Category Archives: Surgery Information



Cardiac arrest As part of our obligation as a doctor we have to have annual update cardiopulmonary resuscitation training and this also applies to the whole practice team.

We have found over the past few years that it makes sense to have sessions which include a cross-section of staff and even opening it up to patients that want to participate aswell as the the young adults of staff.

A report of a rare miraculously saving of a life 

On December 23rd 2017 Dr Livingston was cosily at home recharging her batteries after a very busy surgery watching “Love Actually” with her daughter and her boyfriend when there was a loud frantic knock at the door. It was the  nextdoor neighbour she was totally beside herself. Her husband had collapsed.

Dr Livingston knew he had heart problems so she immediately went into ‘doctor mode’ She instructed the 2 teenagers ( her daughter had attended CPR training ago but her boyfriend had never attended any training) to bring their phones  ( not usually far from there sides, anyway!) Her daughter who remembered that there was a pocket mask strapped to the stairs in the hall had the presence of mind to grab that as well and the team hurriedly followed the neighbour to the house.  Sure enough the husband was sited against a wall in a collapsed state. Immediate assessment demonstrated he was unrousable, not breathing and with no pulse. He had had a cardiac arrest.

The team managed to drag him onto the kitchen floor. Instantly  the learnt procedure was put into action, and Dr Livingston allocated instructions to her team- the boyfriend called 999 and was communicating with the ambulance service ,very calmly listening and responding appropriately to their questions.

Meanwhile, Dr Livingston had immediately started CPR (basic life support with my daughter). Her daughter maintained good airway and Dr Livingston commenced chest compressions. She commented how exhausting it was and infact had not performed  this for many years in a ‘real situation’ and then only in a hospital situation. Her daughter astutely observed that her mother was getting tired and then took over cardiac compressions. Before the ambulance arrived a police car arrived with a defibrillator. Although she had had training on this but she had never actually used and automated external defibrillator. They followed the spoken voice instructions it gave them.

After about 3 shocks the A.E.D said in a clear voice ‘movement detected’. The team paused in shear amazement ‘It was incredible,’ commented Dr Livingston.

Subsequently, two ambulance crews arrived and they took over and when he seemed stable the patient was transferred to Ealing Hospital. On arrival at hospital the Glasgow coma scale was used to assess the severity of brain injury and prognosis. The initial Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma, remarkably his was 15.

This was a true miracle, as it is reported that of cardiac arrests in a hospital set up only 7% of people survive this man not only lived to tell the tale but survived his near-death experience without any damage to his heart muscle or his brain, an outcome extremely rarely seen following an out-of-hospital cardiac arrest.

When Dr Livingston and myself discussed this, I felt empowered to blog about this and Dr Livingston felt it was paramount to share her story with other GP’s by posting on a closed facebook page called Resilient GPs. Usually she would get 1 or 2 responses  but on this occasion had over 700 !!

Many GP’s after reading the account  decided to open up their basic life support training to the staff’s teenagers and family and purchase pocket masks and keep them at home and in the car. Dr Livingston will be advocating to all staff and both her daughters to put a pocket mask in their  cars.

Moreover, the practice would be prepared to offer hosting CPR courses at the surgery for anyone interested or facilitate where a course could be done. 


When the team  got back home after lots of cups of tea Dr Livingston asked her daughter how she was feeling and was she upset by it?

She admitted it was scary but even though it was 2 years since she had attended the course she said the thing she particularly remembered the trainer saying, 

‘If you dont do anything they will die so you may as well try. Even if just do chest compression that will help. That is what everyone needs to know- have a go !!’

 Dr Livingston felt immensely proud of these teenagers , who not only immediately jumped into action without thinking  but ‘saved a life’.

Well done – an absolute game – changer. 

A week after this there was routine practice training update. The first time with the new practice defibrillator. The trainer simulated a cardiac arrest, which was brilliant, but completely forgot the practices had it’s own device.!!

The most important thing if some one has a cardiac arrest is to fibrillate as soon as possible

A few days later Dr Livingston  passed the gentleman’s son in the street and asked how his father was feeling. He replied, ” he seems fine but that his ribs were aching a lot” he was virtually totally unaware of the magnitude of what had happened and not only had he survived but that his life had been restored without brain injury.

As days went by it gradually it registered this man’s life had been saved by a team that was confident and empowered to act quickly and efficiently and then the team were showered with gifts!


You could easily learn this skill and be a potential life-saver.

The British Heart Foundation are determined to transform the UK into a Nation of Lifesavers: a country where everyone knows how to save a life.

Also you could inform the surgery that you wish to participate in training and when enough people have signed up they will arrange a session.


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Several months ago I wrote a blog promoting a book written by one of our patients ‘Prescription for Disaster’ by Candace Lafleur It is a very personal report of what a disease can do to someone, but the way Candace deals with it, is amazing. She shows us that even in the worst conditions like hers, life is worth living and how you can keep on laughing. Reading it makes one laugh from the belly and cry from the heart as it has that underlining sadness that we as doctors are aware of when treating patients with chronic illnesses but her attitude inspires us as doctors to be hopeful and inspired.

She also made this video to emphasise the importance of attitude when dealing with a chronic illness and admits to all the normal emotions besides laughter. She would like to think by showing others how she has hung on to her personal hopes and aspirations and achieved success in her life with the disease she has not allowed it to dominate and prevent achievement.


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NHS England has ordered an independent taskforce to develop a five-year action plan with the aim of improving cancer survival rates and services.
The taskforce includes cancer specialist doctors, clinicians, patient groups and charity leaders, who will collectively look at ways to improve cancer prevention, first contact with services, diagnosis, treatment and support for those living with and beyond cancer and end of life care.

Early diagnosis of cancer:

The problem UK has relatively poor track record when compared with other European countries. It is estimated there are probably an additional 5-10,000 deaths each year most of which can be attributed to diagnostic delay.

Later diagnosis due to mixture of

  • late presentation by patient (alack awareness)

  •  Late recognition by GP

  • Delays in secondary care

In the last 18 moths new research from the National CANCER Intelligence Network has published the startling findings that in England 25% of cancers are diagnosed as emergencies. The figure rises with age implying that older people with symptoms are less likely to be investigated or referred early. More easily diagnosed cancers such as breast, uterine or melanoma are less likely to present in A&E but more difficult ones such as brain or pancreas are more likely to present in A&E .

58% brain tumours

39% of lung cases

25% colorectal cases

present as emergencies. Older women, women and people from ethnic minorities were more likely to present late.

If if a patient presents to their GP with symptoms we have the facility to refer under a 2 week rule which the patient is informed of at the consultation and an immediate referral is made to secondary care and they are contracted to see the patient within 2 weeks. However, it has been found that under half of current cancers are diagnosed with the 2 week urgent referral system.

For many years we as GP’s have used a risk stratification tool to establish a patient’s risk of a cardiovascular event( heart attack or stroke) and high risk patients are seen and treated and given relevant health education and this has resulted in a significant fall in cardiovascular events. One tool which is started to be used for cancer is QCancer  based on the QResearch database and pioneered at Nottingham university

It is a single tool to look at multiple cancers.

It has asymptomatic based approach but also takes into account risk factors such as age, smoking, alcohol, family history and weight.

90% of patients with cancer present with symptoms

Symptoms that  can be significant 

Key symptoms in model (identified from studies including NICE guidelines 2005)

 coughing up blood  vomiting blood  blood in the urine(painless)

Rectal bleeding  Unexplained bruising  Constipation, cough for >l 3 weeks

Vaginal bleeding (women) after intercourse or after menopause

  Testicular lump (men)  Loss of appetite  Unintentional weight loss

 Indigestion +/- heart burn  Difficulty swallowing

 Abdominal pain or swelling  Breast lump, pain, skin  Night sweats

Neck lump  Urinary symptoms (men)

We have started to use this in the practice and some of you may be aware of being handed a questionnaire in reception if not please ask for one. We will then create a score in the format of Cates Plot and relative risk which is entered in the records.

An example of a result showing an individual’s risk of having a cancer and a further breakdown of the results demonstrates which is the most likely cancer at risk – in this example it is a colorectal cancer. 


If the score suggests  you have a risk of cancer  you will be asked to make an appointment to discuss this to arrange appropriate referral and investigations.

 It will also be updated if new symptoms occur. 

Hopefully during the next 12 months this will be fully integrated into our computer system rather than relying on paper questionnaires so that alerts can be triggered during regular consultations.

The following 12 types of cancer will be considered :-



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Visiting doctorAs a GP for many years if I visited an elderly person on a Friday or after 3.30pm in the afternoon and although their illnesses could be treated in the home if they were living alone I would often have to admit them into hospital.
Social services would often need 48hrs notice or more to implement social care in the way of carers or meals on wheels etc. We relied on the goodwill of neighbours or relatives dropping everything to travel long distances to the rescue.

Earlier in my career and sometimes latterly there have been occasions when I have made a meal, waited for relatives to come, the neighbours to return from work, rung the Cat Protection League to get the cat sorted out, hung out the washing, visited several times a day and night all simply to keep a person out of hospital. This is what many older GP’s did and in some areas of the country probably still do.

Alas, the situation has changed considerably, in that more older people are isolated with neighbours working longer hours and keeping to themselves and close relatives often scattered around the world as well as people living longer and with more complex medical needs.

Doctors have an increased work load and the consultations needing to encompass health prevention and screening and there an increased need for documentation by computer to record every aspect of the consultation. Also, with the introduction of more medications  and patients surviving severe medical illnesses longer GP’s are now responsible for their management. When the final year students are attached to the practise for 2 months each time they express their surprise of how many complex cases are managed in Primary Care.  Lloyd George fileGone are the days of a scribbling remark in a handwritten file in a packet – the Lloyd George file and the rest of the information being retained in the doctors head and if a patient’s condition became in anyway complex they were whisked away to experience a prolonged hospital admission.

It is a long time since I wrote the following abbreviations in patients notes!

  •       GOK ( God Only Knows)
  •        TEETH – Tried Everything Else; Try Homeopathy
  •        PIN (pain in the neck)
  •        SALT – Same As Last Time.
  •         FLD – Funny Looking Dad.
  •         ATSWWT – Always Thinks Something’s Wrong With Them.
  •         VIPIA – Very Important Pain In the A**.
  •         FFFF – Female, Fat, Forty and Flatulent.

These changes have resulted in more ‘social’ admissions which are often prolonged and can lead to a decrease in a persons independence when they are ready for discharge as the ward they are admitted to does not have the multidisciplinary team to avoid this.
Incredibly health and social care have worked totally independently. I remember when I was a junior doctor (SHO – Senior House Officer – the old nomenclature ) the consultant at the time commented that if I wrote letters for the patient they were rehoused very quickly and what was my trick. “Sir, (as we addressed our seniors in those days) could it be that she signs herself as the Senior House Officer, piped up the Registrar!”

At last this is being addressed and following the formation of the Ealing Clinical Commissioning Group (ECCG) in April 2011 plans implement patient-centred plans to provide the right care at the right time and at the right place for the residents of Ealing.

The ECCG launched these plans on 16.05.2012 in a document:-

Better Care, Closer to Home (2012 – 2015)

A three-year strategy for coordinated, high quality care out of hospital
Our objective is to provide the right care at the right time and at the right place for the residents of Ealing. This was carefully thought out by a comprehensive team of people from all social and health disciplines lead by Dr Mohini Palmer an experienced GP
In their document they quoted:-
“Our vision is to ensure that our health care system keeps patients well and at home and, when patients do become unwell, provides cost- effective, evidence based and timely care at the right place appropriate to their needs.
As demand rises with increasing health needs and the development of new treatments, we need to respond to the challenges while delivering the highest quality of care. We need to build and preserve what we do well and continue to look for new developments to deliver the best standards of care.

There are times when we use hospitals to provide care for patients when that care could be provided closer to their home and in the community. Developing the right care outside hospital is a key part of how we will continue to maintain the provision of quality and cost effective care for the residents of Ealing.

This is our three-year strategy to design and deliver out of hospital care.

To achieve this, our out-of-hospital initiatives will be:​

  • Inclusive: We want our services to be inclusive and for this to happen we will involve patient and public groups in our proposals. As we develop our initiatives it should be clear to all users how we are developing our plans.
  • Integrated: We will work with all our stakeholders who provide out of hospital care e.g. primary care, community services, social care, nursing homes, voluntary groups to provide joined up care.
  • Sustainable: Our approach will be sustainable and we will invest when we need to deliver the care.

Our strategy aims to improve quality and efficiency across the system, the experience of all patients, and make the best use of our resources.
We recognise this is a different and substantial shift from how we deliver health today. In the coming months we will be meeting with patient and public groups to explain our plans and to fully involve you as we develop our initiatives.
We need to continue to respond to the challenges we face and to evolve to deliver the best sustainable health care for the residents of Ealing.”
As demand rises with increasing health needs and the development of new treatments, we need to respond to the challenges while delivering the highest quality of care. We need to build and preserve what we do well and continue to look for new developments to deliver the best standards of care.

There are times when we use hospitals to provide care for patients when that care could be provided closer to their home and in the community. Developing the right care outside hospital is a key part of how we will continue to maintain the provision of quality and cost effective care for the residents of Ealing.

We need to change the way we deliver care. At present access to care and the quality of care are variable across the borough. Improving the access, quality and scope of out of hospital services will require new ways of coordinating services, investment and greater accountability. Exhibit 1 sets out reasons for transforming out of hospital care.”

Further details are found in NHS North West London’s Shaping a Healthier Future programme in the following document:-
How have we delivered better care, closer to home?

The examples of the initiatives:-

*Urgent Care Centre: this is already providing 24 hour urgent care to patients at Ealing hospital
*111 and single point of access
*Improving access to GPs – at our surgery we have cooperated by
– providing extra slots for emergency appointments
– providing a later surgery ( Wednesday evening until 8pm)
– introduced by Ealing CCG. If you feel unwell on Saturdays and Sundays, you can call NHS 111 for medical help and advice. If the trained adviser thinks you need to see a GP, they will direct you to the practice in your area that is open. We are part of the rota of GP’s

*Integrated Rapid Response Service: started in July 2012 and provides a response to patients to provide care in their home and to support them on discharge from hospital.

*A new service started in October 2012 called ICE (or Integrated Care Ealing) which cares for patients at home if they are not sick enough to be admitted to hospital but are too unwell to stay at home without extra care. The service provides nurses, physiotherapists, and health care assistants, under the clinical leadership of Ealing Hospital Consultants. In 2013/4 there has been an increase in the number of staff and types of clinical conditions that the service manages.
Dr Livingston and I have used this service on many occasions and proved it to be extremely useful and helped in avoiding unnecessary hospital admissions.

*We also have a GP wards – Rosemary and Magnolia Wards at Ealing hospital totally geared to manage the acute condition eg urinary tract infection, which although treatable in the home can present with confusion, which settles after 24-48hrs and admitting a patient for 1-2 days and then discharging with a care package saves a prolonged admission. We also have the ICE team who are a multidisciplinary team with nurses, physiotherapists again linked to social services.

*We have Community Matrons allocated to each network  and they coordinate the multidisciplinary team to attend patients with complex medical problems.
* All  patients older than 75years of age now have an allocated named GP who oversees their holistic management.
* In our practise we have seen many of elderly and formulated care plans which not only look at their physical and mental health needs but their social  aswell. These patients are reviewed at monthly intervals to note any significant changes in their status. It is also a chance to look at future planning particularly ‘end of life care’ so that whilst a patient is reasonably well they can have a say in their advanced care planning. Many people have welcomed this whilst others want to discuss it with their families or simply want to take life as it comes but at least they have a choice.

* Children’s nursing service: Ealing CCG have developed a children’s nursing service to provide care for children closer to and in a more convenient location for them and their families.

* Palliative care service: ECCG are working with the Marie Curie service to provide a rapid response team to assist and support those people who wish to die at home. We are able to get urgent access to McMillan nurses until 8pm so that a visits can bee arranged.

* Psychiatric liaison: ECCG have funded a psychiatric liaison service at Ealing hospital to provide a rapid response to patients who need this care. Dr livingston and myself have been working very closely with the appointed Community Psychiatric liaison Psychiatrists to achieve greatly improved outcomes especially with our complicated psychiatric patients – improving their care aswell improving our own learning needs in this challenging aspect of medicine.
We as GP’s have much improved access to psychiatric services aswell as a range of psychological services using:-
The Ealing IAPT (improving access to psychological therapies) service offers support for common mental health problems such as depression, anxiety and panic. Referrals can made by:-
– making a request to a GP or another health professional
– self referral by calling us directly on 020 3313 5660

How we are working together

The ECCG have identified better coordination of services as a priority in order to improve care. For example:
Ealing GPs now work in six Health Networks ensuring care is clinically led and consistent across GP practices
Within our six geographical multi-disciplinary groups, the Integrated Care pilot to provides integrated care across health and social care
We now work closely with partners in community and social services to support patients to use health and social care services effectively
A service providing coordinated and joined up care to Ealing residents who are in nursing homes evolved last year so that a group of GP’s take responsibility for their care and are accountable to the CCG.

We as practise and part of a network ( a group of nearby practises which are part of the commissioning group which includes Ealing, Acton ,Southall and Northolt have been actively taking part in many initiatives to improve patient care. Healthcare and social care professionals are working together much more closely.

We are actively seeking out patients that have complex medical/social problems and discussing how we can improve their care. We can now contact social services much more easily and over longer hours to effect urgent social care.

We are improving our liaison with hospital consultants including mental health and this has brought about an ongoing and active improvement in management of care as well sharing and educating each other about the management of common medical problems eg heart failure, anticoagulation, chronic obstructive pulmonary disease in the community.

We have a community diabetic team who liaise with GP’s to provide improved care for our large number of diabetics aswell as providing management they provide patient education.

We have increased our communication with social services gathering around a table to discuss these types of patients and share the problems and understand each other’s way of dealing with health problems with social issues.
Now we can access social services at weekends and late in the afternoon and it works! It is sad that it has taken an economic crisis and a need to save money to promote these changes. There have been many years of struggling, stamping feet and despairing to get social support to avoid hospitalisation of a patient who often took up an acute medical or surgical bed for weeks.

How has change been supported

* employing and having advice from experts
* peer to peer reviews – GP’s getting together in their networks for planning and using the expertise in a network to formulate initiatives.
* change of IT systems to to improve working together and monitoring progress of performance
* liaising with the public to establish needs of the geographical area by public meetings
* improving health education by liaising with Ealing council
* the right contracts and incentives to improve care, to underpin the new ways of working have been put in place.

These are many of the challenging initiatives that have been commenced in the last three years. Aswell as the superb work of our CCG governing body there has been a lot of work from many hard working GP’s and practice managers who attend meetings after their surgery’s in an attempt to improve our services.

As I wrote this I felt quite uplifted by what has been achieved and feel that in Ealing every effort is being made to shape a healthier future.

If you want to find out more about Ealing CCG and how it is evolving and to see what is in store for the future log in to website:-


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Primary care plays a vital role in our health and social care system. Good primary care can play a significant role in improving the quality of people’s lives, including those of the older people; people with long-term conditions; new mothers; children and young people and people with mental health issues. We as GP’s nwork with others in the health and social care system to keep people well and are a trusted source of information and advice, often being the first port of call for those in need of care. Crucially, we are the central coordination point for the care of people who move between hospitals, care homes, care in the home and community health services.j

Dr Livingston and myself are passionate about our work as GP’s and between us have worked for >60 years in Prima.ry Care. At 102 The Avenue we have a dedicated, multidisciplinary team who are keen to provide high quality personal health care, attending to our patients needs by acting with integrity and complete confidentiality in a courteous, approachable, amicable and accommodating manner.  We are always willing not only to accept praise but also constructive criticism so that our service remains patient centred. All members of our team are committed to participating in ongoing training and learning to maintain an up to date high standard of care. We particate in events with other Primary Health Care Teams in our network and Commisioning Group so that we can remain in tune with what is happening in the local and national scene and benefit from initiatives that may improve services for our patients.

imageThe Care Quality Commission is the independent regulator of health and adult social care in England.

They have set out a new vision and direction for the Care Quality Commission in their Strategy for 2013- 2016, Raising standards and putting people first and in their recent consultation A new start, which proposes radical changes to the way they regulate health and social care services.

                             We have been randomly selected to undergo an inspection on Tuesday



*A team of inspectors will spend a day at the surgery and during that time will interview the staff and a selection of patients.

* They will also read comments which patients will have completed on specific cards available at the surgery prior to the inspection.

The five key questions they need to ask and obtain evidence from many sources including directly from patients are:-

Is the quality of care





further information :


The overall table of events:-




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What should you expect from your doctor?

We are all aware of the escalating complaints against doctors and read regularly stories of poor treatment. I always feel concerned when I read these articles as when a person develops an illness or medical problem and have to seek medical advise it creates an added anxiety as to whether they are going to receive good treatment or if they are going to be taken seriously.
The number of complaints to the General Medical Council(GMC) – which oversees doctors practising medicine in the UK – increased by 23% from 7,153 in 2010 to 8,781 in 2011 – continuing a pattern which has been rising since 2007.
About two thirds of these complaints are from the general public the remainder are from other public bodies such as the police or coroner services and others healthcare professionals.

However, although there is an increase in complaints it is important to put the figures into context. It is estimated that there are over 100 million patient-doctor interactions each year in the NHS. This ‘complaint-rate’ of less than 0.001% per interaction is something of which most industries would be envious.
Also, as the GMC points out, the rise in complaints may not be due to worsening services, but could be the result of rising patient expectations and an increased willingness to complain.

Nevertheless, we would all like to think that there were no complaints and it is not helpful to hear these figures if you have a serious complaint to make but I thought this would be somewhat reassuring to those who may be having to face medical treatment in the near or distant future.

What are the commonest complaints?

  • concerns with investigations and treatment, such as failure to diagnose or prescribing inappropriate medications
  • problems with communication – such as not providing appropriate information or not responding to people’s concerns
  • perceived lack of respect for the patient – such as being rude or dishonest

Many members of the general public are probably not aware that we are now appraised on an annual basis and every doctor since 2012 will have to go through a revalidation process every 5 years. The appraisal has to show that we are maintaining an up to date portfolio of attendances at educational meetings and literature we have read. We have to discuss how we communicate with our patients, our practise staff and medical colleagues and any complaints we have had and how we have addressed them as well as any accolades we have received. We have produce written proof that all these aspects are being addressed.

In this practise, for more than 10 years we have had a range of medical students assigned to the practise and I am always grateful to patients who are prepared to see them. When they start I am very anxious that they simply get used to talking to all ages and different types of people and learn to extract information in a respectful but effective manner.
I took a group of students to see one of our rather garrulous patients who albeit had a fascinating medical history. One delightful student, a highly intellectual Oxford Graduate in philosophy, who had decided to change tack and study medicine was asked to take this lady’s history. He was amazingly patient and an excellent listener and I decided to not interrupt for about 20minutes. Then I asked him to finish and we thanked the patient and left. When we as a group analysed what information he had extracted it was evident that he had extracted the smoking history of every member of  her family going back two generations and what had happened to them but we weren’t quite sure whether she had ever smoked. We had established how long she had been living in the flat, the price and the prices over the years and who had lived there before including a lady who had put her head in the gas oven and that’s why there was an electric cooker but not much more despite her having numerous medical problems.

I then said to him, “Suppose she then collapsed and you had to report to your senior colleague her main medical problems what would you say?” He then realised his gentle,caring listening manner had been his downfall.

As a group we all learnt from this as to how to focus a patient to get the correct information. As a group we worked with that student who eventually was able to use his listening talent effectively but also extract the relevant information teaching us all important lessons in history taking.
I often ask patients to write down all their concerns in a list to be discussed. This is also useful when attending hospital appointments.

Communication is a dialogue between two people and also involves interpretation of facts obtained.

When I was in practise in Wales patients would frequently report having had a “pull” and this could mean absolutely anything from pain of any sort to collapsing and as it involved careful questioning as well as close observation of the patient’s body language and knowledge of something about them to find out what they meant. Moreover, I soon learnt never to ask what brought them to the doctor to avoid the ramifications of the mode of transport that was or may have been available of ask how they were because the reply could be anything and often not medical!

We all know how difficult it can be to get anything but a grunt from a teenager and in one consultation I had to resort to asking a grunting 14year old boy to tell me what football team he supported and as he said “Chelsea” I flashed an Arsenal key ring in front of him and then words fell out of his mouth.

I have to say that in some parts of the country for example the’ Black Country’ (West Midlands)’ where some of my family come from it is impossible to understand what they are trying to say. As my mother would have said , ” don’t they have a broad accent?”

The Daily Mail were totally misguided when they implied that the communication problem was due to foreign doctors as figures do not support this and after all I was a GP in a Welsh speaking part of Wales!

Surgeons can be particularly poor at communicating as they are ‘doers’ and I have known brilliant surgeons who have weak communication skills. If I am aware a patient is going to have surgery or a procedure I often suggest that if they don’t get or understand the answers or explanations they need or want they can be seen by the GP to get this information. We can phone, email or write to or even meet the consultant face to face to get that information. They are more often than not charming and only too glad for us to liaise with them.

When it comes to rudeness or lack of respect, in the same way patients should not be rude of disrespectful then there should be zero tolerance for a doctor to behave in this manner.

imageThe GMC lays out very clearly the duties expected of doctors and I have reproduced this from literature which is sent annually to every doctor registered with them:-

Duties of a Doctor

The duties of a doctor registered with the General Medical Council
Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and make sure your practice meets the standards expected of you in four domains.

Knowledge, skills and performance

  • Make the care of your patient your first concern.
  • Provide a good standard of practice and care.
  • Keep your professional knowledge and skills up to date.
  • Recognise and work within the limits of your competence.

Safety and quality

  • Take prompt action if you think that patient safety,dignity or comfort is being compromised.
  • Protect and promote the health of patients and the public.

Communication, partnership and teamwork

  • Treat patients as individuals and respect their dignity.
  • Treat patients politely and considerately.
  • Respect patients’ right to confidentiality.
  • Work in partnership with patients.
  • Listen to, and respond to, their concerns and preferences.
  • Give patients the information they want or need in a way they can understand.
  • Respect patients’ right to reach decisions with you about their treatment and care.
  • Support patients in caring for themselves to improve and maintain their health.
  • Work with colleagues in the ways that best serve patients’ interests.

Maintaining trust

  • Be honest and open and act with integrity.
  • Never discriminate unfairly against patients or colleagues.
  • Never abuse your patients’ trust in you or the public’s trust in the profession.
  • You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

I have to say for the most part I find my fellow doctors fulfil these duties honourably and I am proud to be part of the medical profession.
We are all patients and I trust that we all do our part to be as helpful in providing relevant information, cooperating appropriately and working with them to manage our medical problems.

If you do have a complaint please address them to the practise manager or PALS – the complaints procedure is on the website.


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If you read the main website on the following link you will be able to view the practise profile and what actions have been taken following previous PPG meetings.
Last year was directed at health education and a major reason for starting this blog.


• To give Practice staff and patients the opportunity to discuss topics of mutual interest in the Practice.
• To provide the means for patients to make positive suggestions about the Practice and their own healthcare.
• To encourage health education activities within the Practice.
• To develop self-help projects to meet the needs of fellow patients.
• To act as a representative group that can be called upon to influence the local provision of health and social care.
• To involve further patients from the wider population.

imageAs I am sure you are all aware the NHS has become NHS ENGLAND and has reinvented itself with the prime aim to improve the health outcomes for people in England.


We believe the new approach we are taking will really make a difference and deliver the improved health outcomes we all want to see.

Central to our ambition is to place the patients and the public at the heart of everything we do. We are what we want the NHS to be – open, evidence-based and inclusive, to be transparent about the decisions we make, the way we operate and the impact wehave.

We encourage patient and public participation in the NHS, treat them respectfully and put their interests first. This allows us to develop the insight to help us improve outcomes and guarantee no community is left behind or disadvantaged.

We empower and support clinical leaders at every level of the NHS through clinical commissioning groups (CCGs), networks and senates, in NHS England itself and in providers, helping them to make genuinely informed decisions, spend the taxpayers’ money wisely and provide high quality services.

Engaging with our staff is equally important to us too. Our staff are what makes NHS England an excellent organisation: an exemplar in customer focus, professionalism, rigour and creativity.

Grounded by the values and principles of the NHS Constitution, we are an organisation who shares ideas and knowledge, successes and failures, and listens to each other carefully and thoughtfully.

At NHS England, we practice what we preach. By working collaboratively and building coalitions with partners everywhere means we can achieve greater things together and deliver the best patient service not only in England but in the world.


It is with this in mind that we are continuing to develop our PPG and your views as patients will be important when we have our CQC inspection.
We need your support during the changes that are anticipated and feedback from you to establish what is going well and we need your positive suggestions as to how we can make improvements to the practise and your healthcare.

Small practises such as ours are under threat and we are finding ways as to how we can work more closely with other local practises and have started to share resources such as anticoagulant management,lung function measurement,children’s phlebotomy and nursing home patient care as well as training our staff. We recently held our cardio-pulmonary support training session with staff from other practises and patients were also invited.

We have joined a network with other local practises to meet to discuss care pathways for patients with complex medico-social problems as well as finding learning needs and addressing them.
Doctors and/or practise manager always attend CCG meetings so that we keep up to date with local and national changes and a chance to meet doctors from other networks to formulate ways of improving health care by commissioning.
The 2013/14 prosectus and links can be found on the following website

Following the CQC inspection there will inevitably be suggestions of actions that need to be actioned. You may have noticed certain changes such as all staff wear name badges including me when I remember! Also there are EXIT signs and all staff are being trained in more advanced health and safety including fire safety. All staff are trained regularly in first aid and life support and awareness of patients with particular needs.
We have all been alerted to the special needs of patients with learning disability and sensory impairment and are attempting to find ways of accommodating them sensitively as advised by healthcare professionals who are expert in this field.

What are our priorities and vision for the future?
Ealing CCG has seven overarching priority areas of work, as follows:
*A better start in life – increasing breastfeeding initiation, reducing avoidable childhood injuries, and increasing childhood immunisations.
*Increasing life expectancy – reducing cardiovascular disease deaths, reducing cancer deaths; and reducing alcohol-related hospital admissions.
*Shifting unplanned care towards planned care – increasing the amount of services delivered in a community setting, improving unplanned care services in Ealing, and reducing the delays in hospital discharges.
*Reducing variations in primary care – better early diagnosis and treatment, and reducing variations in hospital referral patterns by GPs.
*Improving recovery – increasing the range and access to rehabilitation services.
* Enhanced mental health services – increasing the provision of community services.
* Improving care at the end of life – increasing the proportion of deaths in preferred places.

These are the areas of work which we are discussing in our CCG meetings and implementing in our networks and in the practise.

The main areas a PPG can help are:-
*Improving services provided by the surgery
Carrying out surveys into a whole variety of subjects eg health needs/expectations and major cause of ill-health in a particular area.
• To explore the changing needs of patients.
• Measure patient satisfaction.
• Gather ideas for improvements or modifications needed for the delivery of services.
• Discussions at meetings.

*Offering support to other patients
e.g Befriending service, Carers Group

*Improving facilities at the surgery
• Fundraising for new furniture, toys or decorating.
• Keeping the plants or gardens of the surgery maintained.
• General environmental improvements.

*Providing health promotion and education
e.g diabetes awareness day,contributions to the blog and notices added to our notice board.

* Supporting voluntary organisations in the area
e.g Age UK, MIND, Heart Foundation, Cancer UK, Dementia Concern
We have several patients who make contributions to these and other organisations

This year the CCG want to particularly want to focus on Carers
Many people who are caring for someone do not necessarily see themselves as a ‘carer’. Rather they are mothers, fathers, daughters, sons, partners, husbands, wives or neighbours. However, being identified as a carer by the council can help you get the right support you need to look after the person you care for.
To understand what support can be given to Carers the following website is helpful



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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 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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Patient’s role in NHS England

As we all read the papers or listen to the news it is now blatantly obvious the NHS on its 65th birthday is in serious trouble.
The NHS is “about to run out of cash” – and faces a £30 billion funding gap by 2020, senior health service officials have warned.
It is down to NHS England to advise sweeping changes – a call to action……

Formally established as the NHS Commissioning Board on 1 October 2012, NHS England is an independent body at arm’s length to the Government.
NHS England   will play a key role in the Government’s vision to modernise the health service with the key aim of securing the best possible health outcomes for patients by prioritising them in every decision it makes.
The main aim of NHS England is to improve the health outcomes for people in England.
    • We believe the new approach we are taking will really make a difference and deliver the improved health outcomes we all want to see.

      The new health and care system becomes fully operational from 1 April to deliver the ambitions set out in the Health and Social Care Act. NHS England, Public Health England, the NHS Trust Development Authority and Health Education England will take on their full range of responsibilities.

    • Locally, clinical commissioning groups – made up of doctors, nurses and other professionals – will buy services for patients, while local councils formally take on their new roles in promoting public health. Health and wellbeing boards will bring together local organisations to work in partnership and Healthwatch will provide a powerful voice for patients and local communities.
    • Central to our ambition is to place the patients and the public at the heart of everything we do. We are what we want the NHS to be – open, evidence-based and inclusive, to be transparent about the decisions we make, the way we operate and the impact we have
    • We encourage patient and public participation in the NHS, treat them respectfully and put their interests first. This allows us to develop the insight to help us improve outcomes and guarantee no community is left behind or disadvantage
    • We empower and support clinical leaders at every level of the NHS through clinical commissioning groups (CCGs), networks and senates, in NHS England itself and in providers, helping them to make genuinely informed decisions, spend the taxpayers’ money wisely and provide high quality services.
    • Engaging with our staff is equally important to us too. Our staff is what makes the NHS England an excellent organisation: an exemplar in customer focus, professionalism, rigour and creativity
    • Grounded by the values and principles of the NHS Constitution, we are an organisation who shares ideas and knowledge, successes and failures, and listens to each other carefully and thoughtfully.
    • At NHS England, we practice what we preach. By working collaboratively and building coalitions with partners everywhere means we can achieve greater things together and deliver the best patient service not only in England but in the world.


      At the same time this potential crisis reaches the headlines we as GP’s are asked to choose whether to liaise with the Patient Reference Group(PRG) to get ideas of how we can improve our services by increasing efficiency and cost effective commissioning. We as a practise have opted to participate in this Direct Enhanced Service (DES) and work with the PRG.

      Patient Reference Group
      The purpose of the patient participation DES is to ensure that patients are involved in decisions about the range and quality of services provided and over time, commissioned by their practice. It aims to encourage and reward practices for routinely asking and acting on the views of their patients. This includes the patients being involved in decisions that lead to changes to the services their practice provides or commissions, either directly or in its capacity as gatekeeper to other services.It aims to promote the proactive engagement of patients through the use of effective Patient Reference Groups (PRGs) and to seek views from practice patients through the use of a local practice survey. The outcomes of the engagement and the views of patients are to be published on the practice’s website.

      Suggestions of aspects which may be discussed – NHS England
      One aspect that practices may wish to focus on is ensuring convenient access to the practice and also from the practice to other services in its role as coordinator of care, facilitating access to other health and social care providers.
      Access has many dimensions; the relative importance of these will vary according to the specific needs of the registered population. These dimensions include:
       lists being open to all
       hours of opening with the ability to be seen urgently when clinically necessary, as well as
      the ability to book ahead
       continuity of care
       range of skills available – access to different professionals
       a choice of modes of contact which currently includes face-to-face, telephone and electronic contact, but can be developed further as technology allows
       geographical access, enabling care as close to home as possible.
      Access must be flexible enough to meet the varying needs of individualsand requires sufficient capacity to meet the population’s needs. Details of access arrangements (including opening hours) should be made widely available to the patient population to enable patients to exercise choice.

      Patient Reference Group (PRG) may be an existing formal patient participation group or a similar group that is representative of the practice population, which would feed in its views alongside the findings from the surveys and agree with the practice priority areas for possible change. This would result in an action plan to be agreed between the practice and the PRG.
      Practices taking part in this DES will also carry out a properly constituted survey of a sample of the practice’s patients looking at a broad range of areas which could include convenience of access (opening times, ability to book ahead, ability to be seen quickly, telephone answering), patients’ experience of the treatment and service they receive, the physical environment in the practice and other issues specific to individual practices.
      As I am sure some of you are aware we have already participated in having meetings with a cross section of patients during the past few years to discuss results of patients surveys addressing issues such as access to doctors, telephone access, car parking,email prescription requests, children in surgery and more recently patient education and we have attempted to improve our service and act on points raised in the survey. The minutes of these meetings are published on our website. This was formerly called the Patient Participation Group but will know be known as the Patient Reference Group.
      We have tried to make our meetings representative of the patient population but along with our GP colleagues we have found the numbers participating are small and some types of patients are not represented. Nevertheless, we are persevering to reach our patients by our website,written newsletters and survey sheets distributed over a period of time to a wide cross section of patients.


      We will be announcing a PRG meeting in the next few weeks and conducting a survey with patients attending the surgery and strongly encourage as many people as possible to participate. Although it is good to hear favourable comments on things we are doing well it would be extremely useful and perhaps more so if we could have constructive criticism of things we are NOT doing well,and even better if we can have ideas of how we can provide a better service.
      When we obtain the results of the survey we will hold a further meeting to discuss the findings and hopefully come to an agreement as to how we can implement plans for changes to the services provided.
      If you have suggestions please contact the practise Manager,Sangeeta Kathuria by email(, appointment or by letter.
      We need everyone to pull together to keep our NHS continuing to provide a service to all who need it.


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