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Inflammation, Inflammation, Inflammation

Friday 27 April 2018

Calor, dulor, rubor, tumor. Any first year medical student can recite and recognise heat, pain, redness and swelling as the cardinal signs of inflammation, and as she approaches her eighth decade, running on fumes but working harder than ever, it’s no surprise perhaps that the NHS is starting to feel a bit sore. In that context, yesterday’s Quality Improvement Showcase event at Musgrove was an eye-opener in terms of what’s been achieved across numerous departments, whilst coping with a huge surge in demand. Roy Lilley, the keynote speaker, was clearly impressed with what he heard and saw, tweeting enthusiastically after he left. The key is to engage and enthuse your staff, and I suspect having a dedicated team of 25 people helps a bit. The few of us there from Primary Care made the point that quality improvement happens every day in our individual practices to improve efficiency, and is formalised as part of the SPQS programme, but how we work to improve things across the system is going to be vital if we are to get through the next decade. A joint approach is already a feature of the 100-day projects currently focusing on urology, ENT and atrial fibrillation.

The monthly Somerset GP Board meeting was held last week at the revamped Monks Yard. We were joined for the first half by the CCG, who wanted to talk with us about the Primary Care aspects of the ongoing Health and Care Strategy. We want to take a lead role in formulating and contributing ideas over the next six weeks or so, and already have a number of discussion papers and documents that we can use to inform the process. There’s widespread acceptance in the system that Primary Care needs to be at the centre of whatever comes next, but it’s more important than ever that we recognise where we’re starting from in terms of workforce and workload, or as one of the slides in our workforce paper puts it: “The Stark Reality”. More, most assuredly, anon.

0300 101 0080 is now embossed on my temporal lobes as I’ve had to dial it on a regular basis recently. Anybody not recognising this as the IT support line- well, I salute you. With the migration to NHS mail and OneDomain have come a number of challenges, not least to our sanity. Working across different sites, coupled with senior confusion, means I’ve been locked out quite a bit recently. Having to change NHS mail passwords every 90 days isn’t going to help either. I normally end up resetting passwords at times of maximum frustration- something often reflected in what I come up with. Although amusing and pertinent at the time, it can be awkward when asked to divulge B********c**u****n***24! to the PM or a visiting IT guru. I pound the keyboard in frustration, often with my forehead, more often these days, and yet the IT crowd have been invariably polite, understanding, and even sympathetic.

Compare and contrast this with the experience of a friend of ours who works in North London and visited last weekend. Set aside the fact that there appears to be little or no relationship between the practices, LMC and CCG (they have been told they have to work with dysfunctional neighbouring practices, and take on a lot of extra patients); her consulting room computer has been off-line for five weeks, meaning staff have had to “hot terminal”. Signs of a system in distress, no doubt, but there are flags of a different colour waving frantically much closer to home as well. Primary Care in Plymouth is in a really parlous state, and the national media picked up on the story of Dr Rachel Tyler, a GP in a practice that has handed back its contract. She found herself doing practice paperwork whilst in hospital having chemotherapy. The GPC was quick to point out that the situation there is likely to play out in other areas before too long.

In addition to my dyspasswordia, the Outlook calendar is also causing me grief, as meetings get entered (and then linked on my iPhone calendar) from any number of sources.  Clearly I need to get a grip (somehow), but last week I had no less than three notifications that I was expected at a meeting at County Hall to hear about “Social Impact Bonds and Outcome Based Commissioning” (yep- my thoughts entirely). It came with what seemed like a personal message from the STP team, so I duly went along. I bumped into one of our favourite CCG managers negotiating hard for a packet of fruit gums at a nearby newsagent. I’d wanted to bend his ear about Improved Access anyway, and we shared part of his five-a-day on the way to the meeting. The meeting itself was about a method of funding programmes addressing social problems such as homelessness or truancy. It was interesting enough as a principle, though not enough to justify an hour out of a busy day, but the chance to have a chat with our CCG colleague made it worthwhile, as did the opportunity to meet a genuine Dr Sin, an energetic T-shirted Singaporean who presented the concept of SIBs with gusto and enthusiasm.

My role with the GP Board means that really for the first time, Primary Care has a place alongside the other provider organisations in many of the formal meetings. More importantly this has allowed us to build useful relationships right at the top of the Trusts and the Council, and several of the Chairs and Chief execs have come to the LMC offices in recent months for more informal discussions. It helps build trust, and it’s always useful to make sure we’re all more or less on the same page. Earlier this week we were about to start the first meeting of another group- the Provider Stakeholder Reference Group (essentially it’s part of the governance structure for the ongoing Health and Care Review, and will do what it says on the tin), when Barry back at base started to take incoming from practices who had received a puzzling communication relating to data protection from one of the Trusts. This appeared to be a misinterpretation of the imminent GDPR regulations, and was almost immediately recalled, but not before I’d exchanged emails with a helpful very senior manager in the Trust concerned who was sitting about four feet away at the time, but separated from me by an oblivious social care manager.

Somewhere in the agonal moments of the last bloggage, I attributed my revival towards the end of a fraught duty-day to a combination of 120 parts Cadbury’s Dairy Milk and one part naproxen. My knee had been throbbing, as had our post-Easter appointments list, and I commented that I’d ended the day “positively prancing”. I went on to suggest that although my knee was less painful, another factor might have been the sugar-rush. Wary that my proposing any good coming from carbohydrate might have had Campbell and his posse reaching for their pitchforks and torches, I’m pleased to report that another theory didn’t so much present itself, as leap from the pages of the last Saturday Times Magazine. The clue was in the “positively” bit.

It’s well known in rodent circles that Cambridge rats tend to be more lugubrious than most. To the casual observer, it’s hard to fathom: the manicured Backs are pleasant enough for them to hang out on during the summer, with lashings of posh titbits discarded by the pretty frocks in punts; the M11 has opened up exciting, if hazardous, scuttling rights to the London sewer system for a spot of Rattus R and R; Cambridge don’t tend to sink as much in the Boat Race these days, and more than anything else, it’s not Oxford. So why do the light blue rats have the darkest blue moods? Water voles berating their morose passing cousins about their long faces and hang-dog looks with a perky; “Cheer up mate, it might never happen!”, have no way of knowing that it already has, repeatedly.

As a student, I used to fill the local rats with reserpine, and then assess them for glumness, on the basis of their behaviour and social withdrawal. Reserpine was licensed in humans as an antihypertensive, and worked by depleting noradrenaline and serotonin, but did so both peripherally and centrally (effectively doing the opposite of SSRIs and SNRIs). Patients on it would often become depressed and even suicidal- not its strongest selling point- and our aim was to create a lab model to trial cunning new antidepressants. Since then, I’ve spent more than 30 years  lowering blood pressures in patients of all shapes and sizes, and I know that hammering it down too far or too fast will make any sentient being feel pretty hacked-off, but we hadn’t got any rat sphygmos, and so they all got a standard dose based on their weight.

Four decades on, and you’d hope that by now most of the rats would have negotiated their way through the Talking Therapies system, and be back in gainful ratting and gnawing. Unfortunately for them, they now have a new nemesis in Edward Bullmore, the University Professor of Psychiatry, who along with his pals has been injecting them again, but this time with cytokines. This mimics an inflammatory response, and once more they’ve become withdrawn and listless. Last weekend’s article was a preview of Bullmore’s new book, The Inflamed Mind, which talks about depression being (another) disease of inflammation. He argues that our fixation with correcting levels of serotonin, one of about a hundred neurotransmitters, is akin to cranking up just the violin part in an orchestra.

Blood from depressed patients often shows raised inflammatory markers, and many of the genetic markers are genes responsible for immune function. Low mood is a recognised side-effect of interferon treatment, and increasingly seen in the period after certain inoculations, such as for TB. There’s an established link between stress and inflammatory processes, and Bullmore postulates that when our ancestors roamed the plains of Africa, a bit of low mood and anhedonia, accompanied by an increased inflammatory response might have had evolutionary advantages to a population subjected to short-lived episodes of severe stress and/or infection. That’s not say it does us any favours today, when the nature and chronicity of our stresses are very different, being bombarded as we are with the incessant tribulations of Katie Price, Jacob Rees-Mogg and the lunacy of Trump, inter many alia.

I’ve already got a couple of reasons for popping a daily aspirin and maybe this will become another. In the meantime, I’ve had a gander at this afternoon’s list, and it’s not looking good. In my top left drawer, next to the tissues, I have an emergency NSAID on standby. It’s sitting next to a colossal bar of Galaxy.

You can’t be too careful.


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