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Monthly Archives: July 2013

Aside

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Originally General practice  attracted a fee for services and the doctor would treat people who couldn’t afford the the fee on a charitable basis as his contribution to the community.

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I entered General Practice in 1979 and was in partnership with Dr Noel Thomas who was the fourth generation of  a well established practice in a South Wales town called Maesteg. The population I cared for were miners, steelworkers as well as farmers and their families. They were hard working and there were many diseases which were particularly common in this part of Wales- miners contracted pneumoconiosis as a result mining coal alongside silicon rock and heart disease was rife. Also, back problems and other orthopaedic problems were common due to high number of men in heavy manual work. There was a high incidence of cystic fibrosis and spina bifida in children.
The surgery had about 5,000 patients and  Dr thomas and myself were full time and Dr Noel Thomas father Dr Ralph Thomas whom I succeeded continued to do one surgery each week. We had 2 nurses who acted as receptionists and nurses and 2 other part- time receptionists. One of the nurses, Vera had been an A&E sister and had a vast experience of trauma medicine including experience of mining accidents and the other nurse, Mary had been a paediatric sister and I particular remember her describing how she nursed children in iron lungs during polio epidemics. We also cared for our patients who were admitted to the cottage hospital for acute medical reasons or to the attached Maternity unit. We also had patients in  a long stay hospital LLynfi which was for the chronically ill patients.
Dr Thomas Thomas the great grandfather of the medical partner I was with in Maesteg, South Wales had practised in the days when he relied on fees for his services. and in the town there remains a water pump which was dedicated to him for his work in the Cholera epidemic of 1860.
It was at this time that his son Dr Bell Thomas  started to treat workers particularly miners and steelworkers in General practice. General practice covered workers under the Lloyd George’s National Insurance Act of 1911, but not their wives and families, whose proper demands were restricted by the need to pay fees for service.
When they were sick, it was the GP to whom people wished to turn. The work of the GP had been described in idealistic terms by Lord Dawson in his report of 1920, which laid out the structure a health service might take.
The GP
*.should be accessible,
* attend patients at home or in the surgery,
* carry out treatment within his competence
* obtain specialist help when it was needed.
* attend in childbirth
* advise on how to prevent disease and improve the conditions of life among the patients
* play a part in antenatal supervision, child welfare, physical culture, venereal disease and industrial medicine.
 Nursing should be available, based with the doctor in the primary health centres Dawson envisaged.
This picture was in stark contrast to the day-to-day pattern of the GP’s life.
In inner cities overcrowding led to domestic violence, lice infestation and skin diseases such as impetigo.
 CAH Watts, a GP writing of his experiences in a mining community before the second world war, recalled the waiting room with rows of seats for about 60 patients who sat facing a high bench like a bank counter.
Behind the counter stood the three doctors and behind them the dispenser. The doctor called the next patient to come forward. Having listened to the complaint, he turned to the dispenser to order the appropriate remedy. There was rarely any attempt at examination.
Even when I started in practise it was considered unusual to examine a patient .
(This was the case in a practice not far from here 15yrs ago! Even worse was the GP  who was bed-bound and her unqualified daughter Gloria saw the patients, diagnosed their condition, wrote the prescription and ran upstairs to get the it signed by her mother)
Visits usually numbered about 50 and were made on a bicycle. This had decreased to between 10-12 by the time I started in practise.
Diphtheria was endemic and every sore throat was viewed with suspicion. Antiserum was one of the few active treatments available to the GP, and if given within 24 hours of onset the results were excellent.
Otherwise, the mortality was about 20 per cent.
In the practice we have an elderly patient who has described  to several of our medical students her experience of having diphtheria as a child and how those that died around her or who carried off to hospitals never to return.
Patients with  diphtheria or scarlet fever were taken away in a yellow ‘fever van’ to the infectious diseases hospital for at least six weeks often known as the ‘ Isolation hospital ‘ which were situated on the outskirts of small towns;
 no visitors were allowed.
Lobar pneumonia was common, and with the more fortunate patients there was a crisis about the seventh day. It struck terror into the patients’ and the doctors’ hearts, for the mortality was thought to be at least 50 per cent and the sulphonamides given were invariably  not curative.
My predecessor, Dr Ralph Thomas son of Dr Bell Thomas when I worked in Maesteg South Wales described many of these experiences often referring to a patient he noticed coming through the door.
He related the anxious moments of how he had to wait by the bedside to see if the patient ‘pulled through’ . By the time I had qualified more antibiotics were available and this occurrence was less frequent but did occur.
My nearest experience to this was when treating a young person with heart failure (secondary to heart valve disease following rheumatic fever) in their home by injecting  intravenous diuretics and waiting for the chest to clear and the breathing become easier. Unfortunately on several occasions I had to experience a patient dying before my eyes as the medicine failed to take effect. The local hospital was 20 miles away and in the Winter months roads were blocked, ambulances were poorly equipped by modern standards and medication was  less sophisticated.
Major  surgery was only possible if the patient was willing to travel to London 200miles away with no Motorway. Only the most advanced heart cases were referred to London and then the waiting list  was long and the prognosis was poor and many never returned or if they did come back it was with a stroke or other serious complication.
Alternatively , heart surgery was performed by the general surgeon overseen by the general physician who took ECG’s during surgery and cared for them postoperatively. I recall a physician showing me an amazing ECG which went flat as the surgery was performed and as the heart was repaired  the  rhythm  returned to normal as the heart recovered.

At that time nearly about 35years ago it was found that a patient would have a better chance of survival staying at home rather than being admitted to hospital.

Most dreaded was tuberculosis, blood in the handkerchief after a fit of coughing. Some families were especially vulnerable and it tended to strike young people. The course could be lingering or extremely rapid, with death within weeks.
Lung cancer was rare. If it occurred, it would probably not be recognised.
Miners were particularly vulnerable and I remember doing an attachment at Sully Hospital outside Cardiff which was built for the purpose of admitting TB patients who had 6-12 months stays. Every patient had an amazing view of the sea from their hospitaI bed. It was a pleasant place to work but the downside was that each morning we had to check everyone’s sputum on a daily basis reporting a full description! But again treatment was evolving and immunisation  for TB had become available, hence there were fewer cases.
Chest problems when I worked there were mostly attributed to pneumoconiosis a disease contracted by miners and incredibly debilitating, nevertheless an interesting group of patients to work with – full of tales, humour and of course great voice if they still had breath to sing.
Almost half the babies were delivered at home, mainly a matter for midwives. Pain relief in labour, although available in hospital, might not be provided in the home.
 When things went wrong the GP would be summoned, because procedures such as breech birth or manual removal of the placenta might be required.
Most GPs used chloroform as an anaesthetic though some felt it was quicker and safer without.
As they might have neither the skills nor the equipment to handle problems, in many places obstetric flying squads, based in the hospitals, had been established. These could deal with haemorrhage, shock and eclampsia (fits during late pregnancy, labour and the period shortly after), transfuse patients, give anaesthetics, and undertake operative obstetrics in the home.
In Maesteg the miners  had raised money to build a hospital with a maternity unit but I remember the ‘Flying squad ‘ going out to Obstertric  emergencies. Sadly a street in my practise in Cymfelin near Maesteg had the highest incidence of spina bifida/ anencephaly in the World. Now virtually totally prevented by taking folic  acid  supplements and  I along with other doctors at  that time were involved the original trials.
Tales of obstetric disaster, haemorrhage after delivery and problems with forceps were all too common, although remarkably many women survived crises which would be unthinkable today. Serious infections (puerperal sepsis) killed mothers after childbirth, particularly during the winter months when streptococcal infections were endemic.
Pain and discomfort were accepted as part of life to be endured with stoicism. The family doctor had to be tough to get on with his many interesting and rewarding tasks.
If he had access to a hospital, he might set a simple fracture or reduce a dislocation. Working class people did not expect to be comfortable.
Most went hungry and their undernourished children showed evidence of rickets until vitamin D supplements, provided by welfare clinics, controlled it. Many were miserably cold in winter unless they were roasting in front of the coal fire in the kitchen. I remember patients describing these events when children ran around in bare feet and men fought over food for their families.
Although screening is considered part of modern NHS I was inspired 35 years ago by Dr Julian Hart , a neibouring GP in his practice in Glyncorrwg, Wales, as his practice was the first in the UK to be recognised as a research practice, piloting many Medical Research Council studies. He was also the first doctor to routinely measure every patient’s blood pressure and as a result was able to reduce premature mortality in high risk patients at his practice by 30%. Inspired by this as soon as I became the Principal at the Avenue I performed a new patient check on every patient who presented  and this now continues for all new patients. The Government as just announced it in today’s headlines ‘Free health checks could save lives, Jeremy Hunt says’
I remember in the first year I diagnosed 19 new diabetics including an 18 year old and many new patients walking around with high blood pressure.
Successful treatment by the family doctor was accepted with gratitude and the many failures were tolerated without rancour or recrimination.
Patients’ expectations were not high. The death of children from infectious disease was the way of the world. Mothers of feverish children expected, if the child was not to be admitted to the fever hospital, to be told that bed rest was crucial until the fever had fully subsided.
GPs’ hours were long, as most practices were single-handed and deputising services were non-existent.
I remember working alternative days and nights with my GP partner  aswell doing daily ward rounds at the geriatric hospital and the Cottage hospital.
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There were no McMillan nurses and terminally ill patients were seen up to 4 times daily ( last visit 10pm)  to administer pain relief. We got to know these families well and the reward was simply managing the situation and showing empathywithe patient and the family  throughout and after the distressing illness.
 Local rota systems operated on a ‘knock-for-knock’ basis to make a half-day practicable. A car and a telephone were desirable – but not essential. If it mattered enough there was always a way of contacting the doctor sooner or later.
People did not trouble GPs without good cause. If someone phoned I was able to say how urgent was the call and if not very urgent I could finish my supper first and patients respected that you were someone who had a life. I did my own on-call until 2005 when the Government encouraged us to opt out.
 Most had to pay for the doctor and the medicines. The professional attitude to working class patients was frequently robust, and sometimes downright rude, but this was accepted with tolerance. In middle-class practices there were greater courtesies. However, where I worked in Wales the working classes were respected as their work in the mines and steelworks was tough and the Miners funded the Cottage hospital which had a maternity suite, general ward, operating theatre and a children’s ward and supplied ‘the opening medicine'( laxatives ) in the form of a delivery of stout each day!
There was the ritual preparation of a napkin, a spoon and a glass of water for the doctor’s visit. There might be five shillings (25p) on the mantelpiece for the fee; three and sixpence (17½p) if the family was not so well off.
High up the social scale the doctor might be treated as a rather superior type of servant. Patients often paid in ‘ kind’ by leaving home grown vegetables or hand-knitted garments at reception or even on your doorstep.

Medical diagnosis was often of academic rather than practical importance. Treatment was limited to insulin, thyroid extract, iron, liver extract for pernicious anaemia, digitalis, the new mercurial diuretics, barbiturates, simple analgesics, morphine derivatives and harmless mixtures.

In my experience medication such as Ipecac et Morph ( for coughs ) or Gentian ( tonic) Mist Pot Citrate ( known as cockles water) for cystitis Mist magnesium trisilicate ( ant- acid for indigestion) ,mandrax and barbiturates for sleeping and intravenous heroin for heart attacks , adrenaline for asthma were medicines I prescribed and administered regularly.
It was difficult to keep track of prescribing, all prescriptions were hand written often illegibly and I am sure compliance and abuse was not uncommon.
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Records were in Lloyd George wallets and belonged to the Secretary of State and for written records this is still the case. Electronic records only started to evolve in 2001. Generally record keeping was poor and frequently doctors wrote inappropriate remarks on the notes such as PIN ( pain in the neck ie difficult patient) or a diagnosis of GOK ( God only knows) but this stopped when patients were allowed access to notes after 1990.

Entry into a practice was generally by purchase of goodwill, the usual price being one and a half times the annual income.
GPs started with a substantial debt. On average about 1,000 national insurance patients generated about £400-£500 per year, an income boosted by the care of the families who were not covered by national insurance.
Most  GP’s had no pension, waived fees or never received them from poor patients and I they retired due to severe ill- health or died  they spent the rest of their lives in poverty. A Benevolent Fund was established , fund-raising carried out by doctors wives. I remember local women coming for afternoon tea always on a Tuesday afternoon  at  the doctors house, raising money for doctors left in poverty.

The NHS Act 1946 provided a family doctor to the entire population. The Bill emphasised health centres that were to be a main feature. At public cost, premises would be equipped and staffed for medical and dental services, health promotion, local health authority clinics and sometimes for specialist outpatient sessions. The programme was aborted before it even started.

Whereas Bevan had persuaded consultants into the service in part by merit awards, the GPs had been unwilling to join until virtually the last moment. The public, however, were encouraged to sign on with those doctors willing to enter the scheme, leaving others with the choice of joining as well or losing their practices. Within a month 90 per cent of the population had signed up with a GP. Twenty thousand GPs joined the scheme as they saw private practice disappear before their eyes.

The NHS Act made it illegal to sell ‘goodwill’; instead a fund was established that compensated GPs when they retired, but it was not inflation-linked. The GPs’ contracted for a 24-hour service, the nature of the complaints procedures and even the patients’ NHS cards were virtually unchanged (and still are). GPs, fearing that they might be no more than officials in a state service, argued successfully for a contract for services rather than a contract of service. As a result they remained independent practitioners, self-employed and organising their own professional lives. The Spens reports determined pay, which was entirely by capitation.

GPs’ income depended on the number of their patients; even their expenses were averaged and included in the payment-per-patient. Their independence thus assured, GPs were taxed as though they were self-employed, yet, unlike most people in small businesses, they could not set their fees. With a few exceptions, such as payment for a medical certificate for private purposes, no money could pass between patient and doctor. This system, combined with a shortage of doctors, provided no financial incentive to improve services, but neither was there any incentive to over-treat patients.

Now many doctors are salaried working for self employed doctors or in PCT(CCG) health centres.

In 1966 the Royal College of General Practitioners submitted evidence to the Royal Commission on Medical Education. This was to prove of decisive influence in shaping the recommendations of the Commission when they were published in 1968 (Todd Report). The Report made a powerful case for the recognition of general practice as a separate discipline within medicine, requiring its own form of postgraduate training organised by general practitioners. The fulfilment of the College’s work came in 1976 when parliament approved legislation making vocational training a requirement for any doctor seeking to become a principal in general practice and set up new national organisations to administer the act.
I was one of the first doctors to be selected to be part of a Vocational Training Scheme which took 3 years to complete and involved 6 months in 6 specialities. I worked as a junior doctor in General Medicine/ respiratory medicine, obstetrics & gynaecology, paediatrics, orthopaedics and trauma and ENT and General practise and at the end of this received the post graduate degree MRCGP following an external examination.
I decided to work for a further year in paediatrics before becoming a Partner in a practise in Maesteg,South Wales.

I have to say I loved those days in General Practise and  felt it an honour to serve that community  and it was with great joy that a bus load of staff and people I worked with  travelled up to London to my wedding  when I married my clergyman husband.  Even though the rumour which went around the Thursday market was that I was  marrying a missionary from East  Africa rather than  a vicar from East Acton! Also they were very concerned that I was going to live in London- would I be safe?
I did arrive in London to a very different General Practise and I took several years to get used to a multicultural society and a’part-time service but more conducive to married life!
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But as we all keep hearing the world has changed and we are forced to change with it but hopefully we can take the good things from the past recognise vast medical progress. People are more aware of their health and health prevention, communication and recording our work using IT has allowed us to better define the problems we face in order to improve the quality and efficiency of our work.
We can all be a Dr Tudor Hart recording results and findings on to  Dr Foster website.  (Foster Intelligence is a provider of healthcare information in the United Kingdom, monitoring the performance of the National Health Service and providing information to the public. It is a joint-venture with the Department of Health and was launched in February 2006. It aims to improve the quality and efficiency of health and social care.
It monitors the performance of the National Health Service and provides information to the public)

It makes sense to direct services where they are needed Southall needs more diabetic consultants and cardiologists than Reigate. Also to find out what we are doing well and what we are struggling to do effectively .
Based on results of this analysis and other audits it has become apparent how costly it is to use secondary(hospital) care if it can be done more or just as effectively and less costly in primary care.

However, it is paramount to knock down barriers of communication between hospital and primary care staff and I have seen great changes to improve this. Does a patient need to attend a hospital to hear everything is fine?

Blood tests can be carried out in general practise. Type 2 diabetes without complications does not need a specialist diabetic consultant and a mechanical back strain does not need an orthopaedic surgeon to treat. A few examples but there are many more and this has convinced both parties that a more rationale approach is needed to decide where a patient is best managed. Albeit, there are still health professionals out there who are vehemently hanging on to what they have always done but each year they are getting less and -at meetings those voices are disappearing.

The new NHS is evolving – the sun is rising.
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Integration has been the NHS buzzword of choice in recent years, and unsurprisingly, features heavily in the college’s blueprint for primary care –

The 2022 GP.

The 20th century model of healthcare – splitting up hospital and community-based care, as well as health and social care, is ‘outdated’, the report says.

‘We are moving instead towards a 21st century system of integrated care, where clinicians work closely together in flexible teams, formed around the needs of the patient and not driven by professional convenience or historic location.’

GPs will increasingly work in federations, leading multidisciplinary teams encompassing nursing and hospital staff, using electronic records to support co-ordination of care.
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Contractual arrangements will be varied, with many GPs employed in salaried roles by federations, foundation trusts, and third or private sector providers, alongside independent contractors, the report suggests.

As the NHS celebrates its 65th birthday, it is entering what the RCGP identifies as a new era.

Over the next decade, patients will face ‘more complexity, morechoice and more uncertainty and will rely on the expertise, skill and compassion of their GP like never before’.

The college has called for 10,000 more GPs and a sharp rise in funding to help the profession absorb the pressure.

But to remain fit for purpose, it says, general practice must evolve, not simply expand.

So what is the RCGP’s vision for general practice in 2022 and how
realistic is it?

Adapted GP role

The RCGP is clear that as part of this shift, ‘the role of the GP will need to be adapted’. The report, co-authored by RCGP chairwoman Professor Clare Gerada, outlines a vision of the 2022 GP as an ‘expert generalist’.

This new breed of GP will be trained to manage increasingly complex patients with chronic conditions and polypharmacy, handling ‘urgent and routine needs’, and providing ‘first-contact care to the majority of children and those with mental health conditions’.

GPs can no longer stick to the 20th century model, in which they are considered ‘omnicompetent independent doctors’, the RCGP argues. Instead they will need to work ‘as part of a family of interconnected professionals’ that could include hospital specialists given additional generalist training.

Many Medical students now do 4 months in General Practise as part of their registration which now takes 2 years. until a few years ago it was 12 months and was 6 months general medicine and 6months general surgery. Two thirds of medical students will become GP ‘s.
During the past year we as GP’s are meeting with specialised consultants to discuss complex patients and consultants are visiting GP’s to discuss management of particular conditions and communicate which type of patient needs referring.

Meanwhile, GPs will train to take on extended roles in core areas that need ‘a generalist approach’ – perhaps care of those with dementia, homeless patients or those in nursing homes.
This month care of all nursing home patients in the defined Ealing CCG area has been taken over by a group of GP’s who will manage the care of residents and be accountable for the standard of care.
This model will be extended to other groups of patients if it is successful.

Complex needs

Practices will also need to reshape their services to meet the needs of more and more patients with complex chronic conditions.
Forming ‘micro-teams’ that bring together primary care, social care staff and clinicians from other specialties, such as paediatrics or mental health, could help provide continuity of care to named groups of patients in need of extra support.

This team-based approach may also provide the solution to rising rates of doctors working part time, the report suggests, through an ‘increased focus on team-based continuity’ and more ‘buddying up’ arrangements between doctors.
This has been attempted over many years with great resistance but the climate is changing and those not wanting to comply will be under great pressure from CQC inspectors.

The standard 10-minute appointment slot will become a thing of the past. GPs of the future will offer ‘flexible lengths of appointments, determined by need’ and will need to ‘adapt their working day to offer fewer but longer routine appointments for review of patients with complex needs’.

Online NHS

A generation of patients brought up with the internet will mean many ‘will expect to interact with their general practice team virtually’, with traditional face-to-face GP visits ‘no longer accepted as the default way to access care’.
We already use emailing as a a way of communicating with patients and ordering repeat prescriptions. Also more recently patients will check their own blood pressure in a pharmacist, supermarket or using there own machine and having face-to-face much less frequently. Pre-consultation questionnaire will be used to prioritise what needs to addressed in the consultation.
My only concern is that opportunistic screening and the doctor- patient relationship will be limited. However, with doctors working less hours and larger practises the norm and finances strained this will be seen as the only way forward.

Better planning across federated practices will improve co-ordination and continuity of out-of-hours care, although GPs will not be required to offer direct patient-to-doctor access out of hours.

The RCGP vision also sets out plans to train GPs to have a better ‘understanding of the needs of their practice population’. This could help shore up the profession’s role in commissioning, amid Labour pressure to hand more control to local authorities.

Funding

Professor Gerada and her co-authors acknowledge that without substantial investment to expand the GP workforce and premises, ‘the vision will be made much more difficult or will become impossible’.
Small practises will not be viable and CQC will have the power to lose a surgery that does meet the required standards. This will encourage mergers of small practises but in my opinion it is better to look around and plan this before someone else does. Working in these multidisciplinary groups at present is helping finding like minded GP’s that can work together. There are some delightful caring young GP’s in the area who I would have no problem working with and they need to be nurtured.

Step one is winning the battle of ideas – an action plan in the report highlights a need to ‘promote greater understanding of the value generalist care brings to the health service’.

RCGP council member and deputy GPC chairman Dr Richard Vautrey believes this battle will be won over time, simply because no alternative exists. ‘It is economically essential for the NHS to be built on a primary care base, it’s in politicians’ interest to value it as the way the NHS can survive and thrive long term,’ he says.

The RCGP vision is realistic, he says, because many of the innovations in the report are already being delivered by GPs in parts of the UK.
We have formed a network ( a smaller section of the ECCG consisting of all local practises and meet regularly 1-2 times each month with other health care professionals to discuss complex cases and we have found ways of sharing resources and experiences which have most beneficial in managing patients biopsychosocial needs aswell addressing our own learning needs.

But he adds: ‘One concern is that as practices struggle with workload, it is hard to develop in the way they want to, because they don’t have the resources. Resources are crucial.’

The ball is in the government’s court – it must invest and build on the innovation and modern working of GPs across the country, or miss out on what The 2022 GP calls ‘a historic opportunity to harness the power of general practice to transform the health service we will have in 2022’.

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GENERAL PRACTICE – THE EVOLUTION

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FEEDBACK FROM PATIENT – CPR TRAINING

Recently we held a Cardiopulmonary Resuscitation training afternoon at the surgery. This is compulsory for all surgery staff to attend on a regular basis. On this occasion we also advertised it in the surgery as an open invitation to any patients to attend. We felt that it was good to members of the public (patients) to be given the opportunity to attend as these will be the people we may be working with if an event should happen.
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However, the interest was less than we expected but one patient wrote the following:-

I wanted to thank you for giving me the opportunity to attend your first aid training course, it was a privilege to be able to attend. Although I had attended a first aid course a few years ago, I found that the quality and content of this one, was superior. The course covered a range of topics including CPR, care of the unconscious patient, choking, anaphylaxis and heart attacks, with plenty of opportunities to practice and get involved. I found the use of a dummy to practice CPR particularly useful as was the discussion of the realistic scenarios one might face and the best course of action to take. This is something, that was certainly lacking in the course I attended previously. The interaction with the other members of the audience was also very useful. Since a number of staff members, doctors and nurses from the avenue and other surgeries attended, I had the opportunity to hear of their opinions and methods when it comes to first aid. Overall I found the course very insightful, helpful and satisfying. I would strongly recommend it to everyone be it healthcare professionals or patients. The skills you learn can literally make the difference between life and death.
I think that it’s wonderful that the surgery is allowing patients to attend these courses. I think this is a wonderful opportunity for everyone and the price is extremely competitive to the say least. I will most certainly be looking out for any other courses like this that might be available.

Thank you to this patient for sending me their comments. When I have attended this course before expectant parents seem to be the most interested especially as these training sessions cover accidents and acute problems in children.
If you would be interested in attending a CPR training session please contact
Sangeeta Kathuria ( practise manager) http://www.sangeeta.kathuria@nhs.net
It would be helpful if you could suggest what time and day would be most convenient- the sessions usually last 3 hours.

 

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THE PINK DRAGON IS REVEALED

Since I have let out  the secret concerning the dragons in the garden I have been asking the Dragon experts (children < 4yrs) a little more about what they see and the general consensus is that the most visible dragons are pink, blue or purple. I was a little surprised as I had not seen any of these.

Then…..
The other evening I was sitting quietly finishing off my paperwork and there was a knock on the window – yes you are right it was Denis and who was with him but a PINK dragon. I was a bit surprised and opened the door to meet his companion. ” This is my friend Polly. I haven’t seen her for ages but she called around and asked if I knew a doctor who wasn’t frightened of Dragons and could see her and I thought you would just the doctor,”said Denis.

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“Do come in and tell me what the  problem is” I said
Polly started to cry real dragon tears, ” I have lost all my dragon scales and I can’t stop scratching as my skin is so…..oo  itchy and now none of my friends  want to play with  me except Denis”
“Oh Polly don’t be too sad  I am sure I can help you.”  I looked carefully at her skin and the worst patches were behind her knees  and elbows and in other creases including under her chin.  “Doctors  call this  eczema which is sometimes caused by allergy  but often we don’t  know why. We must try and help you but you will have to listen very carefully and do what I say:-
Firstly you will have to stop using soaps, bubble baths or anything like that.
Then I will give you some special soft Dragon cream ( an emollient  such as Ultrabase, Diprobase, Dermol , Epaderm or Cetraban ) which comes either in a big pot or a bottle with a pump. It is VERY important that you don’t put your claws in the pot because if you do you will get germs in the cream and cream with germs in will make your skin much worse especially as the skin is so cracked. It is your cream and it is only you ,Polly that can use it so, Denis you cannot share it. Perhaps you could put a sticker on pot with your name on.
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If you have a pot you can use the handle of a spoon or spatula to scoop it out and put on your skin. You will need help from your mummy to put it on the places you can’t reach. Always put the dragon cream on in the direction of tour scales( in humans the direction of the hair) and don’t rub up and down because it will make you itch more. Perhaps you can play some quiet music or watch one of your favourite videos whilst she does it just something to make you feel calm and happy.

You must put this cream over the whole body and use plenty of it and do this 3 or even 4 times a day. If you feel itchy put some more on and perhaps you can have a small tube or pot to put on by yourself.
Also you can use this as a soap and in the shower or bath.

http://www.eczema.org/uploads/BAhbBlsHOgZmIjUyMDEzLzA2LzI4LzIxXzE4XzI5XzIzNF9FbW9sbGllbnRzX0p1bmVfMjAxMy5wZGY?format=pdf. (Eczema fact sheet

The next very important thing is TAP don’t SCRATCH so that this skin doesn’t break and become very sore. To remind you I will teach you a song.
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( post man pat tune)

Tap don’t scratch , tap don’t scratch,
tap don’t scratch with an Itchy feeling
all the dragons singiing
And the itch is healing
And Polly is a really happy dragon
Now I have also noticed that some of the patches are very very bad so I am going to give you some SPECIAL DRAGON CREAM (steroid cream) in a smaller tube. This cream you must use very carefully only putting on small amounts twice a day and stop when the patch looks better.
If you follow this you will find that gradually your skin will get better and be softer and back to green just like  your mummy’s and Denis’s skin.
Take this paper(prescription ) to the pharmacy and come  back next week to tell me how you are getting on. “
Then Denis and Polly turned around and hand in hand danced down the garden singing their new song………
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For more information about eczema: http://www.eczema.org/factsheets

 
 

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KITTY HEELS

imageThis weekend  I had the good fortune to attend a lovely wedding in London. It was the wedding of the first work experience student who sat with me > 10 years ago. Now qualified and making excellent progress in the medical profession she was marrying another doctor in The Temple Church and this was followed by a river trip to the location of the reception.

A very special occasion and as the only guests that I knew were more than half my age (friends of my daughter) one of those wedding suits and hat for a senior guest would seem inappropriate,  so aided by some eager,  enthusiastic, young shop assistants I finally found a dress that they all thought suited me ( not necessarily what I would chosen but then clothes shopping is not my favourite occupation!).

Then the assistant appeared with shoes with ‘Kitty heels’ and suggested that if I was going to a wedding that heels were a must. As I put them on they surprisingly fitted  but I have to say I did feel anxious being that much off the ground! I strutted nervously and unsteadily a few steps across the shop and decided I must conquer this and after all I did have a week to practise. Luckily (as you will find out later) they  had sold out of matching clutch bags. ( a picture representation)
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Each day that week I practised walking around my home and the surgery,  but still fearful of venturing out in the street. I thought the best thing was to try going to post a letter and I managed to get back in one piece. My main fear was falling or turning on my ankle. I have previously had a minor fracture of a bone in the ankle  just stepping from a kerb in flat shoes  so I am aware of the dangers of a postmenopausal women risks of broken bones.
I realised that although with the help of my freedom pass I could travel to the church in Central  London by tube there would be some walking involved. I decided that in no way would I have the courage to walk in Kitty heels any further than the nearest bus stop and  I must leave plenty of time, the only answer was to carry some flat shoes with me as back up. I hadn’t bought my matching bag so now I must look for a matching bag with enough room for flat shoes. I found the bag , not quite a portmanteau,   packed the shoes and  carried my fascinator…..
I stepped off the train found the stairs not too bad but then I stepped on to the street; I had not bargained for cracks around the pavement slabs and all I could see were the  cracks and the fear of getting the heel stuck overwhelmed me and I went back to my childhood stepping from slab to slab avoiding the cracks whilst women scurried past me with heels twice the height and not a fear in sight. I steered myself to the side of the pavement and as discretely as possible changed my shoes.
My next challenge was to find my way to the church,  no problem I thought as I have a sat nav on the phone. When I had circled the tube station  once  if not twice I stopped a tourist who directed me by showing me the way on his Chinese map of London! I walked briskly in my flat shoes and then when I saw the church I stopped around the corner put on my Kitty heels and my fascinator,  braced myself to walk confidently towards the church. Oh no, the road I had to walk on was cobbled- this was a real test. Gingerly I walked up the path to the church now on tip toe and waiting outside were these stunningly beautiful young men and women I had known so well for almost 20 years. I had given them lifts home from a variety of venues some more dubious than others, fed them, hosted them in sleep overs,  given them admin work when they were students,  listened to their gossip their hopes and fears found their cigarette stubs and empty bottles. Along with my own children they warned me which stations were no go areas at night, which lines to avoid and which taxi service to choose to be safe and how to avoid it getting hijacked and much more.  Now they had blossomed into handsome, attractive and vibrant  young people working as doctors, managers, lawyers, journalists, film makers, financiers, and teachers around the globe.
They greeted me with
 ” Hello, Dr Bayer  I love your dress and those shoes are georgeous!” ” Thank you ”  I replied, smiled but thinking to myself how much I would love to put those flat shoes on!
The service was beautiful the music amazing and now as I had been sitting with the young set I was told we now have to lead everybody to the boat to take us down the Thames so we must not hang around and get going.  I then braced myself and followed them trying to look confident and fearless. I reached the boat intact and slumped into a seat with a cup of tea kicked off the shoes nonchalantly and relaxed for the trip.
Finally we reached the destination and as I looked out of the window I viewed the long jetty  to the bank. Then I realised that it was made of decking with cracks between every board. It took only three steps for my kitty heels to be stuck twice needing aid from helpful male boatmen to prize the shoe out. I thought 20-30metres of this was not an option especially as there were tens of people behind me so I simply had to smile elegantly take them off and skip along to the end  with panache.  Unfortunately 20 mins prior to this we had had the only rain shower in many weeks so my feet were a little damp!
At the end of the jetty I put back the shoes and walked through the gate across the newly watered lawn  and discovered how heels sink in soft earth!
At last I arrived at the venue and greeted the parents of the bride  who were poised and elegantly dressed  and they dutifully said thank you for coming and  commented that that they had heard a lot about me. That left me wondering what they had heard?
I was then placed next to retired GP’s who were  bemused  as to why I hadn’t given up work and  that I was still getting some job satisfaction and were envious I had such a great partner who was so supportive at this time of my life.  As we get older it is so important to stand back, hold on to those solid ideals but capture the blind enthusiasm of youth and allow them to find new or reinvent old ideas to manage the present and the future.
I thought it prudent to leave before the dancing to avoid a potential  ‘ kitty heel ‘ disaster!
It was an uplifting experience and a joy to see a group of young people working hard, enthusiastic, travelling from all corners of the earth to reunite on this special occasion.
By coincidence I sat near a young GP  who was now working in the practise where my family belonged in a Nottinghamshire village where I grew up and I was able to reminisce  about my formative years and how things had changed..
 One of the highlights was an abridged Persian( Iranian)Aghd ceremony of marriage and a Persian senior member read beautiful poetry in Farsi and English during the ceremony two pieces of crystallized sugar (shaped like cones) are rubbed together, a symbolic act to sweeten the couple’s life together bride and groom feed each other honey symbolising a better and sweeter life. following this there was sharing of Persian delicacies to demonstrate the hospitality so typical of a middle Eastern culture.It is so important to be aware of these ancient ceremonies so that we can understand the futures of those we live amongst.
more at: http://www.iranchamber.com/culture/articles/iranian_marriage_ceremony.php#sthash.MOAddglL
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The reason I wrote this blog because wearing Kitty heels reminded me of how vulnerable you can be if you set out unprepared at this stage in your life.  I want to remind those postmenopausal women or if you are inviting a postmenopausal woman to join you  how the fear of falling can be a reality and a fractured femur, ankle or simply a fall can spoil not only a  great day out but much more.
Central London is on our doorstep and there is lots to see and experience but go prepared,  take the lead from those who know it well. The Freedom Pass is a ticket to ride it broadens your horizons , it takes you on the train, the bus and on the river for FREE . As an elderly man said to me one day when I remarked how fit he was for his age,  “if you don’t use it you lose it” and  that means getting out there to walk, enjoy and be part of the great city you live in and avoid the fears and lack of confidence that  can so easily take over and it could all be Free.

TIPS for seniors in London

  • Wear good footwear or carry it in a bag

Carry a bottle of water

  • Consider using a walking poles obtained from Arnold’s in West Ealing or any other outdoor leisure shop

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( probably not very chic to attend a wedding !) but they can be bought cheaply and improve confidence in walking on uneven surfaces.
Basically if two trekking poles are used effectively it:
·    Increases speed
·    Provides extra stability
·    Reduces fatigue and
·    In turn can increase the distance traveled in a day
·    Provides an upper body work out too
·    Allows you to walk looking up at the view and NOT down at the ground!
  • Make sure you have enough money for a taxi incase you need it at least
£20-30.
  • Look up your journey prior to setting off. Print it off on if possible using
  • Get a senior railcard  and enjoy the use of your Freedom Passimage
(Trips to Brighton, Windsor or Oxford)
  • Use modern technology  to find  a place to eat and how to get to your destination or take a picnic in a small backpack to have hands free

Find out what’s on and check whether there are concessions.we often have 2 for the price of one tickets in the surgery for shows or plays- ask at reception

For those younger readers  pass on the  tips to your older relatives or friends and let them enjoy some of the fun!
Don’t follow my example and make life difficult, if this amused you and made you laugh that will have added a few minutes to your life!
History of Kitty ( kitten) heels
They were introduced in the late 1950s as formal fashion attire for young adolescent teenage girls as higher heels would have been considered unseemly for girls as young as 13 because of the sexual connotations and unease of walk. They were sometimes referred to as “trainer heels” in the US, indicating their use in getting young girls used to wearing high heels. I think I got it wrong- trying to regain my youth!
 

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Aside

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WORLD HEPATITIS DAY – July 28th 2013

The date of July 28 was chosen for World Hepatitis Day in order to mark the birthday of Professor Baruch Blumberg, awarded the Nobel Prize for his work in discovering the hepatitis B virus.
See no evil,hear no evil,as represented by the three wise monkeys, an old proverb that is commonly used to highlight how people often deal with problems by refusing to acknowledge them. The monkeys have been chosen for the campaign to highlight that around the world hepatitis is still being largely ignored.
Hepatitis simply means inflammation of the liver and can be caused by a wide range of things. One of the most common causes of chronic (long-term) hepatitis is viral infection.
Five distinct hepatitis viruses have been identified: A, B, C, D and E. Hepatitis B and C, which can lead to chronic hepatitis, are particularly prevalent.
The five hepatitis viruses have different epidemiological profiles and also vary in terms of their impact and duration. The transmission route depends on the type of virus. Transmission routes that contribute greatly to the spread of hepatitis are exposure to infected blood via blood transfusion or unsafe injection practices, consumption of contaminated food and drinking water, and transmission from mother to child during pregnancy and delivery. Unsafe injection practices, including the use of unsterile needles and syringes, serve as a major pathway for the spread of hepatitis B and C, and reducing transmission of both diseases means changing these practices.
Hepatitis B and C are two such viruses and together kill approximately one million people a year. 500 million people around the world are currently infected with chronic hepatitis B or C and one in three people have been exposed to one or both viruses. Unlike hepatitis C, hepatitis B can be prevented through effective vaccination.

It is estimated that around 180,000 are affected by hepatitis B in the UK. Around 95 per cent of people with new chronic hepatitis B are migrants, most of whom acquired the infection in early childhood in their country of birth.
Hepatitis C is also a blood-borne viral infection that is transmitted through contact with infected blood. Around 216,000 people in the UK have chronic hepatitis C, and of these 87 per cent are current or past injection drug users. Almost half of the rest are from South Asian descent.

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Together hepatitis B and C represent one of the major threats to global health. Hepatitis B and C are both ‘silent’ viruses, and because many people feel no symptoms, you could be infected for years without knowing it. If left untreated, both the hepatitis B and C viruses can lead to liver scarring (cirrhosis). If you have liver cirrhosis, you have a risk of life-threatening complications such as bleeding, ascites (accumulation of fluid in the abdominal cavity), coma, liver cancer, liver failure and death. In the case of chronic hepatitis B, liver cancer might even appear before you have developed cirrhosis.
Will Irving, Professor and Honorary Consultant in Virology, University of Nottingham and Nottingham University Hospitals NHS Trust, and member of the Programme Development Group, added: “It is estimated that around half of the individuals living in the UK with chronic hepatitis B or C infection are unaware of their diagnosis, but they are at risk of developing serious complications of their infection.

While there is a vaccine that protects against hepatitis B infection, there is no vaccine available for hepatitis C
Both viruses can be contracted though blood-to-blood contact
Hepatitis B is more infectious than hepatitis C and can also be spread through saliva, semen and vaginal fluid
In the case of hepatitis B, infection can occur through having unprotected sex with an infected person. Please note that this is much rarer in the case of hepatitis C
While unlikely, it is possible to contract hepatitis B through kissing. You cannot contract hepatitis C through kissing
Neither virus is easily spread through everyday contact. You cannot get infected with hepatitis B or C by shaking hands, coughing or sneezing, or by using the same toilet. There are different treatments for the two viruses. While treatment can control chronic hepatitis B, it can often cure hepatitis C
Even if treatment is not an option it is very important to maintain a healthy lifestyle. Alcohol, smoking, eating fatty foods, being overweight or extreme dieting (eating no food at all) may worsen liver disease.
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Hepatitis B

The World Health Organization (WHO) recognises that hepatitis B is one of the major diseases affecting mankind today. Hepatitis B is one of the most common viral infections in the world and the WHO estimates that two billion people have been infected with the hepatitis B virus and approximately 350 million people are living with chronic (lifelong) infections. 500,000 – 700,000 people die every year from hepatitis B.

It is part of our contract as doctors that we have to have been immunised for Hepatitis B and our immunity is checked by blood test. We also do the same for our nurse and phlebotomist.

The hepatitis B virus is highly infectious and about 50-100 times more infectious than HIV. In nine out of ten adults, acute hepatitis B infection will go away on its own in the first six months. However, if the virus becomes chronic, it may cause liver cirrhosis and liver cancer after up to 40 years, but in some cases as little as five years after diagnosis.

The hepatitis B virus is transmitted between people through contact with the blood or other body fluids (i.e. saliva, semen and vaginal fluid) of an infected person.It arises primarily from injecting drug use, heterosexual contact with someone who is infected, travel to countries of intermediate or high endemicity, homosexual contact, and contact with someone in the same household who is a carrier and mother-to-child transmission. Although not all people will have any signs of the virus, those that do may experience the following symptoms:

Flu-like symptoms
Fatigue
Nausea
Jaundice (yellowing of the skin)
Stomach ache
Diarrhoea/dark urine/bright stools
Aching joints
Unlike hepatitis C, there is a vaccine that can prevent infection. If you think you are at risk, you should get vaccinated as soon as possible.

Hepatitis C

Hepatitis C is different from hepatitis B in that the virus more frequently stays in the body for longer than six months, and therefore becomes chronic. Four out of five people develop a chronic infection, which may cause cirrhosis and liver cancer after 15–30 years. There are approximately 170 million people chronically infected with hepatitis C worldwide. In 2000, the WHO estimated that between three and four million people are newly infected every year.

Hepatitis C is mainly spread through blood-to-blood contact and, similarly to hepatitis B, there are often no symptoms but if they are present can include:

Flu-like symptoms
Fatigue
Nausea
Aching muscles and joints
Anxiety and depression
Poor concentration
Stomach ache
Loss of appetite
Dark urine/bright stools

Although this is considered a global problem we must be aware that this is on our doorstep and now when so many people travel throughout the globe it is imperative that travel immunisation is considered if you wanting to travel or in a high risk occupation.
In 2011 there were 160 reports of acute hepatitis B in London, a 13% increase from 141 in 2010. This corresponds to an incidence rate of 2.06 per 100,000 population, which is nearly twice the national rate (England rate 1.13 per 100,000) and nearly double that seen in any other region. The highest rates of acute hepatitis B infection were in Islington, Brent, Newham, Lambeth, Hackney and Tower Hamlets.
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Do you have concerns?
If you have any concerns regarding Hepatitis this can be screened in the practise by an ordinary blood test or it is possible to attend a GUM clinic on Level 8 at Ealing Hospital

GUM stands for genito-urinary medicine. The clinic can help you with any concerns you have about sexually transmitted infections (STIs).

It provides a walk-in and limited appointments based service. To make an appointment call (020) 8967 5555 during clinic opening times only.

Monday 9-11:30am Male and female walk-in
Five male appointments available
4-6:30pm Male and female walk-in
Five female appointments available

Tuesday 4-6pm 19 and under female walk-in

Wednesday 9-11:30am Female walk-in
2-4:30pm Male and female walk-in

Thursday 2-4:30pm Male and female walk-in

Please be aware that waiting times may vary, so please allow a minimum of one and a half hours for your visit.

Your results: Ealing GU clinic operates a no news is good news policy. We only contact you within two weeks of having your initial tests, if a result is positive. You can also get your results from the results line which is ONLY available during 9am-12pm on a Tuesday morning. You must have your clinic number to get your results.
More details are available on the following website
http://www.level-8.org/index.html
You can use this website to learn more about safer sex, infections or the services offered by the young women’s clinic.
GUM clinics are provided throughout the UK to find a clinic near you simply click on the following

http://www.nhs.uk/Service-Search/Sexual%20health%20information%20and%20support/LocationSearch/734

If you are concerned you may have had or you could be in contact with
Hepatitis B. Immunisation is available at the surgery, travel clinic or GUM clinic.
Travel clinics

http://www.travelvaccination.co.uk/?gclid=CJKwmZzP0bgCFXTJtAod-zQA9w
Our local clinic in Hounslow and Southall
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http://www.globetrotterstravelclinics.com/

Globetrotters Travel Clinics are one stop shops for all of your Travel Health needs. They provide Travel Health advice and services, as well as premium Travel Health Products.

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What does hepatitis B immunisation involve?

For full protection, you will need three injections of hepatitis B vaccine over four to six months.
You will have a blood test taken one month after the third dose to check the vaccinations have worked.
You should then be immune (resistant to the virus) for at least five years. You can have a booster injection five years after the initial injection.

Hepatitis B vaccine on the NHS
GP surgeries and sexual health or GUM clinics usually provide the hepatitis B vaccination free of charge if you are in an at risk group.
GPs are not obliged to provide the hepatitis jab on the NHS if you’re not thought to be at extra risk.
GPs may charge for the vaccine if you want it as a travel vaccine, or they may refer you to a travel clinic so you can get vaccinated privately. The current cost of the vaccine (in 2013) is around £30 a dose.

How safe is the hepatitis B vaccine?
The hepatitis B vaccine is very safe and other than some redness and soreness at the site of the injection, side effects from it are rare.
Read more about vaccine safety and side effects.

Emergency hepatitis B vaccination
If you’ve been exposed to the hepatitis B virus and have not been vaccinated before, you should immediately have the hepatitis B vaccine plus an injection of antibodies called specific hepatitis B immunoglobulin (HBIG). This is because the vaccine doesn’t work straight away. The immunoglobulin works immediately, albeit temporarily, so you’re protected until the vaccine starts to work.
Immunoglobulin should ideally be given within 48 hours, but you can still have the jab up to a week after exposure.

Babies and hepatitis B vaccination
Babies born to mothers infected with hepatitis B can be given a dose of the hepatitis B vaccine after they are born. This is followed by another two doses (with a month in between each) and a booster dose 12 months later.
Some babies also have an injection of immunoglobulin after they are born to help prevent infection.

HEPATITIS EFFECTS EVERYONE EVERYWHERE: KNOW IT CONFRONT IT AND PROTECT YOURSELF

“see no evil, hear no evil, speak no evil”

 

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Patients must be at the heart of everything we do- no decision about us ,without us

imageUnder the NHS Constitution, you have
“the right to be involved in discussions and decisions about your healthcare, and to be given information to enable you to do this.”

There are times when you need to make decisions about your health. This could be about which treatment is best for you, or whether you should have a screening test.
To address this patient decision aids (PDAs) have been developed to help support difficult decisions in which patients need to consider benefits versus risks.

Decision aids prepare patients for decision-making by increasing their knowledge about expected outcomes and personal values. The PDAs are not meant to be a substitute for discussion with a skilled Doctor or nurse but will supply up to date evidence to help a patient and healthcare professional come to a decision about the best way forward. It is hoped that their use in such discussions will result in better informed, patient-focused decision-making.

A patients idea of what is in their best interest may be quite different from what a health professional perceives as the best decision. The decision may be influenced by many factors such as previous experience, influence of the media or culture. However, it is important that the health professional during a consultation has up to date information concerning options and can provide. Realistic expectations.

Many patients are now more informed and are able to carry out their own research and in some instances this can form a useful platform of discussion.
I am frequently challenged about treatment following articles written in the ‘Daily Mail’ so much so that I always tell new students much to their surprise that at least 5 mins of their study time each day should be studying the health section in the Daily Mail! Also patients attend with print-outs or other references from the Internet.
steps of PDA use in consultations
1. Describe the clinical condition(e.g.atrialfibrillation)
2. Describe the treatment options (e.g. no treatment, aspirin, or warfarin) and outline the dilemma (all have risks and benefits, and different patients view the risks differently)
3. Offer a further, more detailed discussion. Some patients are content with the healthcare professional deciding, some prefer a joint decision, others wish the healthcare professional to provide the information but wish to make the decision themselves
4. Work through the PDA, explaining the images and adjusting for baseline risk if required
5. Allow the patient time to consider what they wish to do. They may wish to take away a copy of the PDA and discuss it with family or friends

Use of PDA’s is now recognised nationally and NICE recommended that people should be offered information about their absolute risk of cardiovascular disease and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that:
• presents individualised risk and benefit scenarios
• presents the absolute risk of events numerically
• uses appropriate diagrams and text

NHS Health Checks in Ealing, North-West London
The NHS Health Checks programme was delivered locally by Primary Care Trusts (PCTs) in England.(now replaced by Clinical Commissioning Group(CCG)
The Department of Health requires that all adults aged 40–74 years are invited for cardiovascular risk assessment by 2013.
Ealing has a relatively socio-economically deprived population of 375 000, with a high proportion of residents from ethnic minorities. The local Health Checks programme is delivered by practice nurses and health-care assistants in general practice. Disease-free individuals estimated to be at, or greater than, a 20% 10-year risk of a CVD event were targeted in the first year of the programme (1 September 2008 to 31 August 2009); the method of risk estimation is detailed subsequently.

The PCT provided each general practice with a list of patients to be invited in year one, and the practice then contacted patients by a letter inviting them to attend a Health Check. Each practice was responsible for completing a full Health Check, including appropriate laboratory tests and reminding non-attendees. The local programme started before the national roll out of NHS Health Checks in April 2009. Ealing went beyond the Department of Health requirements by including patients with diagnosed hypertension and those prescribed statins and commenced screening at the age of 35 years, due to the high burden and earlier onset of CVD and diabetes in the area. CVD risk estimates were based on the informationrecorded in the GP information system in the past 5 years.
The screening process has become increasingly sophisticated and those participating will be aware of the process and how other illnesses are taken into account, family history aswell as measurements of blood pressure,cholesterol,blood sugar, weight height and BMI. Exercise as mentioned in a previous blog is calculated by the GPPAQ (http://www.patient.co.uk/doctor/general-practice-physical-activity-questionnaire-gppaq) to determine if a patient is inactive or to what degree they are active and with all this information the cardiovascular risk (the risk of heart attack in the next 10years) is calculated. If a significant risk is identified the patient is seen by the doctor who will discuss treatment options discussing the reasons for treatment and evidence why it should be implemented and allowing the patient to reflect on this referring to a PDA.
imageThe risk is explained in this case using a Cates plot which is the use of 4 face categories to visually indicate the following:

People not affected by a treatment (green faces for those with a good outcome and red for those with a bad outcome)
People for which treatment changes their category from a bad outcome to a good outcome (yellow faces)
People for which treatment causes an adverse event and changes their category from a good outcome to bad outcome (crossed out green faces)
It is important to avoid framing the information, resulting in an unbalanced picture of either benefits or harms. As an example, consider the PDA for use of statins to reduce the risk of cardiovascular (CV) events in patients with a 20% 10-year risk of CV events. The Cates Plot looks like this
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http://www.npc.nhs.uk/evidence/eidm4_shared/resources/how_to_use_pdas.pdf
We could say only ‘Over the next 10 years 80 people will not develop heart disease or have a stroke’, or we could say only ‘Over the next 10 years 20 people will develop heart disease or have a stroke’. The first phrase could create greater reassurance, and the second greater concern. Best practice recommends presenting the data in both ways. We also need to use words which convey that there is an irreducible uncertainty; it is impossible to know what will happen to any individual person and say whether he or she will benefit from the treatment or not.
These people will not have a CV event, whether or not they take a statin- green
These people will be saved from having a CV event because they take a statin- yellow
These people will have a CV event, whether or not they take a statin – red

When a CVD check is carried out you will be shown the Cates plot relevant to you.
This can be used in many situations where treatment is discussed with the patient so that they can make an informed decision.
More about this concept can be seen on http://www.nntonline.net/

An expanding directory is being made to cover a wide range of conditions for use by health professionals.
The same idea has been used by a well used website
http://www.patient.co.uk/brief-decision-aids and deals with more everyday problems

Smoking cessation. Tennis elbow. Carpal tunnel syndrome
Leg cramps. Enlarged prostate. Contraceptive choices.
Menorrhagia (heavy periods). Plantar fasciitis. Warts and verruca
Irritable bowel syndrome

They help people think about the choices they face in the testing, treatment or management of their condition. They describe where and why choice exists and provide information about the options available to them.

Typically a decision aid will provide, for each option, information on potential outcomes, benefits and risks, and the frequency and likelihood of these.

As many treatments relate to
Types of decision support:
There are two main types of decision support: extensive tools, which patients can access before and after seeing a healthcare professional; and shorter tools, which are used within the actual consultation.

Extensive decision support tools
These tools were the first and are the most common type of decision aid. As such, they have also undergone the most research.
They include:

patient information leaflets and booklets
DVDs and audio tapes
interactive media and
web based tools.

Brief in-consultation decision aids
Although these are relatively new, healthcare teams have found these brief tools to be extremely valuable in implementing shared decision making in clinical practice.

The clinical teams at Cardiff have focused on developing and testing Option Grids.
An Option Grid is designed for sharing with patients during consultation. It enables the patient to compare the various options available in relation to the factors that are important to them personally. The grid helps do this by providing side-by-side answers to the questions that patients frequently ask when they face important decisions.

All these have been developed during the past few years in a concerted attempt to keep patients at the heart of everything we do. In my experience involving patients in decision making improves compliance aswell as outcome of treatment. When I stated in Medicine the patient was totally at the mercy of the health professional making the decision thankfully this has changed.

 
 

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Rat poison to be replaced?

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Warfarin has been used to thin the blood to decrease the tendency for thrombosis or as secondary prophylaxis (prevention of further episodes) in those individuals that have already formed a blood clot (thrombus) since I was born – for many years.
As GP’s we are now committed and compelled to take part in clinical-led commissioning and I shall be referring examples of this frequently.
Clinically-led commissioning is a continual process of analysing the needs of a community, designing pathways of care, then specifying and procuring services that will deliver and improve agreed health and social outcomes, within the resources available.
One such example is the provision of anticoagulation therapy services and for many months in Ealing Central Commissioning Group (ECCG) have been reviewing
how anticoagulation therapy is currently initiated including looking at recommendations for the new oral anticoagulants (noac) dabigatran, rivaroxaban and apixaban and the anticipated reduction in need for vitamin K antagonist monitoring services (INR monitoring).

You may be aware that anyone who takes warfarin must be monitored on a regular basis by blood test(INR) which until recently involved regular visits to the hospital to attend a clinic. As part of the commissioning we have taken over the monitoring of INR in general practise. But due to the complexity of initiating and stabilising treatment commissioning has been a long involved process to assure generalised commitment, safe practise and most of all taking into account the full cross section of patients needing this treatment.
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The discovery of warfarin was centered in Canada and the United States1. In the early part of the 20th century, farmers in the northern prairie states of Canada and the USA began planting sweet clover plants imported from Europe. Although the sweet clover proved to be nutritious when used as fodder, it also brought a fatal disease which decimated cattle herds and horrified farmers: sweet clover disease, in which affected cattle developed relentless, spontaneous bleeding. Schofield, a veterinary pathologist in Alberta, reported in 1921 that the disease was caused by consumption of spoilt sweet clover hay. The fresh plant was known to contain the compound coumarin, which was not pathogenic. The mystery of why spoilt hay caused the disease was solved by Karl Paul Link and his co-workers in 1940 : in mouldy hay, coumarin is oxidised to 4-hydroxycoumarin and then coupled with formaldehyde and another coumarin moiety to form dicoumarol, an anticoagulant. This was responsible for the disease. Dicoumarol was patented in 1941 and was therapeutically used as an anticoagulant.
In 1951, a navy recruit unsuccessfully attempted suicide with 567 mg of warfarin. His surprising full recovery induced research into the anticoagulant potency of warfarin in humans. It was found to be far superior to dicoumarol. Clinicians quickly discarded dicoumarol in favour of “rat poison” warfarin : it was introduced commercially in 1954. In that same year, President Eisenhower was treated with warfarin following a heart attack.
As an aside I remember several years ago a delightful 98year old lady appearing in surgery asking to register provided she was not too old. She had been the Professor of Agriculture of Warsaw ( and honorary Professor at Glasgow)and believe or not in the waiting room at the same time she rediscovered an old student ( at that time 88yrs) a patient well known to me and he had been a farrier and a reputable breeder of Welsh mountain Ponies in South Wales before retiring to Ealing. It turned out that she had introduced sweet clover to Poland!

Warfarin is used used by more than 75,000 patients for short term or long term use and not only is it cheap at 2p a tablet but its anticoagulant effect is well tried and tested and its effect can be easily reversed in the event of gastro-intestinal bleeding or need of surgery. The anticoagulant level is easily measured. However, warfarin is slow to take effect and stabilise; constant monitoring is necessary as there is significant interaction with alcohol and some medication, food stuffs commonly leafy vegetables and cranberry juice and all foods containing Vitamin K and should be taken carefully
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diet sheet
http://www.atrialfibrillation.org.uk/files/file/Publications/120426-st-FINAL-Warfarin%20and%20Diet_pdf.pdf

Patients must be totally compliant and maintain a record of INR readings(the yellow book)image
there is a risk of bleeding but someone would have to fall 200 times to have significant blood loss ie from bruising.
Recently a new class of drugs have been released and Rivaroxaban will be the drug of choice in Ealing- this decision has been met after consultation with our local consultant cardiologists, who we meet with in the surgery or at joint meetings. At present it will only be used in those patients who may need to be travelling frequently, with a uncontrolled INR, adverse effect with Warfarin or those who have had a stroke whilst taking Warfarin. As it is a new drug careful monitoring needs to take place and trials carried out to support a more widespread use.

 
 

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Work Experience

imageOne of the aspects of being a doctor that I have enjoyed during my career has been the opportunity to teach medical students and be supportive of younger doctors. I have also enjoyed having students from our local schools to work with us in the surgery helping with admin and office work as a work experience.The first student who came 14 years ago when most GP’s were cautious about allowing school students to be in the surgery. She was a friend of my daughters and I had known her for several years as she had come back after school for tea and been on sleepovers! I said she could come to the surgery but warned her that it was totally confidential and she must not tell anyone who,what she had seen when she came. She seemed thrilled at the idea that she could even tell her parents not to ask questions and her mothers feedback was that after 2 weeks she felt her had suddenly ‘grown up’ and she herself was determined to become a doctor despite doing my best to tell her all the disadvantages. Indeed, she went to UCL medical school and during her studies returned on several occasions to work in the surgery including being our first phlebotomist. She qualified and is now a senior registrar in medicine and next weekend she has asked me to attend her wedding as she feels that the experience at the surgery 14 years ago set her path for the future and her invitation is a way of saying ‘thank you’ so I shall look forward to this with great pleasure.
Since then each year we have had various students and several have gone on to medical school or found it a useful experience.
imageOur present work experience student is also hoping to study medicine and I have been impressed with her enthusiasm to see all aspects of the practise and ask plenty of questions to discover what goes on behind the scenes. She is a student from the Alec Reed Academy Year 10  and she wrote this statement for our blog:-
I was warmly welcomed into the surgery by all members of staff on Monday 15th July when I started my work experience at the Avenue Surgery. During the work experience I learnt a lot just by being in reception . With the help of the receptionists: Tega,Liz,Paramjit,Madhu,Debbie and Margaret have managed to understand that the reception work is a lot more than I thought. I witnessed their hard work in talking to patients, booking appointments, talking to the patients on the phone, making up new files,faxing papers and doing photocopying. To be honest, despite the sta ff having a lot to do each day everyone managed to answer all the queries I had and showed me around the surgery. They spared some time and showed me how to do certain jobs. Therefore,I would like to thank all the staff members at the reception for helping me out.

Not only that,nurse Mary had also managed to give me some time and explained her role at the surgery. She gave me an insight to all the different roles she had inside this surgery. She shared all her past experiences with me and told me a bit about herself aswell. This helped me as it gave me all the information that I might have not found on the computer or on google regarding what Nurse Mary does at The Avenue Surgery.

On top that Dr Bayer spent time discussing medicine with me. She told me about political issues associated with medicine. She taught me how the system of medicine works and the way a GP works. She also taught me how become a specialist doctor and how to become a GP. She took a small interview with me and gave me detailed responses on how to react to questions that I might be asked in future interviews.

Lastly , Sangeeta (the practise manager) had helped me a lot because she gave her approval and allowed me to work in the surgery. She allowed me to attend the Practise meeting. She completed the forms given by my school on time and provided me with an amazing team to work with.

I would like to thank all the members of staff who have helped me throughout my work experience and given me some of the amazing facts and information into work experience.
Thank you all
SP

SP is going off next week to India to work in a clinic as a volunteer and hopefully report back to us. We wish her well.
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Have you seen the Dragons in the surgery garden?

Don’t worry I haven’t lost the plot – read on

Introduction
Many people have talked about fairies at the bottom of the garden but I want to tell you about the dragons at the bottom of the surgery garden. You may be surprised at my letting out this long guarded secret but I felt it was time to let the secret out! They are very friendly and the young dragons often play with fox cubs and cats from next door. I have to say they only come out when all the patients and infact all the staff have gone home. I hadn’t told anyone and poor Dr Livingston got such a shock when they appeared one night when she was busy working after surgery had finished. I think she thought she was back in Wales as there are so many there but they are red and talk Welsh. The dragons in the garden are green and you can easily miss them.
I first came across red dragons in Wales : they are so important that the flag of Wales (Cymru) is a red dragon!!! ( Y Ddraig Goch) and has been for many years ( 1,184 years to be precise) ever since the red dragon conquered the white dragon .

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The story as written by Nennius a monk tells how young boy visited and revealed to King Vortigern, last of the Celtic kings of Britain that he had seen two serpents, one white and one red, who had been hidden deep underground fighting with fierce shrieking until finally the red one summoned his strength and drove the white one away.
The story is then explained by the mysterious child: “the two serpents are two dragons; the red serpent is your dragon, but the white serpent is the dragon of the people who occupy several provinces and districts of Britain, even almost from sea to sea: at length, however, our people shall rise and drive away the Saxon race from beyond the sea, whence they originally came.” The King then left North Wales where this event took place and built a castle in the South (on the Welsh/English border ) it was thought to be Caerwent, in Monmouthshire now part of Gwent.

It’s interesting that in February 2003 during his enthronement at Canterbury Cathedral Archbishop Rowan Williams ( a welshman from Monmouth wore hand-woven gold silk robes bearing a gold and silver clasp that showed the white dragon of England and the red dragon of Wales to symbolise the peace between the two countries.

The red dragons are very friendly now but do tend to breathe more fire if England is playing rugby against Wales!!

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Story strictly for children ( adults can only read under child guidance)

Here’s a picture of the family in the garden. If you can’t see them because of their green colour ask a 3/4 year old because they always manage to find them and some children have seen blue and purple ones aswell!
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Introduction
The family of dragons that live in the garden are Denis(means friendly) who is 5 years of age, his mother Daphne(because she was born under the laurel tree) and father Derek ( meaning ruler) and Dolcie ( means sweet one)who is just 6 months. I don’t know how they ended up living in the surgery garden but they do have a slightly Irish accent and they are green so perhaps Liz or Mary the nurse had something to do with it!
Also Derek’s brother is called Declan…..makes you wonder!

The Day Denis Dragon couldn’t breathe fire.

One evening last week when the sun was shining I was busily working and I suddenly heard a tap at the window. At first I thought it was the cat at the door miaowing for milk but when I  looked up I saw Denis Dragon looking very sad. I thought he had probably kicked his ball over the wall whilst playing with the cat and he wanted me to get it. I opened the doors to the garden and said , “What’s the matter Denis ?”
“Dr . Bayer I can’t br….br…. breathe fire.
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It was poor Denis, he was wheezing (not the cat miaowing) and he was very breathless and no fire was coming from his mouth. That is very serious for a dragon because breathing fire is very important to heat their food and keep themselves warm and keep dangerous creatures away.
The next thing his mother Daphne was scampering up the garden and looking very worried.
“Come inside both of you and don’t worry Denis I have a special steam machine which will make you better in no time and don’t be frightened because its a bit noisy. It sounds like Thomas the Tank Engine warming up before he trundles off to see Edward and Henry along the track.” I said

We walked slowly to the back room and I listened to Denis’s chest , counted his pulse on his wrist and how fast he was breathing and put a funny machine on his finger- it pinched a bit and the lights came on and numbers started appearing and I told Denis that I was measuring his Oxygen. It wasn’t long before I had set up the steam machine (adults call it a nebuliser)by squeezing some special medicine out of a tiny plastic bottle into a into a little cup and connecting by a tube to the machine. “Are you sitting comfortably,Denis?” I said and Denis shuffled a bit and held his mummy’s claw. I put the mask over his nose and mouth (a special one as dragons have big noses) and I switched the machine on. His mummy stayed with him all the time and as the steam puffed out Denis slowly felt much better and after we stopped the machine after about 5 minutes Denis was so happy to be feeling better that he gave a huge puff of fire so much that my tea nearly boiled out of the mug!

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Here is a picture of a little boy on a nebuliser

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” Now Denis that’s not the end of story, because your mummy has told me that for a little while she has noticed that you have been getting more and more tired, the fire you have been blowing has been getting less and less and at night you have been coughing all the time . It has been worse since the trees and flowers have been in flower showering out pollen. Also she noticed that when you were racing with the cat and fox cubs that you were nearly always last and were not wanting to play with them anymore. I think you have got something called asthma.
Human being children come to the surgery with this all the time and when we give them special medicine which they have to breathe in they get better and can play happily with their friends and start running as fast as their friends again and for young dragons they can breathe fire more easily.
The breathing medicines are called inhalers, because breathing in is called inhaling and the one I will give you is a blue one: it is called Ventolin and is called a reliever because it makes you better.
You must be very senlsible and never play games squirting it in the air and you don’t have to try it out first just shake it and you will hear the liquid in it swishing about.
It is very important that you use these inhalers whenever your chest feels tight and you need to give one to your teacher in case you start wheezing in school and remember to take it with you when you go out anywhere.
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This only relieves you for a short while and at this time of the year your chest will easily get tight so I think it is a good idea to take something to prevent or stop you getting wheezy.
Guess what we can give you another inhaler to do this and what do you think it’s a called? ”
Denis thought for a while , “is it a stopper?” said Denis.
Not quite I said. Try again, I said it prevents wheezing that’s a clue.
“I know it’s a preventer” shouted out Denis nearly singeing my hair with the fire he breathed out in excitement.
You must take this in the morning before school and when you get home in the evening.
There is just one thing I must show you with before I teach you to use the inhaler. When children including dragon children try to breathe in with the inhaler it is so hard a bit like when you were a baby and it was hard to drink out of a cup so we have special thing called an aerochamber and this makes it much easier. When you use the aerochamber your breathing will be much better and mummy will be very happy to see you much better and will give an extra special bear hug.
Infact here are the instructions shown by a friendly bear. I think dragon children like teddy bears to cuddle aswell!
Click on link……
imagehttp://frx.com/pi/AeroChamberPlusFlow-VuSmall-Medium_PI.pdf

 
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Posted by on July 18, 2013 in Training and Advice

 

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The NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP)

I was reading my latest edition of GP magazine  or my ‘medical comic’ as my husband says and there was an article on the National  AAA Screening Programme  which began in March 2009, following research that showed it could reduce the rate of premature death from ruptured AAA by 50 per cent. The roll-out across the whole of England should be complete by 2013, as Ealing has not been screened yet those over 65yr old men should be hearing more about this in the coming weeks.

What is an Abdominal Aortic Aneurysm?
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An abdominal aortic aneurysm is a dilation (ballooning) of part of the aorta that is within the abdomen. An abdominal aortic aneurysm (AAA) usually causes no symptoms unless it ruptures (bursts). A ruptured pAAA is often fatal. An AAA less than 55 mm wide has a low chance of rupture. An operation to repair the aneurysm may be advised if it is larger than 55 mm, as above this size the risk of rupture increases significantly.
40 mm-55 mm: about a 1 in 100 chance of rupture per year.
55 mm-60 mm: about a 10 in 100 chance of rupture per year.
60 mm-69 mm: about a 15 in 100 chance of rupture per year.
70 mm-79 mm: about a 35 in 100 chance of rupture per year.
80 mm or more: about a 50 in 100 chance of rupture per year.
As a rule, for any given size, the risk of rupture is increased in smokers, males, those with high blood pressure, and those with a family history of an AAA.
Here we go again prevention again  those same old high risk factors appearing again!

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It has been claimed that no aspect of vascular disease management has changed as much in the past decade as the management of abdominal aortic aneurysm (AAA). Repair of an abdominal aortic aneurysm may be performed surgically through an open incision in the abdomen and inserting a graft or in a minimally-invasive procedure called endovascular aneurysm repair (EVAR) which involves inserting a stent-graft via the major arteries in the legs (femoral artery) Under X-ray guidance involving no abdominal incision. The EVAR  can be carried out under epidural and in patients that would be unable to cope with a general anaesthetic.
It reminded me of those on -call days as a surgical houseman admitting someone with a leaking AAA  involved a long surgical procedure and often a prolonged hair-raising recovery which in those days for me meant little sleep  and watchful waiting…    often going back to theatre as the rather crude grafts leaked or became infected as the surgery was performed by a General  surgeon  rather than the skilled vascular surgeons of today. Many patients were too ill to cope with general anaesthetic and the complication and death rate was high.
Those days are past the prognosis for treatment has drastically improved so it makes sense to screen and offer a good outcome to those who are found to have an AAA before symptoms such  as a pulsing feeling in the abdomen, similar to a heartbeat and/or pain  in the  abdomen or lower back are apparent.
< NHS AAA Screening Programme
A new NHS AAA Screening Programme is being gradually introduced across England and aims to reduce deaths from ruptured Abdominal Aortic Aneurysms through early detection.

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The roll-out of the National Screening Programme  began in March 2009, following research that showed it could reduce the rate of premature death from ruptured AAA by 50 per cent. The roll-out across the whole of England should be complete by 2013.
The NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP) has been rolled out across England and increasing numbers of men will have to  choose whether to undergo screening, which accounts for
approximately 2% of all deaths in this population group.
The NAAASP only screens men aged 65 and over. However,younger men, or women with a family history, can be scanned under existing NHS procedures.
GPs are recommended to consider referring patients with a sibling or parent with an AAA for a scan at the medical imaging department at an age five years younger than that at which their relative’s AAA was first diagnosed.
Self-referral may be appropriate  if a patient missed out on an automatic invitation.
Screening for AAA
An AAA occurs because of degeneration of the wall of the abdominal aorta. Large AAA are rare, but can be very serious;ruptured AAA accounts for about 5,000 deaths every year in England and Wales. Small AAA pose little immediate risk, but can expand, so it is essential to monitor them.
The screening process for AAA is a simple ultrasound scan and patients receive their results immediately. This ensures that men with a small AAA who require regular ultrasound surveillance are identified and offered advice on reducing cardiovascular risk factors. Their GP may be asked to review their medication and reassess their BP monitoring.
Antiplatelet and statin therapy is recommended for men with a small AAA and smoking cessation can reduce the rate of expansion, in addition to its other health benefits.
Other screening outcomes include a small number of men with an aorta of 5.5cm diameter or more, who are referred to a vascular surgery team. Most men who have no signs of an AAA are reassured.
The main risk factors for AAA are smoking, hypertension and a family history (first-degree relative with AAA). Men who are most likely to benefit from self-referral for screening are therefore those in their late 60s and early 70s who have one or more of these factors.
Each GP practice is informed when a patient of theirs is screened, then updated with the results. Patients can then discuss the results with their GP.
For more information:-
Benefits and risks
Despite only just completing national roll-out, the programme has already delivered promising results. NAAASP data for 2012-13 show that 209,000 men were screened for the first time during the year, with 77% of those invited actually attending.
More than 3,000 aneurysms were detected. While most were small and will need regular monitoring, a few patients werenreferred to vascular surgeons to discuss possible treatment options.
More than 300 large aneurysms were detected by screening and treated during the year, and the programme is making progress towards its aim of reducing deaths from ruptured AAA among men aged 65 and over by up to 50%.
In addition to delivering clinical benefits, the NAAASP has been assessed by the UK National Screening Committee as deliveringnvalue for money to the NHS.
There are, however, risks associated with AAA treatment, which are clearly communicated to men when they are invited for screening.
If a large AAA is detected or develops, intervention carries risk – the mortality rate following elective AAA repair is about 2%.

Screening is a patients choice and if unsure it is always advise able to consult your GP regarding individual risks and benefits.

 
 

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