Hay fever injections

Every Spring we see posts about the so-called “hayfever jab”. Unlike many of our competitors, we very deliberately DON’T offer Kenalog injections for hayfever. Why not?

Kenalog is an injection which was once approved to treat hayfever. The idea of just having one or two injections to keep hayfever at bay for months may seem appealing. However, the evidence shows that Kenalog, a long-acting steroid, is no more effective than safer treatments. For that reason, it is no longer approved for use in the UK (and most other countries) as a treatment for hayfever.

Most doctors no longer offer the treatment, and Allergy UK – a national charity supporting allergy sufferers – explicitly does not recommend its use for hayfever. International experts also warn against the use of steroid injections for hayfever. Yet despite this, many private medical clinics and aesthetic services offer the treatment. Many of those giving the treatment are beauty therapists rather than doctors or nurses.

Although steroid injections do usually help with hayfever symptoms, there is a real risk of side-effects, some of them serious – they can affect blood sugars, mental health, and bone health, and may make you more vulnerable to infections. So they are not routinely recommended because there are effective alternatives which are much safer. Alternatives include antihistamines – which can be given as a nasal spray, or as tablets – and nasal steroid sprays, which are much safer than Kenalog because much less of the steroid is absorbed into the bloodstream. Most of these options can be bought from your local chemist. If those don’t work, then your GP – either NHS or private – will be able to advise about prescription-only treatments.

If, despite those prescription-only treatments, your GP can’t get on top of your symptoms, then it may be appropriate for you to be referred to an allergy specialist. Specialists can sometimes offer options like immunotherapy treatment, though that isn’t an option for everyone.

Patients sometimes seek Kenalog because they have an important event coming up, but even then, we would not recommend it; there are other alternatives which are as effective but safer, such as a short course of oral steroid tablets.

At Formby GP, we want our patients to know that they can trust us. We will not try to sell you things which we believe would do you more harm than good. As doctors our duty is clear: to first do no harm.

References:

https://www.allergyuk.org/news/kenalog

https://www.pure.ed.ac.uk/ws/portalfiles/portal/332099603/Int_Forum_Allergy_Rhinol_2023_Wise_International_consensus_statement_on_allergy_and_rhinology_Allergic_rhinitis_.pdf

Heather’s notes from RCGP Council 8 March 2024

Wow! What a momentous day! You’ve no doubt already seen the news on Twitter: RCGP Council has voted to revise its position on Physician Associates! It was actually a fairly packed agenda, and we discussed a couple of other very interesting papers as well. I’ll run through it in order…

Physician Associates

The Council paper had been kept confidential until after the vote, but I am told it will shortly be uploaded to the members’ section of the website, so if you’re a member you will hopefully soon be able to find it on the Council page on MyRCGP. 

Mindful that Physician Associates would be on the March Council agenda, and cognisant that this is a topic which has aroused strong feelings in many of our members, I felt that as a Nationally Elected Member of Council I should consult my electorate to inform my position. In January I created my own informal survey of RCGP members – if you haven’t seen it, my results are presented here. This proved to be tremendously useful, as it meant I could represent your views with confidence and authority, and the results seemed to be taken seriously within the Council chamber. (One Council member came up to me in the ladies’ loos to congratulate me on doing it!) I am so grateful to the 457 RCGP members who spent time filling out my survey. You have all helped to drive change within our College. Thank you!

Due to the intense (and appropriate) scrutiny of the management of conflicts of interests, Council members had to submit a written declaration of their interests in advance of the meeting, and then separately had to re-state relevant interests before speaking.

I spoke to the motion as follows:

I’m Heather Ryan, nationally elected member. When I joined my former partnership, there was a PA at the surgery, who left fairly shortly afterwards, and I didn’t have much involvement with them. I occasionally let PA students sit in with me in the Secure Unit. I’m a private GP and we don’t employ PAs. My husband was a Nationally Elected Council Member when Council voted on PAs last time.

As a Nationally Elected Member of Council, I was keen to ensure I was representing my electorate on this contentious issue. So I undertook my own survey of RCGP members, advertising on social media platforms. I got 457 responses, all of whom self-declared they were members of the College. Respondents were asked how well they felt that RCGP was currently representing their views on PAs, on a scale from 1 (not at all) to 5 (very well). The majority – 72.9% – felt that RCGP was not representing their views at all, and a further 69 respondents (15.1%) gave a less strong but still negative response. Only 5 of those 457 doctors felt that RCGP is currently representing their views on PAs very well.

So, our members are not happy. What can we do better?

95.2% of the doctors who responded to my survey felt that RCGP should undertake a formal consultation of its members’ views on PAs. Most respondents felt that RCGP’s position should be that any incorporation of PAs into Primary Care should not be at the detriment of GP trainees’ learning opportunities, and, sadly, several respondents gave me examples of how their own GP training had already been affected.

The view of my members is that GMC regulation of PAs will add to the confusion amongst patients and clinicians, so in vote 4 I will vote for option B despite the caveat that it is likely to delay the registration of PAs. It is better that we get it right, than that we get it wrong quickly*.

Council, at this critical time for our profession, we must ensure that we take our members with us in any decisions we make. For that reason, I beg you to please vote yes to the questions put to us today, and in particular, vote yes to a public consultation.

* My questionnaire didn’t ask about this specifically, but colleagues made their feelings clear via other channels!

Most Council members spoke, and those who didn’t speak nevertheless had to declare their conflicts of interest before we voted.

The outcome of our vote was, as summarised in the RCGP press release, that RCGP’s position on PAs is now as follows:

  • RCGP opposes GMC regulation of PAs
  • GPs must be able to choose if they supervise PAs
  • The training of GPs must be prioritised over training of PAs
  • PAs must be considered additional members of the team – not substitutes for GPs
  • PAs do not replace GPs 
  • RCGP will undertake a formal consultation of its members’ views on PAs, including scope of practice and supervision

Most of the credit for today’s victory goes to the incredible Victoria Tzortziou-Brown, RCGP Vice Chair for External Affairs, who showed great leadership and courage in bringing this paper to Council in its current form.

Approval of Standing Orders

Fair play to the RCGP officer team: after the excitement of November’s AGM and Council meeting, I was really impressed by how they approached the revision of the Standing Orders. The concerns I raised about the process for bringing motions to Council were incorporated into the next draft of the Standing Orders; and then the Hon Sec hosted a webinar for Council members in which the proposed changes were discussed, following which further amendments were made. As a result, I was happy to support the new Standing Orders, and I spoke to commend the Officers for the way in which they had engaged Council members with the process.

There was also some discussion about how declarations of interest will be managed going forwards. In principle it was agreed that Council members’ declarations of interest should be made available to the wider RCGP membership, though there are some practical and governance questions about how this can be implemented, so it’s unclear exactly what form this will take or how quickly it will happen.

Health inequalities

This was a great paper which prompted a lot of thoughtful discussion. It was humbling to be reminded of the depth and variety of expertise we have on Council. Points raised included culturally competent care for patients with learning disability; and how GP surgeries should not make showing photo ID or proof of address a condition of registration, as this risks excluding the very patients who most need healthcare.

I spoke to make the following points:

  • I am pleased to see the call for targeted recruitment and retention schemes to support maintaining GP numbers in deprived areas
  • In North West England we have several successful ‘deprivation’-focused GP training posts, plus local initiatives to ensure GP trainees gain some experience of working with disadvantaged communities – such as arranging for trainees to spend time with a homelessness outreach worker, and a scheme I have until recently facilitated in the mental health unit in which I work, where GPST3 trainees would spend an afternoon with me
  • I am pleased to see that the paper discusses the difficulty that some patient groups can have in booking an appointment. Interestingly the paper doesn’t talk much about the challenges that older people can face when contacting their GP surgery. I do my private work in a very affluent area, yet many of the patients who consult me are wealthy, educated older patients who report that they have really struggled to access their NHS GP because they cannot, or do not want to, use eConsult. The word “elderly” only appeared once in this paper, and I would ask that the needs of older adults, who are at risk of digital exclusion regardless of their socioeconomic status, are not forgotten.

GP retention

Council ended on a high note with an excellent paper which summarised the College’s recent policy work on GP retention. I was particularly pleased to see that RCGP is calling for all international medical graduates qualifying as GPs to have the right to apply for indefinite leave to remain in the UK. Such a scheme would address the ludicrous situation we currently have, in which newly-qualified GPs risk deportation if they can’t find a job quickly enough after they complete their training.

One Council member spoke very well about how one of the groups with the worst retention rate is female GPs aged between 30 and 45, and factors which may be contributing to this, including the cost and difficulty of arranging childcare; recent changes to the retained GP scheme; and the reduction in availability of locum work.

I said the following:

I think this is a great paper – thank you for bringing it, Kamila. I was particularly pleased to see the mention of flexible working and I would echo [other member’s] comments. I was a GP partner when I had my eldest child, and I found it really difficult to stay in a substantive GP role because core contracted hours are 8am to 6.30pm and in the remote ex-mining area I lived in, nurseries and childminders didn’t offer long enough opening hours. I was fortunate that my husband, also a GP, picked up the slack – but he once had to take our 8-month-old on an emergency home visit to a nursing home. Given that childcare options are often worse in deprived areas such as the one I worked in, support for flexible working may well help mitigate the impact of the inverse care law. 

As a GP educator in Sefton, where a high proportion of our GP trainees are international medical graduates, I was also pleased to see the suggestions put forward about how we might tackle the visa trap which sees excellent newly-qualified GPs threatened with deportation if they can’t find a job quickly enough.

That said, when we discussed this paper at our Faculty Board meeting on Wednesday, one of our members drily said, “if you want to retain GPs, you need somewhere for them to work”. I think this superb paper would be even better if it were clearer about the fact that we will not be able to retain GPs unless General Practice as a whole is funded adequately, because at the moment, our very profession is fighting for its survival.

One GP also contacted me to point out that the Performers’ List puts barriers in the way of retention, especially for doctors in low volume or niche roles. I would urge RCGP to consider its position regarding the Performers’ List.

Conclusion


I remain, as ever, your humble and obedient servant: as a Nationally Elected Council Member, I am here to represent you, so please do keep your feedback and suggestions coming! The outcome of today’s Physician Associate paper feels like a big step forward, but our work isn’t over; keep your eyes peeled for the member consultation!

Nits – sorting facts from fiction!

Autumn term is well underway and talk at the school gates is turning to nits (or rather head lice – nits being their eggs). Many parents feel itchy as soon as they receive the first WhatsApp message about them, whether or not they or their child are affected!

Did you know…

1. The most reliable way of detecting head lice is by using a nit comb. A 2008 study showed that “detection combing” is almost four times more effective than just looking at your child’s scalp.

2. Old eggs can remain glued to the hair for up to 6 months, even after successful treatment has eradicated the head lice – so experts advise that you only treat your child if you see a living, moving louse.

3. There is no evidence that head lice prefer clean hair, despite the urban myths.

4. Head lice are more common in girls than boys, and the peak age for infestation is around 7-8 years.

5. Many parents use essential oils such as tea tree oil to repel nits. However, there is no good evidence that this works (but your child will smell nice!).

6. The use of other treatments to prevent nits is controversial. One trial in 2014 showed that 1% 1,2-octanediol spray (which is sold as Hedrin Protect & Go Spray) gave a significant amount of protection from head louse infestation – though it did not always prevent it. However, the official NHS website advises against using chemical sprays regularly to prevent nits in case they irritate the scalp. For what it’s worth, in the 2014 trial, very few children had any problem with the spray, and so we (Heather and John) do choose to use it on our children.

7. If your child has a confirmed head louse infestation, there are various methods you can use to treat it. Evidence suggests that mechanical removal of lice (e.g. by wet-combing with a nit comb) is less effective than chemical methods. However, some parents prefer to try a chemical-free option first, using kits like “BugBuster” or the “NittyGritty” comb.

8. Agents such as dimethicone and cyclomethicone have been shown to be highly effective in clinical trials. Rather than being conventional insecticides, these chemicals work by suffocating the lice or by damaging their skeleton. These treatments are great because, unlike traditional insecticides, head lice can’t develop resistance. Treatments available over the counter include Full Marks Solution and Hedrin 4% dimeticone lotion.

9. There is growing concern that head lice are developing resistance to insecticide treatments such as malathion and permethrin, so we would not recommend them. Make sure you read the label or speak to the pharmacist so you understand what you are buying.

10. Experts suggest that there is no need to use a course of head louse treatment on your child because there are cases of lice at school – the advice is to use a nit comb to check the hair and treat only if you find a live louse.

11. Although head lice are unpleasant and cause itching, they almost never cause serious health problems. If your child gets nits, don’t panic!

I hope this has been helpful. Here are some helpful links and references:

https://www.nhsggc.org.uk/…/stafford-head-lice-2012.pdf

https://bmjopen.bmj.com/content/4/5/e004634

https://pubmed.ncbi.nlm.nih.gov/10937452/

https://www.nhs.uk/conditions/head-lice-and-nits/

Midstream urine (MSU) samples

Instructions for collecting midstream urine samples

First, remove and set aside any packaging from the sample bottles. In the kits we provide, the sample bottles themselves have red tops, and will need to be taken out of the larger transport tube with a white top, and the foam insert. Before you collect the sample, please make sure that your name, date of birth and the date of collection are on the bottle(s). If we have labelled them for you, do please correct the collection date if appropriate.

Please also check that the request card has been completed correctly.

We recommend collecting two samples, preferably before starting any antibiotics. The first sample should ideally be collected on the first occasion that you pass urine in the morning. If you would prefer not to wait until the next morning, please try to collect the first sample more than two hours after you last passed urine, if possible. Alternatively, if your symptoms tend to be worse later in the day, you can collect the first sample then.

The second sample should be collected on the next occasion that you pass urine.

Before collecting the sample on each occasion, women should rinse and squeeze out a clean baby wipe, and gently insert it into the lower vagina (even if on their period). This helps to prevent contamination.

Please do not part your labia or pull back your foreskin.

Now you should be ready to collect the sample. Unscrew and set aside the red cap of the sample bottle. Then start passing urine and pass the sample bottle into the stream of urine, holding it there until the level of urine in the bottle reaches the red line.

Then screw the red cap back on the sample bottle, double-check that your name, date of birth and today’s date are on the bottle, wrap the foam insert around the sample bottle, place it into the transport tube, and screw the white cap onto the transport tube.

Once you have collected both samples in this way, place them in the blue postage paid mailing bag provided along with the completed request card, seal the mailing bag and simply put it in the post. It physically takes a few days for the laboratory to culture the sample. We aim to email you the report within 5 working days.

Chickenpox and shingles vaccinations (draft)

Why should I have a chickenpox or shingles vaccination?

Serious illness as a result of chickenpox in childhood is rare. It can be more problematic in adulthood, especially in pregnancy or in the context of other underlying health conditions. Most adults have been exposed to chickenpox and are therefore immune to it. However, the virus which caused chickenpox can be reactivated and cause shingles, usually later in life. Shingles can be unpleasant, and sometimes results in lasting discomfort.

Immunity as a result of chickenpox vaccination might wear off, such that it is better at preventing chickenpox in childhood (usually a relatively mild illness) than in adulthood. There is therefore some concern that having the chickenpox vaccination as a child might increase one’s risk of the more severe chickenpox illness as an adult. This has to be balanced against the benefits of reducing the risk of shingles.

Evidence suggests that 9 out of 10 children vaccinated with a single dose will develop immunity against chickenpox, but there is an even better immune response after two doses of the vaccine, so it is strongly recommended that two doses are given (4-6 weeks apart).

The vaccines

Vaccines to reduce the risk of shingles are available for adults. The NHS offers these to people aged 70 to 79. Zostavax (a “live” vaccine) is given as a single dose, while Shingrix is given as 2 separate doses 2 months apart.

Vaccines to prevent chickenpox are also available for those who have not already had chickenpox (usually, but not always, young children). They are usually given as 2 doses 4-8 weeks apart.

Are they safe for me?

Allergies

If you have ever had a severe allergic reaction to any ingredient of the vaccine, you might not be able to have it, or special precautions might be necessary (such as administering it in hospital). Depending upon the particular vaccine, ingredients might include the antibiotic neomycin, gelatin, and/or polysorbates.

Immune suppression and pregnancy

If your immune system is severely suppressed, or if you might be pregnant, Zostavax or either of the chickenpox vaccines might not be suitable for you. This is because they are ‘live’ vaccines which contain a tiny amount of the virus.

Why Britons are going private to see GPs

As a recent YouGov survey has revealed that one in eight Britons has paid for private healthcare in the preceding year, a new private GP service has opened in Merseyside.

Formby GP is a private GP service in Freshfield, run by married couple Dr Heather Ryan and Dr John Cosgrove. Heather and John launched Formby GP in January. Clinical Director Dr John Cosgrove says, “It’s no surprise that patients are turning to the private sector.

Recent media coverage of private services has focused on the potentially steep costs involved – some private providers charge up to £550 per hour. Formby GP, however, charges just £120 for a standard unhurried consultation, and £200 for a home visit within the practice area.

The team at Formby GP describe their service as “ethical”. Managing Director Dr Heather Ryan, added, “We like to think we are offering something a bit different. Some other private GP services target healthy young people by offering “wellness” treatments and screening packages. If tests are done inappropriately, they risk causing unnecessary worry, and may pick up so-called problems which weren’t causing any symptoms and would never have caused any harm.

“At Formby GP, we aim to be a traditional GP practice, focused on treating medical problems. We won’t try to sell you tests and treatments that you don’t need.”

Many people do not realise that private doctors can often refer patients back into the NHS. Dr Ryan explains, “We are able to refer patients for specialist NHS treatment. This includes urgent suspected cancer referrals.”

Clinical Director Dr John Cosgrove added, “It’s no surprise that patients and doctors alike are moving into the private sector. In recent years, NHS General Practice has become a lot busier. NHS GPs are now required to offer rapid consultations by phone and email. They cannot also offer the face to face consultations that both GPs and their patients value most. At the same time, because their workload is overwhelming, the number of NHS GPs have been decreasing for years. Many of those NHS GPs that remain are just exhausted, and surgeries struggle to offer the care that patients and GPs would both want.

“We set up Formby GP to offer face to face consultations, whether in the surgery or in patients’ home, on request. Our patients tell us that we are delivering!”

ENDS

Why don’t we offer “all inclusive”?

We aim to offer our patients an unhurried, high quality GP service, with continuity of care at its core, and allow them to make the choice about whether to access secondary care on the NHS or privately, and in all things to make meaningful choices about treatment options.

If you think about it, paying a fixed fee for any service for which demand is unpredictable is “betting against the house” – and the house is always going to win (or go out of business).

There are some private practices that offer an all-inclusive package for around £100 per month (over the age of 50). I would hope that a typical 50 year old would need to pay considerably less than £100/month in consultation fees, but we would expect to be there for them when they need us.

Most concierge-style services that we are aware of set a limit on the number of contacts in a year. Furthermore, many seek to attract the healthy and undertake assessments and tests that are not indicated, and therefore have significant potential to cause harm such as anxiety and complications of unnecessary treatment.

Further, such an arrangement necessarily encourages people to consult when they might not necessarily need to.

One of the challenges for NHS General Practice is that it is free at the point of delivery and therefore has had placed on it expectations (in terms of access, helping people who are not ill, etc) that it could never meet.

We want to form long term, adult-adult relationships with our patients, where we are no longer the gate-keepers, but can help to guide them through their options when they are ill.

Additionally, our practice has a strong emphasis on not recommending unnecessary investigations or treatments, for fear of doing harm. In private medicine, where one is paid for activity, we believe it is important to resist the temptation to encourage unnecessary consultations.

Finally, consider how eager we will be to book each appointment if that is the only way we get paid! We certainly do not want to become embroiled in contractual disagreements about whether we are failing to offer appointments of sufficient length or readily enough, or whether our patients use of our service is “fair” – hardly a respectful interaction!

Our approach might not be for everyone. We consider it to be ethical where others might not always be. Our price list is at www.FormbyGP.com/pricing.

We do, however, offer Priority Club membership, benefits of each include a guarantee of access, waiving of our prescription fees, half price text consultations and access to our community forum. If this appeals, why not ask at your next appointment whether it could be right for you!

Prescriptions

We are of course happy to prescribe most medication that you might need. In practice, we have a little more prescribing freedom than an NHS GP might.

We can prescribe controlled drugs if you are happy for us to share this information with other prescribers involved in your care, including your NHS GP.

Our prescriptions should be accepted by any pharmacy in the United Kingdom. Whenever possible, we will give you a paper prescription which you can take to the pharmacy of your choice. If that is not possible, we can send the prescription to you by email, which you can then show to the majority of pharmacies in the UK.

We make a charge for each item that we prescribe. We waive that charge for our Priority Club members. Our current prices can be reviewed at www.FormbyGP.com/pricing.

Regrettably, we are unable to issue NHS prescriptions.

Your pharmacy will charge you for dispensing your medication, even if you do not pay NHS prescription charges. They will usually not have to charge VAT. It is likely that prices will vary, so you might like to shop around before choosing a pharmacy.

Accessing your health record

We are often asked if we are able to access your NHS GP record. Because we are outside the NHS, we don’t automatically have access to it. However, this isn’t normally a problem: in many cases, we are happy to rely on information you provide us regarding your health conditions, medication, and allergies, and we will ask you about these before your appointment by means of our registration form.

Medical records storage – Fitzsimons General Hospital.
Lebovich, Bill, creator, Public domain, via Wikimedia Commons

You have the right to receive your record in electronic format from your NHS GP if you ask for it electronically (a “Subject Access Request“). If you would like, you may then share it with us, either by emailing it to Clinical@FormbyGP.net, or uploading it from our registration form. Often, a summary of your record will suffice. Sometimes, however, we will need your full record, such as if you ask ask us to write certain reports. It can sometimes be helpful to know recent blood test results, to save us duplicating work privately; if you have online access, you will often be able to view your results there.

With your consent, we will usually keep your NHS GP and any other relevant professionals updated. If you would prefer us not to, that’s generally fine too, so long as you are happy for us not to prescribe any controlled drugs. If we feel that information-sharing is particularly important, such as in particularly complex cases, we may broach the subject with you again and explain why we would recommend information-sharing.

Reports and “medicals”

If you have been asked for a medical report or examination, we can help! Simply email Clinical@FormbyGP.net the request or form that you have received and let us give you a quote.

Many such reports – such as an HGV medical “D4” – we will be happy to complete during your consultation for no extra charge. On the other hand, some might simply require us to review your GP record, and we might not even need to see you.

Please email us a copy of your NHS GP record before your consultation. For some reports (including HGV medicals), a summary of your GP record will suffice.

Some reports, however, expect the examining doctor to have access to your full GP record. For these, please download from your NHS GP your full record and then email or upload it to us.

If in doubt, just email us the blank report or form and we can advise you what we would need.

There are a small number of organisations that ask a doctor to certify that you are fit for a particular activity that they organise. At the time of writing, the Paris marathon is an example. It is very difficult for any doctor to say this, as there is no way for them to be certain that the organisers will have in place proper safeguards, not is it possible to predict that your health will not change before or during the event. We would be happy, however, to provide a summary of your medical history and an opinion as to whether that is likely to be problematic.

Cookie Consent with Real Cookie Banner