Now that the tree is down and the last traces of chocolates, pine needles and wrapping paper have finally gone, did you ever find yourself a little short of breath over the Christmas period?  It can all get a bit much what with all the shopping to be done, running around after the kids and visitors to entertain.  Easily put down to being a bit out of shape perhaps?

What if you’ve got a bit of a cough that won’t clear up?  It won’t stay away although you’re doing all the right things to get better.  You already know smoking is bad for you and you don’t need anyone else telling you that.  Perhaps you stopped hearing all those people telling you that you ought to give up years ago anyway.  Everyone at work has been nagging you to do something about that persistent cough you’ve got though.

The truth is that for some of us, our old habits are beginning to catch up with us.  If you’ve smoked for much of your life you might find that your cough is actually the first signs of a disease called COPD (what used to be called emphysema).  This is a disease where the passageways in the lungs become too narrow, making it more difficult to breathe in and out.  It leaves you feeling short of breath and anxious.  If the disease gets worse you might end up needing to breathe oxygen using a facemask, barely able to leave home.  Sadly for too many, COPD proves fatal.

In our area COPD is getting more common, particularly if you are a woman.  COPD used to be a disease that mainly affected men, because men smoked more than women.  But in the 1970s greater numbers of women started to take up smoking just when the number of men who smoking began to decline.  In England smoking reached its peak in the late 1980s and has been declining ever since.  Now less than 1 in 5 people smoke and its falling all the time. 

More and more women are being admitted to hospital with COPD and severe breathing problems after a lifetime of smoking.  The number of women in their 50s and 60s in hospital with these problems has more than doubled in just 3 years and for the first time last year more women than men ended up in hospital because of COPD.

In the Great Yarmouth and Waveney area there are about 7,000 people with this disease but only about 4,000 of them have been diagnosed by their doctor.

The good news is that if you have the early signs of COPD you can stop the disease getting worse by stopping smoking.  Most people find it hard to give up but every year thousands do.  Your chances of quitting are four times higher with free help from the NHS Stop Smoking Service – and if you’ve tried before and failed to quit you can keep coming back for help.

If you haven’t been diagnosed yet then your doctor can’t start to help you.  So get that cough checked and think if it’s time smoking is an old habit you can live without.

For free help to stop smoking you can call 0800 022 4332 to talk to an advisor now or text QUIT to 65000.

It’s all a bit odd isn’t it? On one hand we hear ever more scary news from the world and national economies; on the other, the shops are full of all manner of luxuries, all with enticing red labels, encouraging us to buy more than we know we need. “Buy one get one half price” “BOGOF” “reduced” – it’s all the same – I don’t save money by buying what I don’t need, irrespective of how good a deal is on offer!

It’s even more striking in the context of the reason for the festivities in the first place. As a (not very good) follower of Jesus, I think that this special time, and the ancient story of his birth has much to tell us (even in the NHS!). And it’s in stark contrast to what we see around us.

Firstly, the tradition of Christmas tells us about an all-powerful being choosing to become small and weak and vulnerable so that we could understand and relate to the love that God has for us. Downsizing, not “living it large”.

Secondly, the story shows us not how important celebrity, wealth or power is but how important it was that Jesus should taste the life of the lowest and most marginalised in society. The disadvantaged first not last, the marginalised at the center.

Thirdly all through the nativity narrative we see glimpses of a deeper story – why give embalming spices to a new-born baby? The purpose of Christmas was not for Jesus to be frozen for evermore on the front of a card, or in primary school tableau.  The ancient narratives take the story on, to a much darker ending - one which we are far less comfortable with. Sacrifice – giving of self, for others.

As we enter ever more threatening financial times, there will be difficult decisions ahead about services. What can we afford, what can’t we? These choices face many of us personally right now – many of us are shrinking the excesses of Christmastide already, and this is good – here’s hoping there are fewer admissions to A&E post-party this year! But overall, we will need to shrink our expectations and accept that the NHS will do less for us. We can’t afford luxury. We need to downsize, to shrink. To focus on what is really important.

As we do this, we would do well to reflect the priorities the story of Christmas shows us. We should seek to narrow inequities, to prioritise those most vulnerable within our communities; put the marginalised at the centre.

And this should bring us back to the core of the NHS. It’s not for us. It’s for them. It is systematised sacrifice, communal compassion, generic goodwill. It’s a part of the underpinning fabric of our society that we do ill to erode via individualism and selfishness. I believe this means that we may all need to make personal sacrifices as we see the NHS focus on what may not be personally important to us right now. So rather than a culture of entitlement – “I’ve paid my dues all my life, the system owes it to me” we should cultivate an attitude of altruism; a readiness to put aside what I want, in favour of what others need.

As we “consume” healthcare at this festive season and beyond, these principles have much to teach us – both as a health and social care system, but more importantly as individuals making choices about what we do and how much of it; about how and when we use services, and about the underpinning philosophy that keeps the NHS going.

Happy Christmas!

The weather has turned, the surgery is filled with coughs and colds and we are getting as many people in as possible to have their ‘flu jabs’.

This year in our surgery we have had a good uptake.  With a practice size of around 11000 patients we have about 3400 that are considered ‘at risk’ and we will have immunised about 2500. That’s a bit over 70% and is in line with both the average for England and for our PCT.

It is an organisational nightmare; every year we ponder over how we will get them all done. We have to do most of them in big batches and invite lots of people at a time.  We try and give everyone a set time but inevitably lots of people all come together and then a queue builds up; some people complain, some even go away again but we do our best to see everyone as fast as possible.  We hope for a dry sunny day; wet and windy keeps people away.  I remember the worst year was when we ran out because although we had been promised a delivery it did not materialise; the supply chain seems to be better nowadays and hopefully that will never happen again.

You might ask why we put ourselves through this.  The annual seasonal flu vaccine protects people over 65, those who have long term medical conditions and pregnant women, against the strains of influenza virus that are likely to be circulating during the next winter flu season.

Flu is much more than a bad cold. It’s a virus which can make even healthy people feel very unwell for a week or more. In the most serious cases it can even lead to pneumonia, or other serious infections which can, in extreme cases, result in death

Flu is often spread through the air by coughs and sneezes. It can also be caught by coming into contact with contaminated surfaces.  General tips to help avoid spreading germs to others and avoid picking them up yourself include; always carrying tissues, covering your mouth and using a tissue when coughing and sneezing, disposing of the tissue after one use, and washing your hands as soon and as often as you can.  It’s also important to clean surfaces regularly to get rid of germs

Flu is much more serious than you may think. If you are 65 or over, have certain long term medical conditions or are pregnant, you are especially at risk of developing serious complications as a result of flu, therefore you are eligible for a free seasonal flu jab, and this is the most effective way to guard against potentially life-threatening consequences of contracting flu.

Conditions and diseases which can make flu much more dangerous include:

• heart disease
• chest complaints or breathing difficulties including bronchitis, emphysema or asthma
• chronic kidney failure
• cystic fibrosis
• lowered immunity due to disease or treatment (such as steroid medication or cancer treatment -chemotherapy or radiotherapy)
• HIV infection
• liver problems such as cirrhosis or hepatitis
• if you have had a stroke or a transient ischaemic attack (TIA)
• diabetes
• a neurological condition e.g. multiple sclerosis (MS) or cerebral palsy
• a problem with, or removal of, your spleen eg sickle cell disease.

If you are pregnant, you are at greater risk of complications from the flu.  Having the vaccine now could help you avoid catching the flu and protect your baby.  If you have children aged six months or over who suffer from any of the conditions above, they should be vaccinated too.

Anyone undergoing chemotherapy or radiotherapy treatment should also get vaccinated.  You should also have the seasonal flu vaccination if you live in a residential or nursing home, or are the main carer for an older or disabled person.

Each GP practice tries to keep an up to date list of those eligible and will normally invite them in or at least publicise when to arrange to come for vaccination.

Every year there are people who complain about the flu jab making them ill and how they will never have it again; please reconsider!

Vaccines contain either a greatly weakened form of the bacterium or virus that causes a disease, or a small part of it.  When the body detects the contents of the vaccine its immune system will be primed to make the antibodies (substances that fight off infection and disease) required to fight off the infection.

Before a vaccine is put into general use it has to be licensed. In order to be granted a licence, the manufacturers have to demonstrate its quality, safety and efficacy in preventing the particular disease for which it is intended.

The seasonal flu vaccine contains inactive flu viruses. This means the viruses cannot reproduce and cannot give you flu, but your body’s immune system can recognise the virus and will be able to fight it if you are infected over the winter. The vaccine takes around ten days to work and will protect you against three strains of seasonal flu, including swine flu, for around a year. You have to get vaccinated annually, because the virus continually changes and develops new strains. This means that last year’s vaccine may not protect you from this year’s flu virus.

Some people get a slight temperature and aching muscles for a couple of days after having the seasonal flu vaccine and your arm may feel a bit sore where you were injected.  This can be a sign your immune system is responding and the vaccine is working.  Any other side effects are rare and are minor compared with the risks associated with seasonal flu.

As with any vaccine, it does not give 100% protection.  Flu vaccines have been shown to prevent confirmed influenza in between 70% to 90% of healthy adults.  However, the effectiveness of a vaccine will depend on how well it matches with the strains of flu that are circulating.  The vaccine protects against the three strains experts believe are most likely to be common this winter and is the most effective way to protect yourself against the serious complications of flu. This year’s vaccine also provides protection against swine flu so most people will only need one jab.

But remember!  The seasonal flu vaccination will not protect you against the common cold or other winter viruses.  There are still lots of people who do not want a flu jab and once we know we try not to worry them again about it but please, if you are of those who are invited when you don’t want to be, remember we are trying our best to make sure people don’t miss out.

There are a few people who cannot have it. If you have serious allergy to eggs (and I do not just mean you do not like them as one elderly lady in a residential home said to me when I asked about allergies!) you should not have them.  

The seasonal flu vaccine can be given at the same time as the routine childhood vaccines and at the same time as pneumococcal vaccine.  The vaccination should be delayed if you or your child has a fever, but it can be given if they have a minor illness such as a cold.

So if you are eligible and you’ve missed out or have changed your mind please contact your GP surgery as soon as possible.

I’ve got the week off this week and loads of outdoor activities were planned. Now the weather’s started to change, I’m not so sure canoeing and tennis will be quite so much fun in the cold and rain!

It’s not just our leisure time that can be affected by the weather. Lots of people with long term health conditions know that their health varies with the seasons too. We need to do all we can to look after ourselves and get ourselves set for the winter months ahead. Certainly we’re trying to help people with that in the surgery. The seasonal flu jab campaign is in full swing, and thankfully, many of our eligible patients have taken the offer of a flu jab up. If you are over 65, or have a long term health condition, then you should do the same. If you aren’t sure whether you are in an eligible group for a flu jab, check with your surgery – they’ll be able to help.

If you’re overdue a check-up for your chronic bronchitis, heart trouble, asthma or diabetes it might be a good time to make sure you’re in good shape before the winter really bites. Your practice nurse should be able to help.

The changing seasons bring colder weather too, and that means we should all make sure we keep warm. If you’re elderly or unwell, being cold often leads to greater health problems so it’s important to do what we can to avoid that. I know that fuel costs are always rising, but do try to heat just a couple of rooms and remember to wear lots of layers to keep you warm – the alternative may be an illness or a stay in hospital.

 All in all it’s a good time to take the opportunity to get ready for the coming winter. It’s much better to avoid a flare up of a problem that to have to cope with one when it happens. That’s why a flu jab, keeping up to date with checkups and keeping warm are so important.

 When he was a Junior Hospital Doctor he scoffed at his more senior colleagues who would prescribe cocdamol, tramadol and morphine to a patient ( a bit like putting HP, curry and tomato sauce on your chips – it does nothing to improve the overall effect but will almost certainly make you feel sick). So throughout his career he has been confident in the knowledge that his prescribing of painkilling medication has been according to the textbook, or as close as he can get it. He has tried his upmost and listened to his patients with care and empathised where appropriate.

 During his life Dr Blog has been pretty much painfree. He remembers one particularly painful blow to his nose during a rugby match but now with the benefit of hindsight feels this was more a dent to his pride having been caused by an old school friend. He had a hockey ball strike him on his hand from short range – that did hurt a bit and finally there was the time playing squash when he snapped his achilles tendon. Actually it wasn’t the injury but the physiotherapy that hurt that time! But you get the idea - apart from a handful of episodes and the odd sore throat, Dr Blog has had little need to receive the sort of painkiller advice he has been able to offer to his patients.

 So why raise this now you ask? Well for the past few weeks Dr Blog has had some pain. Not the acute type of pain described above and not enough to stop him doing everything, but an irritating, persistent, annoying type of pain. The sort of pain that when you wake up at 4am you can’t get back to sleep and so you try to take some painkillers which are in a blister pack which you can’t open because your hands hurt so you wake your wife up and before you know it they whole house is up at 4-30am sort of pain. It’s the sort of pain that leaves you with a feeling like when you buy a new car and drive it home only to find it has a scratch down the passenger door. Good days and bad days are distinguished not by what will happen or what you have planned but how your body feels when you wake in the morning and open your eyes for the first time.

 The good news is that by and large the medicines work, the more pain you have the stronger painkillers you need and there is almost invariably something that will help. The good news for Dr Blog is that he is on the road to recovery and is needing less and less of these. The other silver lining to this particular cloud for him is that he will be able to understand and truly empathise with his patients who are in pain. To add to his previous theoretical knowledge he now has a greater practical understanding, which he intends to use to the greatest benefit possible.

 My final points on this topic are to the patients and my colleagues. First to the patients, if you get the standard medical questions about pain – Where is it? What does it feel like? Is there any time of day that it is worst? Does it spread anywhere? Does anything make it better or worse? The answer them as well you can but try where possible to give your story on how it is affecting your life. For the clinicians remember to ask the patient how it is affecting them and give them space for the answer - and if you are going to prescribe those tiny 15mg codeine tablets please remind them to pop a couple out of the blister pack before they go to sleep!

I did not expect to be paddling happily in the North Sea whilst watching my son throwing himself into the waves - in the first weekend in October! It has been fantastic to have summer appear over the past few days – but something of a surprise! Sometimes we don’t get what we expect.

There have been two issues that have struck me in this way over the past few days – other than my very British obsession with the weather.

Firstly the good news. The Out of Hours GP service has changed. It’s now being run by a different organisation, a not-for-profit group already successfully running services elsewhere in England. And while a change in who runs a service sometimes causes chaos and disruption for patients, this one seems to have gone very smoothly. Speaking to the new team, I am impressed by their commitment to getting it right for the people of Great Yarmouth and Waveney. They know that the thing that counts is the quality of the service our population gets and seem genuinely keen to hear from locals – both NHS staff and the public – about how best to do this. I think this is really good news for our community – and is an unexpected and welcome surprise. I’m looking forward to working with them and to seeing their high standards and aspirations translate into real on the ground improvements for all of us living in the area.

But we have had an unwelcome surprise too. This week the CQC published their report into standards of care at the James Paget Hospital – our local hospital for most people in the patch. They have written formally to the Paget raising significant concerns – recognizing some recent improvement too – and asking for a clear plan to get it right. They will no doubt be back soon to check that their concerns have been sorted out. This is an unwelcome surprise for many of us. Unwelcome for obvious reasons, but a surprise because let’s face it, we know who the James Paget are. They are not some faceless organization. They are our spouses, our neighbours, sisters, mates. We know the hardworking people from our communities, who care for the sickest among us in the James Paget, and they are good people – they don’t go to work to do a bad job. We know this because we know them.

So how did this happen? I guess that there must be a hundred and one answers, because complex organisations like a hospital are – well – complex! But in a time like this we as a community look to their leaders to help the James Paget get it right first time every time from now on. And I know they will do this, because I know they are passionate about the quality of care they deliver. They know what the stakes are in real human terms, they get it. So while winter will hit us all too soon, some changes are to be welcomed. I look forward in the near future to hearing that the CQC have passed the Paget with flying colours. I know the Paget will do this for our community because they are a part of it – both the frontline staff and the top leadership – they are a part of us, they know they serve us, and I’m sure they will not let us down again. We know this, because we know them. Support them, encourage them, tell them what the Paget means to you – they want it good just as much as you do. Let’s make it better.

The latest information shows that 93% of children will have had their MMR jab before their second birthday.  This is the highest uptake for many years.  Staff in GP practices have renewed their enthusiasm for encouraging parents to protect their children by getting them immunised and in some practices, 100% of children are protected.

We have recently launched new posters and leaflets encouraging the MMR jab.  As a reminder, children need two doses of MMR.  The first dose at one year of age, and the second from the age of three.

The newspapers both national and local are full of ‘news’ about cost cutting in all areas of public expense. Often in order to make them newsworthy they are made to appear sensational. But the sad fact is that the NHS does not have unlimited resources and we all have a duty to our local health economy to use our resources with care.

The current financial climate requires all healthcare systems to find ways of controlling costs without cutting quality of care.  Did you know that every Trust is under a legal obligation to break even at the end of each financial year? Legally prohibited to go over budget, it must balance the clinical effectiveness of treatments with cost considerations. The money withheld from one patient or group of patients will be spent on another.

There are several areas where there is the potential for conflicting viewpoints. As a practising GP and also with clinical responsibilities on behalf of the PCT I get to see most of these.

Some of you reading this will be in discussion with your GP about the medicines prescribed for you. You might be asked to swap to a cheaper but equally effective preparation (perhaps standard release rather than modified release) or even drug (of the same type and doing the same thing) or you might be asked to stop a drug to see if you need it or can do without it (perhaps a sleeping tablet). None of these recommendations are made without lots of evidence that they are safe and effective and although they may in part be cost related, some will be primarily safety related ( sleeping tablets can cause some people especially those of who are older to feel drowsy or fall over in the daytime). Or you might be refused the only drug now available for weight loss, which is rarely taken properly, and has been calculated to cost £7000 per 1lb lost!

Others may be asking your GP to refer you for things that get better eventually without any treatment (such as warts and verrucas), things not funded at all (such as varicose veins or lumps that are purely cosmetic and not causing any harm). Then there are conditions such as recurrent tonsillitis where there is little proven benefit in acting early but where intervention in the form of tonsillectomy, which inevitably runs some risk, should be viewed more as a last resort. Sometimes unusual requests are sent for consideration by an ‘exceptions’ panel. One such case in another PCT caused the headline of ‘Dying grandfather denied stomach op’ in one national newspaper which decided to be sensational rather than be truthful and accept that the PCT in question had acted entirely appropriately and fairly for all its population. A Trust’s policy on whether a case is exceptional ignores social factors such as age, sex and parental status. Only clinical factors are considered or else the Trust runs the risk of being discriminatory and unethical. I would argue that the newspaper, instead of knocking the PCT, should itself have acted ethically and applauded the PCT for being fair to all and staying within its resources.

Long term care for the elderly and frail is another area of conflict. Unfortunately in England we are not in same position as Scotland where all care is state funded. In England instead we have something called NHS Continuing Care where people are assessed against a national framework to see if their needs are primarily of a social nature (such as help with feeding, medicines, mobility, safety etc) or mainly medical(such as severe behaviour problems, major problems following a stroke etc). Unfortunately relatives and sometimes fellow health professionals fail to understand the fairness for all of following the framework and the assessors acting in a professional manner. The reality is that the NHS cannot afford to provide free care for all. Or not at least if we want to continue to have local A&E services, counselling, palliative care, community nurses and all the other services that we all value. So instead we have to provide care where it is most warranted.

And don’t think this will all change when GPs assume responsibility for commissioning services over the next couple of seasons. The constraints will not change, only the blame when things go wrong or cannot be done will be shifted.

But I don’t want to end on a sour note as I am genuinely hopeful; that we can all act responsibly and maintain and improve our local health service despite the difficulties ahead.

I suppose this is a bit of a plea to all of us locally, both patients and fellow clinicians. Please let’s all work together to protect our services and make them work as well as possible.

I have children and although I am a doctor I am a dad too, and they expect to spend some time with me over the holiday period. My partners are in a similar situation and they too like some time off during the summer holidays, this means that as a practice we generally have fewer clinics each day than we would normally have. At the same time we are suddenly looking after lots more people. We manage these conflicting priorities by performing routine health checks and reviews at other times of the year, and this works well for us and our patients. But despite this the day to day workload is much less predictable during the holiday period than the rest of the year so it is a busy time for us all.

So please have patience, with the receptionists, understand that these holiday makers bring benefits but also need to use our services and understand why your diabetic or high blood pressure check is made for September when normal service is resumed.

The sun can really damage our skin, and getting burnt increases the risk.  Children are at the most vulnerable and it’s important that we protect them. Sunburn in childhood is one of the biggest risk factors for developing skin cancer later in life.  Kids need plenty of time in the shade as well as frequently applied high factor sunscreen (50+). These days, the advice is that no one should be using sunscreen less than factor 15. The days of factor 2 frying oil should be well and truly over.

When I was training, I spent some time working in Australia, and believe me, that experience really makes you think about the damage the sun can do.  I saw lots of skin cancers of various types, as well as lots of people whose skin looked ancient and leathery. In Australia they have a long running campaign to get people to be safe and sensible in the sun. The TV ads are a bit annoying, with a catchy jingle, but the message is getting through. Australians are much better at caring for their skins than they used to be. We could learn from their example.

The message in their campaign goes like this – Slip, Slop, Slap.

It stands for Slip on a shirt, Slop on sunscreen and Slap on a hat.

It sounds a bit daft and if, like me, you’ve ever watched Australian telly, that tune will be driving you mad playing in your head as you read this, but the advice is really important. A tan might last for a few weeks, but at the end of the day it isn’t worth dying for – and do you really want to look like Dale Winton?

When I was 16, I remember distinctly visiting my grandmother one day and being really surprised. She was normally a really happy-go lucky lady who took everything in her stride and smiled through all sorts of disasters. She had to, she had brought up 10 children during and after the war, had lost a baby due to spina-bifida and had struggled to make ends meet. But she smiled through everything and I loved her. Today was different, I had never seen her angry and about such a little thing, I can't even remember what had upset her.

She was an accomplished cook and I still use her recipes for steamed treacle sponges. So a few months later I remember the family laughing when my aunty told us how my grandmother had tried to cook a trifle in the oven. Then she moved to live with my aunty in Ipswich and there was the time when she put on her Salvation Army uniform and went to chat to the girls in Derby Road. The only problem was she was 85 and it was 2 in the morning. Fortunately she was given a lift home by a very understanding policeman. My aunty looked after her tremendously but eventually there came a time when she needed more support than she could provide. My last memories of her were when she was in a nursing home, well cared for and now happy again but completely unaware of anything or pretty much anybody around. She died peacefully of a chest infection.

Now I can look back with the knowledge I have acquired and know that she suffered from dementia. Sometimes, as in her case the early stages can be personality changes. Other times people can say or do inappropriate things and of course there is the symptom everyone thinks of, which is memory loss. Now, unlike when my grandmother was alive, there are drugs which can help a little with some of the symptoms. However, the main priorities remain to keep patients supported and safe - first of all in their own home, and then in a more supportive environment as their needs change.

When I left medical school all those years ago, there were a relatively small number of new medicines. Statins, Prozac and expensive antibiotics were not even twinkles in a drug company’s eye. The ‘British National Formulary’ was a small hardback book that we carried in our white coats and was replaced every five years or so. Now it’s a much larger paperback that would not fit in my coat pocket (even if white coats had not been outlawed) and which is also available electronically on my desktop and is updated every six months.

With this explosion of medicines come all sorts of problems both for the professional, for our patients and for the NHS as a whole. Do I prescribe and if so what?  Do patients want it and will they take it anyway? Will it do more harm than good, how much will it cost and can we afford it?

The ‘drug bill’ for NHS Great Yarmouth and Waveney (NHS GYW) is around £38 million pounds per year; of this a staggering £2 million is estimated as being wasted on medicines which are ordered but not taken and that’s before we start arguing about the evidence for giving various medicines such as antibiotics, antidepressants and sleeping tablets inappropriately.

My pharmacist colleagues at NHS Great Yarmouth and Waveney recently came across one patient who had amassed £1600 worth of medicines that were never used.  And before we all say it would never happen to us I checked my mother-in-law’s tablet box and found the calcium tablets which she didn’t like, the blood pressure tablets that made her ankles swell and the thyroid tablets that she had over ordered because they were on the prescription and she just ticked all the boxes. We all know of the relative who stores up painkillers because ‘the doctor gives them’ but are not actually needed. They are there ‘just in case’ or for other family members. None of these unwanted medicines can be reused. Please take them back to the pharmacy for safety but remember also that they have to be destroyed by law.

So what can we do? If you have a regular prescription from the doctor, only order what you need; or to use a catchphrase “don’t be a hoarder, don’t over order!”

If you have been prescribed a medicine that you don’t want to take - tell your doctor! He or she won’t shout at you. They need to know. If you really feel you can’t tell the doctor then talk to your pharmacist. Remember pharmacists are experts in medicines; they spend four years at university learning only about medicines while we doctors have to learn a bit about everything in our five years.  And you can decide with your doctor whether you should have that medicine in the first place!

And one final word (or two); when your doctor or nurse suggests you don’t have an antibiotic today or perhaps you should try without the sleeping tablet it is not for their personal gain but they are thinking about your safety and the cost to all of us.

There has been quite a bit of controversy this week about the BBC showing a dying man’s final moments on television. During the course of the Inside the Human Body programme, we met a man called Gerald, saw him talk about his life and his family and then watched as he became steadily more unwell and then died.

To many people, showing this on television is very shocking – it’s not an easy thing to think about. As a doctor, I found it really inspiring. Let me explain why.

It was clear that Gerald had a really good death. I know that that sounds like an odd thing to say but bear with me. He died in his own bed at home, surrounded by his loving family and friends. He wasn’t in any pain and he slipped away peacefully. That will suit me nicely when the time comes, and as a doctor, that’s just what I’d like to be able to help my patients have as well, when their times come.

Sadly, at the moment, we’re not as good as we’d like to be at achieving this aim. Too many people, especially in our area, die in hospital. What’s wrong with that? Well, think about what a hospital is like. Bright lights, noise, little privacy, staff who are busy with lots of patients to look after. It’s not the sort of place for a quiet, dignified, calm death. I’m not criticizing the hospital – it does a great job, it’s just a different job. It’s not set up to help people have a “good death.”

So, how do we change the situation? Well, a death like Gerald’s doesn’t just happen. It’s all in the planning. We need to be better at realizing what patients are going to need and making sure it’s there ready when they need it.  We need to help their carers to know what to do when their condition progresses and provide them with the right support.

There are improvements coming that will really help people to be looked after at home in their final days and weeks.  In future, GPs, district nurses, specialists in the care of the dying, social services and some of our local charity organisations will be working more closely together to put the right plans in place. There will be extra training for health professionals to improve their skills. There will be much more information and support for patients and carers too.

All of this is great, but we need to remember the most important person in all of this, and that is the patient. We need patients’ help to give them the death that they want. We all need to talk about our deaths when the time comes. That’s with our doctors, our nurses and often most importantly our families. With the service improvements that are coming and the input of our patients, we will be able to help many more people have a good death. Like Gerald’s.

Some of us like changes, and others don’t – and change is a big issue in the NHS at the moment. Say what you will about the politics behind the changes, they will mean things feel different for us all. Patient or practice nurse, general public or general practitioner, it’s going to be a different world – and one where money will be tighter.

But here’s the thing. Change is also an opportunity. My son builds the model he needs to – today. Tomorrow, it may look different. While NHS services can’t and shouldn’t change at that pace, we need to try to seize the moment and make the best of it for our population here in Great Yarmouth and Waveney. Clinicians getting more involved in leading and organising services might mean that there are changes for the better. I hope so.

So let me give an example. I’ve been thinking a lot about falling recently. Falls are upsetting and dangerous for elderly patients. Dangerous especially if bones get broken. A broken hip is the commonest serious consequence of a fall, and for some, it is a life changing event – 1 in 5 who break a hip will enter a care home; 1 in 10 will die within a month of their fracture. If we could alter this, we would benefit patients, AND reduce NHS costs.

Could we? Yes. Many of these patients have had a previous fall. Some have broken other bones as well. And there are effective medicines that can help strengthen weakening bones, meaning those who do fall are less likely to break themselves, and more likely to bounce. If we treated these first fallers or first fractures right, more serious falls might be averted, and more major harm prevented in terms of breakages. But to do this would mean all those involved in the care of those who fall working together and taking responsibility for not just treating today, but thinking of our patient’s tomorrows as well. Making sure we spot those where the proverbial stitch in time will save suffering, disability, and in 1 in 10 – lives.

This embodies some of the changes that we feel are so important for our whole health system, here in Great Yarmouth and Waveney. Moving from reactive care to pro-active care - preventing harm rather than treating it when it occurs. Taking personal responsibility for championing the highest possible quality of care. Working together – integration – across all the different organisations in contact with our population – be it ambulance crews, carers, neighbours, family, district nurses, podiatrists, physios, A+E staff, GPs. This ought to be what clinicians leading health care is about. We’ve got a long way to go, but the building blocks are in place. Lets build something great together!

Then I thought about why it doesn’t happen for lots of people now? Sometimes it is because we just don’t think ahead, what do we want for ourselves, or our loved ones especially if they are ill? A few years ago I certainly discussed it with my Dad’s GP in the weeks before his death – but then I knew what to do and who to speak to. My sisters said afterwards that caring for our dad at home was really rewarding and helped them cope with losing him. They said they would have felt scared if I hadn’t have known what to do.

We all find it difficult to talk about death and dying but if we do it can really help. There is lots of help on hand so you never have to be left alone and charities like Marie Curie even provide nurses to be with you overnight if you need support. So don’t be afraid, if you are a patient or relative speak to your GP or practice nurse and they can chat about the options and begin planning to provide the care you would wish for.

Obesity and overweight is so common that Prof Mary Rudolf, who advises the Government on childhood obesity, has found that parents do not always recognise or accept that their child is obese. This is because they are comparing their child with others in the same class. She points out that a healthy ten-year-old’s rib should be clearly visible – but many parents would consider that such a child was quite underweight.

In addition, the average local adult is overweight, and this also means that an average adult could consider themselves as “normal” even though they are overweight and at high risk of developing conditions such as diabetes.

Our NHS HeathCheck programme will identify overweight adults and can offer them advice and support for losing weight.

We are developing a new obesity service for children across Great Yarmouth and Waveney. I’ll keep you updated.

We have a range of weight-management courses available for children, teenagers and adults. All are free:

• LIFE4LIFE is a four week course aimed at maintaining a healthy weight. Diet and basic nutrition are covered in the classes. For more information call the Community Nutrition team on 01493 852200 or text FOOD to 65000.
• Fire, Fighting, Fit offers teenagers from 13 to 17 the chance to find out how to keep fit and eat healthily by a bunch of firefighters. The eight sessions are free and held at Lowestoft South Community Fire Station. You’ll be kitted out in firefighting gear and literally learn the ropes. Anyone interested can find out more by calling 01493 852207, text FIREFIT to 65000 or email gyw-pct.healthyhappykids@nhs.net
• Families with children aged 7 – 13 who may be above their ideal weight can sign up for MEND sessions. MEND, standing for Mind, Exercise, Nutrition, Do It!, offers a free 10-week course for families in how to live more healthily. For more information call Steph Edrich on 01493 852207, email steph.edrich@nhs.netor visit main national website at www.mendprogramme.org
• Families with children under five can gain useful tips on how to feed and entertain their youngsters through the HENRY sessions. The free eight-week course offers easy-to-understand advice on healthy meals, keeping your family active through easy and cheap games, as well as tips on how to get youngsters eating their greens and choosing healthy snacks. For more information call Lisa Lorenzen on 01493 852200 or go to www.henry.org.uk

Although it's not very festive I thought I'd tell you about a project we have been working with the University of Newcastle to understand the reluctance of some women to have a cervical cancer screen. Not many years ago, the uptake of screening across the area was universally high. However, in more recent years, uptake has fallen in the urban areas of Great Yarmouth and Lowestoft.

Part of the work has been to speak to women who don't like going for cervical screening tests (we're not supposed to call them smears anymore) or even women who don't go at all.  Focus groups were held and four types of women were identified: "Inexperienced First Timer", "Reluctant Trier", "Grateful Promoter", "Hostile Agressor".

The researchers have explored how practice staff can identify and relate to women in these groups and how they can better support them in their choice.  They have developed training materials for staff and a new leaflet for women in a "chat mag" style. This is being tested at the Nelson Medical Practice in Great Yarmouth and will be rolled out to other practices over the coming months.  It's a really interesting project and hopefully will encourage more women to feel comfortable going for this life-saving test.

I suppose to make this festive I could say go for your cervical screening test.

See you in the New Year.

Whilst some may doubt that volunteering can fully replace the local authority services that are currently being proposed for cutbacks, there is no doubt that volunteering already performs a valuable role in current services.

NHS Great Yarmouth and Waveney funds a "Health Walks" programme. This identifies and trains walk leaders (who are the volunteers). These then organise a number of walks in their area.

This is a very cost-effective investment for the health service. For every £1 spent on the health walks programme - it saves the NHS £7.18.

However, given the need to make cutbacks - will we even be able to afford cost-effective preventive programmes? Norfolk County Council is already proposing to cut their contribution to the health walks programme.

It is a worrying fact that 14% of our community’s burden of ill health and disease (and 8% of deaths) is caused by too much alcohol consumption.

We have noticed locally that hospital admissions due to alcohol are high and rising fast.

Astonishingly, we have calculated that we are spending £8.5m annually on alcohol-related admissions to hospital across NHS Great Yarmouth and Waveney. In Nelson ward – that amounts to £400,000 each year for just that small area of Great Yarmouth.

Digging deeper into the statistics, we have identified two distinct groups of excessive drinkers. The individuals who are personally at greatest risk of admission to hospital live in the more prosperous rural parts of our area, but this is a relatively small number of people. These individuals are not “binge drinkers”, but drink regularly and at rates which are harmful to health in the long term.

However, the areas with the highest rates of hospital admission are the deprived urban areas – and these tend to be the areas where we find “binge drinkers”.  Clearly different approaches are needed to help these two distinct groups moderate their alcohol consumption.

So what we've done here in Great Yarmouth and Waveney is set up a working group from the local councils, police, voluntary agencies and the health service to work out how we can address this growing and expensive problem.  We're on it and I'll keep you posted about how it goes.