There has an exponential in the use of gabapentin and pregabalin medication amongst prisoners over the last decade. These drugs are now almost exclusively used by those with other dependencies in prisons. During this time of increasing use of these gabapentinoids and other prescribed medications, we saw an increase of violence in prisons. This violence may not be due to illicit Spice use and reductions in the number of security staff.
I am the suspicious that us doctors may not be doing any good. Doctors do not have any medication to treat crime, but our best of intentions may now be causing criminal side effects.
Many of my prisoner patients have recognised themselves in the following scenario:
You have a criminal tendency, making you feel nervous, or you may have heroin habit, whereby you have to “find” £100+ a day for that. This make you very nervous, an anxiety state. You go to your kind GP who gives you diazepam at least, but clonazepam is your preferred benzo choice (10x more potent). You now feel relaxed and invulnerable. You feel better inside yourself, but you are now worse to others. Relaxed you can thieve more. Then there is that paradoxical aggression these medications give, so that knife you have with you is now more likely to be used. Of course you prefer the similar effects given by the gabapentinoids, the new benzos, which you can seek for that old ankle fracture and back pain. Gabapentinoids can give a high on their own, make heroin highs better and cheaper, and any spare capsules can be sold on.
Your life is now a mess, and you feel grief, guilt and remorse. These are uncomfortable sensations, which should protect you from more damaging high-risk behaviour. These feelings are depressing and annoying. Your GP now adds in an SSRI for your “depression”, but you may seek Mirtazapine, as you cannot sleep (perhaps partly caused by the cocaine), and you may want a bit of weight on. The anti-depressant detaches you from your emotions (that’s partly how they work in depression), releasing you from guilt and remorse.
You now have ideas that others do not like you, you have no insight as to why that is so. Your mood swings are violent, disinhibited, so now you now have added quetiapine or olanzapine to the cocktail. These major tranquilisers were designed to stop the overthinking in a psychosis and schizophrenia, but here the tranquilisers block thought, further imagination and hope and they also make you fatter.
With this concoction of these prescribed medications you now are free of anxiety, grief, guilt, remorse and hope. You are detached and have no feelings for others. You now have full blown Iatrogenic Antisocial Personality Disorder with multiple convictions.
Weight goes on and on, blood sugar rises. You are now diabetic.
Gapabentinoids and opiates are a lethal combination. Apart from anything else they block with the opiod antidote Naloxone. Patients arriving in prison have their Gabapentindoids quickly reduced to stop but will still be given detox or maintenance for their opiate dependency.
I have added back an archive of NHS Commissioning documents based in Hertfordshire, 1999-2008.
Perhaps someone will copy and paste some of the old documents for yet another new project, as all has been done before under different names. Family health Authorities, Regional Health Authorities, Area Health Authorities. Primary Care Trusts. Practice Based Commissioning Groups, and now Clinical Commissioning Groups. It’s pointless.
All NHS reforms do is play musical chairs. No reform dares start on the basis that these functions are simply not needed. They are moved to different named bodies.
I have worked in Australia where these layers of NHS administration simply do not exist, despite the fact that Australia is considered to be over governed.
Shared Clinical Records Fallacies and its waste of time
Some of the work being binned and shredded
I am clearing out paperwork at our old office. This pile is some of the work I did for NPIT and then CfH, Connecting for Health, the UK health service plan for a single NHS record. It cost billions. It failed.
Although I got reimbursed for some of my time on committees this was such a waste of time and I knew it. I was not popular as never liked the concept of a single health records anyway, and detested the idea that Government should write software. The Government’s agenda and civil service procurement contracts were so precise that it was as if they were writing code.
The main effect, indeed aim at the time, was to kill off multiple medical UK IT businesses. Only four primary care system survived. NHS bureaucracy believed that it would be so much better if there was only one system, one supplier in the NHS. The next best option, as far as they were concerned, was that systems should all look and behave in the same way. The result is that the fast and innovative clinical systems we had have become stuck in aspic. The drive to innovate, to compete was killed off by the pressure and time needed for government conformance. Little attention paid to what doctors, nurses or for that matter what a patient might need. The systems in use now are slower and much less ergonomic than the medical system in place in the late 1990s. Most UK GPs had systems on their desks by then because they saved time and created legible scripts and records. Now systems slow down consultations and act as a barrier between doctor and patient. The doctor has to glare at the screen point a mouse at a tiny icon.
Fallacies of a single record
1 “It saves so much money and time, and improves patient safety if there was a single system and NHS record” Not true. A single record lead to sloppy thinking and lazy doctors. The patient is a day older. The past record is just as likely to bias you in the wrong direction by what was written the past. There is likely to be something new. Take a history and examine the patient. It works every time! This is especially true in an emergency situation. Junior doctors should be forbidden to look at old records for 48 hours.
In the UK GPs can have access to records (paper for the most part) going back to 1927 as the records follow you around. When working in Australia there is no such thing, and lo! to my surprise I did not miss the records clinically. As a matter of prurience I might have. When I told and Australian patient of GP UK record access she said that would a be gross invasion of her privacy. She had a point.
2 “But we must know if a patient is allergic” . If only recording allergy was that simple. Most people who report that they are penicillin allergic are not. A patient may report that she felt upset on that green pill, so not unreasonably the GP puts on his record allergy to green pill, so now the system will almost block the GP annoying the patient when attempting to prescribe green and related hues in the future. Alas a hospital will interpret that to mean the patient will collapse with anaphalaxis to green pills. To avoid this the GP now needs to record green pill allergy in greater detail, more than the patient nor he needs in his practice. Detailing what was reaction, what type, intolerance of allergy, rash, urticaria, wheezing and so on and on. It may need a tree of many codes to describe the reaction and how serious. It is so tedious that it is left. But this coding dilemma occurs with recording of almost any disease. Heath Data has fractual properties, like the length of the coast of Britain, seemingly approaching infinity once you draw round each pebble or then grain of sand. The level of detail you need to record depends on your need in front of the patient, its use to you, the patient and locality.
3 That leads onto the provenance of data. Where is comes from has a huge effect on its meaning. A nurse may find a patient confused, so she might record dementia on her system (it might even be recorded as Alzheimer’s). For her work that all she needs to do to remind her. However this could be any different type or dementia, or even psychological, dementia-precox (psychosis). Who and when was the data entered changes its meaning, and then who can correct it should it turned out to be a toxic confusional state. Correcting data entered by others is a minefield in shared records. A GP may record heart failure, but a Cardiologist may need to know what type, or worse it has since resolved and is still there on the record.
4 “Clinical systems can improve safety by warning doctors of interactions of patients other disease and between drugs”. Unfortunately the fear of being sued by suppliers for failure to provide warnings, means that the most idiotic warnings pop up. Such as in treating blood pressure: “Adding X with Y will cause BP to fall”…. YES that is what I want! No intelligence in offering up these warnings which are so frequent, so minor, or that the risks are already fully understood beforehand, that doctors simply flash past all warnings as they are wasting time, in doing so increasing the risk a genuine high risk warning will be missed. This is true for current systems and would be worse if there was a central record as that has to be designed for the most junior nurse doctor or admin clerk.
Keep encouraging different systems. The can use common coding systems as they do now. They can work differently, have different interfaces functions and innovate.
When a patient is seen at a different place, such as at hospital, an authorised doctor should be able to do a search of all NHS records within date ranges or selected places, to create a new record. Preferably a day later. This NHS search engine would be secured with two factor authentication or more, with swipe card; the patient notified that such a search was made and by whom and when.
That way provenance of each item is clear. There would be no need to create a single record. There is the NHS spine record, but it is only a summary with few details, and keeping it in sync with GP records is not easy.
Connecting for Heath was doomed. Its premise was wrong, but those concepts and wish for a single patient record still come up. It still a dream of civil servants everywhere. It is not needed and it kills innovation in healthcare computing. Without NHS meddling we would now have slicker, faster, even tablet based clinical systems by now. More patients could be seen in less time.
Gerard Bulger
PS if you invent such a search engine I will need 5% stake in it.
I have just revised my blogs on keeping internet costs down with narrow expensive connections. Its still rather longwinded, so here is a summary!
All gadget providers now believe that every one has unfettered access to broadband. Alas there was still part of the world where that is expensive or does not exist, and those of us forced to use Satellite communications from the field have big problems. The costs are so high an update would break the bank. We cannot control what out phones and PCs do in the background.
My solution was to make sure that anything I plugged into the satellite device/route never knows the route to the internet. I set them so that there was only one route in the IP tables, the route via the satellite to a proxy server. Then I used another browsers such as Opera or Sea Monkey as they have email clients. These browsers can set their own connections via a proxy server independent of the operating system, so nothing else can connect to the internet.
While everyone goes on about the countryside having poor broadband, it’s here in central London, EC1, that has terrible domestic broadband connections. Here with BT or Sky the download speeds are never greater than 7mbs down and 700kbs up. There is no fibre here, no Virgin cable. Blocks of flats have real issues.
At last out block may yet get Hyperopticbroadband cabling. We have this at our other apartment. Although fast is had similar issues.
When Relish Broadband came along offering high speed, up to 50mbs using a dedicated 4G network in EC1 at only £20 a month unlimited use, I jumped at it.
Alas there is no free lunch. Here is my list of Relish issues that Relish/Three broadband does not tell you, or is so hidden in small print that you will miss it. Now that Three have taken over, nothing at all has changed:
You cannot put the Relsih 4G SIM in any other device than their hub/router (This is in their T&Cs). You cannot for example put in in a 4G dongle.
The router/hub is locked down. You cannot change much at all.
The Relish router/hub does offer dynamic IP name assignment with DYNDNS and others, but those will not work unless you buy a fixed IP address!
As above you cannot reach your hub network from the internet because Relish uses CGNAT thus hiding you within their private network. To have normal home broadband you have buy an IP address; that is get the business package.
The router/hub uses Network Translation (NAT) ONLY. The other options are greyed out, so you cannot set it to route the one IP address, and use the router as a modem, which I would much prefer to connect it on to a proper router.
There were sudden drop outs in connection causing pauses. This problem persists but is now much less often after a firmware upgrade.
No IPV6 support. Does seem to be planned either!
Asynchronous. Upload speeds very poor, 4MBs
At first the service was terrible and hardly worked at all, but I stuck with them. To be fair you can send the hub back and cancel the contract at no charge within a month, so you can test it out for free. The help line advice was just to give up and send it back! I wanted it to work. After six weeks the poor signal strength shot up and I was getting speeds of up to 60mbs down and 10mbs up. Almost Korean speeds. During busy times, which here in is during the day, it can fall to as low as 8mbs down and 4Mbs up for short periods. Still, these speeds much better than Sky. And it is unlimited.
Relish marketing have designed the package to be plug and play. That is all very well, but what REALLY annoys me it that there is no technical information page. It’s take it or leave it attitude.
They describe it as home broadband without wires, but the basic package is not. Their advertising is naughty, especially as there do not give any of the details on their web page of what the service actually is. There is no reason to hide the truth as it is still good value.
The base package is not home broadband as you cannot reach your home from the internetunlike all most wired services, except hyperoptic. This could lead to other problems with games and any home cloud you have. Relish uses Carrier Grade Network Address Translation (CGNAT). In effect you are on their private internal network. You do not have a reachable IP address, so dyndns and similar services will not work. This is in effect double NAT. This does not seem to be necessary is IPV6 is coming along allowing everything and everybody to have an IP address. But CGNAT does act as a nasty block from the internet to your home device. Some might like this double firewall.
Hyperoptic are almost as bad as they too use CGNAT so you cannot teach your 1Gbs router from the internet. So you had to buy the fixed IP4 address. But at least with them IPV6 is now rolled out, so should not be necessary, but their router is clumsy handling it. Hyperoptic is fast, low ping and SYNCHRONOUS ! £60pcm for full service and phone.
Hyperoptic today on Rasperrypi: Download: 167.71 Mbit/s Upload: 226.71 Mbit/s
At the start I fought with Relish their terrible help lines, and to their credit they offered me a business IP address, so I can reach my router here. I now pay £30pcm no phone
I wish that these businesses they could have the courage to be more honest on their web pages about the product and give much more technical info. They to sell their products as if a fridge. You plug it in and forget. For a business environment that’s not good enough.
It’s still good value. Its working pretty well, usually very fast but had the occasional drop-out, but that issues seems fixed.
Three Broadbnad, Relish is now stable (May 2019) useful and fast enough. A few times it does drop to 6Mbs which is the TOP speed we get on our Sky/BT lines, but averaged 40Mbs. Relish/Three still lacks IPv6 support and this is becoming an increasing problem.
Test Relish on Raspberry Pi Relisj? Three: Download: 33.08 Mbit/s Upload: 3.83 Mbit/s
I have two connections at at this apartment. Slow Sky (6Mbs), Broadband and Relish. For me Sky Broadband is now the spare connection (failover) should Relish fail. This is switch is automatic; The Draytek Vigor 2860 router I have does load balancing and failover. Sky has IPv6. Three Relish does not. I cannot IPv6 at all use as default routing prefers IPv6, forcing the router to use the slower connection.
Once we had various businesses such as the doctor’s surgery in Bovingdon, the Fundholders’ Support Agency and Archway Development and Consulting. In those days then having a web space made sense.
But a personal space, which is what this has since become, is much less necessary now that Facebook and the rest has taken over any need for a vanity sites.
I think I will keep the website going and add my thoughts, partly because old URLs should never die! Also I feel slightly more in control. I am not alone with that thought. If I hit delete. It’s gone.
