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GP incentives; Walk-in CT scans; Hot Flushes feedback; New anti-coagulants

Do financial incentives for GPs work? Are walk-in CT scans a good idea? Plus Hot Flushes feedback and the new generation of anti-coagulants offering an alternative to warfarin.

Financial incentives for GPs - do they work? Mark Porter learns there are parallels between the latest £55 to diagnose dementia and an incentive to diagnose depression which didn't work and was dropped. Are walk-in CT Scans a good idea - two experts who authored recent reports address concerns about people arranging their own scans. Hot Flushes feedback; plus the new generation of anti-coagulants offering an alternative to warfarin.

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28 minutes

Programme Transcript - Inside Health

Downloaded from www.bbc.co.uk/radio4

THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

 

 

INSIDE HEALTH

           

Programme 6.

 

TX:  28.10.14  2100-2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  ERIKA WRIGHT

 

 

Porter

Coming up today:  CT scans - is it a good idea for people to arrange their own to try and pick up cancers and heart problems before symptoms develop? Two leading experts concerned about the risks coming up later.

 

HRT - our recent item on tackling hot flushes prompted a flurry of emails and Professor Maryann Lumsden is back to answer your queries, including one about hot flushes in men.

 

And anticoagulants - I will be learning more about the latest alternatives to the market leader warfarin.

 

But first, financial incentives for doctors.  The announcement that GPs in England would be paid £55 a time for diagnosing people with dementia prompted quite a reaction last week. The move didn’t seem to be too popular with anyone - including GPs - but it is not the first time doctors have been offered such incentives. Martin Roland is Professor of Health Services Research at the University of Cambridge.

 

Roland

Well in fact they’ve been used in the NHS for a long time, back to 1990 when GPs were first given extra payments for meeting targets for getting cervical smears done and for getting immunisations for children done.  But then there was a very big change about 10 years ago when they were given a large additional payment for meeting a wide range of quality targets for diseases like diabetes and high blood pressure and asthma. 

 

Porter

What do we know about how well they work?

 

Roland

Well they work to a degree but they don’t work quite as well as a lot of people would like them to work and they can sometimes go wrong, for example, relating to the treatment of depression.  Now at the time it was known that GPs quite often underestimate the severity of depression when somebody comes to see them with low mood.  So an incentive was given that doctors would give patients a questionnaire, it was a short nine item questionnaire, which the patient would complete and would help, in theory, the doctor to know how seriously depressed the patient was.  Now many doctors found that an odd thing to do, so it would be strange, for example, you were in the middle of a conversation with a patient who’d just burst into tears about their marriage or their lost job and you’d say well would you mind filling in this questionnaire because that’s what the doctor had an incentive to do.  And so it was very unpopular with doctors and there was an example of one where perhaps you were incentivising doctors to do something which they felt clinically didn’t – often didn’t feel right.  And that incentive was dropped after a few years because it was very unpopular.

 

Porter

I mean sitting opposite you as a GP I suppose I’m pleased to hear that in a way, that the doctors didn’t feel it was right and therefore didn’t chase the money on that particular one.

 

Roland

Well they not only didn’t chase the money but of course they found ways round it.  So the incentive only came into operation if they coded the diagnosis of depression on the clinical record.  So if I was a GP who was sitting there, I was in that situation that I really didn’t want to give somebody this questionnaire, that it would interrupt the flow of the consultation, then all I have to do is write in the records instead of coding depression write feeling upset about job or low mood or something else.  So it was very easy to get round. 

 

Porter

There has been some cynicism about this new dementia target and the payments, I mean do you think that risks going the same way?

 

Roland

Well it’s interesting because I think there are parallels between depression and the proposed new incentive for diagnosing dementia.  Doctors are certainly concerned about it and I don’t think – it’s not that doctors don’t believe that diagnosing dementia is important but I think that there are a range of issues which really cause problems.  First of all to diagnose dementia you clearly need to do some sort of test, you need to give something like a mini-mental state test to the patient and that itself requires a discussion with the patient, not everybody might want to have that test, there certainly is a risk of false positives and certainly administering a dementia test I think requires informed consent from the patient.  Now if you start to think about how that might work in the standard 10 minute consultation with a GP, where the GP’s got an incentive of over £50 if he can get this questionnaire completed, then I think that you can see that GPs might feel very uncomfortable about that.

 

Porter

But also with the publicity that’s been given to that payment, the minute I wheel a mini mental state questionnaire out my patient’s going to look at me as if I’ve got – they’ve got bounty on their head.

 

Roland

Indeed they will.

 

Porter

Professor Martin Roland.

 

Now on to a subject we promised to return to last year when we touched upon the burgeoning practice of offering CT scans as form of check-up - where otherwise healthy people pay companies to scan them for hidden problems like early cancers and heart disease.

 

A seemingly attractive proposition for many, including Inside Health listener John:

 

John

A CT scan of my bowel identified a slow growing polyp which had to be surgically removed. And as I have worked with asbestos in the past, the CT scan of my chest alleviated my concerns about my lungs. The best £850 I have spent.

 

Porter

But others are not so convinced. In the last few months two reports have highlighted areas of concern.

 

An expert working party put together by the Department of Health to assess the latest evidence on the use of walk-in CT scans released its report in June.  And then two months later the Committee on Medical Aspects of Radiation in the Environment (COMARE) published its review on radiation doses associated with CT scans in the UK. The COMARE chair was clinical physicist Professor Alec Elliot.

 

Elliot

CT scans use x-rays which are a type of ionising radiation and ionising radiation is known to have the potential to cause cancer, the higher the dose of radiation the higher the risk.  A CT scan gives a much higher dose than a chest x-ray, indeed it’s one of the highest radiation dose investigations that we use in medicine.  That’s because in order to obtain the pictures what happens is the x-ray tube travels right around the body taking multiple x-rays, we don’t just take one picture, the x-ray tube takes a very large number of x-rays and then the computers add all the data together to give you the cross-sectional images.

 

Porter

And can we quantify that risk?

 

Elliot

Yes we can.  The absolute risk from radiation is defined by the International Commission on Radiological Protection which takes its data largely from atomic bomb survivors and works out what the additional risks of cancer are per unit radiation dose.  We can then measure the radiation dose from the CT scan and arrive at a risk factor which varies with age because the younger you’re irradiated then the longer life span you have left and therefore the greater risk of developing cancer.  So we’re talking of risk of fatal cancer of roughly 300 in a million, one in 3,000 roughly.

 

Porter

So to be clear, to put that into context, for every 3,000 scans we do, looking possibly for cancer, we might actually induce one is what you’re saying?

 

Elliot

That is theoretically correct yes and we will not be able to predict which patient would be the unfortunate one.

 

Maskell

The fundamental problem is that our ability to find things on scans has far outstripped our understanding of what to do about them when we do find them.

 

Porter

Giles Maskell is President of the Royal College of Radiologists and chaired the Department of Health expert working party on the use of CT scans in otherwise healthy people.

 

Maskell

We know, or we’re starting to realise, that the cancers that we find in people when we go looking for them, healthy people, are different from the cancers that come looking for us, by causing symptoms.  So there is a group of diseases which we call cancer and we’re all painfully aware of the nasty end of spectrum but there are also cancers which are much less damaging.

 

Porter

Because it would seem a bit of a no-brainer to most people that go in, you walk in off the street, you order a scan, you’re a smoker, you’ll have one of these CT scans of your chest and it picks up something early that that would be good.

 

Maskell

And it is, intuitively it sounds good and it is a very seductive proposition but – and almost whatever the outcome of the thing, whether you find something or you don’t find something, you’re bound to feel good about it.  Probably most people’s perception of it is that if we scan a bunch of healthy people most of them will get the all clear and a small number will have something serious that we’ll find and something would be done about it.  And in fact that’s not the case.  What happens if we scan a bunch of healthy people we find a load of stuff and we find stuff that we’re not sure what to do about and so very often we end up saying well have another scan.

 

Porter

And they have another scan and they still find that abnormality and then because we’re doctors we feel we have to do something about it but that might not be the right thing.

 

Maskell

Not necessarily, I mean you mentioned the example of lung scanning and I could show you examples of two people who had lung scans, both of them have small tiny dots or nodules, as we call them, on the lungs, a few millimetres across, one of those in two years’ time will turn out to be a very unpleasant cancer, the other one will have gone away.  And we’ve no way of telling at the time we find the thing which one’s which.

 

Elliot

The newer CT scanners have a much higher resolution in the picture, that means that you can detect smaller objects, bit like your HD television.  You have what you might loosely call an HD CT scan these days, which gives the clinician much better data than we had say a decade ago.  The consequence of that is that although we can try to reduce the radiation dose the reductions we make are largely negated by the additional information it takes to get the better resolution picture.  So very roughly the radiation dose is staying more or less the same.

 

Porter

And what’s happening in terms of the numbers of CT scans that we’re ordering?

 

Elliot

The numbers of CT scans in the NHS is rising, showing no signs of plateauing.  We are effectively doubling about every five or six years.  There is much more clinical information in the scan and therefore it’s much useful clinically than in some situations it might have been in the past.  So, for example, you perhaps used to do a barium study of the gut, nowadays you would probably do that by a CT scan.  You could do, instead of endoscopy, where you push the tube down the throat or indeed up from the other end, you can nowadays replace that with a CT scan.

 

Porter

So it’s a better test than it used to be effectively?

 

Elliot

It’s a better test and it has a wider clinical application.

 

Porter

Whole body scans have been frowned upon ever since COMARE concluded back in 2007 that the potential risks outweighed any benefits. Today the market centres on scanning three organs - the bowel, the heart, and the lungs. Giles Maskell.

 

Maskell

There’s a general agreement that just scanning the whole body on spec is not a particularly good or sensible thing to do for some of the reasons that we’ve said.  What we now suggest or what people are suggesting is that scanning particular organs, looking for particular diseases.  So just as you might have a mammogram to look for breast cancer, you might have a scan of your lungs to look for lung cancer, your colon to look for colon cancer, of your heart to look for heart disease.

 

Porter

Your committee looked at those three most popular types of scans and came up with some recommendations that providers should follow, can you outline those for me?

 

Maskell

For example we’d recommend that people who’ve never smoked probably shouldn’t be having a lung scan because the chance of them having lung cancer is so small and we’re only likely to find things which are not relevant to their future health.  Similarly for the heart and for the colon there are sort of age cut offs.  So the worry obviously is that a young person in their 20s who’s had a relative just suffer from or die from cancer will think oh I’m at risk I must have a scan and that’s not the case.

 

Porter

And if providers follow these recommendations I mean would that allay some of your concerns, would you be happier?

 

Maskell

Yeah I think we’d be happier, I think we’d be most happy if people were educated to the point where they understood that actually there’s quite a big downside to doing these things.

 

Porter

But your recommendations are aimed to try and shift that balance by for instance putting an age of CTs of the chest or saying it should only be done in smokers, that’s because they’re likely to be at high risk of having problems.

 

Maskell

That’s quite right.  A very large trial has suggested that if you select a group of high risk people who have smoked for a long time a lot of cigarettes and over a certain age then if you do scan those people on an annual basis with CT you can pick up cancers which you can treat at an earlier stage and you can improve their overall survival. 

 

Porter

But that’s very different from people walking in off the street saying ooh my father just had lung cancer I’m going to get my lungs checked out because I used to smoke?

 

Maskell

That is a very different thing and for lots of reasons.  As a screening programme, people might be familiar with the breast screening programme, there’s a package of information that you’re provided with when you start weighing up the pros and cons, the risks and the benefits of it, there’s a systematic process whereby you’ll be called and reminded and have serial investigations if that’s what’s needed because we do know that having a one off scan is of no value at all in the lung, you need to have it on an annual basis for it to be of value.  You’ll also have the facility for whatever results come out of the scan to be incorporated into your health record, your GP will know about it and so on.  And very importantly if you’ve had previous scans for some other reason you’ll be able to compare those or the radiologist interpreting them will be able to compare those with the previous scans which might help to reassure if there is a little spot there.

 

Porter

We’ve had an e-mail from a listener, Richard Heighton, who asks about MRI scans and could they be used instead.

 

Maskell

It’s a good question.  It gets around the radiation but there of course small other risks associated with high magnetic fields but it doesn’t get round the problem of all the things that we find on the scan and in fact MRI in some situations is more sensitive than CT, so the potential for finding out small things is actually greater with MRI than CT.

 

Porter

Things that you don’t know what to do about.

 

Maskell

Things that you don’t know what to do about.  And of course having found them you’d have to be a very risk minded individual to not do something about them.  And if you were that kind of individual you’d probably wouldn’t have had the scan in the first place.

 

Porter

Let me put you on the spot, if I may, would you consider yourself ever having one of these scans?

 

Maskell

Knowing what I know and knowing the chances of something being found then actually I think I’d rather not thank you very much.

 

Porter

Dr Giles Maskell. We asked one of the leading providers of walk-in CT scans to come on to Inside Health to justify what they do, but they declined.  However, they were keen to point out that they do stick to the latest guidance produced by Giles Maskell’s working group.

 

Well Dr McCartney’s been listening to that in our Glasgow studio. Margaret it is all very well setting out guidelines like these for the companies to follow but does anyone police them?

 

McCartney

Certainly in England the Care Quality Commission do have a responsibility to go and visit clinics that are offering these kind of screening services and make a judgement about whether or not they’re doing it with what they regard as well under their criteria.  And there are parts of the CQC’s judgement that involve how well patients get information about the investigation screening tests that are being offered and what the evidence is for that and there is a requirement within the CQC to ensure that people are given pros and cons.  What’s very unclear is what standards are used to judge the information given.  I sent off for quite a lot of leaflets and information from several non-NHS providers in the UK and really I had to look to find out what kind of information people are getting about the risk of false positives or the reasons why these are not offered on the NHS and I have to say I was disappointed, there’s really very little about the downsides of having scans, either on most websites or in the information booklets that are sent when you phone with an inquiry.

 

Porter

Thank you very much Margaret. And you can download the latest Department of Health guidance and the COMARE report from the Inside Health page of the Radio 4 website.

 

Time now for some feedback and our inbox has been dominated by the item we did on treating hot flushes, and our expert, Professor Maryann Lumsden, is back to deal with your queries, on the line from Prague where she’s organising a congress. Maryann, the first question- is about the underlying mechanism and to be fair you did cover this in our original interview but it didn’t make the final edit due to lack of space, so it’s our fault, I’m sorry. What happens during a hot flush?

 

Lumsden

Hot flushes occur when the level of oestrogen drops, which is what brings on the menopause, the change of life, and there is a heat loss response, the same as when somebody is playing a sport or exerting themselves.  And the reason for this probably rests in the brain because the way temperature control is dealt with in the brain becomes a little more sensitive and so a tiny change in temperature will bring on this heat loss response which is flushing and sweating and causes the very unpleasant symptoms that many women do experience.

 

Porter

And it’s the falling levels of the hormone oestrogen that trigger this response?

 

Lumsden

Absolutely and it is often falling or changing levels rather than just a low level and so in the years leading up to the menopause, the peri-menopause, when levels of hormones go up and down rather randomly flushing can be extremely severe.

 

Porter

We’ve had a couple of questions from people who are taking drugs that block the actions of hormones and effectively give them a menopause, one is from somebody who’s taking tamoxifen, that’s used after the treatment of breast cancer, and a lot of women on this get hot flushes, is there anything we can to help them?

 

Lumsden

Yes, it’s a big, big problem and it causes quite a lot of women who are taking tamoxifen to stop it because it’s such a big problem.  We do try alternative means, we can try low doses of the antidepressant group, much lower than is used in those who are depressed, and this can often be effective if they are started carefully.  There are other drugs, another one which has been trialled in this patient group is a drug called gabapentin, which is used for various neurological problems and again is effective in many women.  And then there are alternative treatments that are being developed, such as cognitive behaviour therapies and relaxation techniques and of course we have to give a lot of advice on lifestyle trigger factors and conservative ways to lessen the problem of flushing but it is very difficult.

 

Porter

Because of course the one thing we can’t do is add in back the missing oestrogen because that’s the whole idea of them being on tamoxifen, it’s to block that.

 

Lumsden

Some patients are so desperate that they either stop the tamoxifen or they say can you add back oestrogen.  And if things are bad enough and the breast surgeons agree then we have on one or two occasions done this just to help people through an unbelievably difficult time but it is not standard treatment, it’s not something one would recommend.

 

Porter

We’ve had another e-mail from somebody on cancer therapy, this time it’s a chap, he’s having hormone injections – zoladex – for cancer of the prostate, which reduces testosterone levels and he’s getting hot flushes, so is there a similar response in men?

 

Lumsden

Absolutely and often flushes are extremely severe and it’s very disturbing because men don’t get hot flushing, if you see what I mean, in the way women do.  So there’s the added embarrassment and distress and we have done trials with this and yes it is exactly the same mechanism.  There are ways that some people have tried of relieving the flushing using different types of hormones, not testosterone, but other hormones, however I have no personal experience of using it because I don’t actually treat the men but I know they can be quite effective.

 

Porter

We must leave it there, Professor Maryann Lumsden, thank you very much.

 

We’ve also had a big response to last week’s item on DIY testing kits designed to help make life easier for people who take the anticoagulant warfarin - used to prevent dangerous clots in around a million people in the UK with underlying problems like an irregular heartbeat or deep vein thrombosis. Warfarin is often referred to as a blood thinner and needs constant monitoring to ensure that it gives the right degree of anticoagulation, so the blood is neither too thin nor too thick.

 

However, the latest generation of anticoagulants - apixaban, dabagitran and rivaroxaban - work differently. They are easier to prescribe and don’t need regular monitoring. And GPs are being encouraged to switch to them but uptake has been slow.  Ander Cohen is a consultant vascular physician at Guy’s and St Thomas’s hospitals in London.

 

Cohen

Warfarin thins the blood in a very non-specific way, it depletes a number of clotting factors and the absence of those clotting factors means the blood is thinner.  Whereas the new drugs are specific inhibitors of just one clotting factor.

 

Porter

Which means that their mechanism of action is more predictable?

 

Cohen

It is, it is because they’re just acting on one factor and it is because they are absorbed more predictably and it is because they’re not affected by food and they’re – not only is their mode of action predictable but the doses that any one person will require are much more predictable too.

 

Porter

So this is a – potentially – a one size fits all drug that you give, do you have to monitor people on it?

 

Cohen

You don’t have to monitor, and for the majority of the patients the same dose fits all.

 

Porter

So the advantages, the immediate advantages to the patient and to his or her GP’s surgery or local hospital is that you put them on this drug, it’s the same dose for everybody and you don’t need to get them back in to have regular testing?

 

Cohen

That’s correct.

 

Porter

What about the medical advantages?  I mean say we’re using this and the most common application would be for people with irregular heartbeats, atrial fibrillation, they’d normally be on warfarin, is this drug as good as warfarin at protecting them from stroke?

 

Cohen

This drug is actually better than warfarin for protecting them from many types of strokes.  So all these drugs have led to a reduction in the most feared complication of anticoagulation, which is bleeding into the brain.

 

Porter

And those are the bleeds that we fear most because they’re the most dangerous type.

 

Cohen

That’s correct.  But there are also other bleeds that are very difficult to manage like what we call internal bleeding, bleeding into the abdomen, also bleeding into the bowel and bleeding into the lungs and the urinary tract.  And all these things, as a whole, are less common with the newer anticoagulants.  The one we have to keep a close eye on is bleeding into the bowel because some of the newer anticoagulants may cause a bit more bowel bleeding but we think we can control that.  And when you put all the data together these are actually lifesaving, there’s more than a 10% reduction in deaths in patients taking these compared to the old drugs like warfarin.

 

Porter

The big problem when these drugs first came out was the cost, I mean compared to warfarin they’re incredibly expensive, but NICE – the National Institute for Health and Care Excellence – has approved them, they have said that the benefits they offer are worth the extra money but uptake has been slow, why do you think that is?

 

Cohen

Well I think uptake’s been slow because doctors are generally aware of the constraints on spending with the NHS but there’s a lot more to it than just the cost of the drugs because there’s a cost of monitoring, there’s the cost of getting the patient back to hospital and what we’re finding with the newer anticoagulants patients are being discharged earlier and they’re coming back with complications less frequently.  So we see reduced hospitalisation from bleeding and we also see reduced hospitalisation with recurrences.

 

Porter

And presumably I mean there’s the cost to the patient as well, I mean the patient’s not having to take time off work, they’re not having to go to the local GP’s surgery, we’re not having to do the tests and spend time interpreting them.  But there’s also a concern about what to do if things go wrong.  I know what to do if someone starts bleeding on warfarin or their blood becomes too thin, we can reverse the effect of warfarin, in general practice, simply by giving Vitamin K, I wouldn’t have a clue with these new drugs, is that worrying?

 

Cohen

Well it’s theoretically worrying but in practice it doesn’t seem to be.  So I’ll give you an example:  If we want to do something about someone bleeding on warfarin we’ll give the coagulation factors and we’ll see if that improves the coagulation within that patient.  If someone on one of these newer anticoagulants has bleeding we also give the coagulation factors, so the treatments are very similar.

 

Porter

But what about patients who are already on warfarin, when should they consider switching to these newer drugs, what sort of factors would make you shift somebody across?

 

Cohen

Well this is a very interesting controversial area because much of the guide says if someone’s stable on warfarin or one of the old drugs you don’t need to switch them.  I disagree, I think, for instance, that many of the patients in the studies were switched on to the new drugs and got the benefits.  I would like to think that patients should all benefit, whether they’re on the old drugs and stable or whether they’re about to be started on a blood thinning drug because the benefits are clear with respect to bleeding, bleeding into the brain and mortality.

 

Porter

Ander Cohen, and listening to that was Margaret McCartney Ander’s obviously very keen on these drugs, he thinks they’re a step forward, do you share his enthusiasm?

 

McCartney

I think they certainly have a role and certainly they are drugs that I would prescribe day to day.  I suppose that I’ve got several concerns about them though and part of it is that our populations is changing, so the people that we’re now treating with these anticoagulants, these stroke preventers, are – tend to be older and frailer with lots of other illnesses and diseases and it’s a very difficult judgement I think between risk and benefit for many patients.  And there have been studies that have looked at the use of these drugs in older people but what’s been really important is that before the trial has started doctors and patients have sat down together and actually made a decision that for some of these patients it’s going to be too risky to go on to any drug at all.  And I think that’s one of the factors in real life that doesn’t always play out when we look at some of the other studies that have been done in very fit healthy people where the decision making process, I think, is a lot easier, it’s a lot clearer where the benefits and risks might lie.

 

Porter

What about this concern about antidotes?  As you know we can use Vitamin K if someone’s on too much warfarin, but Ander Cohen really sort of dismissed that, saying from a hospital perspective anyway the treatment is much the same whether you’re bleeding because you’re on too much warfarin or bleeding because you’re on too much of these newer drugs.

 

McCartney

Well I think the problem is that there’s no specific antidote for these newer anticoagulants, unlike warfarin where the specific antidote is Vitamin K.  So I think that is something that does concern a lot of GPs.

 

Porter

I mean the feeling I’m getting is that this is unfamiliar territory, it’s not necessarily just the fact they’re very expensive drugs, it’s that we don’t know an awful lot about them, we’re not used to using them.

 

McCartney

I think a bit of caution is not a bad thing and actually in my experience I’ve found that quite a few people who have been on warfarin for a long time, who are stable on it, who are happy to use it, who know their own devil, as it were, want to continue on it rather than changing on to a newer drug and I think that’s very much their choice.

 

Porter

Thank you very much Margaret.  And there’s a link to the NICE guidance on the new anticoagulants on our website.

 

If there is a health issue you think we should be investigating then please do get in touch - you can e-mail via insidehealth@bbc.co.uk.

 

That is it for the current series but we will be back in the New Year. Until then, goodbye.

 

 

ENDS

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