Blood test problems

Patients should be aware that we continue to struggle with a lack of a reliable transport sytem for bloods and other lab samples taken for patients in rural Cowal.

The rural practices have been working with the Strachur Patient Participation Group for many, many months to resolve this problem through appeals to NHS Highland, but as Dr Von Kæhne in Lochgoilhead has posted on their practice facebook page, the problems have become much more acute during the Covid 19 crisis.  This is because we are one of only a tiny handful of practices in Scotland that still have to post samples to the laboratory, and of course the postal service is frequently delayed just now.

We are aware this is a serious issue that poses a safety risk to our patients.  We are enormously grateful to everone who has been volunteering to take samples to the laboratory drop off points in Dunoon and the Vale of Leven.

The transport of laboratory samples is an NHS Highland responsibility and it is NHS Highland that currently provide special boxes and postage labels for us to post samples.  We are meeting with them on Monday to discuss our concerns.

A public statement will follow that meeting.


Measures to delay the spread of coronavirus, Covid19

This is a rapidly evolving situation and advice may change at short notice

Covid19 is the new disease caused by novel coronavirus.

There are many known unknowns about this new disease:

- the proportion of people who will require hospital admission
- the proportion of people who will require mechanical ventilation
- the proportion of people who die from the disease (the Case Fatality Rate, or CFR)
- the number of patients who are infected in Scotland
- how long viral particles survive on surfaces
- whether the virus is droplet spread or has some aerosol spread
- what the long´term effects will be on survivors of serious illness

But some things are known:

- most patients have mild or very mild symptoms
- the disease can cause breathing problems and death
- a proportion of patients require oxygen therapy or mechanical ventilation to survive
- patients over 60 and with chronic illness are at much higher risk
- the disease is very contagious
- populations have no immunity to the disease because it is new
- a vaccine is at least a year away
- detected cases are rising rapidly in the UK and Scotland



Infectivity (R0)

The ease and speed with which viruses spread is called the R0.  This is the number of people that each infected person will infect on average.  The R0 for novel coronavirus before any public health intervention was between 4.7 and 6.6.  That is to say, it is very contagious.  For comparison, this is  similar to smallpox, mumps, and polio but much more infectious than seasonal influenza  (R0 approx 1.3 to 2.0).

A virus with a high R0 can be greatly affected by public health strategies such as the ones seen in China - society changes to greatly reduce human contact.  This has dropped the R0 down to around 2-3.

This is why we don't quarantine influenza cases and make massive societal changes to limit the spread of seasonal influenza.  Influenza has a lower 'natural' R0 and so these techniques are less effective for influenza.

Novel coronavirus appears able to spread before symptoms appear and from people with few or even no symptoms.  This is different from SARS, MARS, and Ebola and means that containment by tracing contacts of positive cases is unlikely to be successful at stopping the virus, only slowing it down.


Case Fatality Rate (CFR)

The case fatality rate measures the number of people who die as a percentage of infected people.  Since many people have mild or very mild symptoms, the true number of people infected by novel coronavirus may never be known.  Also, because it can take many weeks from being infected to the time someone dies, the fatality rate cannot be easily calculated during an epidemic/pandemic.

Attempts have been made to estimate the case fatality rate.  In China the rate for children and young adults was very low at around 1 death per 500 positive cases.  However, the rate rose sharply after the age of 60 and the rate was around 1 death per 7 positive cases in over 80s.  Adult patients with chronic conditions such as diabetes and asthma also had higher rates of death.



Lay people often make the error of thinking that the lethality of Covid19 is similar to that of seasonal influenza.  The lethality of seasonal influenza is very low, but even the highest estimates of 1 death per 1000 cases are around 10x lower than the lower estimates of novel coronavirus (1 in 100 cases).  Also, there is a degree of herd immunity to seasonal influenza as the strain usually only shifts a little each year.  So, only around 10% of people will catch seasonal influenza each year.  There is no immunity to novel coronavirus, and 30 to 80% of people are likely to be infected in the first year.


Community Spread

The number of people who are infected in the community is unknown.  Current policy is only to test people who have been in a country with known community spread or who have been a close contact of a person who has already tested positive.  The problem with this is that large number of cases can go undetected.  For example, in Washington State, it was only realised that community spread had likely been ongoing for several weeks in the state when the first serious cases came to light. 


Contain and delay

Information from Italian doctors at the time of writing is that up to 10% of their positive cases required admission to intensive care units for mechanical ventilation.   The UK is very limited in the number of hospital beds and especially intensive care beds per head of population compared to the great majority of G20 countries.   It is essential that we delay cases as long as possible to minimise the number of deaths from lack of hospital facilities.


That is to say, patients with severe disease who are unable to get oxygen therapy and/or intensive care because of lack of beds will die who otherwise would have survived if the spread of the virus had been delayed. 

Issues specific to Strachur.


Strachur is a remote location with a very high proportion of older patients and patients with chronic illnesses.  Strachur  Medical Practice has only 2 doctors and one nurse and is the only health care provider in the area.

The patients in Strachur are at higher risk than an average community.   If a patient was to attend the surgery and then be suspected of being Covid19 the practice would cease to be able to look after patients, perhaps for a prolonged period.


Practice risk to patients


The people at highest risk of being infected in Strachur are the staff of the medical practice, as they come into contact with more sick people than anyone else.  Health care staff frequently work through illness out of dedication to their patients.  The most likely outcome is that the staff will have mild or very mild symptoms but will be contagious to patients and will contaminate the surgery.

Another common scenario is that multiple patients who are older and/or have chronic illness spending 30 minutes or more in a crowded waiting room will be infected by someone with mild Covid19 illness attending the GP.

To minimise the risk of the practice becoming a focus of infection in the community, Strachur Medical Practice will take a series of steps when the doctors think that community spread is either already ongoing or is imminent.

Steps the practice will take to protect patients

The doctors at Strachur Medical Practice now believe that community spread in Scotland is either already underway or is imminent.

To protect patients we need to minimise patients' exposure to the waiting room and other patients.  We also need to avoid a patient with suspected Covid19 attending the surgery.  The practice will therefore:
- close its doors to walk ins
- provide telephone appointments to all patients
- continue telephone triage for urgent cases
- ask patients to collect their dispensed medications from the dispensary window to avoid entering the building
- patients who require to be examined will be invited to attend the most suitable location at a suitable time.

Steps patients can take to protect themselves

- older patients and patients with chronic illness should avoid contact with other people as much as possible.
- keep a meter away from other people
- do not shake hands
- avoid touching your mouth or nose
- wash your hands for 20 seconds with soap and water regularly
- store deliveries for several hours before handling them to reduce the viral load on 'fomites' (objects that may have viral contamination).


Patient Advisory Notice: Patients at potential risk - Manse Gardens Amenity Housing, Strachur

**UPDATE: Trust Housing, who are responsible for Manse Gardens, responded yesterday to the concerns Strachur Medical Practice has raised by sending a legal letter threatening a defamation action unless we retract our concerns.  We take our responsibilities to patient safety very seriously and I have passed my concerns over what we consider an inappropriate response to the Chair of the Board of Trust Housing.  We are currently building a list of people willing to be witnesses should the need arise for a defence of 'veritas' (truth) and 'fair comment' (honestly held opinionl, based on those facts, which are in the public interest). **


STRACHUR MEDICAL PRACTICE
Dalnacraig, Strachur PA27 8BX

8th May 2019 1400hrs

**PATIENT ADVISORY NOTICE**

Patients at potential risk – Manse Gardens Amenity Housing, Strachur

Strachur Medical Practice has seen a significant rise in the number of patients attending the practice complaining of mental health problems they perceive as caused by, or exacerbated by, the current situation in Manse Gardens amenity housing complex, Strachur.

Initial investigation has raised concerns about a sharp increase in the number of residents allocated to the remote facility with complex problems, a reduction in warden support for the facility, and an exodus of low-disability residents who previously provided a balance of support for residents with greater disability.

Strachur medical practice is therefore issuing a public medical advisory that patients may be at risk in Manse Gardens due to system-related issues at the facility.

Strachur medical practice is advising patients not to accept offers of accommodation at the facility pending further investigation and resolution of any safety issues identified. 

If any patients currently resident at the facility require additional support, or require medical support for their application to move to amenity accommodation elsewhere, or if anyone has concerns about the safety of a resident at the facility, please contact Strachur Medical Practice on 01369 860224.

Dr Robert Coull
MB ChB, BSc Med Sci, Dip IMC RCS Ed.
GMC# 4041625
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Appointment Times

Planning your day around a visit to see the doctor?
Remember you are seeing the Duty Doctor, so appointment times are only a rough guide.  The clinic is really a pseudo-walk-in clinic: it's normal to wait up to an hour after your stated appointment time to be seen, and you could then spend an hour or longer being seen.  So please allow up to two hours for your visit and bring a good book.  We have a comfy sofa, a coffee machine, and free WiFi for a reason!

Strachur Medical Practice is a single-handed practice, so patients will always see the Duty Doctor.  This is an important difference from larger practices.

Every GP practice has at least one Duty Doctor each day.  The Duty Doctor's job is to deal with the large number of urgent issues that come up during the day.

For example (in no particular order):
  • urgent abnormal results being called in by the laboratory
  • urgent calls from specialists about patients they are concerned about
  • calls from social work
  • calls from the Community Mental Health Team about a patient
  • District Nurses attending the practice who need to speak to the doctor urgently about a patient
  • Home Carers who need urgent assistance with a house-bound patient and will only be in the house for a few minutes
  • patients needing urgent telephone advice
  • patients who need to be seen the same day but there are no appointments left
  • medical emergencies
  • patients who are suicidal or in acute distress
  • patients who attend the clinic without an appointment needing urgent medical care
  • ambulance calls
  • police calls
  • calls to and from the NHS IT desk about computer issues
  • patients who have run out of medication
  • problems in the dispensary - national shortages of certain medications being a near-daily issue
  • problems with patients who are being seen by a Practice Nurse
Several of these problems will come up on any given day, but we can never predict exactly what or when.  In a multi-doctor practice the Duty Doctor(s) can deal with these things while the other doctors get on with seeing patients who have appointments without too much distraction.  (Even those GPs often run late, but that's a story for another day.)

Traditionally, single handed GPs did not have appointments because they were always the Duty Doctor.   All clinics were Walk In Clinics: patients turned up at the start of the clinic (usually coming early to get ahead of the queue) and they were then seen generally in order of arrival.  Patients will wait anywhere from 1 to 4 hours to be seen in a Walk In Clinic.

To try and reduce the waiting times for patients, most single-handed practices now have 'appointment times' to stagger when patients arrive and reduce their waits.  However, this is not the same as an appointment in a multi-doctor practice, because the patients are still seeing a Duty Doctor.  So it is, in reality, a pseudo-appointment system designed to stagger the arrival of patients to what - at times - can resemble a tiny, under-staffed. emergency department.  As such, patients will still wait to be seen - sometimes there will be no wait, sometimes the wait will be over an hour.  However, most patients will be seen within one hour, which is a big improvement over the 1 to 4 hour waits of a standard Walk-In Clinic.

Because waiting times of up to an hour are normal, staff may not offer an explanation and the doctor is unlikely to be apologetic about the wait.  This can understandably cause irritation, or even upset, to patients who are not used to the system and who misunderstand the 'appointment time' to mean that they will be seen at that specific time.

Patients can also be caught out by how long their appointment takes.  You have been booked for a '15 minute' time slot, but of course that might end up being 30 minutes with the doctor if your case is more complex than your realised, and/or you might need to wait to see the nurse or health care assistant, and then you might need to wait for test results, medications from the dispensary, or to see the doctor again before leaving.  This can mean an hour - or longer in some cases - between when the doctor first sees you and when you leave the clinic.

We still run some walk-in clinics.  These are useful at certain times for patients who can't wait for the next routine clinic: for example, over Christmas and New Year. Walk In clinics will have a 'start time' when patients can begin to queue.  This is not the same as the time the doctor starts to see patients: which will usually be thirty to sixty minutes after patients can start to queue.  There is also a cut-off time for patients arriving for the clinic.  This is to stop everyone turning up in the last hour of the clinic which would mean staff working hours beyond closing time, which would be unfair to the staff and dangerous for patients.  Patients arriving after that cut-off time (which might be before the clinic actually starts) will only be seen if clinically justified.   Walk In Clinics are designed to 'separate the wheat from the chaff' at times of high demand when routine matters should be postponed.  Patients will self-select: patients with routine needs are unlikely to be willing to wait several hours to be seen, which ensures that patients with urgent problems have access to the doctor.

So, when planning your visit to our surgery, remember that you will be seeing the Duty Doctor, your appointment time is only a rough guide, and that the doctor and staff will consider a waiting time of less than an hour to be seen as routine.  Please allow at least two hours for your appointment - one hour waiting time, and one hour for the medical services to be completed - and be prepared to reschedule if the Duty Doctor is particularly over-run on the day of your visit.
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