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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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The Patient Participation Group held a meeting at the surgery on October 17th 2013 in the surgery . The full minutes are on the surgery website:-

We reported on outcomes of planned achievements from last year – 2012/13

  • Passing on of information
    We have managed to obtain 500 patient email addresses to be able to inform patients of current changes in the NHS. Following last years meeting I started this blog in an attempt to let patients and others know about national changes aswell as local events and changes. It has also been an attempt to educate readers about medical topics aswell as some stories relating to my life as a doctor and tying it in to more recent advances in medicine.
  • Clinical Systems We have been in negotiation most of the year with other doctors in our network and having agreed on a system which would be more patient friendly it has been decided to Ho over to this system after April when the busy winter months are over.
  • Patient education Arranging events in the form of talks has been difficult due to patient’s availability but by continuing with posters , providing links on our website, patient leaflets and now deciding to focus on particular at risk groups such as the mentally ill we hope this will be an ongoing
    provision.PLANS FOR 2013/14

    We have brought up 3 subjects to consider and will sending out a survey completed anonymously to gather information from a wider section of patients

    With reference to a paper brought out earlier in the year in the magazine Commissioning Success a bi-monthly magazine from the team behind Practice Business, aimed at helping clinical commissioners get the best outcomes from clinically-led commissioning.
    Collaborative healthcare ‘groups’ and informal alliances can work better than formal mergers, says NHS Confederation.
    Published: MAY 1, 2013

    “The new options for governing through healthcare groups set out in this paper can strengthen rather than reduce the connections to local people, and help maintain safe local services. They could also mean less upheaval for staff and for patients, many of whom worry that they will lose a valued service or even their job.”

    We discussed the present situation of general Practise and how small practises are becoming less viable and ways in which we could consider keeping the personal touch we have created in a small practise. However, being realistic we must now consider sharing facilities with other nearby practises and with a new computer system where access to notes would be more obtainable by other doctors we could reduce waiting times and share resources.
    We have already begun to collaborate with other practises in our network (about 10 practises) in Commissioning services such as anticoagulation and community run musculoskeletal-skeletal services but we need to think of ways to facilitate services at a practise level for more everyday services and how we can satisfy CQC inspectors with regard to standard of premises.
    The survey will provide more feedback from our patients on this topic.

    OUT OF HOURS and A&E
    This has been an ongoing topic in the national news for some time and recently I have been asking patients what they would do if they needed a doctor out of hours and was surprised at the lack of knowledge. This prompted me to write the blog on 111 and please read this if you haven’t already done so. The NHS is wasting phenomenal amount of money asking highly qualified health professionals to deal with health problems which could be dealt with in the home or visiting a local pharmacy. Splinters, common cold, flu, simple cuts, bruises and sprains and domestic worries are not reasons for attending A&E or calling an ambulance. Believe it or not that is what I see every time I do an Out of Hours session at one of our local hospitals. Again refer to this blog which outlines what to do if you have a medical problem out of hours.

    Another topical cause of concern has been medicine wastage and we need to educate patients how to avoid this. We as doctors meet regularly with a prescribing advisor and we work closely with a prescribing pharmacist to find ways in which we as doctors avoid waste and to consider cost-effective prescribing. By doing this there is more chance that there will be money in the pot for expensive medication for conditions such as cancer. It is also helpful if patients buy over the counter products such as paracetamol when appropriate.
    See blog:- Do you use your inhaler as an air spray?

The next step is to send out our survey both by hand in surgery and online and then analyse the results and meet again to discuss.

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Posted by on October 26, 2013 in Training and Advice


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Outside normal surgery hours you can still phone your GP surgery, but you’ll usually be directed to an out-of-hours service. The out-of-hours period is from 6.30pm to 8.00am on weekdays and all day at weekends and on bank holidays.

If it is not an immediate emergency then call NHS Direct on 111.
I appreciate that when this when this was launched there were many problems but it has improved during the last few months and when I asked those that attended the Patient Participation Group there was good positive feedback.

imageNHS 111 is available 24 hours a day, seven days a week.
When you call 111 a receptionist will ask you various questions to assess the urgency of the problem and your needs.

  • If it is advise you need the receptionist will transfer you to a doctor or nurse practitioner.
  • If you wish to see a doctor they will make an appointment for you to see a doctor or nurse at the Urgent Care Centre(UCC).
    The nearest UCC in W13 & W5 is Ealing Hospital. This open 24 hours every day of the year.
    imageDetails of this or other local UCC can be obtained on the following website:- Search/Urgent%20Care/LocationSearch/0If you are given an appointment it is important to turn up or cancel the appointment as the the receptionist has the responsibly to chase you up to find out to find out what has happened before removing a patient off the screen. Having been alongside a receptionist making enquiries as to why the patient has not turned up to hear answers such as ‘the child went to sleep’ or ‘the patient is better and they have gone out’ or ‘we called an ambulance because we can’t afford a taxi’ is not helpful in making a service efficient.
    If you turn up in A&E it is possible that you may be directed to this service but may have to wait longer to be seen. Hence it is in your own interest to phone 111 to make an appointment.

If the doctor seeing you feels you need further investigation or a specialist opinion they will consult their specialist colleagues at the same hospital or another local hospital and arrange for you to be seen. You will not have to queue again in A&E.

  • If for some reason you are unable to leave your home for medical reasons ( bed-bound or terminally ill) the receptionist will refer you to a doctor working alongside them to arrange for one of the mobile doctors to visit. Although the doctor does NOT have access to your medical records the details of the telephone conversation, consultation or visit including any treatment given is recorded and then faxed to your usual doctor for them to receive the following morning. Dr Livingston and myself read these before a morning surgery and if we either need to see you will telephone or write to you but you may be told to see your GP next day. The record is then scanned on to your computer record.
    By doing this we are attempting get good continuity of care.
    I occasionally work in one of the local centres( much to patient’s surprise when faced with me) as do many of our local GP’s and it gives me a chance to appreciate how the system works.
  • If it is a serious injury or illness then call 999 but if you are unsure call 111 first and they can arrange an ambulance or for you to be seen urgently.


A&E departments assess and treat patients with serious injuries or illnesses. Generally, you should visit A&E or call 999 for life-threatening emergencies, such as:

  • loss of consciousness
  • acute confused state and fits that are not stopping
  • persistent, severe chest pain
  • breathing difficulties
  • severe bleeding that cannot be stopped

I viewed this on the NHS Choices ( website and thought it would be good for all to view:-

If an ambulance is needed, call 999, the emergency phone number in the UK.

You can also dial 112, which is the ambulance number throughout the European Union.

Major A&E departments offer access 24 hours a day, 365 days a year, although not all hospitals have an A&E department. At A&E a doctor or nurse will assess your condition and decide on further action.

Dental Problems
Emergency dental service is available Monday to Friday 6pm – 10pm, Saturday, Sunday and Bank Holidays 9am – 10pm.
Tel: 020 3402 1312
Otherwise phone 111 to ask advise.

Mental health emergencies

If a person’s mental or emotional state quickly worsens, this can be treated as a mental health emergency or mental health crisis.
24 hour support line: 0300 1234 244
SANELINE on 0845 767 8000 – open 1pm – 11pm every day
If you use the services of the Gender Identity Clinic and have an urgent issue, please contact your GP.

If it is a medical emergency, please call 999. If you are in acute emotional distress and your GP is unavailable, please contact the Samaritan support group on 08457 90 90 90 or visit

If you are worried about a family member or someone you care for whose health has suddenly gone downhill, you can also call the Samaritans or our 24 hour support line for help and advice.
In this situation, it’s important to get help as soon as possible. Contact NHS 111 to find out where help is available. If you feel the person is in immediate danger then call 999.

Emergency contraception can stop you becoming pregnant after having unprotected sex. Two methods are available, the ‘morning after’ pill and the copper intrauterine device (IUD). The pill can be taken up to 72 hours after sex and is available free from your GP and most family planning clinics. It is also available from some pharmacies. The IUD is a plastic and copper device that is fitted into the woman’s womb by a doctor or nurse within five days of having unprotected sex.
If you need to find a pharmacy who may supply ‘morning after pill’ the following link will be helpful
Also refer to our website to find out where the nearest Family planning clinics are located.

Walk in clinic
If for any reason you are not able to attend your GP surgery or need medical attention you can either walk in to the Urgent Vare Centre at Ealing Hospital open 24hours.
Our local clinic is at:-
Featherstone Road Clinic, Southall UB2 4BQ

Tel. 020 3313 9880

Mondays to Sundays

8:00am – 8.00pm


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Posted by on October 19, 2013 in Training and Advice


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Yesterday a patient came into surgery and said “I am a bit worried about my mum , when I came home from work she seemed a bit confused and she was getting her words wrong she kept saying to my dad  to come and get his ice- cream when she meant to say dinner and called the cat a car. She was otherwise OK and before I went to work she wasn’t like that”
I  knew this patient had high risk factors for a stroke and infact had seen her earlier in the week so I knew this was something to act on and

Although her speech was not slurred she had a sudden change in being able to speak normally and it is the SUDDEN onset of change that is important.
Medical students posted this poster in the surgery and then after a week asked attending patients if they had seen a poster or new how to recognise a stroke and very few knew!
By recognising the signs and getting them to hospital as soon as possible can be extremely beneficial to the patients.When you call an ambulance in West London and tell them what you have witnessed or it is happening to you they know that they must take you to either Northwick Park Hospital or Charing Cross Hospital as these are the designated hospitals with a specialised Stroke unit and are equipped to act fast and administer specialised intensive aftercare.

However if the symptoms are transient and there is a recovery within 24hrs then it is still important to get an urgent appointment or in the case of 102theavenue surgery there is walk in surgery each morning or the receptionist would fit a patient in to a later appointment surgery. If surgery is closed there are walk in clinics or phone 111 for an urgent appointment in the nearest Urgent Care Clinic.
If you want to know more about stroke and what happens physiologically use the links or watch the video below:-


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