Coping with GP workload

The ever-increasing workload of General Practice appears to be at a tipping point.  The reality of being a GP in today's NHS has been honestly and eloquently exposed this week in a brilliant blog by GP Dr Zoe Norris in the Huffington Post. It's clear from the response to this on our Facebook Page that this is a real Hot Topic for GPs in the UK.

What needs to change to improve things is a whole other subject, but in the meantime how to cope in the face of such demand? Of course, there is no 'keep it simple' answer for a question so big and complex, but we can offer some simple advice based on experience. None of this is rocket science, but when under pressure we can lose sight of the simple things.

• We need to be pragmatic and accept the reality of what we can achieve given the system that we have been given to work with. We need to become better at being 'good enough' and saying 'no'.  Like most things in life, it get's easier with practise! 
• We need to look after ourselves, remembering the advice to attach the oxygen mask on the aeroplane to yourself before your children. Making sure that you do have the time for your exercise, yoga, dog, cinema, meditation or whatever keeps you healthy is crucial. Saying 'I have no time' is not an excuse, it's a recipe for depression.
• We need to be tuned into how you are really feeling. This is the single most useful thing that I learnt from my experience of having depression. Are you really coping? If you are breaking down in tears at work, not sleeping, self-medicating with alcohol or drugs or getting unreasonably irritated with patients and colleagues I would argue not. 'Know thyself'...and be honest with yourself, just as you are with patients. Doing a Beck depression score can be illuminating. 
• We need to share. Given that we spend our whole day talking to people, it's surprising that being a GP can be such a lonely job. Sharing is not easy and exposing our fallibility is scary. But, it definitely helps. So, talk talk talk with friends, colleagues and spouses/partners. Social media has, of course, problems but it is a way of being part of a wider group of GPs who feel exactly the same way you do. Join in the conversation. And if your Beck score does show you're depressed, share it with your spouse/partner/friend and DO go to see your own GP. She/he is very busy, but she/he will understand how you are feeling better than anyone and be delighted to help you. Just as you would for them...
• Finally, have this playing on repeat in the waiting room! Choosing Wisely

We're in it together. Keep well,

Simon

Ebola: what we need to know

Based on DoH 2014, CDC 2014, WHO 2014, NHS England Guidance

·      Ebola Virus Disease (EVD)

o   Viral Haemorrhoagic Fever.

§  Outbreaks ’76, ’79, ’84, 95 and several since 2000

o   Transmission to humans from wild animals (fruit bats are thought to be the natural host) and then human-to-human transmission via direct contact of bodily fluids (via skin or mucous membranes) e.g. blood, secretions or diarrhoea/vomit and with materials (e.g. surfaces, bedding) infected with these fluids. Ebola can only be transmitted through direct contact with the body fluids of an infected person. Infected people can excrete the virus in all bodily fluids e.g. semen and breast milk

o   Case fatality rate is approx. 50%, but is 70% in current outbreak

o   Incubation period ranges from 2 to 21 days, but humans are not infectious until they develop symptoms

o   First symptoms are ‘flu like’: sudden onset of fever, fatigue, myalgia, headache and sore throat

§  This is followed by diarrhoea, vomiting, rash then organ failure and bleeding

o   There are two potential vaccines in development

·      Outbreak March 2014 significant as large numbers and high mortality rate in

o   Sierra Leone, Guinea and Liberia

o   Declared public health emergency August 2014

§  Over 7500 cases (underestimate as of October 2014)

§  4,000 deaths so far (October 2014)

·      Implications in the UK

o   Low risk of imported cases at the current time (Oct 2014). Main risk is from

§  Humanitarian and health care workers returning home

§  Travel from infected areas. Ebola should be suspected in patients presenting to primary care who have a fever >38 OR a history of fever in the last 24 hours AND have visited affected areas in the previous 21 days OR cared for/been in contact with someone suspected of having Ebola. People that telephone the surgery and fulfil these criteria should NOT be advised to come to the surgery or OOH centre, but be referred to the local hospital trust for review.


Suspect if present with:

§  Fever (or fever in the last 24 hours) AND

§  Have travelled to an infected area (Sierra Leone, Guinea or Liberia) in the preceding 21 days (or been in contact with someone who has) OR

§  Has come into contact with body fluids, clinical specimens from a live or dead person/ animal with suspected Ebola

o   Consider Ebola and take a full travel history.

·      Other presenting symptoms

o   Fever >38°C

o   Severe headache

o   Sore throat

o   Profuse diarrhoea and vomiting (notable feature of the current outbreak)

o   General malaise

o   Abnormal bleeding/ unexplained haemorrhage

·      Differential diagnosis

o   Malaria, typhoid or other rare infectious diseases

·      If suspected

o   Isolate immediately with appropriate infection control measures and obtain urgent advice from local microbiologist or ID physician.

§  Goggles, masks and gloves etc

§  All used medical equipment, paper towels etc will need incineration and should be kept separate for appropriate disposal

o   Seek urgent guidance from local microbiology/ infection specialist

§  Further guidance from PHE imported Fever Service

·      24 hours per day 0844 778990

§  Diagnosis is confirmed by Rare and imported pathogens laboratory 0844 778990

o   Immediate medical treatment is required

·      Treatment

o   Supportive

§  Eg rehydration etc

§  If patients illicit an immune response they often recover

§  Death is often rapid and usually from sepsis/ shock

o   If recover then in view of risk of sexual transmission

§  Must abstain from UPSI for 3 months

§  Condom use suggested as a minimum

Gail and Simon

KISS of the NICE 2014 Dyspepsia and GORD guideline

NICE 2014 Guideline

NICE are updating their cancer referral guidelines (due May 2015) which will provide further guidance on referral pathways. In the meantime, any clinical suspicion of cancer ‘red flags’ obviously warrants urgent referral. There are some significant changes, including a more active approach to test and treat for HP, lowering threshold for endoscopy in GORD, cutting back on long-term full dose PPIs and lowering the threshold for consideration of surgical referral in persistent GORD.

Common elements of care

·      Diagnosis

o   Consider cardiac or biliary disease in the differential diagnosis

o   If people have had a previous OGD and have no new alarm signs, manage according to previous endoscopic findings

·      Appropriate lifestyle advice, including avoidance of known precipitants

o   Smoking, alcohol, caffeine, chocolate, fatty foods and being overweight

·      Review medications for possible causes, including

o   CCBs, nitrates, bisphosphonates, NSAIDs (including OTC) and steroids

·      Encourage people using medication long-term to reduce stepwise

o   Lowest dose, intermittent use and returning to self treatment with antacid therapy as needed

Who should we refer?

·      If present with dyspepsia and significant GI bleeding, refer immediately (as if we wouldn’t!)

·      Consider endoscopy if the person has GORD (to diagnose Barrett’s) based on patient preference and risk factors (e.g. long duration of symptoms, increased frequency of symptoms, previous oesophogitis ort hiatus hernia, male gender)

·      At any age with symptoms which are non-explained or unresponsive to treatment

·      With suspected GORD and considering surgery

·      With HP that has not responded to second-line therapy

How should we manage uninvestigated & functional dyspepsia?

·      Offer empirical full-dose PPI for 4 weeks

·      Offer HP ‘test and treat’

o   HP Testing

§  Leave a 2 week washout after PPI therapy

§  Use a breath or stool antigen test

§  Consider re-testing with a breath test if symptoms persist and offering second-line eradication (see below on eradication)

·      If symptoms recurrent, use lowest possible doses on as needed basis to control symptoms

·      Offer an annual review and encourage them to step-down meds or return to self-treatment with antacids

How should we manage reflux symptoms?

·      Manage uninvestigated reflux symptoms as for uninvestigated dyspepsia

·      If GORD is confirmed on OGD, offer a full dose PPI (Omeprazole 40mg or equivalent) for 8 weeks to heal severe oesophogitis

o   If initial treatment fails, consider a high ‘double’ dose PPI (Omeprazole 40mg bd or equivalent), or switch to another full dose PPI

·      Offer a full dose PPI for maintenance long-term if severe oesophogitis

How should we eradicate HP?

·      Offer a 7 day twice daily course of

o   PPI + amoxicillin + clarithromycin or metronidazole

o   If penicillin allergic: PPI + clarithromycin + metronidazole

§  If pen allergic people have had previous exposure to clarithromycin, offer PPI + bismuth + metronidazole + tetracycline

o   If symptoms persist after first-line therapy, offer a second course of therapy with different components (see full guideline)

o   Refer if symptoms persist after second-line eradication

For further information, please see the full guideline at NICE 2014 Guideline

Atrial Fibrillation: The APL Tool

This tool has been developed by the Centre for Primary Care & Public Health at Queen Mary, London University to help GPs to easily and rapidly identify high risk patients with atrial fibrillation who may benefit from anticoagulation. Recent research shows that it is effective at increasing anticoagulation rates in primary care and, if implemented nationally, it could prevent 1600 strokes per year.

What does it do?

It is a software tool which rapidly identifies high risk patients with AF who are not taking anticoagulants. It enables you to quickly draw up a priority patient list to contact for review. It also automatically calculates a CHADS2 score for QOF purposes and includes a casefinder tool.

How do I get hold of the APL tool?

The research team have made it freely available to NHS GPs. Please contact the Queen Mary Clinical Effectiveness Group:

ihse-ceg-admin@qmul.ac.uk

or Tel: 0207 882 2553