. How can we do that now?
- © British Journal of General Practice, 2004.