Perhaps it is wrong to generalise too much Whalsay, Shetland ZE2 9AE. from this observation, but it does illustrate E-mail: [email protected] just how holistic we ‘general’ practitioners Persistent cough in have to be. RefeRenceS children Peter Perkins 1. Ballard T. What sustainability means for primary Philipson et al have provided more evidence care: primary care leads to better overall resource on subclinical Bordetella pertussis infection.1 FRCGP, MRCS, Southbourne Surgery, use and higher quality outcomes. Br J Gen Pract After reading the article one could think that 17 Beaufort Road, Bournemouth, BH6 5BF. 2013; 53(614): 457–458. B. Pertussis was just another, impossible to Email: [email protected] 2. Ansari S, Ford AC. Initial management of dyspepsia distinguish, cause of prolonged coughing, that in primary care: an evidence-based approach.Br J Gen Pract 2013; 63(614): 498–499. only a laboratory test will illuminate. I think it RefeRence needs to be pointed out that whooping cough 1. Ansari S, Ford AC. Initial management of dyspepsia is a real syndrome, with a largely forgotten, in primary care: an evidence-based approach.Br J DOI: 10.3399/bjgp13X673630 but unique characteristic that makes clinical Gen Pract 2013; 63(614): 498–499. diagnosis possible, and that we now realise, co-exists with subclinical infection. DOI: 10.3399/bjgp13X673621 I have studied 740 cases of clinically diagnosed whooping cough in the Keyworth Response to ‘Repeat Practice since 1977.2 The characteristic that prescribing = hassle’ distinguishes clinical pertussis is not the ‘whoop’, but the very long intervals (can be future proofing Greenhalgh bemoans the fact that repeat hours) without coughing, contrasting with prescribing has become a chore and the severe choking paroxysms that occur primary care generated its own bureaucracy.1 Much of on average every 2 hours. Patients do not In the September issue of the Journal, Tim the hassle is self-inflicted. volunteer this information, indeed very few Ballard wrote: ‘The penny dropped with me My hypertension was diagnosed while I are aware of it until they have thought about it. at the RCGP Annual Conference in Harrogate was serving in the Army. Once it was brought It is possible, but I think unlikely, that none last year, that the best way of future proofing under control I was reviewed every 6months of the oral fluid positive patients in Philipson’s the healthcare system in the UK is to invest and was given a prescription for 6months study had clinically diagnosable pertussis. in the education and skills of GPs and their supply of medication. On retiring and coming If the right questions had been asked, the teams, in short, helping them to deliver under NHS care, I was still reviewed 6- software may have learnt something, and high quality generalist personalised care. very likely improved on the average clinician. monthly but was only trusted with a month’s At the heart of this is the skill to deliver Pertussis is diagnosable if the supply of medication at a time on the basis of bespoke patient care and manage risk characteristic symptoms are known and without resorting to over-medicalisation and PCT guidelines. the right questions asked, or if the clinician consequent high resource use.’ 1 I fully understand that some patients hears the sound of a real whooping cough In the same issue, in an article on dyspepsia cannot manage 6 months’ supply of paroxysm and learns the tune, which few in primary care, two gastroenterologists medication and in my days as an NHS GP have had the opportunity to do, since the wrote: ‘The initial management of I emptied older patients’ drug cupboards of cough is inconveniently intermittent. uncomplicated dyspepsia in the community hoarded drugs. There is probably more danger from should consist of either non-invasive testing My challenge to you is to regard guidelines cases missed through lack of diagnostic for Helicobacter pylori, so-called ‘test and as what they really are, practice the skill than there is from the unknown number treat’, with proton pump inhibitor (PPI)-based personalised, patient-centred care, which of subclinical cases, which, as opposed to triple therapy for those testing positive (PPI you all espouse, and trust those of us who missed cases, are not very important in the and two antibiotics) and 4 weeks of PPI for can manage their drugs by prescribing transmission of this disease that is still killing those testing negative, or empirical PPI for reasonable amounts and go back and babies. 2 all patients.’ enjoy coffee, cake, and the conviviality of an The gastroenterologists seem to be informal meeting with your colleagues and Doug Jenkinson, teaching us how to cope without an make repeat prescribing less of a chore. Are DM, FRCGP, Retired GP, Gotham, endoscope. Surely, as Ballard’s editorial there any good reasons why you should not? Nottingham NG11 0HT. indicated, our scope needs to be wider than E-mail: [email protected] this: we have to learn not just aboutH. pylori but also about other causes of abdominal JPG Bolton, RefeRenceS pain, about the low predictive values of tests, Retired GP, Somerset. 1. Philipson K, Goodyear-Smith F, Grant CC,et al. about the way symptoms change over time, When is acute persistent couch in school-age either improving spontaneously or becoming children and adults whooping cough? A prospective more clearly defined, and about the power of case series study. Br J Gen Pract 2013; DOI: RefeRence serial history and examination. 10.3399/bjgp13X670705. 1. Greenhalgh T. Repeat prescribing = hassle.Br J 2. Jenkinson D. Natural course of 500 consecutive Gen Pract 2013; 63(612): 369. cases of whooping cough: a general practice Wilfrid Treasure, population study. BMJ 1995; 310(6975): 299–302. GP, Whalsay Health Centre, Symbister, DOI: 10.3399/bjgp13X673649 DOI: 10.3399/bjgp13X673658 518 British Journal of General Practice, October 2013.