Catterick out of hours

Back on blogging after a break!

Some of you may have seen the article in the D&S about the changes to Catterick out of hours. In essence, calls placed after 2300hrs will be passed on to the duty doctor based at Northallerton (rather than Catterick) to deal with. If a patient needs a home visit or to be seen face to face, this will still be done by the doctor in Catterick.

The only change is that the doctor on duty at Catterick will not make the initial telephone call. This allows the Primary Care Trust to classify the Overnight Catterick duty as a 'sleeping' shift and so reduce the overnight payment to the doctor. The change will make no difference to the patients needing a GP after 2300hrs. The only difference we may see is that less doctors will be keen to take a pay cut to work at Catterick, and so the PCT will find it difficult to man this shift. Whether or not this will happen remains to be seen. The PCT is heavily in debt and we must try to make savings wherever possible in order to protect our services. The current OOH changes will only affect the doctors at present and the patients should not see a difference in the level of service provided at present.

Diabetes screening

Long time since the last posting, what with the excitement of the election and the ensuing aprehension about what is going to happen next to the NHS. We have recently been looking again at diabetes screening. We already screen some people at risk (normally those with existing heart conditions, mental health problems and those on medication such as steroids which can increase the chance of developing diabetes) and we have looked again at whether we should run a widespread screening programme. Currently the evidence as well as the cost/benefit does not support this plan to screen everyone. There is good evidence that screening all at risk groups is more effective. Are you at risk? Diabetes UK has an excellent screening tool to assess your risks(http://www.diabetes.org.uk/measure-up/) - if you are at risk, please come and see either of the doctors or Kim for a further chat and testing.

More election stuff - Labour

As promised a further update. Good to see the 3 prospective candidates for health minister slugging it out on the BBC politics show yesterday. Labour have made promises of free health checks for everyone aged 40-74 and the right to see a GP at weekends/evenings. The promises are light on detail - in fact most practices offer health checks to their patients already, and people can already see 'a GP' 24/7 by using the out-of-hours service. This goes along the same lines as the recent guarantee that patients with suspected cancer will be seen by a specialist within two weeks (this has been the case for several years already). Labour do seem committed to improve and expand cancer care services to enable more palliative care at home- this policy would be much welcomed in the Dales, as nursing/carer support is often difficult to guarantee in rural areas. Labour will also scale down the doomed NHS IT project (which it invented), and re-invest the money in frontline services. There is no mention in the manifesto about abolishing car park charges at hospital (a pledge last year at the party conference).

Election Promises - Lib Dems

The current proposals from the Lib Dems are for local GPs to take back their out of hours care, scrapping practice boundaries and to create locally elected health boards.

The practice boundary issue is not really of much concern to us, as geographically our practice area is well defined although we would possibly consider taking on more patients further downstream towards Richmond. The health board shows promise to make sure that health solutions are applicable to the population they serve and any move away from NHS Whitehall and a one-size-fits-all approach is most welcome. Out of hours care is a real concern though. Being responsible for commissioning out of hours cover is one thing, but having to provide 24/7 cover is likely to be unsustainable for a single-GP practice. Not only are there safety issues, but also difficulties finding locum cover for holidays and training days. Such a policy may necessitate a practice merger or at least a change in the way we work.

General Election

During the election campaign, the blog will have a focus on the main health policies of each of the main parties. RMC is keen to remain apolitical, and so will be unable to display any election posters (we have been asked to have leaflets in the waiting room previously).

Foot Care

We are pleased to announce that we can now offer a private foot care service at the practice to run in conjunction with the existing NHS service. Sheila Hunter will be working from the practice, as we had quite a lot of demand for a private podiatry service. There will be no reduction in the NHS service and hopefully this extra capacity will reduce travelling costs and time. Sheila can be contacted directly (01748 835 732 or 07833 166 220) for appointments.

Happy Easter

As another day draws to a close, thoughts turn to the Bank Holiday Weekend! I'll be off to burn a few calories on some Wainwrights- I made the unfortunate discovery of a book of routes which enable you to cover all the Wainwrights in 32 walks, although there are some fairly taxing days- hopefully I'll meet the challenge in the next 6 months, so if you wonder where the weight has gone and why the dogs are so scrawny, you'll know!

Prescription charges to be frozen

The Minister of State, Department of Health (Mike O'Brien) has issued a statement to the effect that prescription charges will remain at £7.20 for 2010-11. There will be no changes to the pre-payment certificate charges either. I would be keen to see an overhaul of the 'exemption' categories, as I think there is an arguement for people with long term conditions, such as asthma, who currently have to pay, to have free prescriptions. People are often discouraged from taking their medicines regularly on account of cost and this can lead to exacerbations and the need for emergency care. Not only does this impact on the patient's health but also the hospital resources, and employers because of increased sickness absence. The simplest solution would be to abolish prescription charges altogether as has been done in Wales, with continued emphasis to use the lowest-cost, most effective treatments for any given condition.

Commercialising the NHS

The British Medical Association has launched a campaign to raise public awareness about commercialising the NHS (http://www.lookafterournhs.org.uk/) . At the moment, there is a big push to involve commercial providers to bid for NHS services. This ranges from the PPI building projects (seen in many other government sectors) to treatment centres. The idea is that competition improves value for money and performance. Some concerns are that money is diverted away from the NHS to private companies. Unfortunately some of the contracts currently in place defy belief- one company I know of is paid up front to perform a given number of minor operations, regardless of whether patients are referred to them or not. At the end of the financial year, there is a big campaign to get GPs to use these centres, in order to make the payment worthwhile! I do think various elements of the NHS (as with any large bureaucracy) need a prod with a sharp stick, as all too often it is easy to sit back and adopt a reactive approach, but is the current approach really benefitting the patients and the tax payers, whom we ultimately serve?

Practice Boundaries

A consultation is underway at the moment to see if we should get rid of practice boundaries and be able to register with a GP wherever we like. I can see this being helpful to commuters and people who tend to get 'one-off' problems where continuity of care is not really an issue. My concern is that the proposals do not recognise continuity of care as a key element of general practice. I think one of the reasons for increasing A&E use and hospital admissions is that general practice is becoming more and more fragmented through part-time working, and too much choice of provider coupled with protocol-driven working, which does not allow common sense or managed risk to strike a balance. I generally encourage people moving outside the practice area to register more locally, mainly because of home visiting. If a home visit is required 20 miles away, it reduces the amount of time I have for other people living locally and takes me outside the practice area (where I normally respond to emergencies on behalf of the ambulance service).

I would be happy to expand the patient list in principle, as this will attract more services to be hosted at the practice and therefore provide more local care for people, but I would be cautious about agreeing to proposals which would require home visits miles away from the practice and have destabilising effect on continuity of care.

Further info:
http://www.theyworkforyou.com/whall/?id=2009-12-16a.268.0

http://www.bma.org.uk/images/reformgpboundaries_tcm41-193919.pdf

Have your say: http://www.gpchoice.dh.gov.uk/

Homeopathy

Should the NHS fund this? Given the current lack of evidence beyond placebo effect, I think the NHS is well within its right to withdraw funding for homoepathy, until the benefits can be proven by rigorous scientific testing. That said, we should not just pick on homeopathy; millions are wasted on poorly researched, political gestures such as walk-in centres. Currently, each North Yorkshire practice is being given its cost per patient figures, and not surprisingly, the walk in centres are by far the most expensive (Reeth was 81 out of 100 (100 is the lowest cost)). There is no evidence that they reduce demand and if anything the fragmentation of care results in increasing numbers of often unnecessary hospital referrals and cost. Unfortunately, the political will is such that backing down from rolling out such schemes, even in the face of new evidence against the proposals, is not an option. Interested to see what our followers' perceptions are!

Reeth Demographics

I thought our followers may be interested in our patient demographics. We are just preparing to send our annual statistics off to the NHS at the end of March. 13 of you are over 90 years old and there are 80 people aged 80-89 which is pretty impressive.

Evaluating your GP

Doctors will soon be regularly revalidated. The cycle of revalidation is 5 years and, much like an MOT, will make sure we are all road-worthy. The current system focusses on making sure GPs do regular educational updates, review their patient care and show how they have improved it, take part in an appraisal with a senior doctor each year and seek the views of their patients and colleagues on their performance.

Having gone through the system for a few years now, I welcome the recognition of my efforts to stay up to date across the wide range of specialities GPs cover. We spend quite a lot of time at RMC looking at patient care and trying to improve on what we do: the dispensary has a 'near miss' book similar to the system used by airline pilots in order to try and recognise error and implement changes to prevent mistakes and protect patients (most pharmacies have an estimated 1% error rate); as a practice we review all significant events, complaints and diagnoses of serious illnesses, such as cancer, to see if there is anything we can learn and improve on in the future; all members of the practice produce audits each year in their area of work, again to make sure we perform to a high a standard as possible.

Our patients can help to make this revalidation practice effective by letting us know when their care is good, when their care is not as good as they would expect, reporting when things go wrong and giving their views in national questionnaires and surveys.

A lot of the data on the practice is available through the NHS website, and in coming months, I hope to publish further information, beyond the statutory requirements to hopefully allow our patients to see the work behind the scenes.

Is alcohol the new smoking?

While numbers of smokers continue to fall, concern has focussed on the effects of harmful drinking on both health and society as a whole. Alcohol is a socially accepted drug and unfortunately we are seeing ever increasing numbers of health problems associated with harmful drinking- this is not necessarily the 'youth' binge drinking; harmful drinking can include folks who drink modest amounts each day, but cumulatively exceed their weekly limits. As well as increased risk of accidents and liver disease, alcohol also increases your risk of high blood pressure and the calories associated with it can increase your weight and put you at risk of diabetes and heart disease. Doctors are urging ministers to set a minimum price per unit of alcohol as a way of controlling harmful behaviour (this has worked in other countries without the sensible drinker seeing any significant cost in their weekly spend on alcohol). Unfortunately the drinks industry is a powerful lobbying body and prefer to demonstrate concern by sponsoring alcohol awareness campaigns (the evidence suggests that these are no benefit at all). A sobering thought is the amount spent on alcohol advertising compared to that spent on helping folks with problems.

For more info, go to: http://www.alcohollearningcentre.org.uk/Topics/Browse/AlcoholEffects/?

Record Sharing

Most of you should have received the details of the proposed system for sharing your record summaries between healthcare professionals. Currently, all your records at the practice are kept confidentially and are not available outside of the surgery. The electronic records are stored off site in a secure server and even if the computers were stolen from the surgery, there is no patient sensitive material stored on them.

The proposed scheme intends to make your record summary (just the important details e.g. heart attack, asthma etc) , details of any allergies and repeat medication available to other healthcare professionals, e.g. A&E staff, out patient clinics. The idea is that this will allow better treatment in emergencies and out of hours and faster transfer of information between staff. Further information can be found at www.connectingforhealth.nhs.uk/systemsandservices/scr

The NHS states that the information will be 'secure and is protected by the strongest security measures available for handling data'. The blog would be interested in your views!

More cuts and ranting!

Channel 4 news ran a feature on hidden NHS cuts last night. Our own PCT is estimated to have a £9m deficit which has to be clawed back in the next financial year - practices are been asked to suggest ideas for savings. Cutting excessive spending is obviously sensible, but unfortunately there are many areas where spending is going ahead regardless of common sense. The PCT is concerned about the cost of A&E attendences by patients from nursing homes, who are, perhaps, sent in unecessarily by less experienced staff at local homes. They have funded community matrons, and one of their priorities is to bring the care homes up to standard to reduce unecessary admissions. All sounds quite sensible until you realise that these are on the whole private nursing homes, run for profit, providing below standard care in some instances, and the NHS is having to use its resources (people and money) to fix the problem!

Generic medication

Following on from a comment on the 'antibiotics' posting, a bit about generic medication. Wherever possible, RMC tries to use generic medication, rather than branded. The active ingredient in the drug is exactly the same, but there is a significant financial saving with generic drugs (e.g. the migraine drug 'sumatriptan' costs £13.60 for 6 tablets as a generic and £42.90 for the same as a branded drug). The current climate would suggest, at best, minimal further cash for the NHS over the next few years, and we must look to provide value for money to the tax payer. Money diverted away from drug company profits can be spent elsewhere on patient care. At RMC we would spend somewhere in the region of £250k a year on drugs and work within a tight budget. The NHS inspects our prescribing each month and there is an annual visit from the health authority to discuss our performance and value for money (next interrrogation is in February). Our practice has above average rates of generic prescribing compared to North Yorkshire and nationally, and our drug waste (unused drugs returned) is fairly small. Our prescribing spend per person is adjusted to account for a more elderly population and is usually less than the national average each month, although our quality score for clinical treatment was 100% last year, showing that we can achieve good quality care and good value for money!

Osteoporosis

A new risk calculator has been launched on the internet for osteoporosis. Although not intended for direct patient use, it may be helpful to get an idea of risk, which could then be investigated further. Patients wishing to use the tool should go to: www.qfracture.org and follow the instructions. Patients who are deemed at risk are more than welcome to come and discuss osteoporosis and further investigations, such as bone density scans, with the GP.

Over the counter medicines sales

The Department of Health is currently planning a consultation for a white paper regarding sales of over the counter medicines at GP surgeries. The website states:

The White Paper proposes reform to current arrangements whereby dispensing doctors may not sell over the counter (OTC) medicines to dispensing patients.

The rationale for this is that patients in some rural communities may have to travel substantial distances to access OTC medicines if there is no convenient alternative, such as a pharmacy, nearby. GPs are prevented through conditions in their NHS contracts which prevent them selling OTC medicines where the sale of such medicines could be seen as generating a profit linked to a course of treatment recommended by the GP. This leads to an anomalous position whereby a local filling station or newsagent can sell a pack of paracetamol but the GP surgery cannot. Relaxing this restriction would provide better services for dispensing patients – particularly in relation to higher strength “P” OTC medicines which cannot be bought through ordinary retail outlets and must be supplied by a pharmacy.

The Department has published, on its website, an initial Impact Assessment prior to full consultation later this summer. This analyses the proposal in more detail. It sets out 4 possible options:

Option 1: No change
Option 2: Permit certain dispensing GPs to sell OTC medicines where there is no convenient alternative
Option 3: Permit all dispensing GPs to sell OTC medicines
Option 4: Permit all GPs to sell OTC medicines

The Department at this stage prefers Option 2 as it meets the policy objectives of improving access to medicines and promoting self care in rural areas.

Option 2 would also make sense for Reeth patients, as it would save time and reduce the carbon footprint associated with driving to town for some medicines.
See www.pcc.nhs.uk/.../briefing_paper_10__market_entry__otcs__dispensing_doctors3.doc for further information.

Snow

By now we will be sick of the 'S' word.  Hopefully a thaw will come soon and we can get back to normal. Thank you to all who have helped in the adverse weather conditions including Phil Bastow and Co. from the Reeth Fire Brigade who came to help dig out the emergency ambulance from Back Lane on Thursday night.  The emergency crew had already been delayed by the weather getting to Reeth, and temperatures of -8 degrees had caused the vehicle to get stuck in the snow and ice. Thankfully after a spot of impromptu digging from the surgery staff and the firemen, the crew were able to leave.

Whole foods protect against depression

The British Journal of Psychiatry have published research to show that individuals with a high intake of vegetables, fruit and fish have a lower risk of depression, and those who eat a high amount of processed food have an increased risk.

No-one is quite sure of exactly why this is although some think that eating more processed foods causes more obesity, which in itself is a risk for depression. Other theories include the folic acid in leafy veg which is used for making one of the 'mood' hormones or the omega-3 fatty acids in fish which act as mood stabilisers.

The take home message for a happy new year is to avoid the Xmas pud and have an extra serving of the sprouts!

Antibiotics

I suspect my patients are fed up of hearing about viral infections by now. In the past, GPs used a lot of antibiotics, especially at winter times for coughs and colds. Unfortunantely, what we are now seeing is bacteria that are becoming resistant to more and more antibiotics. There have been reported infections in the UK which will now only respond to powerful antibiotics given via a drip in hopsital and some bacteria are emerging for which there is no antibiotic at all. The antibiotics we use in practice have been with us for decades and in the absence of new drugs, bacterial resistance is a real worry. Research shows that a lot of conditions get better on their own without the need for antibiotics- the less we use, the more likely they are to work when they are needed.

80% of ear infections in children will clear within 4 days, 64% of conjunctivitis will get better with a placebo medication, 70% of acute sinusitis will settle within 10 days and most sore throats will resolve within 8 days (taking antibiotics in this case will reduce the duration of symptoms by about 8 hours!).

As a GP, I have duty to not only give the best care to each patient, but also to look after our community as a whole. Reducing unnecessary antibiotic use is one small step to helping protect the vulnerable in our community from the threat of antibiotic-resistant bacteria.

Will cutting out salt save lives?

There is established research suggesting that reducing daily salt intake helps reduce blood pressure- most recently, scientists in Naples have also shown a reduced risk of stroke if salt intake is less. The average intake of salt in the UK is 8.6 grammes a day. Current recommendations are less than 6 grammes a day, but ideally we should aim for 3 grammes.

When I discuss this with folks, the majority say that they don't take salt with their food already. Most of our daily intake is actually already in the food we eat, so our focus should be on being aware of what foods have the most salt content and trying to eat these in moderation. For further information, visit: http://www.eatwell.gov.uk/healthydiet/fss/salt/