Emollients in Schools

Lots of us are getting eczema from the incessant application of alcohol gel and soap we now have to endure. Both break down the natural oils in the skin causing it to dry out, get flaky, crack, itch and, if nothing is done, causing fissures and risking nasty infection.

But hey! Whilst life is difficult for us all some are determined to make it a bit worse. As the world is facing meltdown from the economic and mental-ill health effects of COVID-19 some schools are making life worse for themselves and their charges by declaring any child who needs to use an emollient for eczema must have it prescribed! That is, a doctor must sanction it’s use! For God’s sake!

An emollient is just another word for a moisturiser that I think every adult has used at one time or another, even if amongst tough blokes, it was only to sooth sunburn or when pretending to like massaging their partner whilst really hoping it leads to a shag. So let’s be clear: No-one needs their doctor’s permission to use a moisturiser or an emollient. Even young children can be taught to self-apply the stuff quite easily. Are there any women in the country who have not had it as part of their daily routine for much of their lives? The preventative or treatment use of emollients should be encouraged and there should be no hindrance to that, such as requiring a doctor to get involved.

That schools, in some parts of the country, have been requiring doctors to confirm by prescribing the need for children to use emollients for their sore hands is beggar’s belief.

Why would one (underfunded) public service saddle another (underfunded) public service with more cost is beyond me, though it happens repeatedly. Not only does such an insistence cause great inconvenience to parents and an inevitable delay in the kids getting something on their hands it dumps on the NHS the cost of a consultation with their GP or nurse practitioner, the cost of the emollient itself and the cost of a pharmacist dispensing it. Free all this may be, at the point of delivery i.e. to the child, but free, it is not. Every tax payer has to shell out, not to mention the parents in lost time and hassle. There is a real lost opportunity cost here because every time NHS staff time are used that time can’t be used doing something more helpful to preserve or treat the health of their patients. They could, for example, be phoning patients who have missed their cancer screening and trying to persuade them to have it, or supporting patients with poor control of their diabetes, or their drinking. But opportunities like this are lost when the clock ticks by doing something else. Remember we are at least 5,000 GPs short in England alone. You do know the quality of care in the UK, isn’t what it could be, don’t you?

If the NHS wasn’t spending around £47 million annually[i] on moisturizers prescription perhaps it could have coped better with the COVID-19 pandemic. Perhaps it might be able to recover services faster afterwards. Let’s remember all emollients can be bought without a prescription and I suggest if you can afford a car to take your cherubs to school you should buy your emollients yourself and the school should not need a GP to sanction your duty as a caring parent.

If you’re struggling to make ends meet then I’ll happily ensure your cherubs do get some emollient by putting it on prescription. The last thing I want is a child to suffer because their parents can’t afford to pay, what are sometimes outrageous mark ups on retail prices. If it helps here’s a CCG’s table of most cost-effective products. These are NHS prices so you can work out what the retail mark-up is when you shop. If your local pharmacy can’t be competitive go elsewhere, online if necessary though ensure it’s a reputable site. Just because your child might get free prescriptions don’t abuse the NHS if you don’t need to. You want it to be good when you really need it don’t you? You do? Well be a good citizen and don’t undermine it before that time comes. Ten years of austerity in the NHS have done that for you already, and the debt the country now bears is unlikely to mean the service is going to be ace anytime soon.

Luckily for some, CCG pharmacists have worked with the local authorities who have now advised schools that emollients do not need to be prescribed and should not be regarded as medicines. If you need support with such issues there are links here for parents and schools.

We still have to solve the problem of schools not being able to administer paracetamol to kids. Meanwhile the poor little buggers continue to burn up and feel shit until their parent or carer can get away from work, get to school, get them home and get some paracetamol in them. My God, when did we become such an uncaring society?

[i] https://openprescribing.net/analyse/#org=regional_team&numIds=21.22&denom=nothing&selectedTab=summary

Time to cut the cholesterol testing load

GPs and patients this is for you: Routine annual testing of cholesterol is a waste of public resources

There are hundreds of thousands of cholesterol tests being done in the UK under the guise of monitoring. I contend this is an utter waste of resources.

It costs way over £5 for every cholesterol test by the time the phlebotomist has been paid and the sample has been transported to the lab and analysed. It takes even more cash for your GP to process the result and the practice staff, if not the GP themselves, to discuss the result with you. That is rarely a good use of GP time if they’ve done it once before with a patient. Yeah, I know the GP is paid anyway but there are a lot of better things they could be doing with their time to improve the nation’s health and there are only so many hours in the day. If you’re not prepared to heed the advice the first time you get a cholesterol result why should the NHS use valuable resources checking your cholesterol each year? If you have an obsession with the numbers get it done privately and let the NHS spend money on things that will help the population more.

Why do I say this?

Well first let’s be clear I’m not saying that we shouldn’t have a cholesterol done ever. We probably all should. When that’s done is debatable. If we assume our lifestyles have settled into a consistent pattern by the age of 40, when our age and other risk factors start to have a greater impact getting a cholesterol between 40 and 50 is wise. But, please then act on the result, or decide not to and leave your GP and the NHS alone.

Live with your decision. Lowering cholesterol levels and reducing the impact on your cardiovascular risks is a long process so start early or decide to live life the way you want to and accept the consequences (premature heart and stroke disease, earlier cognitive decline, high blood pressure, kidney disease, peripheral vascular disease and impotence).

If you do act on your GP’s advice you should change your diet to reduce your carbohydrate and fat intake, increase activity levels if you can, lower your weight, temper alcohol intake and stop smoking. If you have high blood pressure take whatever your doc prescribes for that. It’s more important than a statin for cholesterol. If you’re not prepared to do these things forget worrying about cholesterol. It’s a low risk factor. It doesn’t have as much impact on your likelihood of developing cardiovascular disease as smoking, obesity, high blood pressure or a sedentary lifestyle, unless it’s very high. If you’re diabetic take that seriously. Diabetes is terrible for your heart and arteries but in Type 2 weight loss can reverse the diagnosis and the impact.

Your GP will use your result to calculate your risk of developing cardiovascular disease over the next ten years, the so-called Q risk. NICE advise offering patients a statin if their risk is greater than 10%. That means out of 100 people with the same risk ten people will develop cardiovascular disease over the next ten years. Taking a statin will reduce that risk by a third – so seven or so will still develop the disease and three will be ‘saved’. Unfortunately 100 people have to take the statin for ten years to achieve this incredibly small impact. But in health economics terms NICE reckon it’s worth it. Having a heart attack or stroke is very debilitating for individuals and can be very expensive for the NHS and society as a whole. A statin for 100 people for ten years costs in the region of £20,000 (the drug costs alone – not the costs in issuing the prescriptions or pointlessly monitoring cholesterols). The costs of treating three heart attacks or strokes will easily exceed £20,000 so you can see why NICE encourage it. Three hospital stays will probably cost this much and then there’s the additional drug costs for ever, time out of work and so on.

I’m not going to get into a debate about the pros and cons of taking a statin. In my book, as a GP, we all have the option of believing what others say about how good or bad statins are, what side effects they cause, allegedly, or just trying them out and seeing for ourselves. The vast majority of patients are able to take statins without any great side effects harm. That’s why you can even buy them over the counter now. In Yorkshire they say ‘You never get owt for nowt’. You decide if any symptoms you develop are due to the statin or not. Stop them. Your doctor doesn’t need to know if they’re minor. Do those symptoms go away? If they do, start them again. Do the symptoms come back? If they do, decide if you can live with them recognising there is a benefit from statins too. If you have bad symptoms, particularly muscle aches talk to your doc. It’s rare but statins can cause muscle breakdown that can be serious. I’ve seen one case in my 25 years as a GP.

There’s some evidence that the long-term anti-inflammatory properties they have might help more than we have recognised to date. I’m really not interested in what the media say about statins or your nextdoor neighbour. Try them for yourself and see, or don’t. NICE say they’re worth trying. That’s good enough for me.

NICE say we should aim to lower cholesterol by 40% from the original measured figure. That requires lifestyle changes too, not just swallowing the pill and carrying on hedonistically, though arguably you might be reducing what must be an even greater risk. But hey! Decide do you want a long healthy life or not? If not stop bothering us please.

Even with the drugs and lifestyle change the 40% is a tough target. After three months you should have had a check blood test. This is important to see both if your cholesterol has come down and whether your liver is coping with the pills. The liver does react to statins and we can detect this, if, the blood test is done. For the vast majority of patients, the liver reaction is not clinically relevant, i.e. it doesn’t matter. Keep swallowing the pills. If your cholesterol hasn’t dropped by 40% you have the option of taking a higher dose. It’s up to you. If you haven’t addressed, as Blur put it, your “pork life mate” then reconsider your priorities.

Once you have achieved a 40% reduction or, if you decide not to up the pills to get there, then just keep swallowing them for the next ten years, or don’t. It’s your choice. You should have a single further check of your liver at 12 months in and if that’s ok we refer to the treatment as ‘fire and forget’ or as some more frustrated doctors put it ‘fire and fuck off’ – we have better things to do than keep measuring your cholesterol level for your personal interest.

That firm attitude is because there is no benefit from measuring your cholesterol every five minutes or even every year. This applies whether you have a strong family history, have had a heart attack in the past or are diabetic. Your statin, will, if you are swallowing the pills, lower your cholesterol by the same amount all the time. What you consume will affect your cholesterol levels so don’t eat tonnes of fat or carbohydrate ever again. If you do want to do this think about why you’re bothering with the statin and what your priorities are.

GPs…ask the question ‘Are you taking your statin?’ When patients say yes – congratulate them – they’re good citizens given they’ve potentially less than a 1 in 30 chance of it helping them personally. When they say no, calmly take it off the repeat prescription list, exception code them in QOF and see if you can understand what they do want from the NHS. If we keep wasting resources it may not be there to look after them at all in the future. These are testing times, er but not of cholesterol! Stop testing!