In our 107th edition, Louise has not one but two COPD-related e-learning articles; Judith has been washing her hands, Liz has been answering your tax questions, Rachel has some advice about medical hierarchy, and Kate has been making stress her friend, all with some more beautiful paintings by Claire.
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
image © Claire de Mortimer
being mindful of
Medical hierarchy may present a challenge, and at times a possible reluctance, to open discussions about patients. Dr Rachel Birch, medicolegal consultant at Medical Protection, discusses possible reasons for this and provides helpful strategies to overcome this.
Most doctors would agree that a medical hierarchy exists in the hospital setting, with junior doctors and specialist registrars making up most consultants’ teams. In many ways, in general practice, once a GP has qualified and completed their training, they may be considered as equal as any other GP. However, few would disagree that newly-qualified GPs can, and do, still learn a lot from more experienced GPs. As such, there exists a more subtle form of medical hierarchy within general practice.
It is important that sessional GPs are aware of this, especially when there may be disagreement about a patient’s care.
Since completing his GP training last year, Dr A has undertaken monthly locum GP sessions in a 2-partner practice. Last month he saw a patient in his early twenties with a significant depressive illness. He prescribed SSRI medication, but booked the patient a review appointment with his usual GP, Dr H in ten days. He wanted to ensure the patient was followed up, in case of an initial worsening of his mood.
Today the patient has come in to see Dr A for review. Although he is slowly starting to feel a little better, he confirmed that his mood had worsened before starting to improve. He did not attend the appointment to see Dr H- one of the receptionists had apparently telephoned him to pass on the message from Dr H that he should see Dr A after 4 weeks instead.
This is the second time that this has happened and Dr A is concerned that Dr H has not appreciated that he booked the review appointment because he was worried about the patient. He wants to raise it with Dr H, but is unsure as to how to go about it- Dr H is the senior partner and the local LMC secretary.
Approaching the discussion
Some recently-qualified GPs may have concerns about how to diplomatically question a much older and more experienced colleague. Whilst medical hierarchy can be positive and helpful if they wish to seek advice or learn from their colleague, in this situation there may be a reluctance and a worry that they may be perceived as being critical.
There may be various potential barriers to initiating a discussion with a senior colleague. Is there a perceived power imbalance, for example? Effectively the partners will be employing the sessional GP, and this could cause some GPs to worry that their job may be at risk. This is more likely to be a concern for salaried GPs doing regular sessions than a locum who does occasional work at a practice.
The personality of the senior colleague could also present a challenge to the GP, who may be afraid of how their colleague will react to their questioning. Other perceptions of power imbalance could be related to gender, or due to part-time versus full-time working.
Whilst contemplating the discussion may be stressful for the GP, it is likely that the stress of not addressing their concern, in the interests of patient safety, won’t go away until the discussion has been held.
General Medical Council guidance
The General Medical Council expects doctors to take part in quality improvement activities to promote patient safety. This includes taking part in reviews of your own work, taking steps to address any problems and regularly reflecting on the care that you provide. This is as true for a senior GP as a newly-qualified GP.
The GMC also advocates a culture that “allows all staff to raise concerns openly and safely.” In terms of communication with colleagues, it is expected that doctors will work collaboratively together, respecting each other’s skills and contributions, and treating each other fairly and with respect.
With this in mind, Dr A should ensure he is prepared for the discussion, and has reflected on exactly what he wants to say. Does he want to outline the way that he prefers to treat patients with depression, or would it be better first to ask Dr H to explain his reasoning?
An informal approach is usually best, and Dr A should avoid telling Dr H that he believes his actions were wrong. Instead, it would be preferable to ask him to discuss the patient, and, as part of that discussion, Dr A can address the issue of Dr H cancelling the patient’s review appointment. It is important to remember that Dr H may well know the patient better than Dr A, and it is possible that there was a valid reason for his actions. Nevertheless, the discussion should provide them both with an opportunity to reflect on the best care for the patient.
The reverse scenario
Imagine a different scenario now, where you are an older, experienced locum GP and are approached by a young GP trainee who has concerns about the care you have provided to a patient. How should you respond?
It is first important to appreciate that it may have taken the GP trainee a great deal of courage to approach you. You should be calm and listen to what they have to say- you may even wish to thank them for bringing this case to your attention. Remember that they are going through their GP training at the moment, and their knowledge in certain areas may be more up to date than yours. It is impossible to know everything, and you may find that your discussion is in fact a learning opportunity. Conversely, you may find that your experience is a learning opportunity for them. You may wish to reflect on this discussion in your next appraisal.
Promoting a culture of openness and responding to constructive criticism is essential for patient safety. It is important that medical hierarchy does not inhibit, but instead enriches any discussions about patient care.
By Rachel Birch @MPSdoctors
When social mores can alter our ability to do the right thing for patients
"Whilst medical hierarchy can be positive and helpful if they wish to seek advice or learn from their colleague, in this situation there may be a reluctance and a worry that they may be perceived as being critical."
“We often see the employer contribution being paid to the locum, but the contributions (employee and employers) not being paid over properly.”
A specialist medical accountant answers some of your recent questions
By Liz Densley @honey_barrett
Let’s have a look at a selection of questions we’ve been asked in the last few weeks:
Can you send me proof of earnings for my mortgage?
Simple question, not necessarily a simple answer!
If we have prepared your tax return for at least the last three years, we can produce a copy of the tax calculation from our system and a ‘year end review’ from HMRC’s system (to create a substitute SA302) – check they match ok and upload them to our secure portal for you to download.
However, if your mortgage broker wants 2018-19 figures, have you provided your information yet? Most mortgage companies won’t accept draft figures without HMRC calculations, so your accountant will need to complete your tax return (including locum income accounts), get it approved and submitted, and let it be captured by HMRC’s processes before the ‘SA302’ substitute can be provided.
HMRC used to provide SA302s but they do not like to do so now, as it can be done on-line, so a paper one can take several weeks to produce (after the return has been captured).
If you only have salaried income, your mortgage lender should accept your form P60 showing earnings (and tax deducted) for the year.
So if you are likely to need a new mortgage, plan in advance and make sure your affairs are up to date.
Is it worth me working some out of hours sessions?
This question came from someone with a salaried position 2 days a week, variable amounts of locum income and the new plan to do some out of hours work.
This isn’t something that an instinct can answer alone, so what needs to be considered?
Are you the higher earner of a couple with children claiming child benefit? The benefit is clawed back for taxable income between £50k and £60k, after which it is fully recovered. So generally earning between £50k and 60k is going to be expensive – how expensive depends on how many children you are claiming child benefit for.
Is your taxable income near £100k? For income levels between £100k and £125k your personal allowance is steadily taken away – leading to an effective rate of tax of 60% on income in that band.
Also at this level of income, tax free childcare is removed.
Is your taxable income close to £110k? Income over this level causes the pension allowance to be potentially reduced, so detailed calculations are needed to see if this creates a pension annual allowance charge. This tax is particularly tricky because it is a tax liability without any matching income. Yes, you can get the scheme to pay it, but the ‘debt’ increases much faster than inflation, and by retirement could, with hindsight, be an expensive route to have taken (but often there’s no choice because doctors don’t have the cash to pay the charge themselves).
Is your income close to £150k? Income over this is taxed at 45%.
Note that taxable income is after pension deductions, not before.
Very often when we are asked this question, and we do the calculations, the answer is that it may be better for the spouse to earn more (if that is an option) and the client to keep their income under a particular limit. Sometimes the use of a limited company can be beneficial.
There’s no automatic answer – we have to look at the figures for the individual each time.
Why do you need pensions information?
Because if we have no details about your NHS (or indeed private) pension, we cannot calculate what your tax liabilities are, or whether there is a risk of an annual allowance charge that you need to plan for.
If you keep an eye on your pensionable income each year, ideally from the Total Rewards Statement, you will know if anything gets missed. Much easier to track it down promptly now, than in 30 years time when you start getting closer to retirement.
Don’t NHS pensions tell you if you’ve exceeded the allowance?
If you have exceeded the £40k allowance, which assumes that your record is up to date too, then yes, they will send you a Pension Savings Statement, eventually. However, if your record is not up to date or is incorrect, or if you are only entitled to a reduced allowance, or if you have a personal pension, NHS Pensions will not be aware of a potential charge and will only send a Pension Savings Statement if you ask for it.
My pensions record is incorrect and I can’t get it sorted.
We have had some good (if painful!) success at getting records updated, and we have contacts within the PCSE if all else fails. Generally, if you’ve tried and not succeeded, we can escalate your case through the complaints procedure to get it sorted for you. You will need to have retained details of pensionable earnings and contributions, usually this will be your Locum A & B forms and proof of payment, as well as payslips from employments. Don’t forget that LocumDeck keeps all this data for you.
Why do you ask so many questions when you do my accounts and tax return?
I can assure you we don’t ask questions for the fun of it! We want to get your return and accounts completed as quickly as we can. But we want to make sure that you are not paying more tax than you need to be, and equally that you are not making claims that cannot be substantiated and could give rise to interest and penalties if HMRC queried them.
Frequently we find that locums have pensioned some but not all of their income, and it can be tricky to work out what is and what isn’t pensioned on the Locum A forms, and whether the Locum A forms match the Locum B forms. We often see the employer contribution being paid to the locum, but the contributions (employee and employers) not being paid over properly.
If GPs have other general questions to which they would like answers here, do please drop us an email and we’ll see if we can include it in a future issue. Be aware though that it can only be a generic answer, and once the full facts are known, answers can be different! If it’s a question to which you need a specific answer, then please either contact your own specialised medical accountant, or ask us to take you on as a client.
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 firstname.lastname@example.org
New guideline from NICE
"Be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer, even if spirometry is normal and the patient has no signs or symptoms of disease and even if they have stopped smoking."
copd diagnosis and
By Louise Hudman
This is an updated guideline from NICE on the diagnosis and management of COPD, published in Dec 18. It's a pretty mammoth guideline, first written in 2004.
There is a useful flow chart on management. One for the wall...
There is a separate guideline on antibiotic prescribing in COPD, also in this magazine.
I will outline the main changes in management and things I had forgotten, rather than summarising the whole guideline. The most important changes are:
Knowing what to do if signs of COPD show up on a CXR or CT Scan.
Which inhalers to use in which patients.
Diagnosis - what tests should be done
Everyone should have the following tests done:
Other investigations that may be indicated:
serial peak flows (if asthma is considered).
ECG / BNP / Echo (if cardiac disease may be playing a part).
CT (if bronchiectasis or fibrosis are suspected).
serum alpha-1-antitrypsin (beware younger people, or those with a family history of lung and liver disease).
transfer factor for carbon monoxide (TLCO - if the symptoms are disproportionate to the spirometry results). This is a measure of the efficacy of the lungs in gas exchange.
What should you do if changes of COPD are seen on CXR or CT scan?
Be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer, even if spirometry is normal and the patient has no signs or symptoms of disease and even if they have stopped smoking.
Assess the patient and perform spirometry.
If they are a current smoker and have normal spirometry and no signs or symptoms of COPD then:
Offer smoking cessation.
Warn that they are at higher risk of lung disease.
Advise them to return if they develop lung symptoms.
If they are not a current smoker and have normal spirometry and no signs or symptoms of COPD then:
Ask about a history, or family history of lung or liver disease. Consider other diagnoses, like alpha-1-antitrypsin deficiency.
Reassure the patient that their condition is unlikely to get worse.
Advise them to return if they develop lung symptoms.
What is the prognosis?
The following features are associated with prognosis:
Breathlessness (MRC scale)
Chronic hypoxia / cor pulmonale
Severity and frequency of exacerbations
Symptoms burden (eg CAT score)
Exercise capacity (eg 6 min walk test)
TLCO (transfer factor for carbon monoxide)
Whether needs home O2 or home non-invasive ventilation
Please remember that this isn't a full summary - I am giving an outline of what is new in this guidance.
What lifestyle advice should we be giving patients?
Alongside all the normal advice we give to patients with COPD, we should advise them of the following things.
Factors that may increase their risk of an exacerbation:
smoking or passive smoking.
viral or bacterial infections.
indoor and outdoor air pollution.
lack of physical exercise.
seasonal variation in risk (ie higher in winter and spring).
What advice should we give patients to help them self-manage exacerbations?
Patients should have a written self-management plan which advises that:
They should take their steroids if they have shortness of breath interfering with their life.
They should take their antibiotics if their sputum is purulent and increases in volume or thickness beyond their normal day to day variation.
They should adjust their SABA (short acting bronchodilator) use to treat their symptoms.
The British Lung Foundation has useful downloads for self-management plans.
Patients should have steroids and antibiotics at home if:
they have had an exacerbation in the last year and remain at risk of more.
they know when and how to use them.
they know to inform their health care professional when they have used them and the need for more.
NICE advises that if a patient has used more than 3 courses of antibiotics and / or steroids in a year, we should look into the reasons why.
What inhalers should be used in the management of COPD?
1. SAMA (short acting muscarinic antagonist) or SABA PRN first line.
2. Step up treatment should be used if: they continue to have SOB or exacerbations despite being offered smoking cessation, having optimised non-pharmacological measures (eg vaccinations etc) and using SAMA or SABA. Use either (depending on the criteria below):
LABA + LAMA OR
Consider LABA + ICS
3. LABA + LAMA + ICS. This should only be used if they have asthmatic features, or features suggestive of steroid responsiveness and if they remain breathless despite using LABA + ICS.
How do you decide between LABA + LAMA or LABA + ICS?
LABA + LAMA if:
They do not have features of asthma nor features suggestive of steroid responsiveness.
LABA + ICS if:
They have asthmatic features or features suggestive of steroid responsiveness.
They do advise that if people are already established on combinations of inhalers which are working for them, that we do not need to change them.
What factors should you consider when prescribing inhalers?
How much they improve symptoms.
Ability to use the inhaler.
Drug's potential to reduce exacerbations.
Minimise the numbers of inhalers and the different kinds of inhalers where possible.
What advice should we give about spacer care?
Don't clean them more than monthly as they can build up static, which can affect their performance.
Wash them in warm water with washing up liquid and leave them to drip dry.
What oral medications can be used?
The change in this section is on the advice around azithromycin. They advise that we consider asking for a specialist opinion before starting azithromycin. As I suspect that most of us won't be initiating this ourselves, I haven't gone into more detail on this, but be aware that there are a lot of criteria around when to start it and things to make sure you do before starting.
So what oral drugs can be used?
Oral phosphodiesterase-4 inhibitors. There is separate guidance on the use of these. They should be initiated by a specialist and are to be used in people who have severe COPD and who are getting frequent exacerbations.
What else is new in the guideline?
There are a few other new details in the guideline, but most of the rest hasn't changed.
Lung reduction therapy. This should be considered after any pulmonary rehab or at other reviews in people with severe COPD if they remain breathless.
Telehealth. This shouldn't be offered routinely for the monitoring of the physical status of people with stable COPD.
Starting home oxygen. We should counsel both the patient and their family about the risks of using home oxygen. This should include the risk of falls and trips over the equipment and the risk of burns and fires, especially if people continue to smoke or use e-cigarettes. Patients should not be offered home O2 if they continue to smoke.
Viewing our stress response positively has less physiological adverse effects
By Kate Little @katelittle71
With ever mounting workload, increasing patient complexity and rising patient expectations and complaints, work is becoming increasingly stressful in the NHS.
Life outside work is more stressful too. Notwithstanding stresses that we may have in our home life, we are now living in a 24/7 on-demand, fast-paced culture that lacks stop cues as we consume countless Netflix and apps on our phones. We have so many distractions at our fingertips all vying for our attention. We have multiple choices for pretty much everything. Not great if you are a maximiser, who sets high standards in decision making.
According to Dr Mithu Storoni, we no longer have the natural stress buffers in our day that previous generations have had. For example, in the past we had to physically move for daily tasks like answering the phone, or doing the shopping. We connected with others face-to-face which would have required movement on at least one person’s part. That activity and connection would have provided a natural way to de-stress. In order to survive and thrive in the 21st century, we have to create conscious buffers to get the balance back.
What is stress and what causes it?
Stress can be literally defined as our body’s response to pressure from a situation or life event. It is often stimulated by something new or unexpected (a new baby, moving house), something that threatens our sense of self (a conflict with someone, someone ignoring us in the street) or a situation where we feel that we have little control (our work perhaps).
When we are stressed our body is stimulated to produce stress hormones that activate our immune system and our neural networks to trigger a flight, fight or freeze response. We can measure this activation through pupillary responses and heart rate variability (HRV).
This stress response can be helpful in short term stress, like giving a speech to a large crowd where you can return to a resting state quickly, but if the system is constantly activated it can have negative consequences on our physical and mental health. Our bodies become more inflamed, increasing our risk of insulin resistance, cardiovascular disease, Alzheimer’s disease, depression and many cancers.
Some stress is good for us
When we have a manageable amount of pressure, we are in what is known by some as the “stretch zone”. We feel stimulated and engaged and our performance improves. Our confidence grows, boosting our self-esteem. This impacts positively on our psychological wellbeing.
However if the pressure is too much, our anxiety escalates and performance plummets (right hand of chart). We enter the “panic zone”. Conversely, if we remain solely in our “boredom zone” (left part of graph) then we can become disinterested and disengaged . Both these extremes impact negatively on our performance.
Stress awareness is key
The first thing is to be aware that we are feeling stressed. This may sound obvious but all too often we ignore stress through habit. This may be a banker who is excited closing a deal and leading a high octane life, it may be a parent juggling work with young kids, it may be a professional whose drive to do well overrides the stress awareness, or it may be a people pleaser who feels uncomfortable saying no, ends up taking on too much and subsequently feels overwhelmed. Doctors often fall in to the latter 2-3 groups.
Next is to be being aware of the automatic responses we have when we feel stressed. For example, unhelpful thoughts like “I can’t do this”, “I’m losing control” or unhelpful behaviours like procrastinating or being indecisive. If you understand that a typical pattern for you is catastrophising for example, this is the first step to change. You learn to see your thoughts more objectively as thoughts, rather than truth, also knowing that they will pass.
This gives back a sense of control which is the prime goal of stress reduction.
Control and Escape
In his book on Lifestyle Medicine, Garry Eggers et al describe a simple model for dealing with stress, the ACE approach: analyse, change and evaluate.
Analyse is simply working out what the stressors are, and whether the problems are a result of external factors or our own coping mechanisms. Often it is a combination of the two.
Change is removing or reducing the potency of the stressor (which may not always be possible in certain home, work or financial situations). We might do this for example by delegating, delaying or dropping the problem. Or by removing, replacing or re-framing it.
Changing our reaction to the stressor involves examining our coping strategies. Are they unhealthy (such as alcohol, caffeine, drugs, blame, violence) or healthy?
Our natural response to stress is to escape (fight or flight). This was helpful evolutionarily to escape from the lion chasing us in the jungle but running away each time is clearly not a practical reaction to the small stressors we encounter daily.
We can escape in different ways though: physically removing ourselves from the stressor (taking a holiday, quitting a job), physically distracting ourselves (exercise, taking a hot bath, massage, sleep) or mentally escaping by reading, art, counting, muscle relaxation or meditation. Each individual will have their own way of coping, some preferring more cerebral methods, others more physical and some a combination of the two.
Fighting is another way of escaping. We can do this without using our fists, either physically through confrontation, challenge or talking, or mentally using techniques such as problem solving, thought challenging, planning or brainstorming.
All these strategies allow us to restore a state of perceived control and calm, alleviating the stress reaction and closing the loop. We can then evaluate what has helped and work on making sure that we build these into our everyday lives.
Making stress your friend
In her TED talk, “Making stress your friend” Kelly McGonigal says that if we view the stress response positively as a means of preparing us for our task ahead, then it has less physiological adverse effects long-term. And if we reach out to others when we are stressed, we release more oxytocin, the “cuddle hormone”. which is a natural anti-inflammatory. This helps counterbalance the inflammatory effects of stress.
So, it seems that how we think about stress, and how we act, matters.
Putting this into practice
I find the stress bucket a useful way to visualise stress and often use it with clients and patients alike.
Listing all the stressors in your life on paper helps you to really appreciate how much you are actually doing. If there is too much going into the bucket it will overflow. So, to prevent that, we need to remove the stressors as in our model previously, or ensure that we have healthy coping mechanisms (the tap to let the water out). These might be the escape strategies above (physical or mental), or changing the way that we think about stress and making sure that we do reach out to others when things are not going so well.
Dr Kate Little, a GP Clinical Champion for Physical Activity and the founder of physicianburnout.co.uk, a resource for doctors that are feeling fed-up, stressed, anxious, depressed or burnt-out. Kate has worked as a GP in the NHS for the last 16 years in a variety of roles – partner, salaried & locum. She has also worked in medical education as a GP trainer and facilitator, and as a GP appraiser.
"This gives back a sense of control which is the prime goal of stress reduction."
making stress your friend
© Claire de Mortimer, GP locum, detail, acrylic
Hand dryers may be all the rage buts its still too early to throw in the towel
In post-war Italy TB was still rife and notices in buses commanded “No Spitting”. In Britain in 1946 the message “Coughs and sneezes spread diseases” promoted the use of handkerchiefs to catch the germ-laden droplets. Presumably a reasonably successful public health campaign, although if you are trapped like a sardine in a rush-hour tube train, you may have no alternative but to sneeze into the shoulder of the person jammed in front of you.
Reducing droplet spread is a great step forward, but rhinoviruses are also transferred from noses to hands and so to any surface we touch. They survive there for several hours for the next person grabbing the handrail or turning on the tap to pick up. So do more dangerous infective agents from other sources. Hence the slogan I recall from my childhood “Now wash your hands”. So, a century after Semmelweis published his paper on reducing the spread of infection in maternity wards, his advice had reached the Department of Health. If followed today, it could cut gastrointestinal upsets by a third, reduce sickness absence from school and work, and save the UK economy more than £1 billion every year. But the E coli counts on peanuts set out for grabs on pub bars demonstrate that the general public still isn’t heeding the message. A surgical scrub isn’t necessary, but the more thorough the wash, the better. The NHS recommends washing with soap (antibacterial not helpful) for as long as it takes to sing ‘Happy Birthday to You’. Twice. Though as most of the pathogens are on the fingertips, even waving the fingers under a dribbling tap may be better than nothing.
Wet hands still pass on a lot of pathogens, but effective drying removes almost all the bugs. Dryers in public toilets are a relatively recent introduction – the researchers of the 1965 Good Loo Guide found that less than five percent of public toilets had hot air dryers, though they probably had roller towels. Paper towels came later. Jet dryers (OK, Dyson Airblades ®) are a 21st century invention.
Which works best? Cloth towels are quick and effective, though try finding a clean area on a jammed roller towel. Studies comparing the effectiveness of paper and jet dryers are limited, and the results tend to support the product of the industry which sponsored them.
It does seem clear that jet dryers are more economical than paper towels, which have to be sourced, delivered, stocked, cleared away, and disposed of in landfill. Add in the cost of calling the plumber to unblock the loos and the fire service to put out fires in waste baskets. But on the road to reduction of infection, cost isn’t even a surrogate end point, it’s just a station on a by-line for institutions that are counting the pennies, not the pathogens.
The paper industry claims that jet dryers blast bugs into the air. The jet dryer industry claims more effectiveness and less mess. The only independent study, a literature search by the Mayo clinic in 2012, found (in a 2009 survey) that most members of the US public preferred paper towels, and recommended that single-use paper towels be used in health care settings.
The bottom line is, do people use whatever drying method is provided? And do they use it effectively?
Time is one hurdle. Traditional hot air dryers are too slow. Jet dryers are quick, but not that quick, and if there is a queue and the curtain is about to go up on the final act, you probably shake your hands and rush to your seat.
Paper towels are quicker. But paper towels dissolving to pulp on a wet floor don’t encourage users to spend time doing even a cursory wash.
Poorly maintained facilities may make users feel they need to clean themselves of the grot, but probably make it more difficult to do so. Fastidious users don’t like the idea of contaminating themselves with other people’s germs, and it does seem illogical to turn on a tap with dirty hands and then re-contaminate them when you turn it off. No-touch facilities reduce cross-contamination and taps which turn themselves off must save water – as long as the system works.
Ultimately, it’s a matter of culture. People will wash thoroughly if they find their hands contaminated by something that disgusts them, like dog-shit, but they don’t make the same connection with illness after a visit to a toilet. Pete Hesgeth, the Fox News presenter, says he doesn’t wash his hands – he can’t see the pathogens so they aren’t there. A majority of Britons seem to share his view, at least unconsciously. Accurate statistics on the public’s hand-washing habits are hard to obtain, but apparently more than 60% of people don’t bother.
Behaviour change is difficult when the threat is invisible. Establishing a hand-washing ritual early in life is a challenge. Health visitors and Sure Start – where it still functions – can explain to mothers that leaving children’s hands unwashed is equivalent to feeding them faeces – sorry, poo – and teach them how to get their children into the habit. Schools have a responsibility to provide adequate facilities and to ensure they are used.
In the consulting room, hand-washing means more than just removing infective agents. It’s a brief time out. It’s a demonstration to the patient. Water or alcohol? Some GPs like the feeling that they are washing those germs down the basin. Others prefer an alcohol rub. It’s quick and it’s effective.
Some facilities are a pleasure to use. Upmarket gastro-pub loos are tastefully decorated with scent sticks and an orchid, maybe a real one. You take a pleasingly coloured fluffy towel square from the pile, enjoy getting your hands really dry and drop it into a wicker basket. But even there I bet you won’t time yourself by singing Happy Birthday – twice.
By Judith Harvey @judithharvey12
now wash your hands
"Studies comparing the effectiveness of paper and jet dryers are limited, and the results tend to support the product of the industry which sponsored them."
This is a new guideline from NICE on when to prescribe antibiotics in an acute exacerbation. It was published in Dec 18. It should be read alongside their updated guideline on COPD.
The most interesting bit for me about this new guideline was that only 50% of COPD exacerbations are thought to be caused by bacterial infections. The rest are caused mainly by viral infections or smoking. Unfortunately there is no good evidence on what signs or symptoms we can use to differentiate between a bacterial and non-bacterial exacerbation.
Another change is that all antibiotic courses are now advised to be 5d only.
One fact that really surprised me is that the NNT with antibiotics in the community to avoid 1 treatment failure is 14 - much higher than I would have guessed.
What should you consider before choosing an antibiotic?
Previous sputum culture results.
Possible resistance after multiple courses of antibiotics.
What should you consider when you get a sputum result?
NICE advises that you only need to change the antibiotic if the bacteria are resistant and if the patient's symptoms are not already improving.
What advice should you give a patient when prescribing antibiotics?
Their symptoms may not completely resolve after the course of antibiotics.
They should seek medical advice if their symptoms worsen significantly or rapidly, or if they become systemically very unwell, or if they aren't improving within 2-3d (or some other agreed time).
What advice should you give a patient if you are not prescribing antibiotics?
Why it is not needed.
That they should seek medical attention immediately if:
symptoms (like sputum colour or thickness or volume) worsen rapidly or significantly.
symptoms do not start to improve within an agreed time frame.
they become systemically very unwell.
What antibiotic should you choose?
This is obviously NICE's advice, but you may wish to consult local microbiology advice too.
1st line: Amoxicillin, Doxycycline or Clarithromycin - all for 5d. NB - if the patient is on prophylactic antibiotics, use an antibiotic from a different class.
2nd line: an alternative 1st line antibiotic if they are not improving within 2-3d or other agreed time frame.
Alternative choices: when there is a higher risk of treatment failure (see below). This should be guided by previous susceptabilities where possible.
Levofloxacin 5d (beware recent MHRA guidance).
Co-trimoxazole 5d (only use this when there is evidence of susceptability and when there is a good reason to prefer this combination to a single antibiotic).
Why only a 5d course of antibiotics?
The evidence suggests that a 5d course is as effective as longer courses.
When is there a higher risk of treatment failure (prompting an alternative choice of antibiotic)?
Repeated courses of antibiotics.
Previous or current sputum culture showing a resistant strain.
People at higher risk of complications.
Should we use back-up antibiotics?
It is not advised in this guideline. There have not been any studies done on whether they are effective or safe.
What is the evidence behind the use of antibiotics in COPD?
The evidence isn't really that great. Most of the studies have been small and used heterogenous groups of people, making it hard to apply the results to normal practice.
The following are the NNT (numbers needed to treat) to avoid 1 treatment failure (ie no improvement of symptoms):
In the community - NNT 14.
In hospital - NNT 10.
In ITU - NNT 3.
antibiotic prescribing in
an acute exacerbation of copd
"One fact that really surprised me is that the NNT with antibiotics in the community to avoid 1 treatment failure is 14 - much higher than I would have guessed."
tackling malaria in remote parts of cambodia
By Jessica Doyle @healthpoverty
As GPs, you are usually the first point of call when local communities are worried about their health.
The communities we work with across Africa, Asia and Latin America don’t have their local GP surgery to pop into when they are sick. That’s why our Outreach Teams are doing such important work all over the world.
Recently one of my colleagues travelled to Cambodia to meet some of the incredible Malaria Outreach Team that you’ve been supporting through NASGP.
Although malaria has been eliminated in most regions of Cambodia, it is still a dangerous reality in many of the remote places where Health Poverty Action works. This is particularly true for indigenous populations who are overlooked by traditional healthcare systems. Often language barriers and a lack of information prevents people from accessing essential care.
Taounsay is part of the team supported by Health Poverty Action in rural Cambodia. He understands the importance of malaria testing and wants to ensure that the people he meets know how to look after themselves, understand the symptoms of the illness and where they can go to get help. Helping people understand the dangers, and showing them that they have the right to access healthcare, is a vital part of his work.
Taounsay and his team often spend three weeks of each month away from their families travelling across difficult regions to find people for whom accessible healthcare is not an option. He can be found travelling great distances by boat or motorbike to reach as many people as possible who are otherwise being forgotten.
“I work with a lot of different people and ethnic minority groups, and I need to speak different languages to communicate with everyone I come across. It can be a hard job. We travel very long distances and the road can be very difficult to pass through, especially in rainy season. We often travel deep into the forests to find people.”
Despite the difficulties of the job, Taounsay is confident in the long-term change he is making in his community: “The people here aren’t always looking after their health – they are often travelling to find work and can’t easily access healthcare. When people have education about their health, they can protect themselves.”
With your support, Outreach Workers like Taounsay can continue to spread education and accessible medicine to these communities. Please click here if you’d like to donate to support Outreach Workers like Taounsay.
Health Poverty Action, As One campaign
"We travel very long distances and the road can be very difficult to pass through, especially in rainy season. We often travel deep into the forests to find people."
Supporting sessional GPs to improve patient care
This magazine is supported by an educational grant from the Medical Protection Society.