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Friday 3 August 2018

Last week, Jill and I found ourselves being simmered gently in the orthopaedic seminar room at Musgrove, for a meeting to discuss communications between Primary and Secondary Care. It was pertinent to the way things are going that of the twenty people in the room, only three of us had a link with Primary care. The rest were made up of assorted communication or liaison managers from Taunton and Somerset Trust or Somerset Partnership. I outlined the main discussion points in last week’s update, but one of the Musgrove consultants stunned us by saying that they no longer have access to the full patient record when they see a patient in the clinic, as ‘paper-light’ working means the corridors are no longer full of porters dragging tons of notes around. Communication, or lack of it, still feeds into a lot of what the LMC does.

Yesterday I met with a director from Consultant Connect. It followed several email exchanges I’d had with them about my own experiences, and I was surprised that although the service works across 50 CCGs and 40 Trusts across the UK, this was the first time they’d ever met with an LMC representative. It was good to tell him about life in the real world. He was armed with the figures for Somerset as a whole, and then broken down by Trust, speciality and practice. The situation varies across the patch: RUH offers the service in 16 specialities, but only 9 at each of Taunton and Yeovil (different specialities in both). Across all specialities and for Somerset as a whole, there was a 60% pick-up rate in July, and overall a 66% success rate since launch in November 2016 (For the record my own success rate is a rather disappointing 15%- although that figure is skewed by my doggedly and unsuccessfully ringing the medics every five minutes one dark February morning). It’s not hard to see why it works better in some specialities than others, although you’d hope that with changes in the tariff system in the future and more collaborative working, it will gain momentum. I’ve found it useful on the rare occasions I’ve got through. We also discussed some nifty developments that have recently come on-line, including a secure photo function available through the app, and how the system could develop further in the future.

In recent weeks there have been precious few stories anywhere to warm our cardiac cockles, or even remove the chill. One of the few that did – the Thai cave rescue- seemed destined for disaster, even after two British divers had surfaced in a cave 3km into the mountain to find the missing football team and their coach sitting on a ledge, gawping at them. Locating them turned out to be the easy bit. The odds of getting everybody out, given their inability to swim and physical condition, especially after the death of an expert Thai naval diver- appeared slim. ‘Slim’ was one of the pre-requisites to get out, given the narrow and tortuous route, much of it submerged and in total darkness. The cunning and ballsy plan, which I don’t think anybody had predicted, was that they would be sedated to the point of anaesthesia, and then hauled out by the rescue teams.

It’s worth a moment to reflect on what this entailed, and the conditions in which they had to work. Each boy was given a wallop of ketamine (5mg/kg as an initial dose), with further 2.5mg top-ups in pre-prepared syringes that had been distributed along the route out, and which were given by non-medics. They were wearing full face masks delivering positive end-expiratory pressure (PEEP) and 80% oxygen. No monitoring was possible, and the medics had to just hope that nobody stopped breathing or had a catastrophic mask-leak during the extrication. From the medics’ accounts, it’s clear that they weren’t optimistic of getting everybody out.

On the subject of getting out, let’s talk Brexit. I’m sure we were all relieved to know the PM has wrested the Brexit reins from Dominic Raaaaab (he’d been very disappointing for the whole twenty minutes he was in charge of negotiations). We’ve now stopped skittering about like gloomy lemmings, and we’re on a strong and stable path through the Elysian wheat fields and marching towards the promised sunlit uplands, apparently, although it still looks like a bloody cliff to me. Mrs May also told us we should be reassured to hear that HMG is stockpiling food, drugs and blood in the event of a no-deal Brexit (something our old mucker Jezza says could happen ‘by accident’). I feel so much better, especially as I’ve already got a cellar full of tinned goods that I’ve been hoarding since Trump arrived. The problem is, of course, that most palatable food has a habit of going off.

What about drugs? We’ve all been frustrated that the supply of many routine medications has been a shambles in recent times, even without Brexit, and much has been made of the fact that most medications are made overseas, including insulins, which have the added requirement of strict temperature control. It was reported last week that no insulin is produced in the UK (or in Theresa May come to that, so you’d expect her to take some personal interest here). This turned out to be an exaggeration, albeit a slight one: Wockhardt UK is based in Wales and makes insulin (Hypurin) from pigs and cows, and supplies enough insulin for less than 1% of the UK population who use insulin (421,000 patients). Sanofi makes its insulin in Frankfurt and announced this week that they’ll be increasing their stocks by four weeks, to 14 weeks’ worth of supplies of insulin and other drugs in the UK. Most of Sanofi's supplies arrive in the UK through the Channel Tunnel, and delays there in 2005, when the French were revolting, led to around four weeks of disruption. Lily and Novo Nordisk also make all their insulins abroad. Mr Hancock says we’re not to panic, and he’s all over it like a rash, but I haven’t much confidence that the drug supply issue will be addressed in time. Together with the regulatory problems, uncertainty about reciprocal health arrangements and the almost complete cessation of EU health professionals moving to the UK, I can’t see Brexit turning out to be a positive story for the NHS. Sorry.

We’ve long argued with anybody who’ll listen that in Primary Care today, you can either have continuity or access, but you can’t have both. We might be leaning a bit too much towards accessibility in our practice. On Tuesday evening at about 6:20pm, a request for a telephone consultation arrived on my appointments screen: “recently back from holiday, earache and temperature.” Grrr. The frustration of a call just before closing time will be familiar to many: Why now? Why me? What, if anything, have they tried themselves? Once I’d regathered and told myself it would be an easy one to sort, I dialled the mobile number provided. The line was poor, and it took several attempts to speak to the mother. Had they given any Calpol? No. Had they got any? No. Can she get some? Well, she’s hoping she might be able to pick some up, possibly along with a massive Toblerone, once she’d got through passport control. I was speechless, which was probably a good thing. “Recently back” evidently now means still trundling down the runway.

I wonder how ‘Black Wednesday’ went around our local trusts. August the 1st is traditionally the day when junior doctors start their new rotations, and for many, their careers. Historically it was always considered a good week to avoid being in hospital if you had any choice in the matter. With the advent of social media, Twitter and Facebook have been overflowing with supportive/inspirational/patronising/unctuous exhortations from others in the profession- but all agree that it’s a stressful time. Not quite as stressful though, as preparing to take-off as a fighter pilot during the Battle of Britain. My current book at bedtime is ‘Spitfire’ by John Nichol- which contains many personal accounts of those who flew and maintained the iconic fighter. One such tells the story of how a new pilot in 616 squadron broke down in tears as he was preparing to leave on a mission. The Medical Officer was summoned: “The doc gave him a terrific punch and a few well-chosen words, and we had no further trouble”, an officer observed. I don’t think revalidation was a thing back then.

Heck- distracted by commotion outside- Mrs Chair, who doesn’t do rodents, had just come across a large Rattus that appears to have pegged it trying to cross the back lawn. It should have picked up the vibe and realised it was on a suicide mission, as everything else in the garden is dead already. There are certainly more rats around with the hot weather. I hope we’re not in for a resurgence of the Black Death- I suspect 111 might struggle.

Mind you, an explosion in the rat population might help to explain the circumstances behind a query that arrived in the LMC office this week. A new registrar in the county was out on a visit with a community nurse to an elderly housebound patient when they noticed a shotgun (and cartridges) propped up in the corner of the room. The patient wasn’t coded as 9DP, and the question to the LMC was whether the police should be informed? Perhaps chat to them about it first (best not to be too confrontational) and then make a judgement….oh, the richness of the home visit.

The Medical Director has been enjoying his annual pilgrimage to his beloved Sark, certainly more than the local lobster population. Every day brings a new crustacean snuff-pic tagged to an appropriate part of the wine list. His texts have become increasingly ‘poetic’ and I suspect I know why. I was sitting at the laptop with something peaty last evening when he was in touch again: “Mention Mars in your blog”, he directed helpfully, “it was a red star in the South lively” (Sic) (hic). “Venus, Jupiter and Mars all clearly visible from here”.

I could see them too, but only one of each.

Nick

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