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Can I offer anyone a TUE?

Thursday 29 September 2016

The Friday before last I found myself talking about the STP (Sustainability and Transformation Plan) again. I do seem to have banged on about it in quite a few different settings and forums, including here, but this was rather different, not least because I was wearing a dinner jacket. Those of you who know that Barry Moyse has joined our practice will not be surprised to hear that standards of dress there have improved, but even in North Petherton black tie is not required attire before 6:30 pm (on weekdays). My right hand held a glass of chilled Taittinger, my left possibly steadying myself against the ancient wooden paneling of a room known as Benson Hall. The small group I was addressing and regaling with the intricacies of the GP Forward View and Somerset recruitment problems included an actor whose big-screen break came playing a Royal Naval captain who went down with his ship in Tomorrow Never Dies, an aristocratic ex-MI6 station chief in Belgrade during the Bosnia crisis (slightly tarnished after tabloid exposés), and the previous Archbishop of Canterbury.

Fascinating and thrilling though STPs might be, you’d be forgiven for thinking that between the group we could have found something more exciting to talk about. I suspect it might in part have been due to my loquacity- I was certainly more chatty than the last time I was in the same room for a pharmacology viva back in 1980. I can’t be sure, but there’s more than a fighting chance that on that occasion I didn’t start every sentence with the word “ananutherthing”, and I probably swayed less. It was all absolutely fine, though, as I’ve got myself a TUE- a Therapeutic Use Exemption- for the Taittinger.

Therapeutic Use Exemptions have been in the news this week with the revelation that Sir Bradley Wiggins used TUEs to allow treatment with depot triamcinolone on three occasions a few days before major races, apparently on the basis of allergy and asthma. I'm not sure about you, but that caused me to feel decidedly uncomfortable, not only because if we treated all our asthmatic or allergic patients that way (was this first-line treatment?), it might trigger an alarm somewhere in the Medicines Management department, but also because it has since been suggested that triamcinolone has been used in doping in the past, something of which I was blithely unaware. The most famous cycling asthmatic of them all is Laura Trott, whose medical records were also released by hackers from the WADA database, revealing she had applied to use salbutamol and salmeterol between 2009 and 2013. That all sounds a bit more reasonable, especially if there was some inhaled steroid and/or montelukast in there as well. I suppose if she grew Wiggo's sideburns it might be worth taking a second look. My excuse for a TUE? To be honest, I'd just had One of Those Days.

We have a Yahoo group for committee members to bat things backwards and forwards across the ether, and that morning we had a couple of topics doing the rounds. One related to the Primary Care Plan for Somerset, and the accompanying Enhanced Service specification proposal from the CCG. We are still in negotiation with the CCG about this but expect that practices will be receiving more details about this soon. We know the CCG have worked hard to come up with something that NHS England were prepared to sanction, and yet will still be something that practices feel they can sign up to. We will be writing separately to practices soon about this. The second string related to the CCG proposals for Full Delegation of commissioning responsibilities for Primary Care. As you’d expect for such meaty topics, and a vociferous committee, there were some quite forthright exchanges, including one of our colleagues from the south of the county having a metaphysical moment, frantically scrambling around for imaginary bargepoles which he proposed to lash together to make the mother of all bargepoles, with which to leave the Full Delegation plan well alone. In the middle of all this, an email from NHS England slipped quietly onto the desktop, about a little local difficulty around a notice displayed in a practice (somewhere in the Southwest) regarding its flu jab programme- which has since sparked quite a storm. More of this, possibly, anon. Anyway, I was taking Friday afternoon off and heading cross-country to a college reunion, and so had lots on my mind as I swung my car onto the M5 slip road at J24 to be confronted by three lanes of stationary traffic, the beginning of a stop-start five-hour shuffle involving four motorways and the loss of even more hair.

My dentist daughter had her first bit of clinical stress and concern this weekend. She'd seen a patient with severe dental pain (it happens sometimes, apparently), and having done all the X-rays, prodding, poking and probing established that the cause wasn't infective, presumably on the basis he was still in the chair. She did what she'd been taught to do in that scenario, chiseled a bit of tooth away, took out the nerve and put in a temporary dressing. Feeling chuffed that she'd sorted the problem and her pain-free patient was immensely grateful, she was deflated almost immediately when one of the partners said to her that they'd have just given antibiotics and sent them away. She then spent the weekend fretting that she'd done the wrong thing, although her trainer reappeared on Monday and said she'd been right all along. The point is that no matter how wizened and experienced, we're all prone to worry and anxiety- I told her that I've had several short breaks abroad ruined by worry about what I had or hadn't done, on one occasion phoning ITU and MAU from Paris as I was sure a patient must have been admitted there due to my imagined error. Earlier this week a very senior colleague texted me "feeling wretched" about a man in his 60's who had presented with what appeared to be simple back pain, but turned out possibly to have lymphoma after the MRI, arranged having presented later to A and E, showed abnormal lymphadenopathy. We all know that s*** happens, and in those situations we rely on the fact that the patients know and trust us, and understand we are doing our very best. I worry that in the looming world, where GPs are scarcer, decisions and accompanying risks are going to have to be taken by other members of the team, and we are going to have to establish lines of accountability and responsibility, knowing that mistakes/normal disease processes are still going to happen. How are we going to deal with the increased anxiety that that is bound to generate? Are we confident that the GP workforce of tomorrow is going to have the width of experience that we have, if they only ever get to see the complex multi-morbidity patients? Is that going to be an attractive enough job for our younger colleagues, or to keep the greyer ones in the hutch?

On Tuesday evening, I was a guest speaker at an event for local pharmacists arranged by the LPC (Local pharmaceutical committee). Actually, they'd invited Harry, who cunningly passed the baton to me. The clue was when he showed me "his" slides, which had my name on the front page. They were very friendly and hospitable, and keen to hear from a GP perspective how the two professions could be working more closely together. They are about to have a new community pharmacy contract, which involves significant financial cuts and has the explicit aim of reducing the number of community pharmacies. We heard about how pharmacy training is being altered and extended to better equip them for the sort of work we might wish them to take up working more closely with Primary Care. The evening was given added spice by several references to the flu immunisation programme, the presence at the speaker table of an NHS manager involved in the excitement alluded to a couple of paragraphs up, and the revelation that I was also a dispensing doctor. Nevertheless, I got out alive, and we all agreed that there needs to be closer working between our two representative committees in the future.

Yesterday I was in London at BMA House to represent the southwest LMCs at a roundtable event involving LMCs, the GPC and NHS England. The intention of these quarterly meetings is to give a reality check to NHS England around the implementation, or otherwise, of the GP Forward View. Over the past few weeks I've sent several messages to colleagues in other LMCs across the region to ask for any feedback on how things are going locally, only to be met by deafening silence, I suspect representing the fact that not a great deal is happening yet- certainly nothing with the speed and impact that we feel we all need to see. The meeting was chaired by Chaand Nagpaul, and all the great and the good from the GPC and the Primary Care Team for NHS England were there. By the time I was invited to give our local feedback, most of the pertinent points had already been made, so I reported on my experience of the feisty GPFV engagement/punch-up session that I attended in August (as reported in the Silly Season blog). Ros Roughton, the Director of NHS commissioning told me that they’d heard all about the “Taunton event”, and it sounds as if we might have been marked out as a tough audience! I think it was Queen Victoria who used to insist the Royal Train curtains were always drawn when she travelled through Taunton (still miffed after the Monmouth rebellion). Do you think we’re getting a reputation? Here’s hoping…..

Right- that's enough for now. I've got a long ride planned for the weekend and need to break into the treatment room. Last time I cycled to Seaton and back, I had a bit of a wheezy struggle on the 12-mile uphill slog to Upottery, despite a fortifying bacon bap by the seaside. At the time, I put it down to losing some fitness after my French trip and being a bit lardy, but have since decided that I must be allergic to hills.

Nick Bray (still kenalog-free)
29th September 2016



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