Caring for the whole person and the wider community for MRCGP AKT

A trial of a new antihypertensive reports that it reduces the 5-year risk of stroke from 8% to 6% compared with placebo. How many patients need to be treated for 5 years to prevent one stroke?

1. 50 correct Correct. Absolute risk reduction = 8% − 6% = 2%. NNT = 1/0.02 = 50.
2. 4 That would follow from an absolute risk reduction of 25%, confusing the relative reduction with the absolute one, the commonest error in this calculation.
3. 100 That would follow from a 1% absolute risk reduction. Check the subtraction.
4. 25 That is the relative risk reduction as a percentage (2/8), not the NNT. Relative figures make small effects look impressive, which is why marketing prefers them.
5. 12.5 That is 1/0.08, the reciprocal of the baseline risk rather than of the risk difference.

The point: NNT = 1 / absolute risk reduction. Always convert relative reductions into absolute ones before discussing benefit with a patient.

Source: RCGP curriculum — evidence-based practice and research Royal College of General Practitioners · tier 0, exam blueprint / regulator

A 71-year-old man with metastatic lung cancer has pain controlled on modified-release morphine 30 mg twice daily. He asks for something for breakthrough pain. What is the most appropriate breakthrough dose of immediate-release morphine?

1. 20 mg That is one third of the daily dose, roughly double the standard breakthrough calculation.
2. 5 mg That is one twelfth of the daily dose and is likely to be subtherapeutic, leading him to conclude that morphine does not work for him.
3. 10 mg correct Correct. The breakthrough dose is one sixth of the total 24-hour dose. His total is 60 mg, so 60/6 = 10 mg as required, typically no more frequently than hourly with review if he needs it often.
4. 30 mg That is half the daily dose in a single breakthrough and risks significant sedation and respiratory depression.
5. 60 mg That is his entire daily dose in one breakthrough dose and would be dangerous.

The point: Breakthrough dose = one sixth of the total 24-hour opioid dose. If he regularly needs three or more breakthrough doses a day, the background dose needs increasing. Always co-prescribe a laxative, and remember oral morphine to subcutaneous morphine is roughly a halving.

Source: NICE CG140 — Palliative care for adults: strong opioids for pain relief NICE · tier 1, national regulator or guidance

A practice is reviewing its childhood immunisation uptake. A mother declines the MMR vaccine for her 13-month-old, citing concerns she has read online. She is polite but firm, and asks not to be pressured. What is the most appropriate approach?

1. Refer the case to safeguarding as medical neglect Disproportionate. Declining MMR alone, in an otherwise well-cared-for child, is not neglect.
2. Remove the family from the practice list for non-compliance Wrong, and not a lawful basis for removal. Declining a vaccine is a competent parent's decision.
3. Agree to give the vaccines as separate single antigens instead Wrong. Single-antigen vaccines are not available on the NHS schedule, there is no evidence base supporting them as safer, and offering them validates the premise behind the concern.
4. Explore her specific concerns, provide accurate information, document the discussion, and leave the door open for a future appointment correct Correct. Vaccine hesitancy responds to being heard far better than to being corrected. Understanding which specific concern is operating allows it to be addressed, documentation protects everyone, and an explicit open door means the decision is revisitable rather than final.
5. Tell her the online information is nonsense and that she is endangering her child Counterproductive. Direct confrontation tends to entrench hesitancy, and it ends the conversation you need to keep open.

The point: Hesitancy is not refusal. Elicit the specific concern, give the actual figures, acknowledge uncertainty where it genuinely exists, document, and keep the relationship intact so the conversation can continue at the next contact.

Source: UKHSA — Immunisation against infectious disease (the Green Book) UK Health Security Agency · tier 1, national regulator or guidance