Why am I not surprised?

As I am writing this Breaking News on twitter (@BreakingNews) has reported of the first few cases of Tamiflu resistant Swine Flu in the US. Seeing as we are giving Tamiflu out like smarties in UK I predict it will be a few weeks before we start seeing resistant cases in the UK too. Great.

Its debatable if Swine Flu will surge back again in the autumn/winter. Certainly all the preparations are based around a second more severe wave of infection. Will it be the same virus or will it have subtly mutated so no-one will be immune who can tell? Its all guesswork from what I have been reading.

I'm not going to rant on about Tamiflu being rubbish in children as you guys already know that. I will say that the recent study from Oxford was dismissed by the Department of Health as the research was done on Seasonal Flu, not Swine Flu. A couple of points worth considering;

1) The reason why we are giving out Tamiflu en masse is based on this study, which was done on, (you've guessed it) Seasonal Flu. So its ok to use one study done on seasonal flu to justify Tamiflu, but not another - huh?

2) Its hard to do studies on an emerging pandemic influenza as its new and not been around long! As we are no longer swabbing who knows what illness the children really have? Hopefully we'll get some decent studies coming out soon but don't hold your breath.

I've been asking people on Twitter if they would have the Swine Flu vaccine if offered. Mixed responses really but some people are now so distrustful of the Governments handling of the Pandemic they would decline. Others don't want to use an untested vaccine.

Please don't confuse the vaccine with Tamiflu. Tamiflu is rubbish. The vaccine isn't. I understand reasons why people are fearful of the vaccine but its manufactured in exactly the same way as the seasonal flu vaccine, just a couple of protein bits are altered. It will still have to meet the stringent requirements for using a vaccine on the public. The seasonal flu jab is only manufactured a couple of months before the flu season but people don't panic that its not tested properly. Seasonal flu kills 12000 people per year in the UK, it would be considerably higher if we didn't vaccinate.

There was a small outbreak of Swine Flu in the states in the 1970's. The vaccine produced then was with inferior technology and there were a number of reactions to it. Vaccine production nowadays is considerably more advanced and safer.

Swine Flu is H1N1, Spanish Flu was H1N1 too and that killed roughly 50 million people. Ok the Swine Flu virus is slightly different but it still has that potential to kill. I don't want people to be dismissive of the vaccine just because Tamiflu was a load of shit. Swine Flu so far has been a mild illness in most. It may, or may not, stay that way. Should you have the vaccine if offered? I think so. Its personal choice though so don't take my word for it. Don't base your decision on the rantings of an irate GPs blog. There may be a risk in taking the vaccine but there is a risk in everything we do in life. I suspect the risk of harm from the vaccine is considerably smaller than the risk of driving to work, using routine medicines or even just mowing the lawn. And if you smoke? Well the risk of harm from that far far outweighs any possible complication from the vaccine.

Later folks! Stay healthy!

Why not just put Tamiflu in the water..?

Hello again dear reader,

Been getting loads of feedback via twitter (@GPforhire) about my last posting. Apparently you didn't realise that Tamiflu isn't all its cracked up to be. Not surprising really as the negative side of tamiflu has had very little coverage. I could be paranoid and think that the government is suppressing reports of its lack of efficacy and side effects but is Labour capable of that?

Things are changing a little, there was this report in the Guardian today, and a previous one in May. I saw a young child last week that got a nasty rash from the drug. We've had multiple patients that couldn't tolerate the tamiflu due to vomiting and then phone us in a panic worried that they'd succumb to Swine Flu without their magic bullet drug.

Just so you know that I'm not making this up heres a few links that have looked at various bits of data.
You might have to be a BMA member to see the full articles

Tamiflu and anti-inflammatories (aspirin, ibuprofen or diclofenac) might be a nasty combo
GPs seeing lots of patients with side effects from Tamiflu
Tamiflu and neuropyschiatric side effects in teenagers - case not proven, caution recommended
Use of Tamiflu in children not supported by the evidence

So for the record, I wouldn't take Tamiflu, and neither would anyone in my family. Not for Swine flu anyway. For Avian flu I'd probably take it but resistance to it is growing.

Another worrying development:

Misdiagnosis.

I know of 3 deaths that have happened recently because they were thought to have Swine Flu but sadly had something much more serious which was missed until it was too late. This number will increase as the number of people assuming they have Swine Flu when they have something else will no doubt increase.

We run a simple problem clinic at our practice (see my earlier blog entry). Its been nearly empty this week. Summer holiday don't make that much difference to the numbers. I think its because these patients are confusing their symptoms with Swine Flu and using the Pandemic Line to get their tamiflu. These patients will probably turn up next week complaining of side effects from their treatment for their non-existent Swine Flu. I know some docs who have been swabbing patients still. Roughly 10% of the patients they thought had Swine flu actually had it on swabs. Thats experienced GPs seeing patients face to face and are still getting it wrong 90% of the time. God knows what the general public numbers would be like. Its madness frankly. Countless thousands of people taking Tamiflu (via the Pandemic line) for a mild self-limiting illness which they haven't even got!!


Quick link before I go. Heres a website run by the Medicines and Healthcare products Regulatory Agency MHRA. You can report any side effects from Tamiflu here. Tamiflu is a black triangle drug and so all side effects (even minor ones) should be reported. Its how we get to know if a drug is doing something odd. Anyone can report a side effect, doctor or patient.

Stay Healthy and see you again soon!

The Week that Was

So its the end of my first week back at work and the Swine Flu panic, er, I mean pandemic is in full swing. We are getting 30-40 patients a day worried they have it. Some do, some don't. Should we be giving them all Tamiflu? Well that depends on what guidelines you read and whether you are bothered by something called evidence-based medicine.

You're no doubt aware of the mountainous piles of Tamiflu the government has stockpiled. Let's get one thing straight. Tamiflu is an antiviral but this doesn't mean its a cure. Its not like taking an antibiotic for pneumonia. At best it will shorten the duration of symptoms by a day. The evidence so far has shown it has no impact on mortality (i.e taking it won't stop you from dying if thats your fate). Its use in a pandemic is unproven.

Lets not forget all the side effects. We are already seeing children who get quite nasty vomiting from it (1 in 10). Trouble is you tell the parents to stop the drug and they shit themselves, convinced that Tamiflu is the only thing stopping their child from knocking on heavens door. So the child vomits themself into dehydration and ends up needing admission.

Interestingly a large study of Tamiflu's potential neuropyschiatric side effects showed a possible increase in seriously abnormal behaviour (such as self-harm) in the under 19s. Its not meant to be used in Japan for this age group such is the number of cases they have had. Of course in this country we have no such qualms in giving it to our children. Tamiflu is classed as a black triangle drug in the UK- this means its a new drug, not all the side effects (or frequency of) are known, or the potential interactions.

One of the high risk groups for complications of Swine Flu is the under ones. The UK has a limited supply of liquid Tamiflu for this group. Guidelines state that all under 1's should be offered the drug. Trouble is is that it doesn't work, no evidence it works and I've been informed via a consultant Neonatologist that the under 1's lack the enzyme to activate it. Also the blood brain barrier hasn't fully formed yet meaning the drug that is known to cause hallucinations and confusion can easily pass into their developing brain. Brilliant. Is that in the press? Hell no, its not even in the Daily Mail which hates all things medical.

Now don't get me wrong. I'm not trying to scaremonger. I'm just letting you know that Tamiflu might make you quite sick, or worse. It lacks evidence of effectiveness and I'd think twice about giving it to anyone under 18.

One flu over the Swine nest

Good evening dear Reader,

I write this as I am watching Bear Grylls eat frozen squirrel brains in a Siberian forest. Still, if its a choice between that and Kendal Mint cake I know what I'll go for.

Work is vaguely interesting at the moment. We are all going to die from Swine Flu.

Or maybe not. In January of this year the RCGP published its Pandemic Flu guidelines which gave information about what do in the event of a new global flu pandemic. It was based on models from previous flu pandemics last century (that makes me feel old) with mortality rates etc... from Avian Flu. That was assumed to be the Big One. Its nasty, it kills a lot of people. Much to everyones surprise it was actually Swine Flu (H1N1) that swept the planet.

So far its killed a few hundred people and infected many tens of thousands (at least). Although these deaths are tragic, things should be put into perspective. Seasonal Flu (normal flu) kills 12000 per year in the UK. Does it get the same kind of hysterical coverage in the media? Not a chance. Mind you I can't be too tough on the media and the government (for once) as their projections were based on the far more deadly Avian flu.

How's things panning out now? Well I'm sure you are aware that Swine Flu is a lot milder than everyone was expecting. True it has killed people but the majority of these had other significant illness (not sure what exactly as no-one will tell us). One person died today of Swine Flu who was otherwise healthy. I am assuming they died from viral Pneumonia - v.nasty but rare, 40% mortality rate.

We've had a few cases through the doors where I work - despite advice to stay at home. I think currently the Staff are more scared then the patients. The difficulty is the guidance coming out from the PCT is mixed, frequent and far too wordy. I get 2-3 emails per day with 4-5 attachments. Each email supersedes the previous one - usually. Its a fucking mess. The Swine flu packs never turned up - not that they are needed now. Tamiflu guidance seems to change every few days. I'm still unsure if its for people presenting within 48hrs of symptoms, just the high risk groups, or everyone. Not that its any good. Government seems to think its a silver bullet but the evidence behind its use is not brilliant. Shortens the illness by hours, reduced viral load but its not without its side effects - including making all your skin fall off (rare but if everyone uses it we might see a case or two)!

Don't get me started on NHS Direct. Fucking waste of space that is. Masks are pointless too but good for scaring patients. I think a lot of the problems come from the original guidance which was based on Avian flu. Which is nasty and kills a lot of people. Where as Swine flu just makes you feel a bit poorly (usually). The guidance is slowly changing to take account of the fact that its not the End of humanity as we know it.

How you diagnose Swine flu? You guess. Thats right. We've been given a few symptoms that people will have but the trouble is is that the vast majority of viral infections we see in GP-land present with this. Even worse with children. Its only a matter of time before we miss a serious illness (meningitis, cancer, etc...) as we are so focused on believing everyone who is unwell has Swine Flu. And then the Daily Mail will have a field day. Whoop-de-fucking-doo.

Of course come winter the shit will hit the fan when Swine flu grows some balls and becomes the killer that we are all worried about. Oh well, such is life.

Why is hospital food so damned awful?

Apologies for the lack of blogging, I've been a bit pre-occupied when my next child made an unexpected appearance early when my wife's waters broke at 36 weeks. I won't bore you with all the details but thankfully baby Toby was born on the 29th May at 1030 weighing 5lb8oz. Mum and baby are doing well.

Anyway there were numerous things that caused problems, not least there being no beds on labour ward- a recurrent problem. You'd think with a Labour government in power they'd at least get that sorted ;)

I don't know if you've ever been to Leeds General Infirmary but its main car park is a bloody nightmare. It is, without any doubt, the worst designed car park in the UK. The angles on the approach to the ramp to go up each floor that you have to swing out wide to get around them. Newcomers to the car park regularly get it wrong and have to do a sort of 3-point turn to get up each level. The worst thing though, is the 1foot thick concrete miniwalls up each ramp. It seems they have designed these to jut out and rip up your wheel arch as you try and navigate the turn.

I've caught my car on it and so has my wife. In fact if you look at each ramp wall you can see a multi-coloured smear of car paint that is a testament to the number of cars that have had their wheel arches ruined on those damned stupid wall ramps. If you, like I did, wander about and look at the rear driver side wheel arch of most of the staff cars in the car park I would estimate approx 25-30% have been torn up by that stupid-ass designed car park. Let that be a warning to you if you ever park at the main car park in the LGI. Drive a small car.

Ok the other thing that I really don't understand is why is hospital food so bloody shit? I've been to multiple hospitals in the past and I have yet to go in one where the food they serve the patients is nutritious, edible and tasty. An adult male requires 2500 calories per day, 2000 for a female. This is higher if you are ill, recovering from surgery or breast feeding. Quite how you are meant meet these requirements on hospital food alone I do not know.

I remember doing my medicine for the elderly job and regularly we'd prescribe fortsips (calorie and protein dense milkshakes) to compensate for the utterly shit food that was served to patients. Honestly if you served this food to prisoners there would be riots. But as its a bunch of old crumblies who can't complain who gives a shit right?

Its no better on the adult wards for medicine and surgery. The portion sizes are pathetic, any salad consists of limp lettuce and a slice of anaemic tomato. Bread is hard, white and cardboard like. Butter is frozen solid. Everything is reheated and alarmingly whatever the ingredients it contains it all seems to taste and smell the same once it comes out of the reheater. Its a fact that the LGI cannot cook any fresh food on the premises for patients.

Get this, it is prepared in Wales and the transported via lorry to the hospital where it is reheated and then served. God alone knows why this is. Carbon footprint be damned I guess. If the swine flu pandemic kicks off and lorry drivers go off sick then I've no idea how they'll get the food to the LGI. I very much doubt relatives will bring it into a hospital full of swine flu patients.

One of the starters on the menu they gave to my wife was Orange Juice. Since when has a drink been a starter?! Oh yes, I remember now, when I did Home Economics when I was 13!! WTF? It that wasn't bad enough one of the main courses was Gravy. Thats right. Gravy. It can't possibly be a bowel of gravy could it? We weren't brave (or foolish?) enough to order it to find out. Needless to say my wife had all sorts of nice food bought in by me to supplement/replace the bloody awful shite the LGI had the audacity to serve to their patients.

So, if ever you have to go to the LGI for to visit a patient then make sure you come in a small car ( or park elsewhere) and for God's sake bring them some decent food (not grapes!).

MPs are greedy cheating bastards. Who is not surprised?

Well well well! What a week! MPs expenses have been exposed by the Telegraph (after all the hard work was done by this person).

Its hard to know where to start! The government has been undertaking a smear campaign against GPs for the past 2-3 years. Finally we get our own back! I would say 98% of what was written about fatcat GPs was complete bullshit. They picked out a few high earning GPs and claimed we were all the same.

Now in parallel we have a variety of MPs who have been 'creative' with their expenses. Of course not all MPs have been misbehaving but they have been tarred with the same brush - much like we have eh?

What really grinds my gears is the complete lack of guilt the MPs have been showing. Ok, so the expenses system may have had very weak rules that could be bent so you could claim for all sorts of uncessary shit. You still have a moral obligation to do the right thing, to act 'honarably'. Just because you can claim for frivolous things that doesn't mean you should. Giving back the money just won't cut it. And as for the Speaker? He is responsible for overseeing all claims, if all these dodgy claims happened under his watch then he must take responsibilty for this. After all, if his expenses committee had done their job properly then none of these claims would have been approved.

My big worry is that this puts people off voting. If we don't vote then how can we change anything? If we don't vote your saying we don't care who gets in. If we don't vote then that mad racist homophobe down the road will and he'll vote in some equally racist homophobe.

Anyway, enough politics. Work has been ok this week. More partners working so thats helped. Practice manager wants me to help do the Pandemic flu planning and looking at workload issues. Should be interesting, said I'd only do it if he gives me some time off clinical sessions. I foresee we will be arguing about workload problems. Must make sure I read the BMA salaried contract and make sure we stick to that.

Just finished series 1 of The Wire. How cool is that series? Got series 2 and will start watching it with the wife when we get some time.

Anyone see the end of Heroes series 3 on TV the other night? What a heap of shit that series is turning into. Not sure I can be bothered to watch the next series.

Enough inane ramblings. Catch you later!

Tax is taxing thank you very much Adam Hart-Davies

After all my ranting last week I was taken off RAC (Rapid Access Clinic) at the last moment. Phew. Doing it on monday though. Bollox. Honestly the rota at work is so borked its unbelievable. Its my understanding that a session of work for a salaried GP is taken to be 4hrs 10mins according to the BMA. That includes paperwork, visits etc... Well we seem to have so many urgent extras that our morning clinic now finishes at 12-1230. That leaves 10-20mins to do visits (normally 2-3 @ 20mins each at least) + any paperwork (referrals, form filling, letter reading, checking results etc).

I honestly have no idea how we are meant to do all this. Its not only me whos getting backed up on the paperwork front. Its fine for the partners to pop in on their day off or stay late and catch up as thats whats being a partner is about - hence the fat paycheck they reward themselves. I know some of the salarieds stay late to catch up and they are slowly (or not so slowly) heading towards burnout. Its really fucked up. I'm glad I am leaving in December to go to Liverpool (part of wife's PICU training). If i wan't I think I'd leave where I am working anyway. I could rant about work all day but frankly I guess its boring to read. Still it helps me get things of my chest I suppose.

When I went into General Practice there was a shortfall in the number of Drs going into GP-land. So for a double edged promotion of sorts the government offered a golden hello (£6000 I think) + GP contracts were renegioated . Funding for GP's was altered and linked to Quality Outcomes Framework (essentially points for reaching certain clinical and managerial targets), in addition GPs no longer had to do Out-of-hours (OOH) cover (for a £6000 pay cut).

So when I went in things were looking rosey. I got a golden hello, no OOH cover and pay for GPs was going up. An unforseen (perhaps) consequence of the new funding arrangement was that it was financially better for a GP partner to hire a salaried GP rather than take on another partner in the business. For example - new partner = £120k reduction in profits, salaried GP = £70k reduction in profits, remaining profit to be split between existing partners.

In addition the government did a spectacular U-turn on the OOH cover, demanding that GPs cover from 8-8pm (even though there was v.little demand from the public for this), for no extra funding.

So now I find myself stuck in a target driven GP-land with fatcat GP partners making the salaried GPs do the donkey work and potentially having to do OOH again. Brilliant. Not only this but the government seriously fucked up hospital Dr training (MTAS) with the result that hospital Drs have had their careers ruined as well.

Labour have majorly fucked up the NHS in a HUGE way. I know of no doctor anywhere who will be voting Labour in the next election.

Well thats all the ranting out of the way. Whats that got to do with the title? Absolutely nothing. Whats happened is that I have been on basic tax rate for my GP specialist work meaning I owe the tax man over £3000. Quite how this has happened I do not know as I spoke to him in Jan after getting a massive tax bill then too and he didn't spot anything. Doing Tax returns, even online is tedious and painful, especially when you get stung for a huge tax bill.