Domhnall MacAuley: Excellence in Practice. RCGP Annual National Primary Care Conference.

Domhnall MacauleyAre you an apple, a pear, or even a melon? Metabolic risk is less if you have the body profile of a pear rather than an apple. If you are shaped like a melon, it is definitely time for a serious diet. You may not have noticed, however, that you are now one of the 30-40% of the population classified as obese.  Individual risk perception is unrealistic and both men and women systematically underestimate their own waist circumference. It is not just our body shape that is important as Kamlesh Khunti, Professor of Primary Care Diabetes and Vascular Medicine at the University of Leicester, pointed out at the RCGP Annual Primary Care Conference. Body fat percentage can vary greatly even in people with the same BMI. He emphasised, in particular, major ethnic differences so that South Asians not only have greater body fat, but have higher glucose levels at all corresponding levels of BMI. Change is subtle- who would have known, for example, that a portion of French fries that in 1960 contained 200 calories now carries 610 calories. Our genes have not changed but our environment has.

Social inequality, closely linked to environment, is a major cause of death but never appears on a death cert. Mortality levels in Scotland began to slide down the European league from the 1940s, according to Harry Burns, Chief Medical Officer for Scotland, and he attributed this decline to loss of employment and industry. Smoking prevalence in Scotland is surprisingly low, particularly in males, compared to other European counties and diet and smoking do not explain Scotland’s position. He first became aware of social inequality when, as a surgeon, he noticed delayed wound healing among his poorer patients: Now, in his public health leadership role, he believes that many of our current health problems are biological consequences of the social environment, that health improvement is a well intentioned failure and, that we need a different model. Our current recession may cast a long shadow.

“Dementia is the new cancer” according to a patient of David Johnson Chairman of RCGP NI, who chaired of the session “Dementia and Older people: Patient and carers perspective”. Everyone talks about it, dreads it happening to them, looks out for early symptoms, and is acutely aware of the consequences. While there are some positive aspects (few people are aware that only 17% of patients with mild cognitive impairment go on to develop Alzheimer’s disease) there is a great disparity in resources. Louise Robinson, Professor of Primary Care and Ageing at Newcastle University, said the picture painted in Terry Pratchett’s television documentary is nothing like the NHS reality. If you ask people about death and dying they know about hospices and cancer care nurses but dementia services seldom feature. Most services are biased towards cancer, but most people don’t have cancer.

“How do you know if a patient with dementia is dying?” You don’t- it is impossible to tell. They cannot talk to you, you don’t know if they are distressed and cannot measure their suffering. Prognostic models are not very helpful and advanced care planning is always too late.  Patients in the later stages of their illness may move to care homes closer to their family but away from their local environment. No one remembers how they were, and their new general practitioner never knew them. In dementia we just do our best to muddle through.

Domhnall MacAuley is primary care editor, BMJ