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The Birds and the Bees

Friday 1 September 2017

I’m often asked, not least by myself, how I got into All This. I’m not hewn from traditional medico-political oak, unlike some of our more strident colleagues of national fame, in whom, if you were to chisel off a limb, you might find the names of Aneurin Bevan, or great GP leaders of the past, burnished through the grain. For the first 10 years of my GP career, my medical ambitions outside the consulting room were confined to occasionally startling, all too briefly, the scorers for the Bridgwater Doctors Cricket Club, popping along to the Medical Club functions at the Castle Hotel in Taunton, and spending occasional weekends away, either in the UK or abroad, enjoying the company of colleagues and learning about new asthma drugs and statins. It was mainly statins: diabetes was insulin, metformin and sulphonylureas, and dementia hadn’t yet been invented.

Sometime towards the end of the last millennium, I’d been sent along to the Battleborough Grange Hotel as a practice representative to discuss the formation of what was to become the Somerset Coast PCG (Primary Care Group). By the end of the meeting, possibly by dint of not ducking or moving fast enough, I found myself in a small group tasked with coming up with a Health Improvement Plan (HIMP) for the good burghers of the Somerset Coast area. I’m the only one of that original group still working, and remember our first meeting well. We met at the NHS Somerset offices in Taunton, and were encouraged to share any ideas we might have, no matter how radical, with our Public health colleagues, to improve population health.

As it happens, I did have something to contribute, but wasn’t sure that it would necessarily find a place in mainstream practice. I’ve mentioned Chicken George before, my brother-in-law who has a large poultry farm on the outskirts of Taunton. His livelihood depends on having a healthy chicken crop, and understands the importance of population health as well as anybody. The day before our meeting with NHS Somerset, I’d been at his farm when the vet had called in, and professional curiosity had led me to follow him down to the chicken houses.

When 40,000 day-old chicks are starting out in life together in a large shed, there is inevitably an infant mortality rate, and twice daily, CG would walk around the shed collecting and counting the casualties. His mathematical prowess extended even further to plotting the figures on a graph, and when the line rose above a standard curve, it triggered a call to the vet to investigate what the problem might be.

The next bit intrigued (and the possibilities excited) me, but I knew it would need a bit of selling to the patient groups. The vet walked into the clucking brood and picked out the first ten birds he came to, no matter how hale and hearty they appeared, dispatching them with a quick flick of his wrist. He took them outside and performed a summary post-mortem on each, which extended only as far as opening the trachea. He showed me what I would have recorded as mild erythema, but enough for him to diagnose Infectious Laryngotracheitis (ILT), an unpleasant and often fatal herpes virus infection in poultry. The only treatment he could offer was oxytetracycline added to the water supply for the whole crop, presumably to prevent secondary bacterial infection. I wondered whether I could apply similar principles to my flock in North Petherton. Identifying a blip in viral URTIs would be easy enough, and I could already name my ten not-so-random subjects for cursory perimortal examination. Being a dispensing practice, I had access to the pharmaceutical wholesalers and so could legitimately buy oxytetracycline by the ton. In addition, I lived only a mile or so from the reservoir supplying water to the town, and looked after the chap who had the key to the control room. Despite my enthusiasm and detailed planning, my proposal was rejected on a technicality, and in the end, we plumped for an augmented exercise referral scheme.

Undaunted, I continued my involvement with the PCG, joined the LMC as a rep for Bridgwater in 2007, and became Chair of the Bridgwater Federation in 2009. During this time, I was also the medical assessor on the team that assessed exercise providers for the Proactive scheme. I’ve always been interested in exercise physiology, and relished the opportunity to develop some professional skills outside my regular GP work. Portfolio careers are rapidly becoming the norm for our younger colleagues, and we have recently had discussions with Musgrove about plans to recruit to jobs that have a hospital-based component, as well as in a local practice. It’s also encouraging to see and hear that we’re attracting some really high-calibre younger GPs to Somerset, and we need to get them involved in helping shape the future services, sooner rather than later.

As Chair of the Somerset GP Board, I’m pleased to have been offered the chance to attend the regular Chair’s meetings. The first one I attended was this week, and brought together the Chairs of the CCG, all the Foundation Trusts and the leader of the County Council, and yours truly. The Chairs’ (and their boards) role is to set the policy direction for their Executive teams to follow, and so their direction and thinking is absolutely fundamental for the development of the STP and any kind of collaborative working. Although the CCG is nominally a Primary Care led organisation, I think our presence at this table is a hugely important step. There is a sense that the system as a whole needs a bit of a reboot, and my aim is that Primary Care should be considered right at the forefront of the organisational planning in the future, and a significant and critical cog in the engine of the machine. It’s absolutely vital that we get this right.

There’s been quite a bit going on recently around Advice and Guidance. There are plans to extend the service, and make it into more of a dialogue, rather than the current single query and response, which is where it currently ends. Sometimes the advice misses the point, or more irritatingly there are specialities where the answer/advice appears by default to bounce it straight to an outpatient appointment many months ahead. I asked the CCG recently whether in those scenarios, the provider gets paid 2 fees, one for the A and G, when neither advice nor guidance has been given, and again for the subsequent OPA. Their reply suggested that at the very least, it’s a murky area.

I found myself pondering recently whether there should be a more general, non-medical Advice and Guidance service, available to the population as a whole. Dial 666, say, for life’s devilish problems? (I’m already working on the marketing). It was a few weeks ago when I’d returned home on a Sunday, and opened my back door to find a fledgling seagull flapping hopefully, but alas not very aeronautically, around the garden, which is bounded by high walls on all sides. We’ve had them nesting amongst our chimneys for a while, and junior had obviously decided to make an over-optimistic and ill-judged break for the coast, or the tip. Thankfully the dog was on holiday in Cornwall, but the gull’s protective mother swooped threateningly at me if I set foot outside the door. How long does gull flight-school last (or put another way, how long would my tomatoes have to go without water, as I didn’t fancy arguing with its parents)? How to stop it bashing itself into the walls, which it seemed determined to do? Several days later it was still there, but by the time I eventually had the idea of phoning the RSPCA (a sort of avian consultant connect), it had disappeared. I assumed it had finally made it over the lowest of the walls, where it had probably been eaten by next door’s cat.

I’m the only partner in our practice who isn’t an apiarist, or at least in the later stages of training to become one. Bazza and Rob converse with a mystical lexicon, and seem to be on some sort of informal rota to collect swarms of bees whenever they alight somewhere unwanted, such as a children’s picnic. I quite fancy the garb with the hat and veil, and the smoking puff-thing looks like a lot of fun. I need a new hobby, so last week went out and bought myself a drone. Like those of my partners, it buzzes in an irritating sort of way, but mine also has four rotas, a 4K video camera, and a range of 4.7 miles- invaluable if I ever felt the inclination to carry out the ultimate remote access consultation. I’m a bit of a geek, as you’ll probably have gleaned by now, and the technology is astonishing. It has a number of “intelligent flight” modes, including one where I can set it on a pre-determined circular course, and just let it wander slowly round, filming as it goes. No more wondering what people are really doing on their iPads in LMC meetings.

I’ve had two excuses to slap on the foundation this week*. Yesterday I met with dynamic “GP in Somerset” social media team for an interview and posing/pouting session, and today the local press are coming over to the surgery. The practice has raised a lot of money for St Margaret’s Hospice over the years, and they want us to present one of those massive cheques. No doubt Bazza and I will have a bit of a squabble about which are our best sides for the camera.

Nick Bray

(*L’Oreal True Match since you asked. Because I’m worth it)

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