Friday, March 16, 2007


You might have heard this one before, but a quick and admittedly cursory trawl through the archive didn't reveal it so here goes.

Jack is in his mid seventies and had his first stroke a decade or so back. Strokes are weird things. the mechanisms are clear, either a blood vessel wears thin and bursts, nuking the surrounding brain tissue, or a clot forms within or lodges in an artery depriving a region of the brain of oxygen long enough to kill it off. In either event a bit of brain stops working.
The thing is, depending on the bit of brain affected you can get weakness or paralysis in muscles (because of the way we are wired up the muscles affected will be on the opposite side of the body to the hemisphere of brain containing the injured bit). This can result in weakness or full blown paralysis, and in either event this might or might not improve over the next few days to weeks. Additionally, again depending on where the vessel was and how much damage was done, sensations can be affected, speech and thought processes can be affected, fits can be caused.

Poor old Jack had quite a bad one, and got a lot of these effects. His right arm and leg didn't work properly, and at times his brain even forgot they were there (a phenomenon known as "sensory inattention"), he struggled to find words and had bouts of quite severe agitation often lasting several hours.

It was clear even early on that he was hallucinated when he became agitated. Eventually he got enough words back to tell his family what he was seeing. And what he was seeing was a swarm of moggies, who had, quite uninvited, invaded the house and were roaming at will. He really couldn't understand why his family were letting them in to torment him like this, and so he got quite cross and began to lash out. Whether this was directed at the cats or the family who were around at the time was not clear. What was, was that he was really quite distressed and unsettled by his hallucinations. And quite unaware that is what they were.

In the end it became clear that these hallucinatory episodes were part of the aura of a variety of epilepsy triggered by the brain injury of the stroke. Treatment with anti-epileptic drugs has really helped reduce the frequency and severity of his attacks and they are now much more manageable, to everyone's relief. However, in the interim the family hit on a novel solution to his distress. They bought him a dog. A big, fluffy cuddly toy English Shepherd. The brute is near life size and holds pride of place on the sofa beside him.

And he helps scare away the cats.

Wednesday, March 14, 2007

Number crunching

The Today programme are at it again. Or rather the Audit Commission as reported by the Today programme I suppose. Now it's the changes in Out of Hours arrangements that "have benefited no-one except the doctors".

Well, in purely financial terms this might well be so. You see, up until 2004 GP out of Hours care was provided to the NHS for free.

No really, it was.

Under the terms of the old GP contract individual docs had responsibility for their patients needs 24/7. To be sure right from the '60s the actual work was done by either co-ops of GPs working together or by commercial deputising services, but the responsibility for these arrangements was left with the patient's own doc, and it was that doc who paid for whatever out of hours arrangement he or she chose to use.

By the end of the 90's out of hours services had reached overstretch and were increasingly looked on not as an exceptional service there for genuine urgent need, but as an extension of normal services for anyone who chose not to make use of their own GP service in hours. Demand was steadily, even exponentially, rising, individual GPs morale was at rock bottom and there were even mumblings of mass resignations or industrial action if the spiralling demand was not better managed. In brief, the demands of the public at large, fuelled by the wholly unrealistic expectations of our political paymasters, had torpedoed and sunk the goodwill that had kept out of hours services going for four decades.

In the new GP contract responsibility for providing out of hours services was passed to the NHS management in the form of the Primary Care Trusts. GPs could still offer to be a part of the service provision, or could take a 6% pay CUT to no longer offer out of hours services. At the same time some of the process requirements made by the NHS for out of hours services (mainly to do with how fast the phones were answered) made it impossible for all but the largest GP run Co-ops to comply. In short we were shouldered out of being allowed to provide the service in a way we would wish, and obliged to pay for the privilege.

Granted, under the terms of the new GP contract our pay increased in a number of other areas, notably in the arena of performance related payments, but it remains the case that we continue to pay for the out of hours opt out to this day. And it should tell you something that the vast majority of us are happy to continue to do so.

For the following other lesser known facts of GP service provision in the UK I am indebted to the Avon LMC. Everything that follows hereafter is their work and was intended for wider dissemination, so do please tell all your friends.

There are approximately 36,000 GPs in the UK

It takes 6 years to train as a doctor and then a further 3 years to train to become a GP.

Each patient on average sees their GP 4 times per year – this means, there are over 250,000,000 GP/patient consultations per year; 15% of the entire population see a GP in a two week period.

The average practice in the UK has about 6,000 registered patients and 3 - 4 GPs. The average full time GP looks after 1,700 – 1,800 patients.

The average face to face contact with a GP costs £20, compared to £24 in a Walk in Centre, £27 for a telephone contact with NHS Direct, £75 for an attendance at A&E and between £100 – 300 for each attendance at a hospital Out Patient Department.

GPs are paid LESS than 20 pence per patient per day to provide all the day to day care that is required. This is less than the cost of a daily newspaper.

Surgeries are open from 8 am to 6.30 pm Monday to Friday.

Some GPs additionally provide care outside these times, via locally based out of hours services.

GPs refer about 10% of patients seen to hospital specialities, which means that nearly 90% of all health needs of the British population are managed entirely in general practice.

In a recent Government survey it was found that patients were more satisfied with their GPs than they were with the hospital service. General Practice in the NHS was the most popular of all public services.

In a recent Government White Paper, they stated that “by international standards general practice in England is efficient and of high quality. Indeed many countries view with envy our system of list based general practice”.

GPs are now paid differently in that nearly 50% of their income is via quality performance-related pay.

The performance-related pay is based on achievements made in the Quality and Outcome Framework (QOF). This consists of over 100 targets of which 76 cover 10 important disease areas, measuring performance against proven standards. This has contributed to the largest and most admired clinical database in the world.

The Government has transferred all its responsibility for funding part of GPs’ pensions to the GPs and then claimed this was a part of a pay rise.

Tuesday, March 13, 2007

Dr J waffles on

It's fair to say this blog has become a bit more of an occasional blog of late. This is unintended, and has a lot to do with me spending rather more time in the company of burly blokes in stab proof vests that I would ideally prefer. Still "you can't always get what you want" as the wise man once said. However it seems this chapter might be about to come to an end since the patient who warrants such tender ministrations is pondering a move to pastures new.

Actually, if I'm honest, there's not been that much to report on the surgery front lately either, other than our continued need for the intercessors with the stab proof vests being present a little more often than they would like too.

But hey, enough about my problems. How have you all been? What's new in your lives since last I rambled on at length about nothing in particular?

Oh, really, that's cool / so not cool/ great/ terrible/ interesting/ actually rather dull... (delete as inapplicable).*

So anyway, enough about you. I shall now resort to that old standby for days like this. Yes, you guessed it, a bit of waffle about the Today programme and the drive in to work.

Listening to the Today programme this past couple of days has been rather depressing. The picture they paint is of a health service that is irreparably broken. The sad thing is they might just be right.

In the last week we have had stories about the utter shambles that is the latest NHS jobs round for Junior Doctors. At the risk of committing Reductio ad absurdem, in brief, all junior Docs have a common training path for the first couple of years of their working lives. Having come out of med school primed with knowledge they get to serve a working apprenticeship learning properly how to BE a doctor. During this two years they are expected to form a clearer impression of the career they are looking for in medicine and then to start to apply for "proper" jobs that will fit them for their chosen speciality (or generality for us "square peg" types). Thus has it ever been since Hippocrates was accepting payment from his eager students for the passing on of his hard won knowledge and wisdom. Until this year.

Over the past few years a bunch of well intentioned boffins have been trying to sort out the yearly scramble for these "proper" training jobs. In doing so, somewhere along the way poor dear baby got flung out with the bath water. Now applicants cannot submit the time honoured (often slightly embellished to be sure) Curriculum Vitae to individual potential employers. instead they have all had to fill out, online, an application form so generic it has been impossible to tell either what their current training and aptitudes would best suit them for, or, indeed, even if they have any of the relevant qualifications necessary to pursue a career in any branch of Medicine at all. The system takes little or no account of their current situation personally, professionally or domestically. In endeavouring to be "fair" to all potential applicants, it appears the system has been evolved to be thoroughly unfair and arbitrary to all instead.

Things are so bad the West Midlands Surgeons have withdrawn from the whole shoddy business and are calling on other specialities and regions to do the same. Finally at the eleventh hour (or even at about five past twelve in the view of the tens of thousands of potentially affected juniors), the powers that be have agreed to look again at this unholy mess. Anyone with any interest at all in quality health care should watch this space. (Just don't hold your breath would be my advice).

Next we have had parallel stories of neglect and inappropriate management of wounded service personnel and the disabled when in hospital. Both stories go to underline the lack of training and even in many cases simple common sense, compassion and fellow feeling, prevalent on our wards these days. We have a culture of Graduate Nurses who often see themselves as "too posh to wash" left in charge of wards of needy and dependent patients, with scandalously inadequate staffing levels and no proper understanding of what "caring for patients" actually means. They can turn in an immaculately presented set of charts, and word perfect management plans, but as for actually feeding, cleaning or attending to their charges, well that hasn't been a priority on our wards for over a decade. Small wonder that there is a reported case of a handicapped patient literally starving to death during a three week hospital admission. Still we can all sleep easy tonight for Mrs Hewitt our esteemed Health Secretary is at last on the case.

OK, enough doom and gloom. This past two days Ambridge has been resplendent in sunshine for the morning drive to work. Yesterday in particular the drive was a splendid motoring experience. Every set of traffic lights was on green as I reached it, all the expected queues at roundabouts and junctions had been transported to some parallel dimension, in short I had an un-interrupted run in for the first time ever. Today's run started out less well with some pillock trying to jam a lorry under a bridge at Borchester railway station, but there after it was almost as pleasant, and better still the morning sun was good and low allowing me to don my ultra cool shades and become, for a blissful thirty minutes at least, the Road Warrior. Lakey Hill was bathed in a post apocalyptic, actinic glare of almost tangible global warmth as the Road Warrior gunned his mighty turbo diesel to one last heroic effort, careening down narrow ravines and across crumbling bridges on some primal errand of mercy or vengeance. Then it was nine o'clock and time to start surgery. Off with the leathers and shades and on with the motley....

* witness the effortless repartee that keeps me at the top of my game as a jobbing GP and Mountebank.

Monday, March 05, 2007

Open the window....

Looking back February was rather a thin month postingwise (probably not a "real" word but what the heck...). Seems it must have been busy. Thinking back fron the cosy distance of the 5th March it probably was actually. You see Ambridge has been stricken with a plague of Biblical proportions, and that despite being home to very few Pharaohs, or at least very few that I know to.

This year, for the first time in a decade or so we have seen significant numbers of folk with real honest to goodness 'Flu. And this despite being about as far away as it is possible to get from Norfolk and still be in England.

'Flu? I hear you say sneeringly. We know all about 'flu. We've seen the ads for Lemsip and Beechams. Those poor souls take a couple of capsules and are back on their feet in no time. What the heck is the matter with folk in Ambridge. Do they all have delicate constitutions like heroines in eighteenth century fiction perchance?

Well no. They don't. And here's a newsflash for you. Those ads you refer to, they lie. I know, shocking isn't it. But it's true. Those nice people in them are acting. They never had the 'Flu in the opening frames, so they had no trouble looking miraculously better by the close of the ad thirty seconds (or "in just three days!") later.

The real problem is that every year hundreds of folk hereabouts go down with a bad cold and call it "The 'Flu". After all it sounds so much better when they have been away from work for a few days. And yes they did feel grotty, perhaps snotty, definitely feverish, and porper poorly for a few days. Poor things.

But when they get the real thing, it's like they've been hit by a truck. Even opnening and closing their eyelids hurts. Death seems to lurk just beyond the doorway, and even after the first flush of lurgy has passed they are left feeling drained and lifeless as one of Dracula's hapless victims for weeks on end afterwards. And no amount of patent nostrum will do the trick.

But this can't be the 'Flu. After all those nice people in the ads got better so much quicker so this must be something much worse....

So for the benefit of those reading this who think they might have the 'Flu, let me just say this. You haven't. If you did, you wouldn't have had the energy to read it in the first place. Just take a Lemsip* and get on with it like they do on the telly. For those of you having it read to them because they feel too ill to read it for themselves, then yes, you might well have the 'Flu, but unless you have other more scary symtoms to go with it like very bad breathlesness or neck stiffness so severe you can't lift your head off the pillow then I'm afraid the best you can do is get whoever is reading this to get you a nice Lemsip* to take the edge off things and catch up on some much needed sleep. Of course if you are that breathless or stiff necked then you might be wise to call your Doc for helpafter all, and tell them I sent you.

* other cold and 'flu remedies are available.