In our 108th edition, Judith makes a noise about being quiet, Liz summarises everything a newly qualified GP needs to know about getting their tax in order, Nigel helps us plan for when our offspring go off to university, Louise has been making sense of LFTs and Rachel has something to teach us about learning.
The Sessional GP
Supporting sessional GPs to improve patient care
Preview attachment 8385 BMJ Live NASGP Avdert AW (3).pdf 8385 BMJ Live NASGP Avdert AW (3).pdf 117 KB
image © Claire de Mortimer
August 2019
every day is a learning day
Dr Rachel Birch, Medicolegal Consultant at Medical Protection, looks at the valuable contribution sessional GPs can make to teaching and learning within primary care. Doctors as teachers As doctors, we are encouraged to share our knowledge and expertise with others, for the benefit of good patient care. In fact, the word “doctor” is derived from the Latin word “docere”, which means “to teach”. The original father of medicine, Hippocrates, taught his students in the shade of a big plane tree. Nowadays teaching locations may not always be so exotic, but the sentiment remains - an important part of the role of being a doctor is to teach medicine. The General Medical Council advises doctors that they should be: “prepared to contribute to teaching and training doctors and students” “willing to take on a mentoring role for more junior doctors and other healthcare professionals” Whilst “see one, do one, teach one” is rarely sufficient training in the modern medical world, there is no doubt that the most effective learning opportunities can come from our peers or senior colleagues. Many doctors enjoy teaching and learning, which can be considered as two sides of the same coin. Often teaching promotes self-learning, as preparing for a teaching session can involve acquiring new information. Learning for yourself can also lead to teaching, for example by sharing your experience and knowledge. Learning opportunities in practice Every day is a learning day in general practice. We are constantly learning from patients, members of the primary care team, and our secondary care colleagues. If a patient comes in with a Google print out about their symptoms, be sure to read it! It may reveal something about a diagnosis that you did not know, even if you do not believe that the condition is necessarily the cause of the patient’s symptoms. When letters come in from secondary care, take a moment to consider what the patient has been prescribed - is this a new treatment development? A lot of this is already done subconsciously, but take time to write down anything new you learn each day, as well as any learning needs you have identified. Opportunities for formal group training may be infrequent, so it is important that practices have good systems in place to share learning and to learn from significant incidents. If there is an adverse outcome for a patient, or a “near miss” incident, those involved in the care should reflect and consider why it happened, and what steps can be taken to reduce the chance of it happening again. Regular significant event meetings for all relevant practice staff are recommended so that everyone can learn - salaried and locum GPs should be made to feel welcome at such meetings. Coffee time (although I appreciate it doesn’t happen in every practice) can be a good time to reflect on your day and discuss interesting cases and learning with colleagues. Learning from locums Both salaried and locum GPs have so much to offer their primary care colleagues, in terms of learning. Many salaried GPs have portfolio careers, working in other practices or in secondary care clinics as GPs with Special Interests (GPSI). Locum GPs are likely to have experience of working in many different practices, with different protocols, computer systems and ways of working, as well as sometimes a totally different patient population and demographic. They are in a unique position to be able to share their knowledge and experiences with other practices, and may well be asked to do so. As a locum GP, you may find that a GP registrar or practice nurse approaches you for advice about one of their patients. Even if you are only at the practice for a day, this will not matter to the GP or nurse - they will appreciate your time and expertise. You may also be asked to provide teaching to medical students or student nurses, perhaps by allowing them to sit in on your consultations. This can be rewarding, and their questions may well leave you with learning needs of your own. Locum GPs can be a fresh pair of eyes when reviewing a regular GP’s patient, since they may not have met the patient before and can therefore consider the patient’s presentation from the beginning. You may suspect a diagnosis that the regular GP has not considered, or you may have seen a treatment used effectively in a different setting. Regular GPs often value the input of locum GPs and the learning opportunities that they bring. Opportunities for teaching Many sessional GPs like the idea of a portfolio career, and find that it fits in with their work-life balance. There may be opportunities for teaching both within and outside of practices. If you have identified that you would like to do more teaching, the following may be helpful: In practice: Ask to attend Significant Event Analysis meetings and provide feedback on any incidents or near misses you may have been involved in. These meetings provide a good opportunity for discussion about how to learn from such events. Share any interesting cases or unusual presentations with the clinical team. Express your interest in teaching medical or nursing students or GP registrars. Often they get to sit in on consultations with a variety of clinicians in their training, so you may wish to offer them the same. If you have a particular area of interest, you may wish to offer teaching this to students or trainees, but make sure that any tutorials are included within your sessional hours. Consider if there is anything you would have wanted to know when you first started at the practice as a locum. Share this with the practice manager in order to help other future locums. Outside the practice: If the practice or locality has protected learning time, consider offering to give a talk on your area of particular interest. Locum chambers and sessional GP groups are an excellent source of peer support as well as education. They often have educational programmes and would most likely welcome a presentation by you. They may also have regular meetings to discuss best practice, cases and significant adverse events. As a more established locum, you may wish to offer to provide mentorship to a new locum. This is something that you could discuss within the locum chambers, in the first instance. If you do take part in teaching activities, you should discuss this and reflect on it at your annual appraisal. You should also contact your medical defence organisation to ensure that you have appropriate indemnity in place. Rachel Birch rachel.birch@medicalprotection.org
By Rachel Birch @MPSdoctors
We're constantly learning on the job, and with that comes the opportunity to pass on what we've learnt to others.
"You may also be asked to provide teaching to medical students or student nurses, perhaps by allowing them to sit in on your consultations. This can be rewarding, and their questions may well leave you with learning needs of your own."
Get your tax, pension and employment status in order as soon as you can
the new GP
"National insurance contributions and student loan repayments are both paid with your tax, and will be calculated via your self-assessment tax return, so these need to be taken into account when planning your tax savings."
By Liz Densley @honey_barrett
You’ve finished your GP training and you’re ready to be let loose on the world, but has your training taught you how to deal with your tax and pension position going forward? As a GP trainee You are taxed under PAYE, so you receive a payment each month where tax, national insurance, pension contributions and student loan repayments have already been deducted and you get what’s left. So, all you need to do is: Know what you can claim for – exam and training costs whilst under a training contract only, professional subscriptions and mileage if you have to do visits in your own car (and you’ve not been paid for the miles). Check you have the right tax code, and call HMRC if your allowances are not right. Make sure, if you are getting to the end of your student loan repayments, that you communicate with the student loan guys to pay off your balance and get deductions stopped. Once you become a fully qualified GP it all changes! As a salaried GP, it starts off pretty much the same with tax, NIC, pension and student loan repayments all deducted at source. But remember, you will need to retain all your payslips, P45s and P60s. But after the end of the year, you have to complete a Type 2 pension certificate to check that you are paying the correct contributions. You need to check your pension Total Rewards Statement each year, to make sure that your practitioner pay is being correctly accounted for (sometimes if the Type 2 certificate does not filter through to NHS Pensions your pension record won’t get updated properly). Where the fun starts is if you do locum work or other freelance work. As a locum, you need to decide if you want to practice as a ‘sole trader’ (a single-handed practitioner) or via a limited company. Do not just assume you will save a lot of tax by using a limited company; it doesn’t always. You are not permitted to pension income through a limited company in the NHS Scheme, so if you are sure you want to maximise your NHS pension, you can forget using a limited company. When can a company be beneficial? If you do not need to spend the income you are earning, and expect to take a career break in the future. If you have a low earning or non-earning spouse with whom you would like to share your business. If you need to reduce your taxable income (perhaps to avoid an annual allowance charge – probably not applicable in the first few years post qualification). At certain earnings levels – it needs to be calculated individually, taking account of salaried income and any other income. If you believe that your business might have risks that are not covered by your professional indemnity insurance, then using a company could protect your assets (if any) that are outside of the company. You need to look at your specific situation (and plans for the future) to determine whether a company is right for you. If you start off as a sole trader You need to notify HMRC that you have started a self-employment. You can do this on line or we can do it for you. You will need to keep business records; bespoke software like LocumDeck can be a huge help with this. Making Tax Digital does not yet apply to non-VAT registered businesses, but there is the intention to bring it in in the not too distant future, so writing up your records as you go is a good habit to get into, and LocumDeck’s inbuilt accounts package will help with this. You will only need to register for VAT if you provide anything other than exempt healthcare services, and that other element of your income is greater than £85k. This is only likely to happen if you get heavily involved with medico-legal work. You will need to save sufficient to pay your tax when it falls due. Your accountant can estimate this for you if you provide income details. National insurance contributions and student loan repayments are both paid with your tax, and will be calculated via your self-assessment tax return, so these need to be taken into account when planning your tax savings. Your tax return will need to be submitted by 31st January after the end of the year of assessment – so if your first period of locum accounts cover the period from August 19 to April 20, the return must be in by 31st January 2021. Automatic penalties are chargeable for late returns, starting from £100 and then increasing by a daily £10/day penalty until nigh on £2,000 of penalties can be built up. Don’t let that happen! Tax payment dates are as follows: (using the above example) 19-20 balancing payment (this will be the total liability in the first year) – due 31st January 2021 20-21 payment on account (this will be 50% of the 19-20 liability) again due 31st January 2021 20-21 second payment on accounts – same amount as the first – due 31st July 2021 20-21 balancing payment (being total for year less the payments on account) – due 31st January 2022 21-22 payment on account (being 50% of the total for the year 20-21) – due 31st January 2022 So, there is a long time-lag between starting self-employment and paying the first tax – hence the need to save as you go. Note that where payments on account are likely to be excessive (such as where self-employment has ceased, or you’ve been on maternity leave), you are permitted to reduce the payments on account to what you expect the liability to be for the year. This has to be on a reasonable basis – you can’t just reduce it because you don’t want to pay it then. If payments on account are much less than the actual liability then that’s fine, they do not change, and the balance is payable in the January as shown above. What expenses can you claim Broadly you can claim any expense that is incurred ‘wholly and exclusively for the purposes of the business’. This means that you cannot claim expenses that are partly personal (like clothing or general dry cleaning), but you can claim expenses where you can quantify the business use – such as part of your mobile phone or internet costs. Costs where the personal use is incidental may also be claimed. For example, a training course where refreshments are provided, the refreshment element would not be disallowed. But a meal out between friends, where you happen to discuss a bit of business would be disallowed. You will find a checklist on our website of the sort of costs you can claim. Keep receipts for expenditure and record it as you go – either on your locum software, or if you don’t use that, on a spreadsheet. Record clearly what the expense is for. It is much easier to your accountant to look at a doubtful expense to decide if it is tax deductible, than to try to guess what you might have spent but haven’t recorded. Motor expenses There are two ways you can claim for motor expenses: A fixed 45p per mile (for up to 10,000 miles which is enough for more locums! 25p per mile thereafter) A business percentage of the total car running costs. Generally, unless you have a very expensive to run car, the 45p works out better. Note that you can only switch between the types of these claims when you change your car. If you buy an ultra-low emissions car (usually a pure electric car), then you can get a high upfront relief (100% of the purchase cost reduced by the private use element). But be aware that when you sell the car – anything you get for it, or its part exchange value – the business element will be taxable income. So, you are really only getting a cash flow advantage not an overall saving. That cash flow advantage may however enable you to buy something you couldn’t have otherwise afforded – so you could look at it as an interest free loan. Where you claim this relief, you have to claim a proportion of running costs (you are not allowed the 45p/mile – as that is deemed to include the capital allowance). Use of home You may make a claim for this on a fixed amount basis – using the number of hours that you work from home on your locum business. Alternatively, you can look at the total house running costs – split between fixed and variable costs – then look at the proportion of the house relating to your study , then the hours you use the study for work vs hours it is used for personal work – and then we calculate the figure for you. If you have a high mortgage and a small home, this will usually come out better – otherwise, not always. We usually suggest we do an accurate calculation once and if it is materially better, continue on that basis – otherwise just use the fixed expense claim. By ‘relief’ and ‘allowable’ in the above paragraphs we mean that your taxable income is reduced by that amount – so the reduction in tax is the amount of the relief at your tax rate. How does pension work for a sole trader? If you are doing out of hours work, you can usually choose whether to pension it or not, and if it is not your sole source of income, it will normally be pensioned under the GP Solo rules (in this case 100% of the fee is pensionable) When you are working as a locum, only 90% of the fee is pensionable and you need to complete forms Locum A and B (all handled automatically within LocumDeck). Full details are found on the NHS pensions website, but broadly: When you invoice a practice, LocumDeck adds the employer contribution to your fee (currently 14.38% as for 19-20 the increased amount is paid directly between government departments) and get the practice to sign the Locum A form. At the end of the month you summarise your Locum A forms on to the Locum B form for the month, and pay over both the employee and employer amounts. To do this you have to estimate your employee tier rate. This can be complicated if annualisation is required! Annualisation – what is this and why do I need to know about it? If you hold a salaried practitioner position from 1st April right through to 31st March in the fiscal year, then you do not need to worry about annualisation. Where you have been a GP registrar (which is not a practitioner post) you will only have had practitioner earnings from, say, August – so you will need to consider annualisation. For salaried work only it is comparatively easy – count days in the year where you hold a salaried practitioner post – say 240 days – then multiply your pensionable income (which is NOT the same as your taxable income) – it should show on your payslip – by 365 and divide by 240 and this will give you the figure that you compare to the tier rate tables to determine your tier rate. For locum work only with no salaried appointment, they have said it needs to be calculated on a daily basis. So, if you worked 4 days per week from August to March (say 34 weeks) – the calculation would be 4 x 34 = 136 days – so take pensionable income (90% of fee) x 365 / 136 to give a much higher than expected annual equivalent. We await the 18-19 type 2 certificate forms to see if there are any changes to this complex calculation. Type 2 certificates After the end of the year you (or your accountant) will need to complete a Type 2 certificate if you have had any salaried income as a practitioner. This will calculate the actual rather than estimated tier rate and you will have to pay (or get back) any difference. If you are purely a locum, you do not (at present) have to complete one of these certificates – but the ‘reconciliation process’ that PCSE are supposed to consider has not worked very successfully in the past. You can contact them to request it if you feel you have overpaid. Note that the tier rate you pay does not affect your pension – it is the pensionable income figure that affects your pension. Student loan The repayments get calculated as part of your tax return and payments are made with your tax in January each year. What to do now? If having read this, you feel you need an accountant (our fee will be tax deductible!), then talk to us and we can help you including getting you set up as a self-employed person and guiding you through the tax/national insurance/student loan/pension minefield, so that you have the peace of mind that it is all being dealt with correctly. Liz Densley is medical specialist Director with Sussex Chartered Accountants, Honey Barrett and secretary of aisma (the association of independent specialist medical accountants). Contact her on 01424 730345 or at liz.densley@honeybarrett.co.uk
planning for university fees
If you've got kids starting university any time soon, it's unlikely your parents would have had to have thought about this
Home region
Studying in England
Studying in Scotland
Studying in Wales
England
Up to £9,250
Up to £9,000
Scotland
No fee
Wales
NI
Up to £4,160
EU
Studying in NI
Are university fees looming in your household? Maybe your teenager is already collecting their belongings together ready to start their next chapter in life as a student. Even if your ‘mini-me’ has only just chosen their GCSE subjects, no doubt university fees will be something you ponder with some fear and trepidation. With maximum tuition fees at £9,250 per year, that's without even starting to think about the cost of homing, feeding and supporting your little darling, university fees can seem an out of reach expense even for the most hard-working and reasonably well off. If your child decides to follow in your ‘medical footsteps’ and become a doctor or dentist then you are looking at around 5 years plus of fees (more on this later). Worse still, if they want to train to be an architect, you could be looking at about 7 years of tuition fees and living expenses - that's a lot of fees! How do I plan for student fees? Forget spreadsheets estimating the total cost of university, it will only reduce you to tears! Just concentrate on the loans and assistance available to you. This will help you to understand the process of university funding more thoroughly. The basics The university funding ‘package’ is made up of two parts: Tuition fee loans Maintenance support Broadly speaking your child should be eligible for both providing they are studying an approved course at a registered university and haven’t previously started a degree or similar course. They’ll also need to be a UK citizen (or have ‘settled’ status) and have been living in the UK for at least 3 years before the course start date. EU students can apply for the tuition fee loan but won’t usually qualify for any assistance towards living costs. Rules and amounts also vary; if you’re a part-time student, over 60, or claiming special circumstances such as refugee status. Tuition fee loans Those of you lucky enough to live in Scotland or Northern Ireland may not have to pay a tuition fee if your child studies in your home country. With such great universities in both, it does beg the question of why go somewhere else? The rest of us need to cough up £9,250 pa normally. Take a look at the chart below to see if you are in the minority with lower tuition fees. Tuition fees by region for courses starting in 2019 Source: Undergraduate tuition fees and student loans Tuition fee loans cover the full cost of the course and are paid directly to the course provider. Maintenance support So that’s the tuition covered! However, these students of ours have living costs and this is often where many parents get a bit confused and misunderstood. The average student spends £770/month on accommodation, food, transport, textbooks, and anything else you deem essential. That’s £9,240 pa! Bear in mind, local variations in cost occur but let's just use this as a working figure. What is a maintenance loan? Your child can apply for a maintenance loan that is payable to them and thus they need to budget carefully. When it's gone, it's gone! Its paid termly in England and monthly in Scotland. The level of a maintenance loan available to your child is decided by your household income. As you can see from the table below once this exceeds £62,212 the maximum loan is £4,168 pa and would be added to the tuition loan and repaid in the same manner as noted above. The table shows the maximum figure you could apply for. However, you aren’t guaranteed to get this! Apply early so you can make a ‘plan b’ if unsuccessful. Also, don’t forget you have to apply each year. Maximum Maintenance Loan 2019/20 Source: The Big Fat Guide to Student Finance 2019 Working on the £770 pm / £9,240 pa living costs estimate, this would mean if your household income is above £62,212 and your child was at university outside of London and not living at home, you would need to find an additional £5,072 pa from your net income. Things are a little different in Wales and Northern Ireland All new welsh students will receive their maintenance package as a mixture of grants (which don't have to be paid back) and loans (which do have to be paid back). The combination is determined by parental household income. The total sum assumed necessary for a welsh student living away from home but not in London is £9,225 pa. The mix between grant and loan varies. Where the household income is £18,370 pa or less the student would receive £8,100 pa grant, and only need to apply for £1,125 loan. This changes incrementally until the household income goes above £59,200 pa. Then the two figures reverse with £1,000 grant and £8,225 loan. The living costs assumed change if you are living at home (£7,840 pa) or go to university in London (£11,530 pa). However, the proportions and income brackets are the same. Northern Ireland offers a mix of maintenance loans and grants too. With a parental household income of less than £19,203 pa, your child would receive a £3,475 pa grant. This reduces as income rises until it disappears and a full loan needs to be taken if the parental earnings exceed £41,065 pa. Do bursaries still exist? The short answer is, yes! However, bursaries are such complex areas that I could write a whole other article about them. You may not qualify for any but it's always worth a look - Student grants and bursaries. What about if you are divorced, are both parents income still taken into account? The simple and relieving answer is no. Your child will select the parent they live with most of the time. If it is equal they are allowed to elect one parent, so it would seem logical to choose the parent with the lowest income. Thus making more of the living costs coverable through the maintenance loan rather than parental contribution. What if you have a budding medic in the family? The funding is slightly different. In each of your first 4 years, you could get: £9,250 tuition fee loan to pay for their course £4,168 maximum maintenance loan to pay living costs, but as mentioned this is means-tested. In your fifth and sixth years, you could get up to £2,389 maximum reduced maintenance loan. You will need to pay more for their living costs in these years or they would need to secure alternative loans from banks, etc. How are these loans repaid? Key points to remember: The loan won’t have to be paid back until after the course is complete and your child is earning more than £18,935 a year in Northern Ireland and Scotland or £25,725 a year in England and Wales. ** They will then pay 9% of their earnings over the threshold income as noted above. It's best to think of it as an additional tax. If your child started earning £28,800 pa. That’s £3,075 pa over the threshold. Divided by 12 months = £257 pm x 9% = £23pm will be repaid in England and Wales. In Northern Ireland and Scotland, it would be £74 pm. As you can see the sum borrowed has no bearing on what your child will repay. Since 2012 the interest rate has been set at Retail Price Index (RPI) + 3%. This means it is now a shocking 6.3% annually. This is rolled up and added to the borrowed sum. If you’re an employee, your ‘income’ that is used to calculate how much you will repay isn't the amount that hits your bank each month. They use the full ‘gross’ income, meaning before tax, national insurance, and any pension contributions are taken out. Don’t forget: If the loan isn’t repaid after 30 years (25 years in Northern Ireland) then it’s wiped out and no more payments are due. N.B. As a rule, if you took out your student loan before September 2012 then your interest rate is lower. If you aren't sure which loan type (1 or 2) you have, I suggest you go to this Government page to see the definition of each. If finding the university fees means drawing down from your personal pension, rediverting private school fees or ‘just’ finding the extra from your income, with some careful planning, and prudent advanced saving university fees can be managed. You could even use your child's education as an investment opportunity, and buy a 2nd property! Your child will need accommodation in a city away from home. Why not repay your own mortgage, with the help of other student tenants if your finances will allow? "Your home is at risk if you do not keep up repayments on a mortgage or other loan secured on it." However you decide to fund your child's university fees make sure you plan, take advice and look as far into the future as you can! Whatever you do don’t stick your head in the sand and rely on a political change to solve the problem. Nigel Farrar nigel@legalandmedical.co.uk 01392 832696 The information contained in this article is does not constitute financial advice. This information is based on our current understanding of legislation. Legislation and tax treatment can change in the future. Legal & Medical Investments Ltd is registered in England & Wales No. 3429678 Registered Office; Splatford Barton, Kennford, Exeter EX6 7XY Tel: 01392 832696. www.legalandmedical.co.uk We are authorised and regulated by the Financial Conduct Authority. Entered on the Financial Services Register under reference 185193. The Financial Conduct Authority does not regulate offshore investments, tax advice, estate planning and some forms of mortgages. The tax reliefs referred to on our articles are those currently applying in the United Kingdom to UK Tax Residents. These tax reliefs are liable to change. The value of any tax relief available will depend upon the individual circumstances of the taxpayer.
By Nigel Farrar www.legalandmedical.co.uk
Household Income
Living at home
Away from home (outside London)
Away from home (London)
<£25,000
£7,529
£8,944
£11,672
£30,000
£6,859
£8,303
£11,020
£35,000
£6,260
£7,661
£10,367
£40,000
£5,626
£7,019
£9,714
£45,000
£4,991
£6,377
£9,062
£50,000
£4,357
£5,735
£8,409
£55,000
£3,722
£5,093
£7,756
£60,000
£3,414
£4,452
£7,103
£62,212+
£4,168
£5,812
"The average student spends £770/month on accommodation, food, transport, textbooks, and anything else you deem essential."
© Claire de Mortimer, GP locum, acrylic
The Royal Opera House orchestra was rehearsing Die Walküre. For more than three hours violist Chris Goldscheider sat in front of twenty brass players belting out Wagner at 90dB. His hearing was permanently damaged. The Opera House argued that artistic standards took precedence over the risk of acoustic shock, but the courts thought otherwise and awarded Goldscheider substantial damages. A musician’s job is to create sound. Rock musicians ramp up the amplifiers and often lose their hearing temporarily after a particularly loud concert. Many don’t acknowledge the warning. Over time, even violinists can lose 6dB of hearing in their left ear. Many publicans and restaurateurs foster sound. They rip out partitions, strip out soft furnishings and turn up the music. Chatter turns to shouting and then to screaming, and by the time the sound level is 90dB – that’s the same as a pneumatic drill – they have created the vibe they think their clientele enjoy. At least that’s what many of them told Action on Hearing Loss. I wonder. You can’t pour your heart out, or even chat to your mates, against a wall of sound. When a bartender brings a legal case for acoustic damage, publicans may think again. Silence is elusive. Over four days, walking along the Thames path from its source to Oxford, we were out of the sound of traffic for just half an hour. Military jets scream over the remote Highlands and police helicopters clatter over secluded corners of Regents Park. Libraries now entertain kids singing nursery rhymes, art galleries display video installations, and the espresso machine thumps and grinds in cafes where people go to read and work. Hospital calm? Gone are the days! Machines, phones, bleeps, call bells (left unanswered because they’re short-staffed), crashing trolleys, long visiting hours with noisy families . . . the noise level in ITU can be over 100dB. Noise affects patients. A Swedish study found that loud environments triggered more re-admissions. More hypnotics are prescribed. Patients self-discharge to get a good night’s sleep. Noise affects patient care. If staff are distracted or unable to clearly hear information or instructions, lives are at risk. Noise affects us all. Raised blood pressure, increased risk of cardiovascular problems, poor sleep and its attendant consequences, low birth-weight, obesity, diabetes and cognitive impairment . . . these are some of the consequences. My worst experience of noise was in Santiago de Cuba. The ancient, grinding engines of trucks and buses which had long lost their exhaust silencers woke us at dawn and deafened us until nightfall. We found relief at a cliff-top café. There was a pervasive smell of drains but, like most people, we could put up with pollution better than noise. Nearly 2000 years ago Juvenal listed noise as one of the seven plagues of Rome (along with high rents and fashionistas). Victorians were assailed by the hawkers’ cries, wooden clogs on the cobbles, clattering carts – rubber tyres were a late 19th century innovation. Now, noise has been weaponised. In Guantanamo it’s been used as an instrument of torture. Holed up in the Vatican nunciature, Panamanian leader General Noriega didn’t surrender until the CIA blared rock music into the building. (You can hear it on YouTube). In contrast, shopping malls broadcast Beethoven to see off hooligan loiterers. Our valuation of noise is very subjective and poorly related to the damage it does, which is determined by its acoustic intensity and how long we are exposed to it. The decibel scale is logarithmic, so a 70dB sound is ten times more intense than 60dB. The safe exposure time for a 90dB lawnmower is two hours; for 100dB it is 15 minutes. And we live in an environment full of 100dB noises. With earbuds you can escape from the cacophony of the street into your own soundworld. It isn’t safe, though. That constant exposure is building up damage, and the hair cells can’t tell prog rock from Puccini. It isn’t just us humans whose lives are disrupted by noise. A blackbird that can’t sing over the ambient noise won’t attract a mate. Whales use sonar communication which is disrupted by the noise from shipping. Unlike some animals, humans don’t have ‘earlids’. When we lived in caves, we could close our eyes, but we couldn’t risk not hearing danger approaching. So we are programmed to respond to noises. In the modern world we are particularly distressed by sound which is unpredictable, or which we feel could be controlled. Under the 1990 Environmental Protection Act, noise is a ‘statutory nuisance’. You can measure ambient noise levels using phone apps such as Decibel Meter and SoundPrint. So if your neighbour is using a leaf-blower (110dB) on Sunday, phone your council Noise Team. In ‘Sound Advice’, the Health and Safety Executive provides comprehensive practical advice to the music industry – to concert halls, marching bands, schools – on the law, venue design, rehearsal and concert programming, orchestral arrangement, baffles . . . and ear plugs which reduce the intensity but not the appreciation of music. If ambient noise ruins your evening, say so. If you find complaining difficult, Action on Hearing Loss’s Speak Easy tells you what to say: to the management, on social media and to the press. With enough adverse comments, restaurants will take noise off the menu. Twenty years ago little attention was paid to food and noise in hospitals, and both were abysmal. Eventually people realised that decent, well-presented meals aided patients’ recovery. Kings College London’s Hospital Project on Noise, Sound and Sleep aims to do the same for noise. It starts with listening to the soundscapes and deciding how it can be modified. Rubber corners on trolleys, acoustic finishes on surfaces and sound masking are just a start. Humans use their ears to tell them where to look, so it is not surprising that we are much more aware of landscapes than soundscapes. It would do us good to actively listen to our sonic environment. We will notice ear-sores and acoustic litter. Aircraft noise, for example. Remember the peace in the spring of 2010 when Eyjafjallajökull filled the air with volcanic ash and planes were grounded? With pressure from governments, doctors and audiologists and the public, even planemakers will respond with quieter aircraft. Judith Harvey judithharvey12@gmail.com
By Judith Harvey @judithharvey12
quiet, please
We can be so deaf to the pernicious affects of noise pollution around us every day
"Noise affects patient care. If staff are distracted or unable to clearly hear information or instructions, lives are at risk."
This is a guideline on managing abnormal LFT that was published in 2017 by the British Society of Gastroenterology, but as it so useful I thought it worth summarising it. Key learning points for me We should be investigating nearly all abnormal LFTs further and shouldn't use the duration or the degree of the abnormality to decide whether to investigate further. Severe liver disease can present despite normal LFTs. 84% of abnormal LFTs will still be abnormal in 1 months time. 50% of abnormal LFTs found in GP are not further investigated. It is thought that this leads to late presentations for lots of people. 20% of LFTs come back abnormal and less than 10% of these are caused by pre-existing liver disease. So we have our work cut out. This image is reproduced in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license; British Society of Gastroenterology. When we get an abnormal LFT result, what should we do? Firstly look at the context. Is it a longstanding result? Is the patient well? Is there a known condition or medication contributing. For example, normal LFT in someone with NAFLD may not be reassuring. It is their risk score that really determines what you do next. Their risk score may still be raised, even with normal LFT. On the other hand, a patient on a statin with a raised ALT may not be so concerning as someone who isn't on a statin. Why can we not be guided by the extent of the derangement? Many resources have talked about investigating when the ALT reaches 3 x the upper limit of normal and things like that. This guideline wants us to investigate straight away. The most common causes of significant liver disease are often associated with only mild derangement of LFT. NAFLD is a good example. Ignoring mild changes means that diagnosis is often late, with a worse prognosis. The current upper levels used for the LFTs, especially for ALT, may actually be too high. It is thought that when they were set, they included a lot of people with occult NAFLD. So results even a bit over the upper level are likely to be significant. Why can we not be guided by the duration of the derangement? Only 50% of abnormal LFTs in GP are being followed up. So we're not doing that well really. Delaying things by waiting a couple of months, or doing another normal LFT test before investigating further leads to fewer people being properly investigated. 84% of people with abnormal LFTs will still have abnormal LFTs in a month, so you may as well just investigate straight away. They suggest that you should really only retest just LFT in isolation if you are strongly suspicious of a transient cause. What further investigations should we do in someone with abnormal LFTs? Follow the flow chart above. A standard extended screen would include: Abdo USS. Hep B / C screen. Anti-mitochondrial antibody. Anti-smooth muscle antibody. Antinuclear antibody. Serum immunoglobulins. Serum ferritin. Transferrin saturation. Who should we refer? If a patient has abnormal LFTs, even with a negative extended screen and no risk factors for NAFLD, they should be discussed with a gastroenterologist or hepatologist. Louise Hudman louisehudman@gmail.com
By Louise Hudman
With NAFLD on the ascendent, we're seeing more and more abnormal LFTs.
managing abnormal liver function tests
"On the other hand, a patient on a statin with a raised ALT may not be so concerning as someone who isn't on a statin."
www.nasgp.org.uk
Promises, promises
This magazine is supported by an educational grant from the Medical Protection Society.
