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Elephants

Friday 1 February 2019

It’s been mad, but now it’s all white. Grrr and Brrr. In the last seven days I’ve had engagements in Colombo, Kuwait, Bridgwater, Taunton, Petherton and Yeovil, in addition to the odd surgery or three to keep my hand in. I’m sure like me you’ll all have stayed up beyond midnight on Wednesday gagging for the publication of the new GP contract, astonishingly arriving this year before the start date. In anticipation of the snow, Jill and I have been stood down from today’s planned trip to Cornwall for our regular meeting with other peninsula LMC, CCG and NHSE colleagues. It might have been a frostier encounter than usual, and not just because of the weather. We were going to raise the recent problems some of our dispensing practices have had with payments being clawed back, and what we perceive as a new and worrying management style from NHS England, and we are still chasing Child Immunisation payments.

Potentially the most significant meeting of the week, however, was on Monday. I was at the CCG offices in Yeovil with a panoply of the great and the good of Primary Care, the Trusts, the CCG, NHS England and Public Health to discuss what the future “provider landscape” of Primary Care should look like, and how that should affect the commissioning policy of the CCG. We were asked early on by the facilitator what we wanted to achieve by the end of the day. The last thing we needed was another talking shop with no particular output, given that it was all-day Monday and the room was rammed with very expensive movers and shakers from across the system.

I suggested it was high time that we identify the various elephants that tend to lumber around the room, often unchallenged, in these sorts of meetings, and shoot them. Will Harris, notating on a large flip-pad, immediately started a new ‘pachydermal’ page - and by mid-afternoon had collected quite a herd. Amongst a long list were tensions between providers, the intentions of Trusts and others when it came to supporting practices who might wish to integrate, equity of funding, risk management, and lack of system-wide support for Somerset Primary Health (SPH).

We got to tea having had the obligatory table-work with feedback (my favourite) and much animated discussion, but had nimbly danced around the grazing elephants and their dung. The final hour was more fruitful, with tensions and perceptions openly tested and challenged. We ended the afternoon with a strong consensus from all those present that if everybody agreed that a strong Primary Care sector was fundamental for future development and survival of the Health and Care services in Somerset (they did), there needed to be significant system support for a strong local provider organisation, and how this needed to be conveyed to, and recognised by, the senior system leaders. For their part, SPH had already been proactive in approaching other local GP provider organisations for possible joint-working, including Devon Doctors who were represented in the room, and who had expressed their willingness to work with SPH.

Last Saturday I went to Kuwait. I’d been there once before in 1983 and hadn’t liked it much, but given the circumstances was delighted and relieved to renew my acquaintance with the airport. We’d both changed beyond recognition since we last met, although only one of us could blame having been ravaged by a noisy neighbour and left in a shambles. Kuwait had spruced itself up quite nicely since the Gulf War, but with none of the ostentatious excess of its Gulf neighbours.

I hadn’t intended to go there at all. I’d started the day in Colombo, and before leaving for the airport loaded up the papers for Monday’s ‘Provider Landscape’ meeting onto my iPad, hoping to breeze through them between films on the flight back to London. About five hours into the flight, by which time I’d watched ‘Argo’ and necked a couple of glasses of passable red, the dreaded bowel-loosening announcement requesting medical assistance came over the speakers. Mrs. Chair valiantly offered to come up with me, but it was soon obvious that her particular expertise wouldn’t be needed by our patient, a 55 year-old male Sri Lankan who had suddenly lapsed into a coma, with divergent pupils, no response to pain and a Glasgow Coma Scale of three (suboptimal). Our eventual presumptive diagnosis was that he had had a significant stroke, and we were relieved to get the patient off the plane alive.

When the call came, I was reading the GP services workstream report that forms part of the local strategy review (Fit for My Future). There are ten key features that the authors considered should form the basis for Primary Care services, so how did they relate to what happened in our locality, 40,000 feet above the Persian Gulf? Here they are:

1. Focus on prevention and wellbeing within an overall approach to population health management. Essentially we need to be proactive, rather than reactive. Here’s an idea: if you’re planning to load 330 random souls into an aluminium tube, turn down the oxygen levels, fill half of them with alcohol before dimming the lights and trust they’re all still be alive 12 hours later, why not ask for medical assistance to assess any dodgy ones before they leave the departure lounge? Supposing, just for example, you have somebody with disseminated lung cancer, type 2 diabetes, ischaemic heart disease, who survived a VF arrest last year, but who’s been feeling increasingly unwell and not eaten or drunk much for three days and needs a wheelchair to get to the gate, I’d have welcomed the opportunity to give them the walk-around and metaphorical tyre-kicking to see if they were sufficiently pink and perky to make the trip.

2. Is person-centred and supports people to manage their own health. The patient was certainly in the centre of things, being seated in the middle of the centre row of the cabin. Help arrived from a number of angles, but he was well past managing anything himself. It was clear we’d have to move him, so two of us dragged/carried him out from the seat, up the aisle and laid him on the floor of the galley.

3. Offers timely access. We were there within seconds of the call, but would have preferred to get involved at least an hour before take-off, not least to fill in a Treatment Escalation Plan prohibiting his getting anywhere near an aircraft.

4. Provides consistently high quality clinical services. Once we had our patient on the floor of the galley, with cattle class and business class curtained off, and established he was still alive, the five of us who had answered the call took a moment to breathe and assess what clinical expertise we had between us. It turned out we were 3 orthopods (lower limb problems comprehensively covered), a consultant anaesthetist and me. The anaesthetist did well to get an IV line in to our dry patient; I put in an airway, slapped some defibrillator pads on him and was relieved to see he was still in sinus rhythm, and then started to ponder his neurological status.

5. Uses limited clinical resources to best effect. We had an ECG (via the defibrillator), a rudimentary stethoscope and sphig., no pulse oximeter, an antique BM meter which gave us an answer in units we didn’t instantly recognise (but importantly wasn’t zero), a variety of airways and cannulas, two 500ml bags of fluid (one Hartmann’s, one dextrose), 2 cylinders of oxygen and a torch that didn’t work.

6. Has a high level of continuity. We had to leave him untended for a few minutes either side of the emergency landing so we could strap ourselves in, but otherwise not bad.

7. Is delivered locally. To be frank, we didn’t have a lot of choice about this.

8. Is delivered in a good quality physical environment. Aircraft galleys are interesting places, and I’ve often wanted to poke around in the various trolleys stowed there. As a resuscitation area, however, there are a few shortcomings. The floor is made of corrugated metal- uncomfortable for a conscious patient, and slippier than you might expect when liberally splashed with condensed water and blood (from failed cannulations). Prior to landing in Kuwait we had to brace the patient against the forward stowage wall, cushioned as best we could with spare blankets from business class (fluffier), whilst securing the oxygen cylinder so it didn’t crash around during what turned out to be a bumpy landing. There was nowhere to hang the fluid bags, so we improvised with an IV bag threaded onto a crew coat-hanger. The immaculate and beautifully dressed SriLankan Airways cabin crew stood to either side offering glamourous assistance where they could.

9. Is fully integrated with the wider health and care system. The captain was apprised of the situation and radioed his superiors on the ground with our assessment of the situation. At the time we were only a few miles from Kuwait, albeit vertically, but in another hour or so we would be over Iraq and Syria, where the term ‘village agent’ has a rather darker connotation. The decision was made that we needed to plug into the local Kuwaiti ‘network’, resulting in a sharp left turn and the sort of tactical descent not usually associated with the Airbus. A far cry from our local paramilitary heroes who arrive kitted up to the eyeballs, the local paramedics who met the plane on the ground wore jeans and trainers, and without any sort of equipment that we could see.

10. Is financially and operationally sustainable. The airline would have incurred significant landing charges, probably had to jettison fuel (we were less than half-way home), and then top-up the tanks again before take-off, but medical staff costs were negligible: a glass of champagne each and a nice letter on strange waxy paper from the captain (going in my appraisal). On a Sleazyjet flight to Geneva, I once got a free cup of coffee for assessing somebody with pneumonia, but know that one of our neurology colleagues got upgraded to business class all the way to Hawaii for deciding somebody didn’t have appendicitis. (I worried about that for a bit, but neurologists do know about the appendix, or at least that it exists, given the link with Parkinson’s disease).

Cycling in Sri Lanka is fabulous. The scenery is spectacular, the roads smooth and the people delightful. I burnt 23,000 extra calories over 10 days of cycling, but still managed to gain weight- testament to the amazing food and my acknowledged lack of willpower. Elephants are a potential hazard on the roads, evidenced by heaps of elephant poo everywhere. Last month, a Thai couple on a moped stopped to take an unsolicited selfie with an elephant, who took offence, and trampled the man to death. My elephant pic on the LMC Tweet was snapped in Yala National Park. Dogs, however, of which there appears to be a standard–issue Sri Lankan version, are everywhere you look. They are more of a potential menace to cyclists, although the chances of them successfully snapping a whizzing ankle are remote, not least because most of them are emaciated and have only three functioning legs, presumably following historic battles with passing traffic. Curiously though, I didn’t see a single dog turd, or any road-kill other than the occasional squashed snake or lizard.

Food for thought, or something.

Right- time to head up, or at least towards, the A38 to support Bazza at the surgery. Stay warm.

Nick

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