How to Use the NHS

Some now expect miracles – there is no benefit and therefore no point in going to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash (these are real examples).

It may be a bit of an understatement to mention that a lot has changed recently. No more so than for those working in the health service and, while many are unwell with Covid-19 and while those that need it most struggle to get the PPE they need, the everyday aspects of their jobs have somewhat fallen by the wayside. Figures for February and March show a 22% fall in A&E attendances. General practice and outpatient secondary care have also seen a drop in demand for routine enquiries.

While this has freed up resources for the issue at hand, some may notice that many of the issues for which they might normally have sought help and advice have gone away on their own. Others have been able to find the answer to their questions online. The sore throat that you had might have cleared up on its own without antibiotics. That painful ankle might have cleared up with measures you followed from the NHS website.

This unusual set of circumstances has highlighted an area that perhaps we can all learn from as we emerge from this crisis (though there is a long way to go yet). As a nation, we have become somewhat spoilt by the free healthcare we can expect; our perspectives have shifted over time as more becomes possible. Some now expect miracles – there is no benefit and therefore no point in going to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash (these are real examples).

In 1948, at the inception of the NHS, paracetamol was yet to become readily available, open heart surgery was 4 years old, statins had not yet been invented and antibiotics were in their infancy. Fast forward to the present day and we are seeing around 200 heart transplants a year in the UK, an entire pharmacy of medications available to us at our beck and call, lifesaving emergency services 24/7 and access to state of the art intensive monitoring equipment. Around half of the UK population takes at least one regular prescription medication. If your hips or knees go, you are entitled to have metal replacements inserted for no extra charge. If you have a rash, you can have it seen to or if you want your ingrowing toenail sorted, you can have it clipped or lopped off. If your ears are blocked, someone will clear that for you too.

With our population increasing and growing older, it is little wonder that the whole thing is beginning to creak. The outcome…? You have to wait a long time for your hip replacement, you might be denied the chance to have your bunions sorted out because it is a low funding priority. Your GP is running late by 20 minutes or even a bit longer. That may seem a bit insensitive or flippant (or both) but, believe me, I’m not happy about it, certainly not if it means people are waiting in agony for treatments. While most people have a rational grip on such situations, a few do not. Those are the ones that sometimes abuse staff who are only trying their best in impossible circumstances.

This current situation may therefore serve as a not so gentle reminder of what are reasonable expectations in terms of our healthcare. That said, between early and late March, there has been a fall of 150 patients per day presenting with symptoms of heart attack. Now, it is unlikely that the Covid-19 pandemic has somehow cured heart disease altogether and, though many people with chest pain turn out to be fine, there will be some within that cohort of 150 who have had real heart attacks; heart attacks that are currently going untreated.

Lack of presentation for this sort of thing, or indeed other worrying symptoms of things like cancer (loss of weight and appetite or a change in bowel habit to name just three), means the health impact of this pandemic will not be just related to Covid-19. For anyone with worrying symptoms like this, you absolutely must not ignore them just because of the outbreak.

There have been some cases of people cancelling urgent cancer referrals due to concerns over the virus. While one can understand the anxiety surrounding this, these referrals are there for a reason. Do not delay them.

We need to use the NHS sensibly. Not too much, but not too little. We have swung from one extreme to the other in the last few weeks. Once we emerge from this, we must all consider how best to use it going forwards, and focus on the bigger issues at hand, no doubt at a time of great change. Self-care is an enormous part of that, not just in how we deal with an acute medical situation but also in how we look after ourselves in general. Smoking, alcohol, diet and exercise are the key areas that cost nothing to improve.

As doctors we want to ensure that everyone who needs to be seen, and whom we can help, presents to us appropriately. At the same time, we would request that others, who might reasonably be able to manage their own minor issues, do so. It is a fine balance and even writing this makes me uneasy that some may stay away for fear of overusing the service. The level of disparity in people’s views of how best to use the NHS is, in my experience, remarkable.

In summary then, urgent care must remain a priority for the service as a whole, but how we look after an ageing population effectively is also vital. Prevention of health problems is key. We should look after ourselves properly as far as is practicable but also seek help when appropriate in order to avert bigger health issues down the line. Staying away isn’t always the answer (particularly at the moment) but there is a balance to be achieved. Now might be a good time to redress that balance.

The Body

Now I don’t want to sound bitter at all, but this was the book I had planned to write. Fortunately I got wind of it before planning got out of hand, but still…

Fair play though, Bill Bryson is a master at this sort of thing, and for someone not primarily medical it is a huge achievement. He has essentially taught himself a large proportion of medicine! This is a superbly written and researched book and I love all of the anecdotes and tidbits. Indeed his previous books had been an influence on my own writing in this respect. 

Despite the fact that it has diverted my future writing projects, I don’t mind. I’m glad he wrote it. I’m not bitter. Probably it is something everyone should read. I would even say it should be on the curriculum at schools. 

A Brief History of Everyone Who Ever Lived

I really enjoyed this one. Not too long and pitched just right for a light but informative read. It has certainly given me a better overview of our genetic makeup and also tempted me, despite the shortcomings mentioned, to get my own genome tested!

Dieting: The right way

“The heaviest man ever recorded weighed in at around 635kg (99 stone) – about the weight of an American Bison.”

As January draws to a close, so too will many new year’s resolutions be wavering. In fact, around 80% of peoples’ resolutions will have failed by the second week of February. One of the most common ones will be to go on a diet and to join the gym. January accounts for around 12% of gym applications but most will have completely stopped after about 24 weeks. Even worse, around 87% of diets will have already failed by the 12th.

While I think the use of new year’s resolutions to kick start such health drives is a positive thing, there is so much information around, particularly online and largely unregulated, that may render those well intentioned efforts fruitless, quite literally.

Dieting is nothing new. At the beginning of the 20th Century, people turned to eating tapeworms to help them with weight loss – that is until they started getting intestinal cysts, meningitis and seizures. For some reason, during the 1930s and again in the 1970s, it became popular to eat half a grapefruit with every meal in the hope that the scales would become more complimentary. In the 1800s, apple-cider vinegar was added to water (apparently popularized by Lord Byron) and in the 1960s, a ‘drinking man’s diet’ emerged which consisted of eating lots of meat and washing it all down with alcohol, even at breakfast. 

The purpose of all of these, you will notice, will have been to lose weight. I suspect now, if you asked most people why they go on a diet or go to the gym, it will be ‘to lose weight’ or ‘to look better’. We have an ideal body shape these days which is endlessly highlighted through online and social media. There is a huge pressure for us to look right.

Arguably, this has been with us for a long time. One only has to look at the statues from ancient Greece and Michelangelo’s famous statue of David in Florence to see the template for the ideal build and shape of a human that has persevered ever since.

Not reaching that ideal puts huge pressure on our mental health. The trouble is, achieving it is getting harder and harder with the choices and options available to us, both in the modern diet and our increasingly sedentary lifestyles.

In the UK, 29% of adults are classed as obese, as are 20% of year 6 children.  It is thought that around 10,660 admissions to hospital each year are directly attributable to obesity. Thus the importance of controlling weight and fitness is not just about looking right.

All too often, people choose to make their lifestyle changes after something has happened – if they are lucky enough to do so – at which point the aims change from honing their body image to things like reducing blood pressure, preventing or controlling diabetes, treating depression, and lowering the risk of heart attacks and strokes. Ultimately, all of this is achievable, but not through the short term fad diets that are so popular in the consumer market of today.

Let’s look for a moment at the physiology of our body and its energy supply. We need energy to live, that much is obvious. That means every cell of the body, in order to function, needs a supply of energy. This comes from our diets which can broadly be split into three categories: fats, carbohydrates and proteins.  The majority of our energy comes from fat and carbohydrates. Fat is too large to be absorbed into the blood stream on its own, so when we eat it, it is broken down in the gut to form fatty acids and glycerol so it can be absorbed.

Fat is mainly stored in the liver and in the subcutaneous (skin) tissue. It can also accumulate around internal organs (visceral fat). When we are not eating and need energy, we draw on these stores to power our bodies, a process kick started by a drop in insulin levels. This will also bring into play the sugars stored around our body, again largely in the liver, in the form of glycogen. A drop in insulin will convert this glycogen into glucose and the fat into fatty acids and glycerol once more, which can then race around the body to power things.

As we eat, insulin levels rise. This encourages cells to take up glucose as a source of energy in the short term, but also promotes a reversal of the process above and stimulates the storage of all of the new energy we are ingesting so we can use it later.

Put simply, our weight is governed by the rate at which we store the energy from the foods we eat against the rate at which we use that energy.

Energy is measured in calories and one calorie is the amount of energy required to raise the temperature of water by 1 degree Celsius or 4.184 joules. 1,000 calories is equivalent to 1 kilocalorie and it is kilocalories that we see on the sides of our food packaging.

Hopefully therefore it should be fairly clear that, in order to maximise our health, there is a need for both healthy intake of food and an active, energy burning lifestyle. If not, then our weight will suffer along with a lot of other things. The heaviest man ever recorded weighed in at around 635kg (99 stone) – about the weight of an American Bison. In the UK, the record stands at 444kg (70 stone) – the weight of the average Moose.

Our intake of fats should be around 30% of what we eat. Any more and it can build up in our bodies and cause problems, for example high cholesterol, heart disease and obesity.

In the same way, getting all of our energy from carbohydrates (sugars) is not the answer either, as this can reduce our body’s sensitivity to insulin and cause diabetes. In a cruel twist, excess sugar can also be converted to fat anyway.

We all lament the fact that, in general, the foods that are bad for us are the ones that taste nice. The key, as I suspect you have heard many times over, is balance. This is not repeated for the sake of it but because it is truly important. Many modern diets will hinge on cutting out whole areas of energy – for example the Atkins diet and its dislike for carbohydrates. While this can result in fast initial loss in weight, it falls down in many other areas. If one cuts out an entire food group, one loses the benefits of the foods within that group. If you cut out carbohydrates, you’re cutting out a tremendous source of fibre, vital for gut health and a healthy microbiome. It is also likely you are depriving yourself of the many vitamins and minerals contained within those foods that your body needs. Longer term it falls short and, perhaps most important of all, it is not sustainable.

This brings me to my most important point. If you want to be healthier, reduce your risk of heart disease and diabetes, look better, feel better, lose weight, or whatever your goal, you need to make a permanent and sustainable change to your diet and lifestyle and avoid something that is unrealistic. If you say that you are going to the gym every day but one having not been for the past 5 years, it won’t work. Likewise, if you say you will cut out fat completely from your diet forever, it won’t work.

That’s not to say that making a change won’t be difficult but crucially, if you do it in the right way, it is something your body will eventually assimilate as the norm.

So…

  • Prepare your food for the week ahead and don’t shop while you’re hungry. If that chocolate bar is in the cupboard, you’ll eat it!
  • Join a gym, club or class but make your activity levels fun and sustainable so you aren’t put off it.
  • Watch out for portion size.
  • Use brown rice, brown bread and brown pasta
  • Avoid saturated fats and eat more polyunsaturated fats and cooking oils.
  • Plenty of fruit and vegetables
  • Set goals and guidelines to stay within
  • Eat 3 main meals a day and snack only on nuts and seeds (a tricky one but very important)
  • Drink 6-8 glasses of water a day
  • Reduce your alcohol intake
  • Stop smoking!

Good luck!

Just Another Cigarette

When you really think about it, that well-known pastime we call smoking is actually quite bizarre. It is the act of inhaling and exhaling the fumes of burning plant material. For me, thinking about it in that purely literal sense makes it seem as weird as it does when you say the word ‘iron’ over and over again until it loses its meaning and just becomes a sound. (A psychological phenomenon, incidentally, that has been labelled ‘semantic satiation’)

It is even more so when you think of the fact that smoking, specifically tobacco, has been responsible for around 100 million deaths in the last century. Why then have we as a species become so intertwined with this strange habit and, for that matter, such a harmful one?

For a start, we didn’t always know that it was harmful. As far as we know, people have been smoking as far back as 5000BC – we know this from various drawings depicting the act. Tobacco specifically is native to the North and South American continents and was used by natives long before the “new world” was discovered by Europe. It was brought over here in the 16th Century when it was smoked in pipes and cigars. Some doctors at the time even thought it helped to prevent cancer, though I hasten to add this was not the universal opinion.

In 1880, an American chap named James Bonsack patented a cigarette rolling machine that was quickly picked up this side of the pond and the modern story of the cigarette began. These days, around 15 billion cigarettes are smoked every day.

It wasn’t until the Royal College of Physicians, in 1962, announced that cigarettes caused lung cancer and other diseases that we realised fully the harmful effects of smoking. By then, however, the manufacture and supply of cigarettes was a global industry and its sheer momentum has made it very difficult to combat over the years.

Just how harmful and costly to our health smoking is cannot be underestimated. Tobacco is the single biggest avoidable cause of cancer in the world. Each cigarette contains around 5,300 chemicals according to cancer research and 69 of these are known to cause cancer. Lung cancer is the most prominent but the habit also causes, amongst others, cancer of the larynx, oesophagus, bladder, pancreas, kidney, stomach, cervix and bowel as well as some leukaemias.

If it doesn’t cause any of these, you can expect to suffer from one or more of the following…

  • Heart disease and strokes
  • Chronic Obstructive Pulmonary Disease – leaving you with chronic coughs and progressively struggling for breath.
  • Peripheral vascular disease – cold and blue feet and legs at risk of ulcers and chronic pain
  • Premature ageing of skin by 10 to 20 years
  • Weak and brittle bones
  • Reduced fertility and impotence (smoking while pregnant causes miscarriage, premature birth and stillbirth and increases the chance of cot death)

I could probably go on, but I think you get the picture. Ultimately, up to two thirds of smokers will be killed by their habit.

By far the best way to stop smoking is to avoid starting in the first place. In the past, this has been made more difficult by advertising of tobacco products. Furthermore, the habit tends to be passed down in families. The very idea of smoking has been normalised to a huge extent – it has been glamourised in popular culture and films especially. Even knowing what I know, I have to admit that the cigar makes 60s era Clint Eastwood look far more impressive than he would without. But we’ve all grown up to accept that. This social conditioning is part of the problem and may have something to do with the whole ‘reckless and carefree is cool’ attitude.

The trouble is that reality catches up with the fantasy eventually and between 2016 and 2017 there were 484,700 admissions into hospital due to smoking and in 2016 there were 77,900 deaths.

Once started, the nicotine contained within is the culprit that makes stopping so difficult. It has both stimulating and tranquillising effects on the brain and creates new pathways that stimulate pleasure centres that begin to rely on the presence of nicotine to work. If a smoker stops suddenly, they will begin to experience withdrawal symptoms. These symptoms may include cravings, depression, anxiety, insomnia and lack of concentration. All that means it is far easier just to light up a fresh cigarette and carry on where they left off.

All the while, the carbon monoxide in the smoke binds to our haemoglobin, the protein in our blood that transport oxygen around the body, and reduces its oxygen carrying capacity. It’ll make running for your train let alone that marathon pretty difficult.

Fortunately, tougher laws on advertising now mean that cigarette packets now have to display warnings about the harm smoking causes. This transfers the responsibility of the harm they do from the tobacco companies onto the smokers who pay for them. It is a bizarre situation in which the companies themselves are now trying to make their tobacco products as undesirable as possible, some countries even going so far as to pick Pantone 448 c, the ‘world’s ugliest colour’, to adorn the sides of their packets.

Such is the reliance induced by smoking that people still spend on average around £140 each month on cigarettes, meaning they could save about £1,700 each year – the equivalent of a pretty decent holiday or a large contribution to the deposit on a house for example.

Practically all forms of smoking are harmful. Whether you smoke it from a pipe or a cigar or even chew it, you are at risk. Shisha is also known to cause cancer. This puts the tobacco companies in a predicament and we are entering a new age in which e-cigarettes and vaping are emerging as safer alternatives. While certainly thought to be safer, e-cigarettes are still new enough that longer term trial data are unavailable.  Meanwhile, the NHS party line is that they are better than other tobacco products at least.

Of course, the best option is to quit altogether. If you do so before 30, then you may be lucky enough to experience the same length of life as an average non-smoker. You will be able to taste and enjoy food more, your breathing and general fitness will improve, and the appearance of your skin and teeth will improve. After a year your risk of heart disease will halve and after 10 years your risk of lung cancer will also halve. At 15 years, your risk of heart disease will be the same as someone who has never smoked.

Going cold turkey is the least successful method. If you are serious about stopping, you may benefit from following a smoking cessation plan. Nicotine replacement products can be obtained through one of these and sometimes certain medications (Champix or Zyban) may also offer support. Visit www.smokefreelifeoxfordshire.co.uk for more information on all of this. Ultimately you have to really want to give up, otherwise you probably won’t succeed. And it may interest you to know that, in contrast to many of his film characters, 89 year old Clint Eastwood is actually a non-smoker.

The Eye

“…fingerprints have approximately 40 individual features but the average iris has 256.”

What do the following celebrities all have in common? Christopher Walken, Dan Akroyd, Simon Pegg and Jane Seymour. It takes only a quick glance at the title of this article to ascertain that it must be something to do with their eyes. Well done though if you said that they all have ‘Heterochromia’, which means that each of their eyes are different colours. Regardless of whether or not one’s eyes have this rather exotic trait, these clever and intricately complex little organs tend to be a focal point and, at an individual level, one of our most vivid and emotive defining features.

They are thought to have evolved initially in single celled organisms that held light sensitive proteins. Over many millions of years, the process of ‘seeing’ became a reality through a mind-boggling transition into the eyes that we see today. Across the animal kingdom, there are many different types of eye and, as is the outcome of all evolution, the creatures they serve benefit in different ways depending on the environments in which they live.

Geckos can see colour 350 times better than us, bees have 5 eyes, most spiders have 8 and worms merely have a collective of light sensitive receptor cells. Not all eyes are structurally the same. For example, some vertebrates, including cats, have an extra layer of tissue behind the retina (the layer of cells that collects and processes light) called the tapetum lucidum. This reflects any light that has got through first time round and reflects it back into the retina again, giving rise to excellent night vision – very handy for catching unsuspecting mice. It also results in the eye-shine we see when some type of mammal is lurking in the bushes and served as inspiration for the ‘cats’eyes’ we see on our roads.

We humans must make do without these handy features and we are limited to just the two eyes. This is better than one though, as it gives us a perception of depth. To enable us to see, we must collect the light from around us and process it. Light bounces off everything (almost) and if we look towards something the light from this will hit our eyes. This light travels first through the cornea and second through the pupils (the holes made by the retractable fibres that make up the iris (the part that gives our eyes their colour). Here it hits the lens, a rounded clear organ that alters in size as we focus differently. This allows it to redirect light from different distances onto the back of the eye where the retina sits, so that it doesn’t produce a blurry picture. At the retina, the light is converted by different types of cells into nerve signals and the information is then taken via the optic nerve to the brain where it is further compiled into what we understand as ‘sight’. Interestingingly, because of the way in which the light is focused on the retina, the unprocessed image is upside down and back to front, so the brain must flip these back the right way round.

As doctors, the eyes are a useful thing to check when examining a patient because they can tell us a lot about a person’s health. Shining lights into the eyes causes the pupils to constrict and faults here can point to certain neurological conditions as can double vision and loss of visual fields. Looking at the back of the eye, we can sometimes tell if there is raised pressure in the fluid surrounding the brain, and at the front, there are characteristic appearances in or around the eyes of people who might have thyroid problems or high cholesterol. In babies, it is important to check for something called the red reflex, the normal red-orange colour of the eye when light is shone. Asymmetry here or a white reflection can sometimes point to something called retinoblastoma which is a type of cancer.

The most common eye examination one might receive is the visual acuity check. Using the Snellen charts, reading the letters on rows of ever decreasing size, we challenge ourselves to get to the very bottom level. The phrase ‘20/20 vision’ is often talked about, which essentially means we can see something at 20 metres that the average person would see at 20 metres. Outside the USA, we use 6 metres as a scale and if you wanted really exceptional vision, you would aim for something more along the lines of 6/7 (in other words you could see something from 7 metres that the average person would only be able to read at 6 metres).

If our vision isn’t quite up to scratch, we might need a correction and this is where glasses and contact lenses come in. Depending on which survey you read, between 69% and 77% of people in the UK wear glasses or contact lenses – so many that it is isn’t surprising that they have become somewhat of a fashion accessory!

More seriously, there are currently approximately 2 million people in the UK living with a level of sight loss that has a significant impact on their daily life. There are around 350,000 people registered as blind or partially sighted alone.

There are a plethora of conditions that can cause such sight loss.

  • In the UK, age-related macular degeneration is a major cause (a deterioration of the macula, a part of the retina, due either to the formation of deposits on the retina or to fluid build-up underneath the macula).
  • Diabetes is a big cause of sight impairment as well – it causes progressive damage to the blood vessels at the back of the eye and is known as diabetic retinopathy.
  • Glaucoma is a build-up of pressure in the fluid within the eye. Your optician will check your pressures by puffing air at the eye using a machine. As long as it is well controlled and monitored it can be treated with certain medicated drops.
  • Cataracts are a gradual clouding of the lens. When vision is too severely affected, surgery is an option to correct this.
  • Retinal detachment is an emergency and characteristically involves a sudden curtain of vision loss falling over one eye. It may be preceded by flashing lights and a sudden increase of floaters and needs an immediate trip to eye casualty.

Incidentally, floaters are small bits of debris that float in the eye and move around with a slight lag as the direction of gaze changes – these are common, and, except as mentioned above, are not normally something to worry about, though they can be very annoying. Unfortunately they are essentially untreatable.

As GPs, we often see a handful of more common and less serious conditions that could have been dealt with first by a pharmacist or managed at home. Red and gunky eyes most often represent conjunctivitis, while red swollen eyelids (blepharitis) or a cyst or stye over the lid can be treated with hot compresses, and a watering eye can be your body compensating for a dry eye, so try some lubricating drops. Most eye conditions do not need antibiotic treatment.

If your eye is painful however or if you are not quite sure, this must be reviewed, especially if it is red as well. There will be a local eye casualty (if you’re in the UK) that patients can call if they are unable to get to their GP. This may be where your GP refers you if they feel it needs more in-depth specialist review.

The following recommendations can help to keep your eyes healthy:

  • Don’t smoke – Unsurprisingly this causes all sorts of problems including macular degeneration and cataracts.
  • Make sure you wear sunglasses – it protects against harmful UV rays and makes you look awesome.
  • Get regular optician checks – apparently around 10% of the adult UK population have never had an eye check. Problems are not always immediately evident and so it’s best to get checked every two years at the very least, more frequently if you’re over 40.
  • Eat the right things – generally anything with lots of omega 3 fatty acids and vitamin A (also known as retinol which helps with night vision!) Examples would be oily fish, kale, spinach, peppers, oranges, broccoli and eggs.

So overall, eyes are pretty marvellous things and, more than that, they are deeply personal. One only has to look at the rising use of retinal scanning to realise just how individual they are -fingerprints have approximately 40 individual features but the average iris has 256. We only have two of them, so we must take the best care of them possible.