Merry Christmas and Happy New Year

The staff at the Strachur Medical Practice would like to wish all of our patients a very Merry Christmas and Happy New Year.

The surgery will be closed on Monday and Tuesday 26th and 27th of December 2006 and Monday and Tuesday 1st and 2nd of January 2007.

Dr Coull will be on call over Christmas and Dr Wright over New Year. In an emergency, you can contact us on 01369 860 224 as usual.

Hot drinks now available in the waiting room

The waiting room now has it's Flavia coffee/tea maker up and running. It's already popular, and patients can now make themselves freshly brewed coffee, tea, or hot chocolate from the dispenser.

Personally, I can't stand machines that make instant coffee/tea from freeze dried stuff. I think it tastes terrible. So, I've invested in a Flavia SB100, which I've seen used in some NHS hospitals, churches, and so on.

It is an excellent machine which makes fresh coffee/tea from individual brewing bags. It's a little more complicated to use at first, but I think the effort is worth it. There is an instruction leaflet explaining how to use the machine, but don't hesitate to ask for a demonstration.

We've also got real mugs, fresh milk, and napkins (as well as take away cups). And we're buying new leather chairs for the waiting room (a leather sofa is awaited as well for those who prefer to lounge while they wait).

A daily newspaper, and new copies of Top Gear, Gardeners' World, Empire, and Marie Claire are available on the coffee tables to read.

To help cover the running costs of the coffee machine, we do ask if you could put £1 in the honesty box when you make yourself a drink (the water cooler is, of course, still free).

If you have any comments or suggestions, please don't hesitate to let us know.

New coat of paint

As recent visitors will have noticed over the last week the painters have been in.

It's the first new coat of paint since the practice was built as far as I am aware (which is what? 15 years?).

Finally the waiting room no longer looks as if it has been the victim of a grenade attack, and the practice in general looks and smells clean and fresh.

There are still two rooms to paint - the dispensary and the reception area. These will be being painted this Wednesday and Thursday (the 4th and 5th of October 2006), and they will cause the most disruption, as we will have to remove all the shelving units from the dispensary (so if at all possible, try and avoid asking for or collecting repeat prescriptions on those days).

New dispensing hatch

We've got our new dispensing hatch in now. It looks great, and means that patients can deal direct with the dispensary when ordering/collecting prescriptions.

I'm hoping that Liz with say a few words about the new hatch, and if so I'll post them here.

Problems with the phone system

I think we finally have the phone system working properly.

It's been a bit of a nightmare getting the phones to work, and although most people will not have noticed, I know some patients had occasional problems getting through to us. This is something that we take very seriously, because of course we want patients to be able to contact us quickly and easily in case of an emergency.

The problem with the phone system that we inherited from Dr Basu was that it was an old system that our engineer could not service. The way the system was set up, all of the extensions rang when there was an incoming call, including an extension bell in the back garden. Apart from the fact that this must have been driving our neighbours crazy, it is disruptive to have the telephone ringing all the time in the consulting room when you have a patient with you. Also, as we had decided to close over lunch, we needed a bypass number so that the GP on duty could call still into the practice when the answering machine was on. We were unable to reprogram the old system, as it was too old for our engineer to service, and even something as simple as connecting an answering machine to the old system was a major problem.

The new phone system arrived and was installed by the engineers the week before I left for my paternity leave, and seemed to be working ok. However, one patient quickly pointed out that the bypass system we were using (which meant patients had to key in a number to get through to reception) did not work if you had an old pulse phone. This was quickly sorted by splitting the phone lines, but once BT had done this for us, we started to notice occasional problems with patients not being able to get through to us, or staff not being able to get an outside line.

We have had the engineers back out to reprogram the system, and it appears to be working well now.

Do please let us know straight away if you notice any problems with the phone system, and apologies for any inconvenience that the teething problems may have caused.

As always, should there be a medical emergency and you are unable to contact us for any reason, then don't delay - please dial 999 and ask for an ambulance. If possible send someone to try and find the doctor at the surgery in hours, or at Strachur House or Manse Gardens out of hours.

New addition to the family

I am delighted to announce that the Coull family have been blessed by the arrival of their second daughter, Annalise Rose Earnshaw Coull, who was born at 10.59pm on the 15th of July 2006 weighing 7lb and 6oz.

Out of Hours Cover

Strachur is over an hour from the nearest Accident and Emergency Department (Inverclyde or Paisley RAH(1)) and around 25 minutes from the nearest ambulances (Dunoon and Inveraray) and Minor Injuries Unit (Dunoon).

Currently we provide 24/7 emergency cover 365 days a year for anyone in the Strachur practice area (from the Rest and Be Thankful to half way down Loch Eck). The new GP contract allows GPs to 'opt out' of 24 hour cover, and currently the Strachur Medical Practice is one of the few GP practices in the UK that has not opted out.

The opt out has been popular with the vast majority of GPs because of the costs of providing 24hr cover. The cost of getting a locum doctor to cover the Strachur practice is between £1000 and £1750 for a weekend and between £100 and £400 for a night on call (£78,000 to £195,000 per year). But the Health Board only pays the practicE around £20,000 to provide the service, so a few bills for locums to provide weekends off and we end up making a loss!

The main problem with providing 24hr cover is not the number of calls that we receive. Unlike town or city practices we receive only a small number of out of hours calls and the vast majority of those calls are genuine emergencies. The problem is the nature of the on-call itself. Unlike an on call district nurse (we don't have one in Strachur), or most other on call jobs, the doctor is on call for life-threatening emergencies. In some cases, seconds can literally mean the difference between life and death for a seriously ill patient. I respond to such Category Red calls with a green light fitted to the car, and have special emergency training to deal with all types of medical emergency. This means that the car boot is full of emergency equipment (no room for shopping!), and I have to be careful when I have my wife and/or child in the car - emergency driving can mean sudden stops, which are not ideal for pregnant women and children, I can't just pitch up at a serious road accident and leave them in the car!(2).

The other main problem is communications. Pagers don't work in Strchur or the surrounding area(3), and mobile phone coverage is variable (I was really annoyed we missed the recent Bluegrass concert because there is no mobile reception in the Village Hall). To complicate matters, when I took over the practice I discovered that the phone system installed in the practice is so old that you can't use an answering machine with the practice phone line(4). So there is all the stress of worrying that people will actually be able to contact you when someone has a massive heart attack, or crashes their car into a tree. In my experience, the worst calls always happen when the mobile phones have gone down, or a power cut has knocked out your answering machine. The idea of one of my patients dying because I they could not contact me literally keeps me awake at night. And of course, there are no banks, cash machines or large shops in the practice area, A trip to Dunoon means constant worry about 'is the mobile working', 'how quickly can I get back to the car if I have to run', 'what will Ellie and Mirrie do if I have to abandon them?', and a trip to Ikea could lead to being struck off by the GMC for leaving my patients without adequate medical cover.

In some ways the stress is actually worse because genuine emergency calls are infrequent - emergency equipment is more likely to die unnoticed in the back of the car when it is only used once every couple of months than when it is in daily use. The same is true of emergency drugs going out of date, or batteries failing.

Having written all of the above, I'm asking myself why I would be stupid enough to continue to provide 24 hour cover! We have thought about dropping it, but of course we feel a duty to provide a safe service for the community and our patients. I don't think NHS 24 is a safe service that I can recommend to patients (more of that in a later blog), and I think Dunoon is a long way away to have the nearest doctor/ambulance if you are having a heart attack in Strachur. Besides, the Dunoon doctors are not very keen to cover Strachur, as they think it's a long way too. Plus, I've spent the last eight years doing this kind of on call, and I enjoy emergency work.

So, in an emergency call the practice number and a message will tell you which number to contact the doctor on (either myself, Dr Wright, or one of our locums). In case of dire emergency, if the phones fail, call an ambulance first, then send someone to look for us - either at Strachur House or Manse Gardens.



Notes:
(1) The Vale of Leven is about 45 minutes from Strachur by road, but has had its Accident and Emergency Department downgraded, and the ambulance crews now bypass the Vale to go to Paisley RAH.

(2) At a road accident, the first emergency vehicle on the scene parks in the 'fend off' position so that if any other car should crash into the scene, they hit the fend off car and not the rescuers working on the injured - not a safe place to leave a 2 year old or a pregnant woman.

(3) The old BT pagers used to work here I think, but BT has since shut down its pager network. The remaining networks (such as Vodafone paging) don't work in Strachur.

(4) The new PBX phone system is sitting in the practice and waiting for an engineer to come and instal it.


Photo: providing emergency cover with emergency BASICS vehicle in Kinlochbervie, October 2000

Appointment times

Up until now the Strachur Practice has had open surgeries. That is, the surgery times were 9 till 10.30 and 5 till 6, and anyone turning up between these hours could wait be seen in the order that they arrived.

Open surgeries are the traditional form of General Practice, and have the advantages of simplicity and ease of access. Basically, you turn up and you'll get seen...eventually. That's the disadvantage - you may need to wait a long time to be seen. Waits of over two (or even three) hours is not uncommon on busy days.

But, after eight years working in small remote practices, I'm acutely aware that the great fear of patients is that an appointment system will mean having to wait days or even weeks to see the doctor - a great problem for larger surgeries in cities and towns*.

Thankfully, there is another way to run small surgery appointment systems which combines the best of both worlds. I've set up four such systems in the past for Highland Health Board in remote practices similar to Strachur and they all worked very well.

The idea is that you phone the practice first to be told our best guess as to when you will be seen. This avoids the long waits and uncertainty, lets people plan their day better, and is great for people who have to get friends or family to bring them to the surgery.


Photo: The kind of queue we want to avoid

Of course, the appointment times are only estimates - medicine is complex, and sometimes we need to spend longer than average with patients, or there may be an emergency that can't wait, but the important thing is that you won't be turned away. If you need to be seen that day, then you will.

So, from now on call us before you leave to come down and we'll tell you what time to come down. If you want to arrange a time for later on (up to several weeks in advance) then let us know and we will give you one of several 'available in advance' appointment slots. If you prefer, come to the surgery as before, and we can tell you roughly when you will be seen, so you can go and do your shopping, or whatever else takes your fancy, in the meantime.

Of course, if you prefer the old system, you can still turn up and wait in the waiting room and catch up on the local gossip.




*In fact the larger city and town practices are getting much better at seeing patients sooner (not least because they now get paid a bonus for doing so in the new contract).

New Centrifuge arrives

Our new centrifuge arrived this week.

We had to pay for it ourselves (the Health Board does not fund them) and it cost us around £800, but it means that for the first time the practice will be able to do kidney function blood tests.

Kidney function blood tests (U+Es) are essential. They let you check on the salts in the blood that can be affected by medications such as water tablets (diuretics such as furosemide or bendrofluazide), blood pressure tablets (such as lisinopril). In extreme cases, if not monitored properly over months or years, changes to the potassium salt in the blood from some medications can lead to heart problems. This can include, rarely, sudden death.

Without a centrifuge to prepare the blood sample before it is sent to the lab, the sample spoils and the result is useless.

Now with the new centrifuge, we can get accurate blood test results no matter when the sample is taken. This will avoid the risks of salt imbalances in patients taking such medications.

If you are on blood pressure tablets and would like to check if you need a U+E blood test, please call the surgery to discuss your medication.

I take it all back

The manager from the Health Board Estates department came up to see us and could not have been more helpful this time.

The Health Board have authorised us to get in John Brown of Strone to do most of the work, and the Health Board will organise the rest.

So over the next few weeks we will be getting:

• the treatment room door (rotten) replaced


• dispensary shelving to store drugs


• new shelving for our notes (which were scattered all over the place)


• broken door locks replaced


• the sinks that didn't work fixed


• the toilet fixed


• the rusty railings repainted


• the rusty/damaged gates repaired and repainted


• the gate posts repainted


• the grounds repaired


• the parking spaces repainted, including adding a second disabled/parent and baby space at the front


• the rooms repainted

Of course, this will mean some disruption as we get around 16 years worth of maintenance work done in the space of a few weeks, but it will be well worth it in the end.

Health Board estates department not meeting its responsibilities?

One of the things that struck me most when I looked at the Strachur Practice before coming here was the poor state of repair of the health center building and grounds. The Health Center, Doctor's House, and grounds are all owned by the Health Board and the practice rents the building from them.

As has been mentioned in a previous post, the layout and design of the practice is poor. But much more worrying was the fact that there was no running water in the treatment room, and that the treatment room's external door was rotten the whole way through. Not only can you see daylight through the holes, with water pooling on the treatment room floor whenever it rains, but clearly it is not possible to maintain a clean clinical environment. It turns out that this was an internal door which was fitted externally, and that this problem had been ongoing for at least two years.

This breaks so many laws it's hard to know where to start - Health and Safety, Infection Control, and of course the legal responsibility on landlords to provide an watertight building.

Anyway, when we did our walk-round with the Health Board on the 14th of April, I pointed these out to the Estates Manager, Steve Bernard, who is responsible for the Health Center. I was assured that these issues would be dealt with by the 23rd of April. However, the Health Board's contractors failed to turn up on the 23rd as promised. Nor did they turn up on the 26th as was then promised. Phone calls to these contractors produced a series of 'no-one at home' type calls and unanswered messages. So, we have told the Health Board that we are engaging our own contractors to put these serious issues right, and that we will then bill the Health Board for the work.


Of course, these are just the most serious problems. We also have:

• outside 'security' lighting that doesn't work - I nearly fell and broke my neck leaving the practice after dark one night
• walls that are pockmarked and dirty - for a new tenant, the Health Board really should have repainted the premises, and I think that the current state of the practice is depressing and unprofessional
• gates, fences, walls and grounds that are unkempt, rusty and dilapidated - not only is this ugly, depressing and unprofessional, there are rusty sharp pieces of wire sticking out which could cause injury.

So, we are insisting that the Health Board tackle these issues rapidly too and will be giving them a deadline of two weeks after which we will commission our own contractors.

Argyll and Clyde Health Board had a very poor reputation, and in my experience and opinion (and, it would seem, that of the Scottish Executive), management incompetence was rife in the Health Board. Thankfully, Highland Health Board has now taken over responsibility for the area. Highland Health Board, as with any public body, has its problems, but is in my opinion one of the more competent Health Boards in Scotland. Certainly, the standard of the Health Center buildings in Highland area is very high.

So, hopefully, as Highland Health Board reforms the health services in the Argyll area, the standard of our buildings should improve to a more acceptable level.

Changes to the practice building

One of the first things patients will notice is the change to the practice premises.

As with any 'small business', GPs tend to run their practices differently depending on their own styles, and a new doctor taking over the practice is a bit like a new shop opening. Of course, we can't shut the 'shop' for a couple of weeks to allow refitting to take place, so the changes will take place between now and the beginning of May 2006.

Firstly we cleaned the practice premises, and disposed of any old or out of date equipment and stock. This took me around five days, with help from my wife, Ellie, and our new practice manager, Gill McCormick.

The practice construction and layout is far from ideal, having been first built in 1967, and then extended around 10 years ago. The treatment room was unused (the district nurse had been using it as an oversized office and store room), and was reached via stairs which is a problem for any patients with mobility problems. The dispensary was in the reception area, and was too far from the doctor's consulting room to allow easy supervision of dispensing.

Sadly, as the premises are rented from the Health Board, we will need to wait for a new coat of paint (which is badly needed). Amazingly, when I arrived I found that the water supply did not work in the staff toilets or the old treatment room. Even more concerning, an internal door had been fitted as the external door in the old treatment room and had completely rotted away at the bottom. You could see daylight, and water was pooling on the treatment room floor! We have met with the Health Board (now NHS Highland) and they have assured us that these problems will be fixed within the week.

So, having sat down with Dr Rosemary Wright, Gill McCormick, and the rest of the staff, to work out how best to use the space, we decided to move the rooms around. The treatment room has become an office for the practice manager, a store room, and a coffee room for staff which can be used for meetings and training. The nurse's room, which will double as a treatment room, and the doctor's consulting room have been swapped round.

The dispensary will be moved to the small room between the receptionists room and the new doctor's consulting room. This will allow the doctor to supervise the dispensing, improving safety and reducing the chance of errors in dispensing. The reception office will be used to house a new filing area for patient records, which are currently spread out over two rooms. A new access hatch has been ordered specially for the dispensary, which will allow patients to order and collect their prescriptions from a separate window in the main corridor.

The waiting room has been cleaned, and old magazines and posters removed. New posters will appear on the notice board shortly, favoring local notices. Other notices will be transfered to leather-bound files which patients will be able to read in the waiting room. The old 'advertising' TV in the waiting room will be coming down, and a new play table for children with a fixed wooden train set has been ordered.

These changes are all designed not only to improve the look and feel of the practice, and make using the practice easier, but also to improve safety and make the practice more efficient.

We hope that you like the changes, and we appreciate your patience while the renovations are carried out. If you have any suggestions or comments, don't hesitate to let us know - or post a reply below.

Welcome to the Strachur Medical Practice weblog

Well, here I am with my family arrived at Strachur from Inverness to take over the practice from Dr Basu.

I thought it would be a good idea to keep a blog of my time in Strachur*, which will hopefully be of some interest to patients (or anyone else!).

This way patients will be able to get an idea of the background to the changes that we are going to make, and any plans that we have for improving the service in the future.

It also allows patients to discuss the way their surgery functions with their GP in an informal way.

I hope you find it useful.



*obviously this blog will be non-confidential matters, such as personal experiences in the area, but mainly the running of the practice.