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Viruses, Vectors and Valentines

Friday 14 February 2020

It’s Valentine’s Day, but more importantly it’s ‘Foxtrot-it Friday’ as our Practice managers will (nearly) be calling it from now on. Those who attended the LMC ‘Managing your Resilience’ day at Taunton Rugby Club yesterday know what that means: loads of shredding. Dr Phil Hammond, closing the day in brilliant and witty style assured us that we’d all feel better for it, and the important 20% of paperwork would probably appear again at some point. He also told us to do our daily CLANGERS: Connect, Learn, be Active, Notice, Give back, Eat well, Relax, Sleep.

I’m asked with increasing and pleasing frequency what I’m going to do in retirement. My list has more than a bit of ‘clanger’ about it: exercise regularly, sleep more, laugh a bit, worry less, play more golf and piano, and attend almost no meetings. They remain blissfully unaware, but I also intend to become a nemesis for the sea bass cruising the South Devon coastline. I’ll occasionally dip into past blogs to remind myself of all the fun I’ve had over the past four years; for every episode I can see behind the written word to what was happening at the time, the personal and professional context in which it was written, and what was really keeping me awake at night. So how will I feel re-reading this, my hundredth blog?

If I’d known even a month ago that this fortnight would see a new and significantly improved PCN DES contract land, the BMA name the date for a special LMC conference, Boris try to seize greater control of the NHS, Brexit happen, Trump get exonerated by his Republican cronies in the US Senate as we learn that his Chief of Staff had to explain Pearl Harbour to him, the biggest storm of the decade breeze through, and significant workforce challenges arrive unexpectedly and alarmingly on my own doorstep, but that none of these would earn top billing, I’d have been on the roof with the Book Of Revelation in one hand, binoculars in the other, scanning the horizon for four horsemen, riding hard (whilst admonishing myself for the unwieldy mess of this paragraph-long sentence, which really needs to stop here and now).

No points for guessing that I’m focussed on Covid-19, as we’re calling it, for this week at least. The LMC has been party to the thrice-weekly Pandemic Incident Response Team (PIRT) calls. We’re no strangers to the regular escalation calls that happen across the system when the manure hits the blades, but having 30 or so people from a variety of backgrounds on a call requires a certain amount of discipline, not least making sure that your phone is muted if you’re not speaking.

At the end of last week, the ‘case definition’ changed to include travellers who had developed symptoms within 14 days of travel to a variety of popular Asian destinations, rather than just mainland China, a decision quickly justified by the case of a businessman who went from Singapore to a ski chalet in France, where he found and infected two Brighton GPs, amongst others. Immediately, it felt more of a threat, and one of our practices had to shut briefly yesterday morning for a precautionary ‘deep clean’, after somebody came back from Thailand and coughed.

You might ask why we should be so exercised about a virus that is still mainly confined to China (about 99% of all confirmed cases are there) with an overall mortality of about 1% with just 1300 deaths reported globally. Seasonal ‘flu in the UK kills between 10-30,000 people each year, and it wouldn’t be a bad time to push that figure out to the panicking punters just to emphasise the reality of seasonal ‘flu; vaccination rates might even be higher next year. The problem is that we can’t really be sure about the figures coming out of China (although they published the genetic make-up of the virus online very quickly, allowing an international effort to produce a vaccine), or predict how it might mutate. I heard a virologist say this week that it was unfortunate that SARS died out so quickly in 2003, reducing the incentive to produce a vaccine against coronavirus.

On our PIRT calls earlier this week the acute Trusts reflected on the guidance they had or hadn’t received and discussed the practicalities of providing the ‘pods’ in which to see and test suspected cases or contacts. There was much discussion of ‘fit-testing’ for masks used by health workers seeing patients and the news that stubble and beards, so à la mode, meant that for some providers, only about 25% of staff could wear masks that fitted properly (they have to resort to the full hood). With the situation rapidly evolving and so many parties involved, it’s perhaps inevitable that confusion can occur.

On Monday morning, the LMC started to receive reports of symptomatic patients who were not ill enough to require an ED or 999 disposition being referred back to their practices by 111. We fed this back to Devon Doctors, who provide the 111 service, on the morning call. It transpired that the wonderful NHS Pathways guidance that 111 is mandated to use had been updated over the weekend and was causing problems across the country. I was due later at the CCG in Yeovil for a Partnership Executive Group (PEG) meeting and spoke to a couple of the managers before it started, and we agreed to gather later to thrash the problem out.

I left PEG early and hopped across the corridor to another room where a mini-COBRA committee had been gathered. With Devon Doctors on the Batphone, we heard that 111 providers had been discussing the Pathways guidance, and a pragmatic workaround was agreed between the parties.

I sent an update to everybody on Tuesday morning, but a few hours later had a call from one of the clinical directors at Musgrove as some practices had directed possible cases to the ED themselves, rather than to 111 as the guidance dictates; hence my clarification later in the morning. If in doubt, please refer to the PHE website where the most up-to-date information should be available here. ​​​​​

Elderly readers who remember the popular BBC panel game, ‘Call my Bluff’, can probably imagine Frank Muir or Patrick Campbell suggesting definitions for the word ‘Pangolin’: a baroque musical instrument perhaps, the inner wooden circle used in a needlepoint frame, or maybe a fleshy relative of the jackfruit, a popular staple in the Indonesian archipelago? Nope, none of these, but a relative of the armadillo and anteater, which has recently emerged as a top suspect in the transmission process for Covid-19.

Bats (but hopefully not Batphones) are among the commonest carriers for coronaviruses, but unlikely to spread it directly to humans, so there needs to be an intermediate host. For SARS this was the civet cat, whilst dromedaries helped spread MERS. The Pangolin is an endangered species and officially protected in China, where selling them can lead to 10 years imprisonment. Despite this, they are apparently the most poached and trafficked animals in the world.

Their undoing, in more ways than one, is that they are easily peelable and the Chinese use their scales to treat a variety of conditions, such as arthritis, menstrual pain and skin conditions. They haven’t arrived on the PAMM radar yet but when Brexit bites, anything could get onto the formulary. Just to add to the Pangolin’s woes, once shelled, the meat is considered a delicacy. Researchers recently sequenced the Covid-19 virus genome and found a 99% match with the virus found in Pangolins. Gotcha.

One thing I won’t miss in retirement is the drive to Yeovil. On Wednesday I was at the CCG again for another meeting, after which I got a sneak preview of the integrated desktop due to be rolled out to practices as part of the SiDeR project. Accessible via a desktop link, a row of tabs allows you to access data from different providers, including the GP record, the acute and community Trusts, the local authority and St Margaret’s Hospice. Possibly the most useful tab might prove to be the one on the far right, listing contact details for anybody involved with the patient.

So, we’ve actually left the EU. I changed my mind about Big Ben bonging to mark the infamous hour. Initially it seemed as ridiculous as the 50p coin and special festival we’ll have to endure in 2022, but in the event I’d have happily shinned up the scaffolding (£79.7 million well spent) and hammered it with any handy part of my anatomy to drown out the sound of Little Englander knuckles dragging around Parliament Square, as they celebrated ‘getting their country back’.

A singular joy of Christmas is the resulting pile of books to plough through in the gloomier months. This year, mine cover an eclectic range of subjects, from Trump’s golfing misdemeanours, a history of lighthouses, the psychology of sport, to my current book at bedtime, ‘Liquid’ by Mark Miodownik, a brilliant read on everything slurpy, sloppy and sticky. My favourite, though, arrived in the post by timely special delivery on January 31st, has 32 pages in a burgundy cover and slips neatly into any pocket. Oh, and it’s got a harp on the front.

Roses are red,

Violets are blue,

I’m emerald green

Now we’ve left the EU.

Lá Valentine sona, as they say across the sea.

Nick

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