Monthly Archives: May 2015

A letter to the Prime Minister

Claire RobertsonClaire Robertson is a GP in Inverness.

LETTER TO THE PRIME MINISTER

Dear Mr. Cameron,

I have been meaning to write to you for some time, but, as I am sure you can imagine, life and work take over and the days fly by. The time has come over this last week having watched with interest the election results unfold and the Conservative majority see you remain our Prime Minister. Now that this second term is underway I plead with you listen to your dedicated public servants:

I am from a working class background. My grandfathers were a miner and a dairyman respectively. My parents, brought up well, went on to university and Art School in the 70s and became an art teacher and architect, both working in Moray for local authorities. I went to a good state school, did well academically and graduated in 2003 from The University of Aberdeen as a Bachelor of Medicine and Surgery. During my training, I spent time in Fairfield Medical Practice, Inverness in my fourth year and it was there, one Friday night driving home to see my mother, I knew my future lay in general practice.

I entered a GP Vocational Training Scheme in 2004 and trained in the same practice, becoming a fully fledged GP in 2007. I have worked full-time ever since in Fairfield Medical Practice, as GP partner since 2008. I work exceptionally hard, deal with difficult situations and many challenges. My admin time is in my own time. Our days are all about care balanced continuously with managing increasing demand. When I started as a partner we had 4000 patients but we now have over 6000. We are a small business. This increase in 2000 patients comes with little increase in funds in our Global Sum payment. Naturally we have increased staff, but GPs are what is needed and GPs are the most expensive commodity. We have to pay our reception and nursing staff, so we continue to manage our demand by working harder and harder. We have not increased GPs since I joined. Running costs increase year on year, as do salaries for our employed staff. We fight the daily media onslaught: greedy GPs, GPs care worse than ever etc, etc.

My care has never lessened, despite the increased demand from patients, health boards and Governments (revalidation, CQC etc). I try hard, so hard, every day to manage expectations and demand. It becomes the hardest part of my work. I cannot describe how hard, each day starting a fresh with the mantra to be an exceptional advocate for the patient, care, treat, diagnose, manage risk and expectations, provide value for money, use resources effectively and protect the NHS from inappropriate demands. By the end of the long day and in excess of greater than 120 patient contacts, the mind is sore and fit to burst at times. Treating the sick is the easy (if heartbreaking) part of the job. The service I provide is exceptional value for money. To be able to see a GP you know, who knows you and your family for 30 years of life hopefully. The benefits are well documented. Continuity of care (not access to a GP but your GP) reduces admissions, referrals and expectations. Those who see us, trust us, and the Health Service benefits in an un-measurable way.

The politicians, your party included, fuel the demand. Why do you need to see a GP every day of the week? You do not. Nor do you need routine referrals on a Saturday or late night Friday for the chronic condition you have had for years. Politics and media are fuelling unacceptable and unaffordable demand. The NHS is unaffordable as it is as you know but is a precious an envied service that we must never lose. I am trained to be a gatekeeper and effective manager of NHS resource and the desire to win votes pre election serves only to make my job harder. Yet, I make yours easier and save money for our country daily, weekly, minute by minute.

Your party in the last five years has made great attempts to begin long needed reform. The welfare reform, Universal Credit, is to be commended. Welfare and health reforms are never popular but we (the strong–shouldered) must stand strong. Reform is needed if we are to survive. However, politicians must be brave and honest. Of course, everyone would like to do everything 24/7 but I cannot do the things I wish to do when I finish late or start early, when shops and post offices are closed and accept I do not need to. General practice needs more resource certainly as do many areas of this 24/7 NHS you promise. I do not wish for patients to have to wait, but most can and should be told this. We can triage and manage illness demand safely. The rest are worried well. We must not pander to them, we must educate them.

You pledge 5000 more GPs. How is this going to be achieved? Daily the job becomes less attractive. At times even to me the job can seem unachievable constantly fighting the inefficiencies within secondary care and social care, having more and more work transferred to primary care without resources which takes up time to see patients, yet I try and try, harder and harder. Why? To make it work. To make the service better for all and for our future in this United Kingdom. Tiny drops in the ocean, but maybe, one day they will make a difference. The trouble is, it is hard to sustain this. GPs retire and leave to new pastures, as this level of work is not possible long term. How then can you recruit 5000 new GPs? The press and politicians slate us, not supporting us. Never saying to the public, actually your GPs provide an excellent service and you must use it more responsibly and learn to manage your own health. No, daily expectations are fuelled and demand increased, leading to dissatisfaction. The expectations are unrealistic and unaffordable.

We have a wonderful NHS. It can and should be more efficient and flourish but increased access to general practice is not the answer. Increased resource to general practice is needed urgently but you must allow us to manage our patients’ needs. (Our practice signed up to extended hours some years ago under the Labour government, funding has reduced and costs of opening increased, it is now just about affordable for us to continue with. Few patients attending work 8am-6pm, they just choose to come then as the appointments are seen as convenient.) I frequently offer people a number of appointment options during triage to be told “no I can’t come then or I don’t have transport, don’t worry I’ll just call NHS24 after 6pm and then I’ll get a free taxi up to A+E”. Our service is for medical need, not convenience and Governments should be brave enough to say this and deter the mis-users.

I respect our country, you Mr. Cameron and your Government. I thank you for keeping our country together last year. I thank you for my opportunities as a public servant and that of my partner, also with a similar upbringing to myself and attendee of the same school – a Royal Marine from the age of 16-27 and since in the Fire Service. We work very hard and are comfortable I admit but have the financial pressures of many and appreciate no Government suits everyone but we deserve respect and honesty. You have governed well and strongly and I hope that you can serve a second term honestly and sensibly as the country needs stability. I plead with you in this second term to save the NHS and our public services and the increased demands politicians fuel. It is unaffordable, unnecessary and will cripple us.

Good luck with this second term, but I plead with you please save our NHS in the right, brave way. Be brave and honest as our Prime Minister. Please tell people they can expect what they need but not what they want. If you find this plea unacceptable or the situation unbelievable I invite you to spend a day, seeing our demands as GPs to see for yourself and maybe then your party can truly understand what the country needs.

Yours faithfully

A letter to the Health Secretary

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

LETTER TO THE HEALTH SECRETARY

Dear Mr Hunt,

Many congratulations on being re-appointed as Secretary of State for Health in the Conservative cabinet. May I suggest we treat your re-appointment as a fresh start?

As a gynaecology SHO performing intimate examinations I was once told to ‘go in like a butterfly and come out like a lion.’ The idea was to cause minimum discomfort by combining a gentle approach with a swift withdrawal. This was not a strategy you adopted when you began your intimate examination of the NHS in 2012. It did in fact feel quite rough and quite prolonged. This time around perhaps you could be a little more gentle with your ideas and re-organisations and, when we finally get a period of stability, come out like a lion and stop meddling.

On many occasions you have talked of ending a culture of bullying within the health service and yet have yourself employed a beatings-will-continue-until-morale-improves attitude when dealing with its staff and this has endeared you to few. Attempting to bully the allied health professions of the NHS to fall into line with your ideas has not won you many friends.

For years NHS staff have hardly been able to turn on an NHS computer terminal without being greeted by your semi-psychotic stare and oddly geometric haircut as your picture has headed the endless bulletins and memoranda that spew forth from the Department of Health. Whilst producing a new edict may feel like a good days work to you, for those of us receiving it, it feels like an imposition, an interference and the promise of much more work for very little gain.

The smoke and mirrors re-organisations of the health care system that health ministers like yourself are fond of, the kind that generate a lot of activity, a rebranding or two and an apparent improvement in outcomes, actually distract from the business of treating patients.

Please remember too that the health care system is just that, a system for delivering health care. It is not a government tool to be used to address whatever national woes are troubling the electorate at any given moment. The NHS is not a branch of the benefits system nor is it an outpost of the immigration service.

Please dispense with ethically barren ideas such as denying benefits to people who refuse treatment for obesity. Doctors, nurses and other NHS staff should not feel obliged to coerce patients into treatments for purely financial reasons. Ideas such as this are eye catching and superficially gratifying to our vindictive sides but are unethical and unworkable in reality.

Neither can GPs solve the problems with immigration. Whilst it may seem an appealing idea to catch unsuspecting illegal immigrants whilst they are at their most vulnerable, the point when they seek medical help, most GPs would be reluctant to guilefully dupe immigrants into believing they were going to be given treatment for their illnesses before gleefully slinging them into detention. Please resist the compulsion to medicalise problems that are essentially social and political.

No-one would say that the NHS is a perfect system, but it is a good system. There is work to be done and changes to be made but trying to force all of them through between election cycles is devastating to the day-to-day functioning of health care.

You may like to think of the NHS as a wild stallion galloping powerfully through the plains of the UK. To tame it you can tie it up, beat it and try to break its will. This might work but, at the end of it, your stallion will be damaged both inside and out. Or you can whisper to it, coax it to your will with gentle reason and calm debate, and together we can ride off into the sunset.
I wish you well in your second stint at the helm of the NHS, and I hope you will wish us well in return.

Yours sincerely.

Exercise and sudden death in older athletes

_DSC1230John Brooks is a GP from Congleton.

The early works of Morris and Rose suggested that those who were more physically active had less coronary heart disease than those who had a more sedentary way of life. The rise in popularity of running in the 1970s and 1980s led to some exaggerated claims that marathon running could somehow give immunity to coronary heart disease. Cases of sudden death in marathon races get a lot of publicity but the risk is probably no higher than people going about their daily activities.

Sudden death from cardiovascular disease in young athletes is low and thought to be mainly due to inherited or congenital abnormalities. The most common of these is hypertrophic cardiomyopathy with a smaller group made up of such conditions as Wolf-Parkinson White syndrome, Marfan’s syndrome and mitral valve prolapse1. The cause of the sudden death is a fatal cardiac arrhythmia that occurs in a seemingly fit athlete. Gentle jogging three times a week seems to be relatively safe and good for your health2 but how safe is long term endurance and intensive exercise particularly as we get older ? This question is important for those athletes who want to perform well at club level and elite athletes.

Studies of cardiac adaptation to acute and chronic participation in endurance sports have shown both enzyme changes and evidence of cardiac remodelling.3 We know that during ultra- endurance exercise cardiac troponins are raised but they are rapidly cleared from the blood. The relevance to this and cardiac damage is uncertain. The cardiac changes due to chronic endurance exercise are now well established as left ventricular hypertrophy and a low resting heart rate. The “athletic heart” is similar to the heart seen in the cardiomyopathies due to cardiac remodelling but in the majority of cases it can be distinguished on ECG and ultrasound.4 These changes are an increase in the ventricular cavity of no more than 66mm and a left ventricular hypertrophy of no more than 15mm. Athletes, due to the changes in the left ventricle, will have an increased stroke volume and probably an improvement in the diastolic filling. Studies of lifelong athletes have found a small number of cases of interstitial fibrosis which could give rise to cardiac arrhythmias. Finally athletes who retire often have an incomplete reversal of their left ventricular hypertrophy. The studies so far have not suggested any deterioration in left ventricular function or increase in cardiovascular disease.

[bctt tweet=”The  veteran athlete with a slow pulse and palpitations may well be worth investigating.”]

For most senior athletes endurance training will improve their overall cardiovascular health but there remains a small group who develop premature cardiac arrhythmias – especially atrial fibrillation and atrial flutter. Endurance athletes with sinus bradycardia have a higher incidence of sinus node disease and pacemaker implantation. Recent research suggests that the cause of the bradycardia may in fact be due to electrophysiological changes in the sinus node and remodelling of pacemaker ion channels and not due to an increase in vagal tone.5 From the practical point of view it is worth remembering that a seemingly fit veteran athlete with a slow pulse and palpitations may well be worth investigating.

References:

1. Sudden death from cardiovascular disease in young athletes: fact or fiction? Sharma S, Whyte G, McKenna WJ, Br J Sports Med 1997; 31,:269-276
2. Park run eases the loneliness of the long-distance runner. Nigel Masters Br J Gen Pract 2014; 64 [625] : 408
3. Cardiac adaptation to acute and chronic participation in endurance sports. George K et al. Heart 2011;97 [24] 1999-2004
4. Sudden cardiac death in athletes BMJ 2015;350:h1218
5. Alicia D’Souza et al Exercise training reduces resting heart rate via a downregulation of the funny channel HCN4 Nature Communications 5, Article :37758 doi:1038/ncomms4775 13/05/2014