Leatside Surgery Blog

Cardiac Screening at Leatside

2011-12-22T15:56:00.000Z

In March we are hosting a weekend Cardiac Screening event for local young people (14-35yrs).

Details are here.
You can book online for screening by going here.

This event has been organised in conjunction with CRY by the parents of the late Ollie Marsden who died at Rugby training on October 22nd 2008.
Ollie had an undiagnosed heart condition which he was completely unaware of.
It caused no symptoms at all until he died.
Despite me being at the scene (admittedly armed with only a hockey stick) and, soon after, my GP colleague and BASICS trained Doctor, Dr Morris with a full paramedic crew with the full gamut of resuscitation equipment, we could not save him.
If there had been some form of screening beforehand, his was the kind of heart condition that could have been picked up.
If it had been he is likely to have still been alive today.

Cardiac screening takes two forms.
An ECG is the simplest and easiest thing to do, and this is what will be being done at Leatside in March.
The screening equipment, and the program as a whole, is supported by Philips.
The benefit of screening in this way is that they are looking for the particular signs of these heart complaints that can cause sudden death.

As a GP I am used to looking at heart traces for signs of heart attacks or angina and so on.
The traces in the younger people may show more subtle signs, so the expertise is on hand to look for these signs.
If there are any worrying signs then an Ultrasound scan of the heart (Echocardiogram) may be undertaken there and then.
If the ECG is entirely normal then no scan is required.

The testmyheart website has a Q&A section that covers a lot of questions you may have.

I am pleased to allow CRY and Philips the free use of the whole of Leatside Surgery on March 17th to help them run this event.
I don't think it can ever be a regular event, but if we only pick up one case we may save a tragedy.
Better that we pick up none.

Grasp-AF

2011-10-06T17:03:00.003+01:00

Atrial Fibrillation (AF) is an irregularity of the pulse.
Having this irregular pulse puts the patient at an increased risk of having a stroke.
This risk can be reduced by taking aspirin or warfarin.
The risk of having a stroke increases with age so we tend to recommend warfarin for the older folk with AF.

So what is the risk?

If you are less than 65 with an otherwise healthy heart then the annual risk of stroke is about 1%
If you are between 65 and 75 that risk increases to 3% especially in those with diabetes or known vascular disease
Over 75 or anyone with a damaged heart valve or a previous stroke, the risk is nearer 6%

Imagine 1000 people at 1% risk of having a stroke each year.
Without treatment about 10 of them will have a stroke.
So 990 of them will not have a stroke.

However, if those same 1000 people each take low dose aspirin, over a year:

• About 2 people will be ‘saved’ from having a stroke by taking aspirin
• About 8 people will still have a stroke, even though they take aspirin.

If we look at the 6% risk category in 1000 people it is likely that about 60 would have a stroke.

If those same 1000 people each take low dose aspirin, over a year:

• About 12 people will be ‘saved’ from having a stroke by taking aspirin
• About 48 people will still have a stroke, even though they take aspirin.

So aspirin seems more efficient the higher the risk.

Warfarin is better still and in this same higher risk group being on warfarin 36 people a year would not have a stroke because of being on warfarin; and only 24 would have a stroke even though they were on warfarin.

Statistically about 3 of those 1000 people in that year might have a serious haemorrhage because they were on warfarin. But it would save 21 more strokes than the aspirin, so in the end the benefits statistically outweigh the risks.

There is a document here called a "Patient Decision Aid"

This shows those same figures somewhat more graphically.
It is funny but when you look at the picture of 1000 people and who might have a stroke it seems to be to reduce the impact of the risk of a stroke.
BUT you just can't tell which patients are the ones that will be the ones to have a stroke.

We are moving now to attempting to identify more people with irregular pulses and will then try to decide individually with them whether to recommend taking aspirin or warfarin to reduce the risk of stroke.

We have something like 250-300 patients on our list with AF. I haven't sat down and risk assessed them individually but we must be looking at a potential half-dozen strokes a year without aspirin or warfarin, so that may translate into a couple of strokes a year avoided if we had the majority of patients on preventive treatment.

New carers' support service launched in Devon

2011-10-05T21:38:00.003+01:00

Carers in Devon can now find out about support and information from one place for the first time, as part of a £1.3 million investment by Devon County Council and NHS Devon.

As part of the new Devon Carers Centre a new telephone helpline has been launched to give carers better access to support to help them stay healthy and live a normal life outside of caring.

Carers will be able to access the following services through the helpline:

• Support and information at the ‘first stop’ from the helpline advisor
• A network of local carers’ support workers who provide face to face support and activities for young carers to enjoy being young people
• Opportunities to meet other carers in their area for mutual support, friendship and time away from caring
• Short carers breaks

The new helpline (08456 434 435) is open from 8am to 6pm Monday to Friday and on Saturdays from 9am to 1pm.

The helpline is run by voluntary organisation Westbank, working closely with other carers’ voluntary groups, who will also provide support in their local area. A website has been launched at www.devoncarerscentre.org.uk/

Self referral for mood disorders

2011-10-05T21:03:00.002+01:00

I had news this week that our patients are now able to self-refer for psychological treatment of anxiety and depression. The self-referral system for physiotherapy has been very helpful so extending into mental health areas should be too.
If you wanted just a quick reference on helping yourself they have a leaflet you can download here.

I've lifted a few bits from their leaflet to post here.
It doesn't really make it clear here that if you are already undergoing treatment with the mental health services then self-referral isn't appropriate.
They also would prefer that if you are low or anxious during pregnancy and seeking help that you go to your GP initially.
Common sense suggests that if you are significantly ill with mental health problems then this route of referral would not be appropriate initially either.
Veterans and those with a complex history of childhood abuse should really start with their GP also.

The Depression and Anxiety service is a primary care service delivering evidenced based psychological interventions in line with NICE guidance.
These include Cognitive Behavioural Therapy (CBT), Eye Movement, Desensitisation and Reprocessing (EMDR) and Applied Relaxation.
Psychological interventions take place both in a group setting and via individual sessions.

The service is for people in the South and West of Devon who are 18 years and over.

Our team is able to help you with the following:
• Panic attacks
• Depression
• Anxiety
• Excessive worry
• Social anxiety/shyness
• Phobias
• Post traumatic stress disorder
• Agoraphobia

Your GP can refer you or you can refer yourself and we will let your GP know.
You can refer yourself by phoning 01626 357260.
Outside of office hours there is an answerphone. Please leave your name and contact details and we will phone you back.
You can email on: tr.southandwestdevondas@nhs.net

We will talk to you about your difficulties and agree with you the best way forward.
We can refer you on to other services and give you telephone numbers of alternative treatment options.

We aim to see everyone within four weeks of referral and the initial appointment will take approximately 30 - 40 minutes.

We will look at treatment options with you which are based on Cognitive Behavioural Therapy (CBT).
This looks at the way that thoughts, feelings and behaviours interact, sometimes in a helpful, and sometimes in an unhelpful way.

We provide a choice of help that includes:
• Working with you to identify the difficulty you are having
• Help you in deciding where to start
• Recommending reading that would be helpful for you
• Providing information about other local resources that might be helpful for you
• Identifying thoughts and actions which may be unhelpful for you
• Identifying strengths and support to draw on
• Guidance in setting realistic goals and support in achieving them
• Providing support through self management programmes that have proven to be effective
• Group work and/or individual therapy.

We also offer Eye Movement Desensitisation and Reprocessing (EMDR).
This is a specific treatment for people who have experienced a trauma.

Flu Vaccination 2011

2011-09-07T22:29:00.001+01:00

This year our usual Flu vaccination "campaign" coincides with our move back to Leatside.
For various reasons we are now going to have to try to do the bulk of the vaccinations from where we are now at the Creameries site by the Station.
I had hoped we could do it the week after we moved back but technicalities to do with guaranteeing the cold-storage chain mean we can't really.
SO - we will be getting the vaccines delivered on 6th Oct we hope, then will have a day set aside on Friday 14th Oct to do most of the jabs.
We don't want everyone to pile in at once so I will put an ad in the Totnes Times at the end of this month to explain how we hope to space people out.

As usual it would be daft to have the jabs in the fridge and not be giving them out, so the week of the 10th to the 14th Oct, if you are in seeing the nurse or a doctor and qualify for a jab, then you will probably get one there and then. I'll be keeping a few available during each surgery that week, and I'm sure everyone else there will be doing the same.

This year as usual we would expect to be giving the jab to anyone over the age of 65 and anyone with a long-lasting condition that would mean if they got flu they would be more at risk of serious illness or death. This usually means heart and lung conditions, kidney or liver disease, diabetes or stroke/TIA, people with MS or cerebral palsy and those with Parkinsons. Others where they may have a lowered immunity such as those on long-term steroids, have no spleen or are having immunosuppresive therapy.

This year the Dept of Health has put a greater emphasis on jabbing healthcare workers. Only a third of hospital nurses had a flu jab last year. GPs weren't much better with only 38% having a jab. I had mine as always.
The other emphasis is on pregnant mums. This is because during previous flu outbreaks it has become clear that pregnant women were much more prone to complications from flu than others. This was particularly evident during the swine flu outbreak, and there is still a concern that this strain might come back.

I see people with Influenza every year and I still don't think most people appreciate just how bad it can be, particularly in the younger population. I have my jab every year because I really don't want to catch it.

Registrars

2011-09-04T19:37:00.000+01:00

I don't think anywhere that I had introduced the fact that we have two new registrars at the surgery.
From August 2011 until the end of July 2012 we are lucky to have two registrars with us - Lorraine Hutchinson-Gale and Rizwan Irshad.

Lorraine's training is being supervised by Dr Frankland and Rizwan by Dr Watkins.

Lorraine worked for many years as a nurse in Torbay and Exeter.

She did her training at the Peninsula Medical School.

She has a family of four children ranging between 14 and 23 years of age and when not busy with them enjoys walking her two golden retrievers in the Devon countryside.

Rizwan was born and raised in Newton Abbot and went to school and sixth form locally.
He studied medicine in St George's Hospital Medical School in London.

Outside of work he enjoys keeping fit and going to the gym.
He has competed locally in powerlifting for the BDFPA and regularly goes the gym. He also enjoys other sports (both playing and watching) and spending time with his family.

Twitter & Facebook

2011-08-31T23:13:00.000+01:00

I have decided now to go even more "modern" and start a Leatside Facebook page and twitter feed.
That just might be gobbledegook to you, but for many this means a quick way of getting any information we might want to disseminate.
This Blog is useful for me to have a rant, or go on about something in more detail; but these other social networking sites are good for a quick, snappy bit of information about any small thing we might be doing.
I suspect a different audience may see these than you here reading this blog. We'll see.
I'll be putting the buttons up on the website in the next day or two.
http://www.facebook.com/pages/Leatside-Surgery (I think....)

(Update- I can't seem to get the "buttons" to go quite where I want them to on our website yet- still playing - 4.9.11)

South Hams Health Profile 2011

2011-07-03T21:39:00.000+01:00

This web site shows some of the latest health stats for our area...
The two that jump out are our high incidence of melanoma and a high rate of higher risk drinking.

Dr Loverock's retirement

2011-05-10T23:02:00.000+01:00

As Dr Loverock has now retired his regular patients are now jockeying for position to see which GP they will end up seeing regularly instead.
Dr Thake is with us now finishing his GP Training before he joins the Doctors full time in August. He is the "official" replacement for Dr Loverock.
He has worked as a Doctor for many years here and overseas but only in the last few years decided to do the official UK General Practice training, which he is now concluding.

The practice has also just changed one other technicality to do with registering patients.
Patients used to be registered with one or other partner, regardless of which Doctor they ended up seeing regularly.
We have now changed things so that all patients are registered with the practice rather than an individual Doctor.
Our computer system also allows patients to be allocated a "usual Doctor" and this is how we will now be dividing you up. This is the Doctor named at the bottom of your repeat prescriptions and the one who signs them.
If you feel you have been allocated the wrong "Usual Doctor", let us know and we'll change it.

More Measles

2011-05-04T22:49:00.000+01:00

A letter recieved from Health Protection at NHS Devon a couple of weeks ago.
As far as I am aware we have not seen any cases of measles recently.
The majority of cases were in the under 30 age group.
The European vaccination website euvac suggests that 18% of measles cases in France were hospitalised. There has so far though been only one death which seems an unusually low number for such an outbreak.

"MMR and measles outbreaks

This is to you alert you that France is currently experiencing a large outbreak of measles with over 3,700
cases confirmed so far this year. Outbreaks have also been reported in countries bordering France and in
other parts of Europe. http://www.euvac.net/graphics/euvac/pdf/2011_jan_feb.pdf

There has been a much smaller increase in confirmed cases of measles in the United Kingdom during the
past month and the vast majority of cases have occurred in people who have not been immunised with most
relating to older children attending secondary school, university students and in adults. Many of these cases
have links to those in France.

In light of this information, we are asking practices to consider the following:

1. Immunise those children who present to your practice and have not received two doses of the MMR
vaccine

2. If a patient presents with a history consistent with the signs and symptoms of measles and you are
aware that they have recently been travelling, please take salivary samples for analysis to confirm
whether or not they have measles

Measles, mumps, rubella (MMR) vaccine

Immunisation with MMR vaccine is the safest way that parents can protect their children against measles,
mumps and rubella which are diseases that can have serious consequences for babies, young children and
their families. Not all people respond adequately to a single dose of vaccine, so to ensure greater protection,
people need to receive two doses of MMR. Two doses of measles, mumps, rubella (MMR) vaccine offer full
protection against the three illnesses, provided the first dose is given from 12 months of age."

Feedback and Patient Input Group

2011-04-14T22:16:00.000+01:00

I think as a practice we could do with more feedback from our users (patients).
We don't have, and have never had, a suggestions box.
We did have a patient participation group, which is currently inactive.
We get complaints, as all practices do. This is a form of feedback.
We get some plaudits, but being modest tend to shrug them off as nothing.
We can get feedback via the comments section on this blog.
We can see comments submitted via the NHS Choices practice page.
Another website people use is patient opinion.

We do look at any feedback we get and see if it needs any changes to be made.
Of course we aren't always in a position to make changes, and if changes do seem appropriate what amount of discontent would we need to see before changing anything? ie I don't think we should always change something on the back of one bit of feedback; but we might do.
It is a difficult time at the Surgery to get good feedback. Clearly the current accommodation isn't what we would like. We have few available appointments due to a combination of leave and Easter (and the Royal Wedding). We have a locum until Dr Thake can start properly in August. etc.

I thought that we might initially invite comment or feedback in the main area that taxes us most of the time - the management of urgent cases.
This might cover the process of phoning in- to access your own GP or the duty doctor to call you back. How your case is then dealt with- eg with advice or a prescription or an appointment to see you. Maybe a house call. Is that appointment suitable for you?

and so on..

We shall be looking at reconvening a patient participation group. If this sort of thing fires you up perhaps you might want to get involved. We could do with a few people who are patients who have some sort of background in management or business who are used to systems and change? on the other hand any people who have a clear idea about how they would like things to be would be welcome.
Perhaps if we just get that sort of input we'll get a "predictable result"- if you are a bit of a wildcard perhaps you might be able to have a useful if alternative input.

If you do think you have something to add in this way then why not email in on leatside.surgery@nhs.net for the attention of Andrew Moore. As the practice manager he will be the convener of the group.

If you would like to comment on the area of urgent or same-day appointments then please email in on the same address with the content line "Feedback".

The third option is of course to use the comments section below the blog. Each comment is emailed to mine and Andrew Moore's inbox before it is published....

Leatside Statement of Intent 2010-2015

2011-04-14T21:09:00.000+01:00

I found this document the other day. It had been written by my practice manager in response to a revisit from the investors in people as well as the outline plans for our redevelopment coming to fruition, so a statement of intent was firming up the rationale for redeveloping.

Leatside Surgery Statement Of Intent 2010-2015

What we are here for:

To provide healthcare to people who register with the Practice for their immediate and long term problems. In doing this, to build and maintain the relationships with individuals and families that allow them to visit our surgery with confidence and trust.

To deliver our services in a way that helps our society make the long term improvements in the general health of the public that it wishes to.

What we value most highly:

Our ability to maintain the highest standards of healthcare and customer service

Our ability to make patients feel understood, cared for and safe

Our ability to make sure people working for the Practice feel happy and rewarded in their work

Our ability to ensure the safety of patients and people who work in the surgery

Our ability to deliver services that meet the requirements of the NHS

Our ability to respond to change in the NHS and society generally and use this change for the benefit of the Practice and its patients

The most important things we want to develop over the next three years:

To develop the Practice business:

by expanding our capacity to provide services to an increasing population, having regard to government plans to remove restrictions on patients registering with GP Practices such as ‘Practice areas’

in the context of the new NHS ‘market’ approach to healthcare provision by seeking out new ways of providing services locally

identifying areas of the Practice business where costs can be reduced or resources redeployed should the financial problems of the UK economy and the NHS lead to further restrictions or curtailment of the Practices NHS income.

To continue the organisational development of the Practice in respect of:

the numbers of doctors, nurses and administrative staff employed by the Practice and the distribution of workload and skills between these groups

the use of IT and communications technology to improve and streamline Practice operations

To continue to implement systems that assure the quality of care patients receive particularly through mechanisms for clinical governance, learning, appraisal and accreditation

What are we going to do about this over the period 2010 to 2015:

We will continue to work toward meeting achieving the highest targets under QoF.

We will develop new services through PBC funding following our successful implementation of schemes for COPD and continence.

We will consider further developments in our IT and records system, particularly a move to a web based medical record keeping system and greater use of voice recognition software

We will increase building capacity to reflect the continuing expansion of Practice services

We will continue to increase our involvement in graduate and post graduate training of doctors

We will implement changes that improve the way we deal with requests for same day access to doctors and nurses and find a better balance between ‘quick access’ and ‘booked’ appointments

We will improve the way we market the Practice to ensure we are able to take advantage of changes in government policy or increases in the local population yo increase our list size

Patient Survey 2010

2011-04-04T21:24:00.000+01:00

I have just seen that the latest patient survey results are available online here.
The full reports can be found here.
The highlights in comparison with the PCT are noted on one of the pages, and, despite the limitations of the small sample size used, it seems that we are easy to get hold of on the phone compared to other practices.
Having a modern telephone system allows flexibility in how people can phone in. It does also mean that by providing times when you can ring in to speak to your Doctor we set you up for disappointment if you can't get through because others are on the line.
My patients often tell me that they waited but couldn't get to speak to me. The trouble is that there is only so much time available in the day and I have to do Surgeries and house calls as well as find time for a bite to eat.
We could all spend longer on phone calls but it would likely be at the expense of some other area.
Some of my patients have my direct email address and for them that is now becoming an easier way to get hold of me. Some of the other doctors don't use email to communicate with patients at all. It is debatable whether that is really an effective way of keeping in touch but I am trying it out with a select few- by invitation if you like....
Perhaps in the comments here you could let me know what you think.

More on Midwifery

2011-02-23T12:01:00.000Z

I wrote on a blog here back in October that there was the beginnings of a threat to local midwifery services.
Since then things have moved on but I have to say that at this exact point in time I'm really not clear whether our midwifery service is going to be badly affected or just affected.
I had let Richard Davies at the Totnes Times, and Steve Peacock at the Herald know that something was afoot.
They did a dutiful bit of investigative digging but couldn't get any definitive word from Torbay on what the changes were going to be.
Their getting in touch with Torbay must have put the wind up someone though, because within days we had had calls from the Consultant in charge of the changes and one of the midwifery managers literally popped in to the surgery to attempt to reassure the doctors that the changes were going to have no impact on our service at all.
At that point I let the newspapers know of the reassurance, and Richard has since put in a piece to say all is well.
Now it begins to look again much more like that might not be the case after all.

South Hams had in 2009 a Home Birth rate of 11.3%- just below Glastonbury area I think, but the second highest in the country nonetheless. The England average is 2.7%. Some areas have only accidental home births.
This page shows a map on National Home Birth rates- demonstrating how high the south west is in general compared with other areas of England.
Our midwives in Totnes have been working for years at supporting home births, and if the statistics are anything to go by must be national experts by now. In a national survey only 22% of mums had met the midwife delivering them beforehand. In our area that is 43%. That is one of the major findings of effective team working in midwifery, and it is valued. If the proposed changes go ahead then this might suffer.
As doctors our main concern is that if midwifery services are reduced then midwifery led care will suffer. If that suffers then mums to be will end up more likely to deliver in hospital (possibly).
We know from the stats that Torbay has a Caesarean rate of around 25% of all deliveries.
It sort of flies in the face of progress doesn't it?
And why?
To attempt to save money.
As I understand it one of the major costs in providing midwifery services is the massive insurance required.
Having babies is still a dangerous business. 4.7/1000 births result in a dead baby statistically. (Not as dangerous here as in parts of Africa-184/1000 in Angola is the highest I could find)
Health trusts have to insure their professional staff against mishap. I don't have the costs but I have been told that relative to cutting staffing levels, the insurance costs outweigh the staff-cutting cost benefits vastly. The insurance costs won't change for cutting staffing numbers.

Torbay have written: "following extensive consultative work, the service is being reconfigured to safeguard the current high standard of maternity care that is nationally recognised as an exemplar, whilst acknowledging and facilitating the needs of an increasing number of pregnant women who have additional health and social risk factors, and are vulnerable".
They are doing this by "reducing the number of midwifery teams, but each team will have more midwives". So what was the previous ratio of midwives per birth, and what will it be after the changes? Expectant mums may now meet any of a large number of midwives, so the chance of continuity of care into their labour and afterwards is reduced.
Because each larger team covers a larger area, the worry is that the on call midwife in the team will be pulled all over the place geographically- which must make responsiveness to needs less. Some changes have been made to respond to the European working time directive, but this will include travelling times within the larger areas, and to and from the base for each midwife team. Getting in and out of Brixham (which is where the base is proposed to be for our midwives) can be a nightmare in the summer.
Why haven't they consulted AT ALL with the public or the GPs in this.

There are many more technical points and questions but that might make this all too long and boring.

All of my GP colleagues at Leatside have signed a letter drafted by Dr Morris to the Chief Executive of South Devon Healthcare Trust asking her to stop the process of change and review what is going on here.
This letter is copied below:

Paula Vasco-Knight

Chief Executive

South Devon Healthcare Trust

Dear Ms Knight

I am writing on behalf of Leatside Surgery with regards to our high level of concern over the upcoming changes that we have been informed second hand are going to take place within the midwifery service. We have been told that our current provision of midwives will be dropping to 2 covering the Totnes area and that the base will be in Brixham. We have real concerns over these changes. Ten years ago our midwifery team was a nationally recognised team of 13 midwives just serving the Totnes area. We also had the highest home birth rate in the UK and national recognition in the media. Over the years this team of 13 midwives has been reduced down to 6 and the home birth rate has dropped down from being the highest in the UK down to average.

We have been in correspondence with the midwifery directorate and had reassurance that services to our patients will not be affected but we fail to see how dropping from 6 to 2 midwives will be of benefit to our patients. We are also concerned that there has been no sign of any negotiation or consultation with any of the usual parties. Certainly when this was brought up at the LMC last night there was general concern and surprise and I gather they will also be writing to you. I also believe very little has been negotiated or discussed with the PCT. Certainly for future commissioning the proposed set up is not one we would recommend as we foresee poor prenatal care and a substantial decrease in service to our local population.

The whole change has caused a great deal of distress in the midwifery team who are concerned about the fragmentation of the team and increased journey times to their place of work. There are also simple practical problems with the team being based in Brixham with the increased travelling times in the summer months due to increased traffic. A simple journey which might normally take 30 minutes might very easily run into 2 hours or more.

Andrew Lansley, throughout the white paper consultations, has stated that frontline services are to be protected and there has also been a push for an increase in home births and we fail to see how these changes would achieve either of these goals.

We would welcome due process to be initiated on this project and it’s initiation date to be postponed until this occurs.

Partners at Leatside

The Creameries

2010-11-28T15:38:00.003Z

We are now moved in. Start work there tomorrow morning.

No phones though. Somehow BT couldn't get their act together to plug in their end of our ISDN line at the exchange, so our phone computer is still at the Surgery. Hopefully get that sorted mid week though. It may of course make getting in touch a little tricky for a few days but we have a contingency plan of leaving some staff at Leatside manning some phones until it gets sorted. I am quietly pleased that the computer system works. You've probably little idea how much thought that took, and in some ways how much we rely on it nowadays.

I've been either amazed or amused by the number of people who seem to have no idea where the Creameries Social Club is. I've told them it is "down at Unigate" and I get a blank look back. I then say it is "just by the "Up" platform at the station" - but then someone came back with "where's the station?". Astonishing.

So, to help you along, here are a few pics. You can click on them to enlarge them.

The view from Totnes Railway Bridge
- you can see our big yellow sign from here.

turn in by Redworth Traffic Lights

(Free) Car parking this side of the building and in front
Keep the commuters off it!!

The ramp up to the entrance

...and here's the entrance..

in the waiting room

...more waiting room.

this is the corridor between the portacabins (it drips)

my consulting room in the portacabin.

and here's a map.

So there we have it. All ready for use I hope. If you still don't know where it is put TQ9 5JP into your SatNav and it will get you there.

Moving Day

2010-11-18T22:03:00.000Z

Moving to Dairy Crest in a week!!
We will be moving on Friday 26th. Open for business Monday 29th.
That day will of course be a bit chaotic at Leatside.
We have a skeleton service planned for that day as we have to get everything moved.
The worst bits to move I think are the techie bits.
Our Toshiba phone system for example. We have had a bit of trouble getting a decent ISDN30 line into the new place, which actually put back our move by a week.
Rather than get a secure NHS Net broadband connection installed there we are using a wireless link from Dairy Crest back to the Surgery and leaving our server and major hardware there. Ingenious.
The paper records will be kept secure at the surgery as well, so if anyone needs the paper in the middle of a consultation we will have to send a runner!
Bob the bus will change route to accommodate our move.
There is some parking on the temporary site, but not a whole lot. We are hoping that the train commuters won't use all our spaces. We are preparing some of those lovely, very sticky "polite notices" to slap on their windscreens if they do. For cars leaving the surgery we think it might be best if as a routine everyone tuned left at the top of the road to head back into town, to then come back round the roundabout if needs be. Remember how difficult it used to be for the milk factory traffic to get out onto the lights?
Once we are moved in then all we can do is hope for fine weather this winter/spring so that Midas can crack on with getting the changes at the surgery done as quickly as possible.

Moving to Dairy Crest

2010-10-26T16:20:00.002+01:00

OK. Plans are in place. Things are moving.

We will be operating from the Dairy Crest Social Club building (pictured) on Monday 29th November.

Looks lovely doesn't it!

Boots shop will be there too, but may not be able to dispense medicines. We are pretty sure it is Morrisons who have appealed against the PCTs decision to allow the pharmacy to move there with us, so that is now held up in further red tape.
It seems one major point of the objection was the lack of disabled access.
I've just been there today (16th Nov) and walked up the disabled access ramp that had been specified to be there all along. I think their appeal is, as they say, "vexatious" and I feel the PCT should dismiss it.

How will we all squeeze in?

We'll just have to get used to losing our sense of personal space, and have a load of Portakabins too.

Not so sure the midwives will be there though.

It seems their management it looking at ways of reducing costs- proposals include having NO home visits for antenatal or postnatal checks. All these checks would be done at their clinic. The clinic wouldn't be at the Surgery either as it is currently. One option they are looking at has the patients on the Dartmouth and Totnes patch having a Newton Abbot Hospital based midwife for all their care. This would mean you having to go to one of their community clinics for even the 3rd day postnatal checkup. Just imagine, drained and exhausted, with a newborn child and a perineum bruised and torn, dragging yourself the clinic for a check up. What impact this all might have on your ability to get a home birth I don't know. What it would mean is that if you had your baby in Torbay then you certainly wouldn't have the same midwife as had done your antenatal care.

Health care assistants would do much of the work currently done by trained midwives- including some of the postnatal checks etc. I can't believe that would be safe.

It does seem as though now they've built Newton hospital they are having to justify its existence- by dragging all and sundry there from all over the place for whatever reason.

There is a posh delivery suite at Newton though- currently though only 3 or 4 births a month. You can park there though.

While I am ranting... has anyone seen any sign of any work starting at Rushbrook?

Back in February / March we finally had the possibility of moving temporarily into Rushbrook finally removed.

"The project work and pre planning we have already undertaken with regard to Rushbrook together with our timings, mean it is likely we will need to commence work on the site before your centre will be ready for re-occupation" was the message we had in March. At that point we could have got going and been well settled in with building work at Leatside well under way.... "could we back in for New Year???"

As it is we have had to use a less suitable site at much greater expense. Much more.

No going back now but it makes me very cross.

Does anyone know how Rushbrook came to be in Devon County Councils hands?- did they buy it off Dr Jellicoe? Does anyone walk round there and still hear a faint distant call of a peacock?

Red Tape

2010-10-09T15:51:00.000+01:00

Thankfully, and perhaps surprisingly, as a GP I seldom get tangled in red tape.
Usually in my profession if something needs to be done I am in a position to just do it.
There is the overriding principle of doing whatever is best for the patient and in the end that really does trump all other concerns most of the time.
In business however life is different.

As you may be aware we are having to relocate the Surgery for a few months while some improvement work is done.
Relocating Boots Pharmacy is turning out to be tricky.
We've had Midas build a space at Unigate for the pharmacy to move in to. That is the easy bit.
Getting the PCT authorities to agree that it is alright for them to move there temporarily is another matter.
It turns out that pharmacy rules are complex.
For a temporary move the pharmacy is not allowed to move more than 500m from its original position. Or perhaps 800m in exceptional circumstances.
A temporary move apparently has to be for 12 months at least (?), but we hope to move for 6 months at the most.
Various committees have to look at the proposed move and invite feedback.
The committee met and after looking at the objections (yes, there were objections, we think from Morrisons) passed it to the Devon PCT to agree.
When they met they deferred a decision til December, because they were apparently busy working out how to manage their own demise. (PCTs are devolving their authority to consortia of GPs)
All this time we are accumulating costs having had to engage Midas to start the project as well as paying interset on the loan we've taken out to do the work, and not getting any work done.
It looks now as though we are just going to have to move anyway and hope that Boots can sort themselves out.
I hope that someone from the PCT can then come down and see if a pharmacy can function in the middle of a building site with all the noise and dust, power going on and off and all the other difficulties of access.
Common sense may then prevail.
It would be better if they could make that, what seems to be, common-sense decision now, but the suits are so tied up in due process that the right decision may never be made it seems.
Quite why our Primary Care trust has no apparent interest in Primary Care is beyond me.
We are taking a risk borrowing a LOT of money to provide the people of Totnes with a good quality Health Centre / Surgery that should last a good few years now. You'd have thought they might show some interest or support.
As it stands we are now looking at starting work from the Unigate / Dairy Crest / Daw's Dairy site on Monday 15th Nov. We'll let everyone know when it is for definite.

Another blog one day might be on why it was we couldn't use Rushbrook temporarily.
As and when I find out why that is I'll let you know here.

Flu Vaccine 2010

2010-09-30T16:39:00.000+01:00

Quote from the guidelines on vaccination:

Influenza vaccines are prepared using virus strains in line with the WHO recommendations. Current seasonal influenza vaccines are trivalent, containing two subtypes of influenza A and one type B virus. In recent years these have closely matched viruses circulating subsequently, although the seasonal influenza vaccine produced in 2009/10 was poorly matched to the influenza A (H1N1)v strain that was subsequently predominant. Should a new influenza A subtype emerge with epidemic or pandemic potential, a monovalent vaccine against that strain is developed and implemented as in 2009 when the influenza A (H1N1)v strain emerged. The influenza A (H1N1)v strain is expected to be the predominant influenza strain once again during the 2010/11 influenza season. For this reason, WHO has recommended that this strain be included in the trivalent seasonal influenza vaccine for the 2010/11 influenza season.

You can read the full guidance here.

Influenza has a local link- some say it was John Huxham who first introduced the term to medical use in England.

John Huxham 1733, born in Harberton in 1672, lived later in Staverton.

10K follow up

2010-08-14T17:26:00.000+01:00

I am please to report here that we all completed the 10k.
I was happy to get round in 1h15m, the others were quicker.......
Through the sponsor forms at the surgery we raised something over £300, which is fantastic... so I thank you all who gave money.
This you will remember was to support Totnes Caring. Through the race organisers Teign Trotters, Totnes Caring have already had a cheque for £750 from the entry fees and so on as well.
The only downside (apart from my not being able to negotiate any stairs for a couple of days) was that some of the sponsorship money collected went missing from the surgery.
We have asked the Police to look into it, so they have been and looked at our CCTV and spoken to a few people, but unfortunately with no result.
We shall therefore offer up a cheque to Totnes Caring based on what we guess the amount missing was on top of the figures we know for certain. As it stands that will be around £350 I think.
It is really gutting to see that money offered in good faith has been taken.
Next time we do any fundraising we shall be certain to make sure stringent measures are in place to protect any donations.

Totnes 10k

2010-07-16T18:39:00.000+01:00

On August the 1st, just before 11am, an intrepid team of runners will emerge from the doors of Leatside and make their way to Borough Park.

These highly trained athletes, and Dr Watkins, will then engage with local running clubs in running the Totnes 10k.

This will take them from the park, out along the river to the drive then alongside the river round the back of Dartington to Staverton- back then up through North Wood and in through the Old Postern and the Cider Press, back into the Park.

In undertaking this we hope to raise a bit of money for Totnes Caring.

The team will comprise Dr Andrew Frankland, Dr Dylan Watkins, Dr Sarah Oxtoby, Dr Richard Hawker, Sally Smeaton and Sandra Day from the reception team, and Jane Peters from the District Nurses.

I am writing this just as I embark on a 10day holiday in France.

Hopefully in between croissants and Souicissons and oodles of local Vino I might manage the odd jog to bring my fitness up to that of the others!

Dr Morris will hopefully be standing by on the day with Oxygen and defibrillator.

Support Totnes Caring by supporting the 10k and the Leatside Runners.

Totnes Caring do a great job supporting the elderly in their own homes. Have a look at their website to see more of what they do.

If you want to give online then hopefully early next week Totnes Caring will have set up a just giving page.

Search for Totnes Caring at www.justgiving.com
OR you can give some sponsorship money at the surgery.

New developments at the Surgery

2010-06-03T08:40:00.000+01:00

Why are we considering an extension?

Amazingly, it is now 20 years since we first considered moving from our old surgery in Fore Street; 15 years since the first plans were drawn up; and over 10 years since we moved into Leatside. Much has changed in this time. Some examples of this change are:

· Over 2000 more people have registered with us as patients.

· We open longer hours.

· We spend a lot more time helping people with chronic diseases such as diabetes and asthma, monitoring their health and adjusting therapies.

· We do a lot more to investigate cardiac and blood pressure problems; causes of allergies; types of skin lesions; types and severity of respiratory disease; and diagnostic work generally.

· An increase in the number of contacts our doctors and nurses have with patients: from around 60,000 per year to 90,000 per year.

· An increase in the number of doctors from 6 to 10; and an increase in the number of nurses and healthcare assistants from 3 to 9.

When we worked on the design of Leatside, 15 years ago, we knew much of this change was coming and so made sure we had room to expand. Mostly we were successful with this, but we have now almost reached the capacity of the building and so need to consider how we will continue to provide services over the next 15 to 20 years. In doing this we think we need to plan for:

· A further increase in the number of people registered with us of 3000 or more.

· A further increase in the amount and type of care we give to people because of NHS plans to transfer care from hospital and specialist centres to GP Practices.

What changes to the building are we planning?

By extending the building at ground floor level and creating a first floor we will increase the overall size of the building from 1022m² to 1602m². This will provide us with:

· An additional 7 rooms for use by doctors and nurses immediately with the possibility of a further 6 rooms in future through changing the use of other accommodation.

· A doubling in the size of Boots Chemists who, like the GP Practice are struggling to cope with increases in the number of people using their service.

· An increase in the number of car parking spaces for use by patients from 36 to 41 and better facilities for parking bicycles.

· The opportunity to make other improvements like installing a lift to provide better access to the first floor and improving the sound proofing of consulting and treatment rooms.

· Accommodation for other individuals and organisations to provide services including:

o An opticians

o An osteopathic practice

o The private practice of some local consultants

· An opportunity to start up services to provide more specialist care currently provided in places like Torbay Hospital.

How are we going to get this done?

Not easily! The work we are planning will affect almost every part of the existing surgery. Added to this the shape of our site our surgery sits on, with only one entrance, means that it would be both very difficult and very unpleasant to carry on working here whilst the building work is underway. For this reason we have been exploring possibilities for using temporary accommodation for the six months it will take to complete the building work. To this end we have been discussing with Dairy Crest the possibility of using a building and car parks close to the railway station and have applied to South Hams District Council for planning permission. Although we have some way to go to finalise all of these plans we are hopeful that we will be able to start our project by the autumn. Through our website www.leatside.co.uk and through information sheets in the surgery we will endeavour to keep you updated on our plans.

Your thoughts..

We are interested to know what you think and particularly if there are ideas or services not mentioned in this outline that you would like us to consider. Over the next month or so we will be publishing more details on our plans so please have a look and let us know.

Review of Allergy Clinic post

2010-05-08T17:26:00.000+01:00

I was pleased this week to discuss my blog on the Devon Allergy Clinic this week with its lead clinician, Marleen.
It was refreshing to have a mature chat with someone leading an alternative clinic that didn't just settle into a pointless argument and I was impressed by her approaching me to discuss it.
I feel that in my blog I was mainly critical of the Med-Tronik (not Medtronic) machine she uses, the RM10.
She was concerned that this criticism might detract from the more mainstream approach she uses to food allergy and intolerance. On balance I feel that the blog was targeted at this machine and that the conventional approaches she uses weren't explicitly criticized.
Aligning herself with the Truth Campaign's Steve Hopwood's Arcturus Clinic may have led me to believe that Marleen is more wacky than actually she turns out to be. Her training and diploma in Allergy are entirely mainstream.
The area of food intolerance is however an area where many people who suffer do feel the need to go seeking help. I do recognize that in medicine we are not well equipped at all to advise or help people with food intolerances and that we do not have the answer a lot of the time. (I worked in 1993 in Martin Stern's Allergy Clinic in Leicester and understood from that time some of the difficulties see MAARA and the older, pretty much out of date site of his now, AAIR). This is therefore an area where people will seek help in other directions an I feel they must be careful in judging the qualities of the alternative help they seek. On a separate matter she brought me up on my selective posting of comments regarding the blogs.
In fact the only comments responding to all the blogs on the site so far that I haven't posted have been hers. I can't recall any other comments for any other discussion that I haven't felt able to post.
I don't think that this was because it was her, but more that this isn't really a chat room for discussion, and that seemed to me to be what her comments were inviting.
I shall think a bit more though about the posting of comments.
I have just now been reading one of the BBC blogs on the reporting of Taliban casualties in Afghanistan. I find the comments section uncomfortable reading. This is what can happen. So I appreciate comments- positive or negative; but don't wish it to become a discussion forum.
Any comments or suggestions to how I approach this appreciated- I'll read them all, but I may not publish them!

The Devon Allergy Clinic

2010-03-29T00:09:00.000+01:00

I'm pleased that some patients have been in to the Surgery to further discuss their Allegies having been tested at The Devon Allergy Clinic. One of the franchised locations is the Arcturus Clinic in Totnes.
They use what seem to me to be some dubious testing techniques.
"The patient holds an electrode in one hand that is connected to the testing unit and a probe is placed on an acupuncture pressure point on a finger or toe on the opposite side of the body, thus placing the patient in a circuit with the machine. Samples of the potential allergen are placed in the diagnostic unit which will then indicate whether there is any resistance from the patient to the substance in question."
They use a machine called a Med-Tronik RM10. (We do use some machines in medicine made by a company called "Medtronic", which should not be confused with "Med-tronik").
Their website says: "The electro-acupuncture according to Voll is based on the ancient tradition of Chinese medicine. By means of acupuncture it searches for overriding, impaired regulation principles that could possibly be the cause of an illness.

In electro-acupuncture the therapist employs a "pressure measuring stylus" which he positions at the acupuncture points to measure the organism's electric resistance. Thus he gains information on a patient's bio-energetic condition"

The machine looks impressive of course (see above) with buttons and a big dial- one of the hallmarks of Quackery. Their "Mora" machinery claims to offer holistic testing against a number of substances, based not on the substances themselves, rather "the complete digitally stored information spectrum of a substance is transferred into its original analogue oscillations to the MORA - device" That is to say, loaded off a CD! Funny, almost.

The allergy clinic website makes some discussion about food allergies being IgE mediated, which can be true, but doesn't then seem to explicitly state that their testing is based on no such science, though does later say that skin prick tests and specific IgE tests are available.

I haven't been able to ascertain the cost of this testing, but don't suppose it is cheap.

I don't particularly mind if people want to get their allergies tested there, but feel I ought to express my concerns about the testing because of its highly doubtful scientific basis and that if people do choose to have tests done there using this machinery that it is probably a waste of their money.

Home Births

2010-03-28T23:43:00.000+01:00

One of the more lucid, balanced views of the evidence of safety of home births that I have read...
"How safe are home births?

Cholesterol and Primary Prevention

2010-03-18T21:00:00.000Z

I’ve suddenly developed a new interest in cholesterol.
Not particularly because of a new academic research paper or anything.
Just that I’ve discovered what mine is. And it’s a little high. 8.2 if you are interested.
We are all being told now that our cholesterol needs to below 5, but that’s not really the whole story.
HDL levels are very important too.
Remember, we aren’t actually too excited about the cholesterol itself: it’s the implications of a high cholesterol that are really important. For example having a heart attack or a stroke.
Predicting the risk of that happening depends on several factors- cholesterol is one, but the amount of that cholesterol that is of the HDL type is very important too.
It is the proportion of the Total Cholesterol that is HDL which is most strongly statistically associated with risk of stroke. (TC/HDL). A low ratio is good regardless of the total level of cholesterol. 3 or 4 is good.

Adding in TC/HDL to your blood pressure, age, whether you smoke of have diabetes and so on can be used to come up with an estimated risk to the individual of developing heart disease or stroke over a 10 year period. In this country we have been using an American equation to do this for years, but we now have our very own English equation. See www.qintervention.org to have a look. This is good because it also shows some “what if?” scenarios… such as “what if I were to stop smoking?”
I plumbed all my figures in to this website, including my Cholesterol at 8.2, HDL at 1.5 (ratio 5.46), BMI of 30.5, Systolic BP of 116 and got a 10 year risk of 2%.
So even with a cholesterol a bit high and being just a little tubby, my risk is actually ever so slightly lower than average for my age.
Phew.
BUT, my risk of developing Type2 diabetes looks a little high. So perhaps I’d better lose a little weight anyway

Questions.
Should I go on a statin?
Will losing weight help my cholesterol?
What can I eat to improve my cholesterol?

Well, I don’t feel the need to rush onto simvastatin. In prevention of heart disease and strokes etc in healthy individuals the benefits are hardly measurable for men, and arguably not there at all for women. We do discuss their use once someone seems to have a risk in the order of 20-30% over 10 years.

Losing weight should lower my cholesterol, but it seems that what you eat can have a strong effect too.
Walnuts and almonds, soluble fibre, olive oil, plant stanols; and of course cutting down on animal fats.
(Apparently Pasties aren't good. Damn!)
Drinking just a little alcohol might boost my HDL cholesterol.

So all in all I come out quite encouraged. I know I’m going to die anyway one day, but the risk doesn’t seem imminent. I shall try to eat appropriately and lose a little weight. Perhaps just a beer or two on a Friday night as well.

The Government has started a bit of an agenda with GPs to start looking at this area of primary prevention of heart disease and stroke. We are being asked to use our computer records to estimate which of our patients who appear healthy might actually be statistically at increased risk. Once we have found them though, what to do with them? We do appreciate that every individual patient will have a different response to being told they might be at high risk. Probably then we’ll end up writing to you if you might be at high risk and leave it to you to decide whether to come in and discuss it further or not.

Training at Leatside

2010-02-21T21:32:00.000Z

Increasingly at the surgery we have Clinical Staff at various levels of training.

Being a training practice is thought generally to indicate a practice with a high standard of clinical care and generally high quality.

These qualities are assessed regularly by those in charge of medical training regionally in order to ensure that their trainees or students aren't going to be short-changed.

Dr Frankland and Dr Watkins are approved trainers for GP Registrars. Dr Loverock, Dr Grant, Dr Martinus and Dr Morris are our trainers for Medical Students.

For a long time we have had Hospital Doctors training to be GPs.

These days these are called GP Registrars.

They can have a varied clinical background. Anything from having come straight out of house jobs to having worked around the world for many years.

They are nowadays attached to the Surgery for 2 stints- one of 6 months and one of 12 months. The training is actually 3 years overall, so the other 18 months is spent at Torbay doing Hospital posts appropriate to General Practice like A&E, Gynaecology or Psychiatry.

These are well qualified Doctors, so when they are at the Surgery they work relatively independently. The level of supervision they get depends on their level of expertise. They are strongly encouraged to discuss any cases where they feel at all uncertain. Cases are reviewed routinely on a weekly basis and each week they share a Surgery with their trainer. Sometimes their Surgeries are videos to be reviewed later together with their trainer. These days we use HD webcams to record the consultations.

At the end of their time training they will have sat a number of quite expensive exams from the Royal College of General Practitioners and if they pass can then work independently as GPs. All of our recent Registars have gone on to get partnerships locally.

Some practices have Doctors in their early work years. What used to be called house jobs are now called Foundation training posts. These take two years and in the second year (as an F2) they can work in General Practice.

They necessarily require a greater degree of supervision and training. This takes more time on the trainers part to do this and can take them further away from their own patient lists. As yet we have not had an F2 but are looking at the possible benefits of this. Anyone who has ever been a teacher or perhaps had an apprentice perhaps will know that often the benefit of a trainee is not going to be so much in terms of a lighter workload, because the supervision pretty much cancels that out - more it is the fresh or different view on things. Students often challenge their teachers in many ways and for the practice or the trainer that is enormously valuable in their own development. There is a super little essay here on burnout in the medical prevention and how it may be prevented. Training others is one of the key approaches to keeping your own practice vital.

Thirdly is the role of medical students. We have had these intermittently at the Surgery for many years. In the old days they used to visit from London and stay for a week or two with one of the GPs. These days they come solely from the Peninsula Medical School and come on a day by day basis. Again, they can vary widely in their level of expertise, so if you are asked to consult with a Medical Student, be reassured that your case will always be thoroughly reviewed by one of the GP partners.

What we have always not managed to accommodate are School-based work-experience students. It is not thought possible to allow them routinely into clinical scenarios due to stringent patient confidentiality. The rest of the non-patient work we do is frankly too boring to be of interest to a student.

It is a shame really, as a keen student planning to apply to medical school would probably really like to have a spell at the Surgery. We feel this certainly shouldn't happen within the confines of the town in which they study. So if you have a son or daughter in that situation we would suggest approaching General Practices in nearby towns instead.

We do occasionally have trainee nurses as well. More often these are attached to the District Nursing or Health Visitors teams.

Moles

2010-02-13T22:09:00.000Z

One of my patients emailed me a little poem about moles this week.

Remember though-, as she refers to, "this medical mole", the NHS pays for problem mole removal, not cosmetic work.

If it's cosmetic work you are after, see a Plastic Surgeon!

Dr Watkins pet speciality is in Mole removal

He’ll soon get his scalpel out if you give your approval

You don’t have to worry because he won’t be pathetic

By expecting you to have it done without an anaesthetic

He’ll get rid of that thing that’s plagued you for years

That thing that looks ugly and has caused a few tears

That horrible Mole that sticks through your vest

The one that’s so big as it sits on your chest

You may have a little one that makes you feel sad

Best get it sorted though before it goes bad

Moles are funny things...some are harmful...some are not

Always best to check it out...see what sort you’ve got

The trouble with moles you can’t remedy with a pill

You’ll be happier when it’s gone...honestly you will

It’s not like yours will disappear down a hole

It’s got to be dealt with...this medical mole

Trust Dr Watkins for he’ll cause you no pain

And just think of the benefit of not seeing it again!

Kidney Impairment

2010-02-09T14:25:00.001Z

As NHS health-professionals we provide holistic care to our patients, and are used to doing this while intermittently focussing on different parts of the body or different bodily systems.
This provides a way of structuring care properly- taking into account the evidence there is for treatments provided.
This evidence and the way it is produced is compartmentalised, so it suits us when systematising care to break it down in the same way.

As doctors we have through our careers become quite accustomed to dealing with heart disease, brain disease, gut disease and so on.

Kidney disease has always been a bit at the periphery of our awareness and care. (Apart from a relatively few doctors who are interested in the kidneys that is).

I wonder why that is.

I think it may be because, by and large, they just work.

Even when scraping along on 20% of their capabilities we really don't feel the effects.
If that was heart or brain we'd be acutely aware of it. Added to that, they seem a bit mysterious.
In medical school we are in awe of their fabulous structure and the beautiful, complicated way they work so well and wonder how on earth that ever evolved.

What is it they do?

Well, they essentially filter the blood. Filtering out molecules that aren't supposed to be in our bloodstream and keeping in the ones that are. This keeps us feeling healthy.
They also do a few other regulatory things like helping with the control of blood pressure and metabolising vitamin D to keep our bodies calcium levels normal and bones healthy.

Next question.... why are they so fault-tolerant?

This I think is because they are actually quite delicate and sensitive things.... being prone to damage they have a large built-in tolerance to it.
Any number of different conditions can damage the kidneys. Inflammatory and autoimmune conditions are ones that interest doctors quite a lot.
Diabetes is the big thing in kidney disease though. Renal units up and down the country are kept going by people with poorly controlled diabetes who have succumbed to kidney impairment of varying degrees. High blood pressure can be either the result of or the cause of kidney damage. One of the big ones is the damage that comes from poor circulation. Not just cold hands I mean, but clogged up arteries. The kidneys filter the blood, so if the blood can't get to or around the kidney to be filtered then the kidneys can't do their job.
Certain medications can damage the kidneys too. And poisons- a classic being poisonous mushrooms.

They tend to weaken as you age as well.

Next question... why am I writing about kidneys?

As kidneys are a bit of a "Cinderella" organ, yet so important, the Department of Health has decided to kick us into action to look with more interest at kidney disease. Which probably needed doing.

The first thing they did was get all the laboratories in the country to give us our kidney-function blood tests in a different way that would be more meaningful.
Previously we got, and actually still do get, a level of a substance called creatinine.
This is a breakdown product of muscle metabolism. If we have muscles, we have creatinine in the bloodstream. If we have lots of muscle we have a higher level.
Our kidneys get rid of it at roughly the same rate that it is produced. If the kidneys don't work well then the level is higher.
What they have now done is age and sex adjusted this figure to give us a figure called an eGFR. This stands for an estimate of the Glomerular (kidney) Filtration Rate.
Now that we have these figures we more easily get an idea of whether someone's kidneys are working well or not.

So, what are we doing with these figures at Leatside?

Well, now we have a list of people where the blood tests suggest or hint at the fact that kidneys may not be working so well.

What we have to do is work out in which patients this is a significant problem or not. Thes we'll call CKD - Chronic Kidney Disease. Chronic refers to the duration an illness has gone on, not how bad it is. Chronos=time. Like chronometer.

One way of doing this is to see if the urine produced contains any protein. A damaged kidney leaks proteins from the bloodstream into the urine.

Another is to see if a patient with an eGFR that is out has any other condition that might cause or contribute to kidney damage. Diabetes, high blood pressure and so on...

The other thing of course is the patient themselves. A bodybuilding muscle-man may have a very low estimatedGFR purely because they have so much muscle.
Someone who is missing a kidney may have a low eGFR but a perfectly healthy remaining kidney.

Once we have formed a clear idea about who might have actual, damaged kidneys then we can arrange care to reduce the risk of further damage and see if there is anything we can do to improve the situation.

What this usually entails is controlling better the factors involved that might be damaging, or might have damaged the kidneys. eg Better control of cholesterol and blood pressure. Tighter control of diabetes.

If, however, someone seems to have kidneys that are really not very good then we usually will refer them to a Nephrologist (Kidney Specialist) for a more expert view on what to do.

We have a Kidney Specialist called Dr Tse from Derriford who does a clinic at Totnes Hospital, or we can get people to see the one who visits Torbay from Exeter Renal Unit.

The severity of kidney impairment is staged- 5 levels.

Stage 0 is normal, stage 5 is on dialysis.

Many of our patients have an eGFR indicating stages 1 or 2, but these really don't need much, if any, attention at present.

It is those people with stage 3 or 4 that we hope to find and work on.

I hope we already know all the patients with stage 5 disease. These are the ones who may need dialysis or a transplant.

So far we have identified over 300 patients with Stage 3,4 or 5 disease. We will be contacting them in due course individually to take this further if needs be. Our computer suggests we'll have nearer 400 in total.

More Info:

UK National Kidney Federation - http://www.kidney.org.uk

The Renal Association - http://www.renal.org/whatwedo/InformationResources/CKDeGUIDE/CKDstages.aspx

Busy Mondays

2009-12-03T22:28:00.000Z

We are very busy on Mondays.

We have some ideas why and have over time tried to accommodate this increased demand for our services on a Monday by providing more receptionists to man the phones that day as well as making sure all the Doctors, including the part-timers, are available that day.

It is increasingly difficult to manage what we see as disproportionate extra demand on one day though.

All the Doctors and the Nurses have Surgeries that you can book ahead of time.

If you want to see any Doctor, routinely, then the next appointment is I think in 2 (working) days time.

If you were to ring today to book to see me personally, the next appointment is about a week away.

All the Doctors get booked up like that.

If you haven't had the foresight to book an appointment anticipating an illness a week away then what you'll do is ring in when you actually feel ill to see if you can see a Doctor (or Nurse).

So...to balance this, each day we allocate 3 sessions of Doctor time to manage this "same-day" need.

In the mornings we have one Doctor able to see patients in a same-day Surgery with 18 or 20 appointments.

Another Doctor is manning the phones -madly ringing people back to discuss the problem they rang in with to see if it can be dealt with on the phone, by the Nurse, deferred a day or two... or some other way. Seeing if we can't manage the demand.

In the afternoon one Doctor does both tasks.

Most days this is fine, but Mondays is getting a bit crazy.

Last week Dr Frankland dealt with I think 110 phone calls in the morning session.

Most other days it is a mere 50 or so in the morning.

The Doctor in the afternoon session is seeing patients who have been booked in to see them as well as trying to triage telephone calls, so that can be pressured too.

(btw I do sometimes wonder why patients ring in to see the Doctor but leave ringing til 5pm? Why didn't they ring earlier in the day?)

You could argue that we just need to provide more medical staff to cover the demand...

We feel though that we have enough cover, it is just that the distribution through the week is excessively skewed.

If we were to take another doctor out of their routine work to cover the excess demand on a Monday then they would have fewer appointments for the routine investigative and preventive work that we do.

What I think we want to avoid is a situation where we make accessibility variable (that is to say, better on a Monday), because that then begins to support the need for people to ring in on a Monday. If there are Doctors available and there is demand then I feel it would in the end only escalate the situation. What we would rather do is see if we could modify the patients' behaviour. To this end we have begun to think what are the basic guidelines for accessing a Doctor.

Something like:

1. Consider when you need to be seen. Being seen the same day it occurs to you to ring isn't always necessary

2. Try to plan ahead, even if just a little.

3. Consider even if you need to see the doctor face to face... a phone call might well do. Or an email. Or see the nurse. (the nurses are all very good)

4. Try to keep seeing the same Doctor for ongoing conditions. It does help. But you will probably need to book further ahead. (Vide supra)

5. Consider leaving phoning til later in the week. It should still get sorted out, whatever it is.

Any others you can think of...? - might be nice to add a comment to the blog for this... I have, after all, written this purely from my own perspective and feedback is appreciated.

PCT Funding of Leatside

2009-09-29T14:13:00.002+01:00

Devon Primary Care Trust (PCT) has recently sent us some information about the amount they pay to GP Practices for ‘core’ services.

We receive from Devon PCT £62.90 per patient for your health care.

The National average is £59.41 apparently, so you might think we're not doing too badly.

But.. Devon PCT offers a wide range of funding per patient to different Practices. The very lowest is a Practice in North Devon with £60.01 per patient and the highest funded is in Exeter with £112.83 per patient. Yes!... twice as much as we get for your care.

We were wondering as a practice how this has come about.

Most of the higher-earning practices in Devon currently(but not all) negotiated a few years ago to take up a new contract to provide health services to the PCT.
In Totnes we were, and have always tended to be, a little bit cautious so stayed on the old contract known as GMS (General Medical Services).

The idea was that the newer contract would have allowed the PCT to stray from national rules on funding and agree local arrangements.

The purpose of this was said to be to allow local flexibility- allowing practices to get funding for local problems or needs. PCTs were happy with this as they assumed that this would translate into better care for the patients and presumably fewer hospital appointments; as local needs were being met locally.Clearly the amount paid to practices did then begin to vary as can be seen in the disparity of funding mentioned above.

Oddly this doesn’t necessarily seem to be the case now with many Practices that currently receive a higher level of funding still making greater than average use of hospital services and Practices such as ours with lower funding sending people to hospital less often.

What seeing these sorts of figures has done of course is to make us look a bit at what extra services we do provide our community for the relatively meagre funding (for Devon).

Firstly there are a range of services we provide on the NHS for which we receive no funding at all. This includes things like initiating insulin prescribing for newly diagnosed diabetics; dermatoscopy of worrying skin lesions; treating minor injuries; allergy scratch testing; some acupuncture; Doppler studies and compression bandaging; removing blood for therapeutic reasons; intravenous infusion of drugs; and insertion of Mirena coils for mennorhagia. This list is not exhaustive and if we didn't provide these services our patients would have to travel to hospitals such as Torbay to get this care.

Secondly there are a range of services we provide for which we do receive some NHS funding but where we offer a higher level of service than the funding provides for. This includes things like the range and quantity of diagnostic tests we offer including ECGs, 24hr blood pressure monitoring, cardiac event monitoring and arrhythmia analysis; our long opening times, direct access to doctors on their personal telephone numbers and ‘check in’ screens at reception for your convenience; enhanced and personal care of people with chronic lung disease to improve the quality of their life and prevent hospital admissions; and health screening of young children. Again this list is far from exhaustive and the consequence of us not doing these things often would be people travelling to hospitals such as Torbay for their care at far greater cost to the NHS.

Having basked a bit in the warm glow from the good stuff, I do wince a bit still about our telephone system which could probably be better. When we have the spare £7-8,000 for a new better one we'll consider it. It is a key interface between you and us and should be better. We'll be looking for now at how to improve the system we have for now.

So where is this going?

Well, at the end of the day this funding issue is important because it affects our ability to invest in new equipment to improve the service we offer; as well as determining the number of doctors and nurses we can employ which in turn affects things like the availability of appointments.

For this reason we would like to get additional funding for our Practice to at least the level of the average Practice in Devon. Unfortunately the PCT is in a financially poor situation at the moment and doesn’t appear able to agree to do this directly. They might be able to provide additional funding however if we are able to help them make savings in other areas of their budget for example the cost of the drugs we prescribe or the cost of hospital care when we have referred you to a specialist.

There is nothing new in GPs having to think about whether a prescription or referral is necessary and cost has always come into that, but more on a global, “saving the NHS funds” basis - never so directly linked to funding of services in our Practice.

Which leaves us on the horns of a dilemma..

.. on the one hand we know that it might be possible to make the savings the PCT wishes by changing the way we work but on the other hand we feel anxious that if the patients were aware of this they would be concerned they were receiving sub standard care because of our efforts to save NHS money.

It is absolutely clear from the PCT however that if we do save them money by referring less that this will not and can not translate into additional personal income for the partners in the surgery.

Before starting to discuss these points with the PCT we would really like to hear what you think.. are we right to try and get more funding?.. would we be right to reach an agreement with the PCT for additional investment in the Practice in return for savings elsewhere?.. and how would you like to see us improve: more appointments, a better phone system, a treatment or service we don’t currently provide, or…?

Let us know by commenting on the blog...

Transplants

2009-09-03T13:44:00.001+01:00

There has apparently been stuff in the press about getting GP practices to more actively campaign to get patients enrolling in the national organ donor scheme, so I thought I'd make a few jottings on transplants.
27% of the population, or 16million people are currently enrolled to donate organs in the event of their death (including myself).
There are currently 380 patients on the waiting list for a transplanted liver- 38 of them under 25.
I personally was delighted last month when the department of health banned private transplants as i feel confidence in the system to work fairly was undermined constantly with the knowledge that some rich foreigner, paying for it, might take your relatives kidneys.

I think, and it is my experience, that when people agree to donate the organs of a dead loved one they have an idea that they will be doing someone some good.

It is the one good thing people can take away from what is almost always a terribly traumatic time.
There is a sort of expectation as well that the person receiving the organs will appreciate them and try and "do well" as a result.

It doesn't always turn out quite like that. I'm sure George Best meant to do well with his new liver, but just didn't really manage to.
Liver transplant units do have a proportion of patients who have damaged livers through drink or overdose. I remember my first day as a Medical SHO in Leicester General Hospital (August 1993), the Nurse explaining to me urgently that a young lady in one of the bays had had a marked deterioration in her liver over the weekend due to a paracetamol overdose and that she might bleed to death if not treated urgently. After discussing this with the patient she really did seem concerned now to try and live, so my first duties in this job were to arrange her urgent transfer to Birmingham liver unit under Prof Neuberger. Their doctors were and are very used to making sensible, if difficult, decisions on who is likely to make the best fist of it if a new liver comes up.

One in three of all kidney transplants now are from living donors- eg parents to children.
You may know already that our nurse Ali Cull donated a kidney some years ago to her son Pip who was on dialysis.

In a study looking at the reasons why people aren’t signed up to the NHS Organ Donor Register, the over 55s were twice as likely as the rest of the population to say they didn’t think they would qualify as suitable donors. Professor Neuberger, now Associate Medical Director at NHS Blood and Transplant, said: “The belief that there is some sort of age limit on becoming an organ donor is a complete myth. Organs are successfully transplanted from people in their 70s and 80s and the oldest cornea donor recorded was 104 years old. There are also very few illnesses that prevent someone from donating their organs after death – that’s why we would encourage anyone who wants to sign up to the NHS Organ Donor Register to do so and ensure those close to them are aware of their wishes.

So I guess the message is- get youself on the organ donor register. Do it online now. A link to their website here. Or call, local rate, on 0300 123 23 23

GP Second Opinions

2009-07-30T19:59:00.002+01:00

At Leatside we have been thinking a bit about referrals to specialists.

When we refer a patient to a specialist it can be for a number of reasons.

If someone has, lets say, a hernia, then referral is basically just for a procedure to be performed. Not tricky.

If someone is feeling unwell and we think it might be a heart attack then straight to hospital. Again, not tricky.

If someone has been poorly for a while, been to the doctor a few times, had some blood tests run and so on then the doctor might be thinking about referring to a specialist.

At times like this we have been wondering if it might sometimes be helpful before referral for the patient to have an initial second opinion from one of the other doctors at the surgery.

This accepts that sometimes the doctor you have been seeing might have developed a set of ideas about what might be going on. It can be difficult, once your ideas about what is going on don't match the evidence, to expand your ideas about the illness. This is where getting another GP's opinion on what's going on can be helpful. A fresh look at the problem.

For GPs this can actually seem quite a threat- "What if the other doctor can see what is going on where I couldn't?" "I must be a rubbish Doctor to need to ask for advice".
Well, I think we should get over that.
The benefits to the patient seem to be that they can be reviewed by another doctor quite soon without having to wait many weeks to see a specialist,. They won't have to travel, and then won't have to spend an hour finding a car parking space at Torbay Hospital.
If the second doctor feels a referral to a specialist is actually needed then they can make that referral and the patient will have been delayed by at most a week or so.
The benefits to the GP surgery are less clear-cut. We would have to duplicate seeing patients where a referral was otherwise a possibility. Actually, we wouldn't even benefit financially in any way either, as Devon PCT currently has no way of rewarding GPs for keeping referral rates low. In the end it is really just for the benefit of patients and this seems to be the model that the NHS hopes to take forward.
The benefit seems to be more to the NHS as a whole. Not immediately but hopefully accruing over time. The less we feel we need to refer, then funds that would have been spent at hospital seeing the patients (apparently needlessly as you'll see below) can be spent elsewhere on things that actually are needed.
We've been trying second opinions here at the Surgery for a few months with skin moles.
Where a doctor might have been referred to a specialist to review a dubious mole, instead we have been getting one of the other doctors to see it first to see what they think of it.
Actually it turns out that out of 43 moles reviewed, only one was serious enough to have been referred on. So we potentially saved 42 referrals in the space of only about 3 or 4 months.
(All along if the Doctors really thought a mole serious they would have referred it to a dermatologist anyway without the second opinion)
Clearly things that we were referring were often just for reassurance. If we can get that referral from a GP colleague then we all benefit. (Except perhaps a rather bereft dermatologist!)
If you have any thoughts on this topic please comment on the blog by clicking the comment link below and let me know what you think.

NHS Patient Survey

2009-07-02T16:35:00.002+01:00

The NHS has just shown the results of a national survey they have undertaken of GP practices.
They sent out questionnaires to patients of all the GP surgeries in the country asking how they thought we were doing in a number of areas.
The survey can be viewed online at their website.
(Interestingly, you can look at any GP surgery, not just the one you are registered at)
We've had a skim through the results and actually feel like we might have done quite well in some areas. We can at least compare the Leatside data with the data as a whole for Devon PCT, the South West Peninsula (SHA) and the UK as a whole, so we get nice comparative data.
The limiting factor is of course that they haven't surveyed all our patients- just 250 odd.

I suppose some areas of interest are that:
1. You invariably find the receptionists very or fairly helpful.
2. 84% find getting through on the phone easy, and only 10% find it not very easy.
3. Speaking to a doctor on the phone, 69% find fairly or very easy as compared with 25% Nationally or 38% in Devon. Similar figures for speaking to a Nurse. I think we've done quite well there.
4. If you have felt like you needed to see a Doctor quickly then 88% have been able to, which is about average I'm afraid.
5. We are much better however if you wish to book an appointment ahead. 90% could do that compared with 82% across Devon.
6. Waiting times at the Surgery don't seem too bad. 88% thought they were usually seen at the appointment time or up to only 15 mins late.
7. 75% could always or usually see the Doctor they preferred to see.
8. Most were satisfied with the hours we are open, but, if pressed to see when they would like us to be open when we are currently not, most would like us to be open on a Saturday.
9. 96% were overall very or fairly satisfied with their care at Leatside.

Feel free to go to the survey website and pick over these results if you wish.
We are always interested in feedback.

More on Jabs I'm afraid

2009-06-06T21:49:00.003+01:00

I noted in my previous Blog that vaccination rates were low in Totnes.

The PCT has now come up with some figures to show this more clearly.

They have listed the 29 towns within Devon PCT and show us the vaccination rates for them all.

Now, with Totnes' traditionally "alternative" population vaccination rates had been low for a long time.

The PCT a few years ago looked at this and thought the obvious explanation for low rates was the nursing staff. Clearly they weren't promoting vaccination hard enough, or, somehow, in the process were putting people off.

The nurses went and had special training til the PCT were happy with their performance.

Needless to say vaccination rates didn't change as a result, because it wasn't the nurses; it was of course the special population we serve.
in 2007/8 the proportion of children in Totnes who had been given an MMR by the age of five was only 66.7%.
Other towns in Devon with similar, or larger, populations of under 5's were getting rates much higher- eg Bideford- 90%, Dawlish 93%, Tavistock 93.5%.
Similar with DTP/HiB; Totnes 69%, Kingsbridge 96%.
I personally think it is shocking.
People come to live here for a number of reasons I think.
Many people cite living in the area because it is a good place to bring up your children.
If good now means exposing them to the risks associated with dangerous viral illness then I would take issue with it being safe. Safety can, of course be seen in two ways- people clearly see the risk to their child and weigh up the risk of their child suffering a complication of Viral Illness with the perceived risk of the jab. For an individual child the risk of a complication from a virus is indeed low. Get an outbreak and loads of kids in our playgroups and primary schools go down with the viruses, then some of them are going to suffer complications. The risk of a child or two getting very ill in the town in an outbreak is distinct, so from my perspective as a GP it is important to keep on about this I think.

My kids are now more exposed to the threat of illness because others have chosen not to get vaccinations. I don't particularly like to be dictated to, but I accept it where the overall benefit is clear. I am often content to see people go against guidelines and so on where they can make a cogent case to support their variance. I do mind a lot however when vaccinated kids such as my own go down with illness due to the low population, or herd, immunity.

Health Visitors at Leatside

2009-06-06T21:45:00.002+01:00

The Health Visitors have been, since we moved to Leatside, an integral part of the healthcare provision in Totnes. They (Carol Zollo and Jan Laverty) work in and are based in our building, though are employed by Devon PCT, not directly by us.

In order to work effectively together, long ago it was decided that the Health Visitors would use our computerised records as well as us. This meant that the doctors could see pertinent Health Visitor records regarding children who might be having difficulties at home for example. Similarly, if the Health Visitor was faced with a child with problems, they would be using the same file system as the doctors, so would instantly see any important medical details or records of attendance at casualty and so on.

Some years ago we were using Palm Pilots to record Home Visit Consultations, and Carol Zollo used this system extensively in her Health Visiting role because of the benefits it brought to working together as a team.

Since Devon PCT formed out of the various smaller PCTs a while back they have been looking at standardising provision of services across Devon. (This doesn't include Torbay or Plymouth which are separate) In their terms standardising seems to be in a couple of important areas. One is in the number and experience of Health Visitors serving the population. Of course they will be standardising to the areas with the lowest provision. When Carol retires she will be replaced by a less experienced nurse. (Less expensive) The other important area is in record-keeping. Health Visitors had been told that they should now be using a standardised paper record for documentation.So that is what they have been doing, duplicating the record on our computer because of the obvious benefits to care. Since the inquiry into Baby P concluded that sharing of information was key in Child Protection it does seem obvious doesn't it. Well, not that obvious apparently. Devon PCT has now told the Health Visitors that they must not now enter information onto GP computer systems.

I can't think of a good reason why the information should not be duplicated. Come to think of it I can't think why the records have gone from being computerised (searchable, auditable) to paper-based. In the modern era the different GP computer systems share a common information standard so if a child moved practices the information would move to the new computer. I'm quite baffled.

Oh, and the Parenting group they've been running- Time Out for Teenagers, as well as the baby-massage sessions are to stop.

Clearly if there are practices doing things that others aren't, then standardisation would mean making all the practices do the extras. As this would be too expensive, they will be standardising on the lowest common denominator Health Visitor practice.

So innovative advances in practice will be removed.

Watch this space for the next instalment. The District Nursing team will doubtless be asked to go the same way before very long.

One more thing- if they choose to standardise GP funding across Devon we'll be OK as we are already one of the lowest-funded practices in Devon. We get very nearly half the funding of the most-funded practice in Devon- £62.90 vs £112.83 per "weighted" Patient.

Mumps / MMR

2009-05-25T12:43:00.006+01:00

I did a shift for Devon Doctors this weekend.
On an admittedly quiet Sunday morning I saw 3 cases of Mumps. 2 from Totnes, 1 from Ivybridge.
We generally have a few Mumps cases coming up now and again, but having seen a couple in the week, then these at the weekend, it makes me wonder whether we are looking at something more like an outbreak.
I can't help but link it in with the few cases of Measles we had a month or two ago. Both things together make me concerned that the degree of immunity we have become used to in the community may be falling. MMR vaccination is clearly key here. We know that rates of vaccination across the country had been falling for a long time.
This of course stemmed back to when the Surgeon Andrew Wakefield decided he had skills as an epidemiologist and paediatrician and whipped up a scare about a link with measles and Crohns disease/autism together. Subsequent studies by people who do this sort of study for a living have showed no such association, but people are still scared off despite all the evidence to the contrary.
This now means that herd immunity has fallen and outbreaks can occur.
Herd immunity is the idea that a disease needs a certain proportion of susceptible people in a population in order to spread. If most people are immune, then if someone coughs out their germs in a room then the majority of people will be fine. If a couple of people get it though and, themselves each pass it on to a couple more people, then it is spreading.
We rely on most people being immune.
This is where those people who have chosen not to have vaccinations fall into a false sense of security. They had been relying on everyone else (the responsible people) getting their children vaccinated in order that their own vulnerable unvaccinated child would be safe in the relatively immune herd. Now that enough people had felt so secure (due to the effectiveness of vaccination) that they felt they didn't need to get their kids jabbed, we are getting outbreaks.
The Department of Health has been pushing an MMR catch-up campaign. At the Surgery we recently invited several hundred unvaccinated children for catch-up jabs. It was good that a few came along. Many still didn't.

Part of the problem is, I think, that because vaccination programmes have been so effective, most people these days have never seen a case of measles.
More have probably seen mumps. Rubella does a little turn occasionally. But by and large, for todays cohort of parents, these diseases are unknown. Diphtheria is another good case. After vaccination was intrduced in 1940 cases reduced dramatically. I've not seen a case at all, ever, after 21 years in healthcare. It still has potential to spread though, and to kill, so we still vaccinate. Smallpox is eradicated entirely worldwide- due solely to vaccination.

I can see that when you are faced with giving your child a vaccination (with its perceived risk) against a disease which is entirely unknown to you, which you have never seen, then there would be a tendency to be reluctant. To some extent that next step relies ultimately on trust. Trust in the health authorities in our country to recommend what is right and beneficial for us. We can't all spend the time needed to educate ourselves in the science of immunology and infection in order to make an informed choice.

So, back to Mumps: The incubation period is 14-21 days and mumps is transmissible from several days before the parotid swelling to several days after it appears. Symptoms begin with a headache and fever for a day or two before the disease which is characterised by swelling of the parotid glands which may be only on one side. At least 30% of cases in children have no symptoms. Complications of mumps include swelling of the ovaries or testes (Orchitis in up to 25% of post-pubertal males), aseptic meningitis (10%) and deafness. Cases may have no salivary gland involvement but develop symptoms elsewhere. There is no firm evidence that orchitis causes sterility. Contagiousness is similar to that of influenza and rubella but not as infectious as chickenpox or measles. Exposed individuals should be considered infectious from 12 to 25 days after exposure.

Dr Morris and the Air Ambulance

2009-05-14T12:00:00.004+01:00

Earlier this year I spent some time as the Doctor on board South Devon Air Ambulance.

This was to compliment my work as an emergency Doctor for South West Ambulance Trust. Devon Air Ambulance was first set up in 1986 as a legacy following the tragic Death of Ceri Thomas, who`s mother was told at the hospital if he`d arrived at hospital sooner he`d have likely survived.

The first helicopter went into service in August 1992. I`m used to calling it in or standing it down at the scenes of Accidents, or medical emergencies either where time is paramount, or, with our coast and rolling hills, in inaccessible places.

There are 2 helicopters in Devon One based in North Devon at Eagleswell. The one I crewed is based with the police helicopter at Exeter police HQ at Middlemoor. It flies at 150 mph and has a 2 hr flight time. It can carry 4 crew the pilot, 2 paramedics, and my case a Dr ( but not usually). Not forgetting one normally carries the pilot, 2 paramedics and one other person- in my case me as doctor, and then of course the most important person there- the patient.

It can reach 50% of Devon in 5 mins; the rest of Devon within 20 mins. The 2 helicopters fly 1500 missions a year in Devon, and (like the charity I work for ) is purely charity funded , needing 4 million a year to be operational.

The website for daat is http://www.daat.org/site/

Dr Morris

10 Steps to Making the Most Out of Your Doctor's Visit

2009-05-13T10:04:00.005+01:00

(This is lifted from a google knol page. It is American in origin but still summarises pretty well some of the main points to consider when going to your GP. I particularly like point 10. I, as a GP, am your health advisor, and only that. It is your health and you may choose to take my advice)

1. Identify your Agenda

There is nothing doctors dread more than to hear "Oh, by the way..." from a patient as their hand is on the doorknob at the end of the visit. As you can imagine, when the visit is over and the doctor is already thinking about the next patient, it is not the best time to bring up a serious concern.
Most of the time, the doctor has an idea of what he or she wants to accomplish during the office visit based on the "reason for visit" noted at the time you make your appointment. So, if you have more you want to discuss, make sure that everyone from the receptionist to the nurse to the doctor knows what is on your agenda.

2. Make a List

Write down the top 3 things you want to discuss plus any others (if there is extra time). Make sure to think about the things you want to discuss before you get to the exam room. This way you will have all the information you need at the time of your visit. Maybe you have a question about something you read in the paper - bring the article along. If you want to know something specific about your medication - bring the bottle along. You get the idea. It is kind of like going grocery shopping. If you don't write down everything you need, you will inevitably forget the milk or eggs.

3. Ask for the Time you Need

Expecting too much from the limited amount of time allotted for your office visit is another way to sabotage a successful doctor's appointment. In general, a 15 minute visit is about enough time to address one or at the most two concerns. Make sure to let the receptionist know everything you want to discuss at the visit. This way, enough time can be scheduled to make sure you get a chance to get to everything on your list.

4. Be Honest

Let's be honest...some of the things you talk about in the doctor's office are downright embarrassing. Sexual dysfunction, hemorrhoids, vaginal discharge, a rash "down there" are all things that can be hard to discuss with your doctor. However, and let me be very clear here, there is nothing we haven't heard as doctors. And I do mean, nothing. So, feel free to spill all the gory details about whatever it is that is concerning you. It is the best and fastest way to get better.

5. Be Patient

It is understandable that after you have suffered with some type of ailment for weeks, months, or even years, you want an answer today. Usually it will take some time for the doctor to make a diagnosis (maybe after getting a lab, xray, or other test) and to formulate a treatment plan. In fact, you may want to be wary of any doctor who jumps to a diagnosis and treatment before giving your adequate time to share your history, do a careful exam, and get other needed information. It is also important to give the treatment (whether that is physical therapy or a medication) time to work.

6. Be Nice to the Office Staff

I am amazed sometimes to find out that a patient who was perfectly nice to me was yelling at my receptionist just minutes before. Most of the time, the people who are working in your doctor's office actually like people and want to help you. They understand that nobody is at their best when they are sick, but the receptionist, nurse, lab people, and administrative staff do want to be treated just like you do - politely. In my clinic, I have a very low tolerance for any patient yelling at or cussing at my staff. So, if you can't be nice, you may be looking for a different doctor.

7. Make Sure You Understand

It is hard to remember what the doctor said even 15 minutes after you have left the office. A lot of doctors are great at explaining things and writing them down for patients, but a lot of doctors go too quickly through complex information. This really struck me when I had eye surgery. Even though I am a doctor and should know all this stuff (yeah right!), I was given 4 different eye drops to use and couldn't remember which one was just to use "as needed" and which one I was supposed to take every day. If you need to remember more than one thing, it is usually best to write everything down. Ask Me 3 is one approach to making sure patients understand what is going on at a doctor's visit. It recommends that patients ask (and write down the answers to) 3 questions:

What is my main problem?
What do I need to do?
Why is it important for me to do this?

8. Tell the Doctor about Barriers

This is a super-important, often over-looked part of the visit. If you can't read or can't read well (this is actually very common), let your doctor know. You may do better by watching a video or getting one-on-one nursing teaching than by reading a pamphlet. If you can't afford your medication, let your doctor know. What is the point to getting a prescription you can't fill? If you are not willing to engage in lifestyle change (losing weight, quitting smoking, etc), let your doctor know. That way he/she can come up with Plan B to get your chronic diseases under better control.

9. Follow Up as Directed

If your doctor asks you to come back in 3 months to get that little spot on your arm checked, make sure to do it. If you are not any better after one month on the medication the doctor started, follow up. This is the only way to make sure that you get the care you need, that things don't get worse, and that if the first remedy doesn't work, you move quickly to the next.

10. Be the Coach

You are in charge of your health care team. Make sure that you act as the coach. Get input from and advice from your doctor, but take an active role in managing your health care. This incorporates steps 1-9 listed above. Do not be a passive bench-warmer as your health care is decided for you.

Leatside and Swine Flu

2009-05-07T17:50:00.001+01:00

You'll be glad to hear that we have been making plans at Leatside just in case Swine Flu really takes a hold.
I don't think anyone at the moment is really expecting an epidemic of it, but we had better be prepared in case.
For us that means planning for many patients being ill. Possibly many of us doctors and our staff being ill as well.
Also that if people are getting ill with flu that we have ways that we can check over the worst cases for possible complications.
No-one expects that everyone with flu would need to be seen by a doctor. In fact I've been surprised by how many people the experts say get the flu virus but no real symptoms. Most people however will get a typical flu illness.

Our local John Huxham described the symptoms during an epidemic in 1733 here in Devon:

"[It] began with a slight shivering, which was soon succeeded by an uncertain erratic heat, a

heaviness and stoppage of the head, great and very troublesome sneezings, wandering pains
of the limbs, but especially in the back, and often in the breast, but not fixed, though on account of the violent cough frequently very troublesome. By cough and sneezing a vast quantity of thick acrid mucous was thrown off-these seemed only to be the symptoms of a fresh cold as they call it: however soon after some degree of fever came on; sometimes indeed not a small one, and the pulse grew very quick, but by no means hard and tense, as that of pleuritics; nor was the urine very high-coloured, but thick, and for the most part whitish and turbid. The tongue was not dry but daubed over as it were with a great deal of whitish mucus. All complained of want of sleep; a giddiness, or sharp pain in the head, afflicted very many and sometimes a slight delirium; a noise in the ears was troublesome to a vast many, and not a few had an acute pain in the meatus auditorius, which sometimes ended in an imposthume, but a soreness and abcess of the fauces were much more common. All were very apt to sweat; which being plentiful, easy, and continued, within two or three days, carried off the fever entirely ..."

Not much has changed since then actually. We generally expect most people to get a high temperature, marked sweating and muscle aches. Sore throat and headache are common too.
If people are getting flu then coming to the surgery probably only serves to spread it more, so we are expecting to need to provide for a lot of house-calls if it does break out to check on those who might have complications.
Pneumonia is one of the more common and more serious complications of influenza.
People will, of course, come to the surgery anyway, so we have a sort of plan to segregate off an area of the surgery for those with flu to sit and be seen.
Straightforward flu does not need a doctor to assess it. It may be helpful though to consider getting tamiflu for other people in the house if someone does get it. Arrangements to do that should become clearer as time passes, but this will doubtless be done on the phone.
To reduce the risk of flu spreading in the home the American CDC have a helpful page of advice as well as advice on looking after someone with flu.

Hopefully the current scare won't come to anything, but rest assured that we have been planning for the worst case scenario. If it comes to it of course some of our usual services may suffer, but we hope to be able to manage a flu outbreak tolerably well.

Doctor Triage at Leatside

2009-04-30T16:48:00.001+01:00

We have for a while now been triaging all calls where someone wants an appointment that day.
This means that rather than have a receptionist just book an appointment when the patient asks, instead, having the doctor ring them back to quickly discuss the problem and deal with it in the most appropriate manner. That may of course mean booking an appointment, but could just as well lead to a home visit, an appointment for a blood test, dealing with it on the phone. We have called 999 ambulances on the basis of these phone calls!
This is really in response to there always been more call for appointments than we have appointments to offer. a while back it became clear, when we had started consulting on the telephone more, that many problems could be sorted out purely based on the story of what had been going on. Hence, no need to actually see the patient.
So, out of the many people who ring asking for an appointment the same day we are now able to deal with a lot of those things quite quickly (and efficiently) on the phone now. This means the appointments are more available for those who really do need to be seen.
So why do we have either appointments "today" or about a week away?
Basically, its because they get booked up.
We did experiment a while back with appointments that automatically freed themselves up 1, 2 and 3 days hence to allow a rolling release of appointments for those who didn't necessarily need to be seen today, but then a week off was too long. It didn't really work. In the end our best compromise has more to do with our attitude to appointments actually. The "duty" doctor used just to see only urgent cases on the same day. Now we will see anyone, for whatever reason, if they wish to be seen today.
As always, the message is, if it is a routine appointment for a check-up or whatever then book ahead.
If you need to be seen the same day then let us know and you will be seen.

Why you use a tissue when you sneeze!!

2009-04-29T23:22:00.001+01:00

Meningitis

2009-04-28T22:25:00.000+01:00

I was sad to see this story on the news last week - a toddler in Cornwall who lost his limbs through having meningitis.

His poor parents are fund raising for money to provide him with the artificial limbs he will need as he grows up.

The NHS and PCTs are constantly faced with calls on their funding, sometimes for things above and beyond might we might call "usual". It is down to the PCTs to decide how best to allocate funds in the best interests of all in their county.

Doesn't it make you think though that in this case, rather than funding some end-of-life cancer last-gasp hope drugs for vast amounts of money (to the drug companies) money might be better spent on the young, such as little Marshall in this case.

I remember vividly a 17 year old girl I was looking after back in 2004 on the dialysis unit in Leicester.

She had had meningitis, had lost several fingers and toes, lost the use of her kidneys and several other technical complications. She went to have the wounds on her legs cleaned up by the plastic surgeons. That afternoon they rang us from theatre to explain that the deep tissues in her legs were all dead. She came back later that evening having had both legs removed above the knee.

She was devastated, as were her parents and brother. School friends too who kept visiting.

Her life went on though, and she had the prospect of kidney transplants and artificial limbs etc...

In the case of Marshall in Cornwall, imagining the trauma his parents must have gone through, shouldn't the NHS be funding his prosthetic limbs? Rather than having them going out fundraising?

This isn't a campaign on my part I have to say- just a commentary.

Changes to the Minor Injuries Service

2009-04-27T22:03:00.001+01:00

"A minor injury is considered to be a cut, bruise, sting, twisted joint or other minor condition and treatment has in the past been provided at the Surgery.
From April 1st Devon PCT has determined that this service will mainly be available from Totnes Hospital Minor Injuries Unit (MIU).
Devon PCT will now only commission and resource GPs to provide a "minor injuries" service where the practice is more than 10 miles from an MIU"

This I lifted from a Devon PCT leaflet they have provided for patients to inform them of the new changes.
We have lots of these at the Surgery for people to collect and read so that they can better understand that if they attend the Surgery with a sprain or cut or whatever, we will turn them away (bleeding maybe?) and get them to go to Totnes Hospital because they've come to the wrong place. Just as if they wandered in to, lets say, the dentists or even the Chip Shop with the same injury.
Devon PCT doesn't pay us to treat this sort of thing- they now pay the MIU.
Devon PCT tells us that this is a change in response to what patients want.
They want the GP to provide management of long-term health conditions, and that patients would rather go to an MIU for an injury rather than to their own, trusted, Doctor.

I have to say though that it just seems wrong, and I find it hard to believe that "patients wishes" is the reason.
It seems more likely that given Devon PCTs perilous financial situation that finances must be the driver in some way.

Totnes GPs have always been able and willing to help people with Minor Injuries if they have attended the Surgery.
Now we are told that it is not our job and we won't be paid for helping you in these circumstances.
We could of course continue to treat patients with minor injuries as and when they turn up, but, you know, quite frankly if we aren't being paid for doing a job we are unlikely to offer it for free. Just like any other job in any walk of life.
Trust me; we could (and did) offer this service much cheaper than the MIU. In fact we never even thought at all about the finances of it. It was just part of the job..... til we were told it wasn't any more.

Sorry. Really sorry.

If you feel stongly at all about this it might help to let the PCT know. Their PALS (Complaints) details are below:

Patient Advice and Liaison Service (PALS)

Telephone: 0845 111 0080 or 01392 385694
E mail: pals.devonpct@nhs.net
Or wite to: PALS, St Edmunds Court, Okehampton Street, Exeter, EX4 1DU

Swine Flu- Mon 27th April, 2009

2009-04-27T18:35:00.000+01:00

This is the advice we are getting from the Health Protection Agency

"As reported widely in the press, human cases of swine influenza A (H1N1) have been reported in Mexico and certain areas of the USA. This is an evolving situation and it is likely that more countries will be affected.

A CAS alert issued yesterday (26th April) states that no cases have been confirmed in the UK at present. The situation is being closely monitored by the Health Protection Agency (HPA), which is working with the Government to review the current incident and any threat it poses to the UK.

The confirmed cases of swine influenza virus infection have presented with symptoms of influenza-like illness: fever, respiratory tract illness, headache and muscle aches. In addition, some have presented with vomiting and diarrhoea.

The virus that has been identified is a novel influenza A virus, which is sensitive to oseltamivir and zanamivir, but resistant to amantadine and rimantadine. The HPA has produced a WHO Pandemic Alert Phase 3 Algorithm for the management of returning travellers and visitors from countries affected by swine influenza A/H1N1 presenting with febrile respiratory illness.

People returning from a visit to an affected area are advised to monitor their health closely for seven days. If during this period they develop a feverish illness accompanied by one or more of a cough, sore throat, headache or muscle aches, the HP advises them to stay at home and contact their GP by phone or seek advice from NHS Direct (0845 4647)."

Pharmacies

2009-04-25T11:18:00.001+01:00

Now I am blogging I can't help but get on a small rant I'm afraid.

Pharmacies.

We've had, for so long, 3 pharmacies in town.

Coop and Chaplin Bennetts on fore street and Boots on the Market.

When we opened at Leatside Chaplin Bennetts came to join us then became something else, then Moss.

Status Quo for a few years.

Then Day Lewis bought the Boots shop, after Boots had bought out Moss and relocated to Leatside.

New status quo, coop, boots and day lewis.

Then Day Lewis wanted to move in with Morrison's.

Consent to move was declined by the PCT on the basis that they wanted to keep a pharmacy presence at the top of town.

After a while Day Lewis applied to relocate to Bridgetown.

Perhaps because the PCT thought that this expanded residential area might benefit from a pharmacy their request was accepted.

You'll note that in doing this the PCT had rescinded the requirement to have a pharmacy at the top of town.

Day Lewis then reapplied for the move to Morrison's.

This was declined but they won on appeal as clearly the top-of-town principle hadn't been stuck to.

So there we have it- Day Lewis got what they wanted and are moving in to Morrison's.

You probably know that Boots at he Surgery have only really a fairly small space, so we have been in discussion with boots for some time to see if we can offer them more space. (They get more space to work from; we get more rental income from them) This may yet come to fruition as we submit plans to expand a bit on each end of our building. But what we then end up with is only the coop on the main street.

I suppose it may be ok, as the pattern of how people use the town and services evolves and changes over time, but I can't help but feel that it is to the detriment of the town as a whole.

Neither of the lower town sites is ideal. Leatside has a tight car park, but is easily on the path and cycle routes.

Morrison's has the big car park, but £2 to park, then to recoup it.

But then again, parking up the town costs now as well doesn't it.

More and more people are using the pharmacies' home-delivery services, and I think any feedback on how to use these more efficiently might be appreciated... perhaps using distribution/collection points like village shops or pubs?

Online pharmacies like pharmacy2u have been publicising direct by mail shots.

I have to say though that I don't like the idea of these. Pharmacists do fulfil a role in safely dispensing medication face to face and dealing with queries... what might decide which pharmacies do well in town in the end, I feel, is the quality of the pharmacists.

Dermatoscopy

2009-04-24T13:47:00.001+01:00

We have recently bought some new equipment to better be able to look at moles and similar skin lesions with.
The gadget is called a Dermlite 2, pro hr.
It is essentially a good magnifying glass with polarised light source, enabling us to see better into the pigmented layers of the skin close up and see how they are put together.
It is supposed to be particularly useful for clarifying melanomas from not-melanomas.
Cost a fair bit to buy the kit, but we hope over time that it becomes worthwhile by reducing the need to refer to dermatologists for an opinion.
Dr Morris and Dr Watkins both have the kit and are beginning to get the knowledge, so if you have a dodgy mole take it along for a look-at.
Of course, if you can't get an appointment with them it doesn't mean the other docs have stopped being able to give opinions on moles... by all means ask your usual doc. If they can reassure you then fine. It might be they ask for a demoscopy review though.

Better to have funny moles looked at than not though.

Measles

2009-04-23T22:00:00.001+01:00

We've seen a couple of cases of measles this week.
It is actually so much nastier than you think it is going to be...
The last time we had an outbreak must have been 6 or 7 years ago and then I think 2 of the 6 or so cases ended up in hospital with complications.
We do have an MMR catch-up going on at the moment. If you'd like your child immunised then please contact the nurses' administrator to discuss on 860312 from 9am til 10.
I gather from a patient that Mumps is about in her Uni class in Plymouth as well.
It is worth noting as well that at this time of year we often see skin rashes relating to the spring "burst" of UV in the sunlight.
Exposed areas of skin like tops of ears and lips seem to suffer most.
We do also see shingles at this time of year as the UV seems to set that off in some people too...

New Blog

2009-04-23T16:32:00.001+01:00

I decided that a blog may be a helpful way to keep in touch with what we are doing, thinking, planning etc at the Surgery.
The surgery website fulfils an informational role but is rather a formal way of doing this.
The blog I hope can be a more informal area where staff at the surgery can post up bits about things they are doing, projects they are working on, areas of clinical interest, bits of latest research, feedback on feedback we've had, and so on.
I might perhaps get the patient participation group members to contribute as well if they so wish.
Who knows where it might go.

Dr Watkins