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Happy Mums, Happy Tums

Martin Drewry - HPA - 23 Dec, 2019

NB Medical have joined forces with charity Health Poverty Action’s UK Aid Match campaign, where the UK government will match public donations raised towards the charity’s Happy Mums, Happy Tums appeal to support the health and nutrition of mums and young children in rural Sierra Leone. *

Donations made to Health Poverty Action from now until the 31st December 2019 will be doubled by the UK government, and used to train community health workers and equip health clinics to give mums the nutritional information and support they need so their babies have the best start in life.

Martin Drewry, Director of Health Poverty Action, said: “We’re delighted that NB Medical have come on board to support the amazing healthcare workers in Sierra Leone on their mission to improve the health of mothers and babies. With the UK government doubling all public donations, it’s a fantastic chance to support long-term, positive changes to healthcare access and nutritional education.

The Happy Mums, Happy Tums project aims to reach over 6,000 women and children- in rural Sierra Leone’s Bombali and Karene districts by;

  • Working with over one hundred community health workers to identify and refer malnourished children and pregnant women to health services, especially those in households living with a disability.
  • Helping local communities take advantage of the most nutritious locally grown food, for example by assisting in setting up community vegetable gardens.
  • Improving access to healthcare services, for example by providing 40 bicycles to Community Health Workers so they can reach the most remote communities.

Health Poverty Action has worked in the Bombali and Karene districts on childhood nutrition previously, including supporting members of the local community, called ‘Community Health Workers’, who encourage and aid people to see health specialists and attend the closest health clinics.

One family that has benefited from Health Poverty Action’s previous support in Sierra Leone is Fatu’s family, a 22-year-old mother to two year-old daughter Ami, who was diagnosed with malnutrition last year.

Fatu, from the town Kagbere, said: “She got sick, she lost weight and I had to bring her to the health centre.

The health clinic worked with Fatu to suggest nutritional food for Ami that she could afford, and that Ami would eat. By working together, Ami was able to get better.

They told me to wash my hands properly before giving Ami her food, and to give Ami peanuts in the morning and evening."

Without this service, I would have lost my child.”

Fatu brings Ami to the health clinic

HPA Picture 1.png

To support the Happy Mums, Happy Tums appeal, please CLICK HERE

For more information visit the website Health Poverty Action


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Inhalers, The Environment and General Practice

Neal Tucker - 12 Dec, 2019

In case you hadn’t noticed, today there is a general election in the UK. As ever, the NHS is the nation’s top priority, but for the first time the environment is also high on the agenda. While the public sees these as two separate issues, the truth is that they are intertwined.

Two quick examples:

So, if climate change and the environment are medical issues then what can we do in primary care to make an impact? What can we do to benefit our patients?

Earlier in the year NB blogged about metered dose inhalers (MDI) accounting for 4% of all NHS carbon emissions. Inhalers are not the only area to address, but they are potentially an easy win and very much the purview of primary care. A paper in BMJ Open, published in October, showed that switching to DPIs could save money AND dramatically improve carbon emissions.

Unfortunately, the media reports had such a negative spin that patients with asthma felt justifiably indignant that global warming appeared to be placed on their shoulders. Despite this I believe that most patients using inhalers – this applies to both patients with asthma and/or COPD - where it is safe and they are physically able to, would be happy to try an alternative inhaler if a more environmentally friendly option were offered.

Using less MDIs might be an easy win, but inhalers are only a part of the picture. By thinking more broadly about the patient and their condition we truly can have it all: better health, better environment and better finances.

So here are a few suggestions for how to minimise the environmental impact in patients using inhalers:

1. Ensure the diagnosis is correct

  • Between 33-50% of children and adults with an asthma label are ‘over-diagnosed’, either due to mis-diagnosis or resolution of their condition - unnecessary inhalers are lose-lose.

2. Maximise non-drug treatments

  • Here are some of the greatest gain: smoking cessation, pulmonary rehab, simple exercise, even changing the route you walk/cycle to school, work, etc. to avoid polluting traffic.

3.  Where possible prescribe dry powder inhalers.

  • For excellent patient and clinician information see www.greeninhaler.org set up by Dr Alex Wilkinson, respiratory consultant and lead author of the aforementioned BMJ Open paper. An essential read, entirely free to access.
  • DPIs will not be appropriate for every patient, blanket switching is not appropriate, and we also need to ensure there is no guilt attached to MDI use. A patient-led individualised decision is needed, but broadly speaking, the very young and old may struggle with DPIs, and patients need a decent inspiratory flow (my local CCG guidelines suggest >30L/min, which in the real world equates to… um…) but bear in mind that most COPD long-acting inhalers such as LABA+LAMA combinations are dry powder inhalers and effective.
  • An important point is that during respiratory emergencies patients may lack the respiratory drive needed to use DPIs and so MDIs still play an important role here. Patients need to be aware of this. Manufacturers are aiming to make lower impact MDIs but these are still years away.
  • In patients already using MDIs, if switching might be possible, consider asking at their next asthma/COPD review if they would consider using an alternative which is more environmentally friendly.
  • The biggest barrier is clinicians. We need to change our prescribing habits and crucially make sure our excellent practice nurses are on board. As GPs we can get very de-skilled in inhaler prescribing – for a reminder of the available options and demonstrations of good inhaler technique for every individual inhaler have a look at www.rightbreathe.com

4.  Make every inhaler count

  • Ensure good technique and use of spacer with MDIs to maximise efficiency. A government report states that 50% of patients using MDIs do so incorrectly. They are inherently more difficult to use than DPIs which 80-90% of patients do correctly.
  • Ensure people use all the doses in the inhaler – inhalers without dose counters (e.g. most salbutamol MDIs) are difficult to gauge as the active ingredient runs out well before the propellant. Either prescribe inhalers with integrated dose counters or encourage people to count how many doses they have used. If the inhaler is used regularly they can estimate the number of doses used from the number of puffs per day multiplied by the duration used. Interestingly, if you have an accurate enough scales (e.g. digital kitchen scales) you can weigh a Ventolin Evohaler inhaler to see how much medicine is left – click here.

5.  Recycle the inhaler

  • 99.5% of inhalers prescribed in the UK end up in the bin and go to landfill. That’s around 50 million in 2018. Not only is that a lot of plastic, they leach out the remaining propellant HFCs for years to come. You can’t put it in your normal recycling bin (!) but many pharmacies are part of a GSK run recycling scheme . You can find participating pharmacies here.
  • If patients don’t use participating pharmacy start a collection at the practice and pass them on to a pharmacy that does.

As with any intervention, on an individual basis the benefits are comparatively small, but together general practice has the potential to make significant improvements to the environmental impact of healthcare in the UK. Inhalers are a simple place to start, let’s open the discussion with patients – they are interested, they want to help.

This is our first step, but there is much more we can do in practices – in 2020 we will look at simple changes practices can make which make them more environmentally friendly, sustainable AND potentially save money. Regardless of whichever government is in charge.

Merry Christmas and have a Happy New Year.

Neal

for a really insight comparison of inhaler carbon footprints click here.


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(Private) Health Screening - Far Too Much Medicine

Rob Walker - 4 Dec, 2019

‘Doctor, I’ve just had my health check done through work, and been told to come and see you to discuss the results’. A large wedge of paper gets deposited on your desk with lots of bar charts and colour coding. I’m sure this is a scenario that most of us are seeing increasingly, and if you’re like me it tends to lead to a twitchy eye and images of the boiling head emoji 🤯.

So it was with a little internal cheer that I read the Screening Position Statement from the RCGP and BMA in October relating to screening that has not been approved by the UK National Screening Committee. There is a burgeoning private screening market offering everything from simple blood tests to full body scans, ultrasounds and questionable bone density tests, so this paper sets out to fill the huge gap in guidance regarding use of these tests, and where responsibility lies for reviewing the results. All too often the results are simply pushed back to us in General Practice to review, which as the paper states is ‘an inappropriate use of NHS resources and can have a potentially significant negative impact on primary care’. The paper states that the RCGP does not support non-evidence-based screening and that ‘the organisation initiating the screening should not assume that general practitioners will deal with the results. Organisations offering these interventions must organise and fund follow-up so that patients are adequately supported and so that the interventions do not impact negatively on the use of NHS resources.’ As discussed in the BMJ after its publication (BMJ 2019;366:l5707), the lead author Margaret McCartney is realistic that this won’t solve all the problems of non-evidence based screening, but it hopefully ‘will lead to positive change’.

In a time when NHS budgets are as tight as they have been for many years, we simply cannot waste precious resources on interventions that have no proven benefit, and screening in general is an area that I think we need to be looking at much more critically. We are incredibly luck in this country to have the National Screening Committee (NSC), which gives objective recommendations on the benefits and harms of population screening, yet as is happening in the private sector, screening ‘pilots’ and ‘programmes’ are getting introduced into the NHS without good evidence to support them. The NHS Health Check is one such anomaly, and is conspicuous by its absence in the list of NSC recommendations. The latest review of the literature on the NHS Health Check programme (British Journal of General Practice 2018; 68 (672)) suggests that overall uptake is <50% and that current modelling estimates the programme prevents one CVD event for every ~5000 people screened, and there is a lack of evidence as to whether the programme has had any impact on health-related behaviours. The initial modelling suggesting that health checks would be a cost effective initiative was based on the improbably optimistic premise that >75% of people would attend screening and that >85% of those picked up with high cholesterol or high CVD risk scores would be prescribed statins. The fact that the Health Check seems to be making minimal impact should come as little surprise. The latest Cochrane review on general health checks published earlier this year concluded they have little or no effect on total mortality, cancer mortality, fatal and non-fatal IHD and probably have little or no effect on fatal and non-fatal stroke and cardiovascular mortality (all moderate to high certainty evidence). Unusually they go as far as to suggest that further research is not indicated on general health checks as ‘it seems futile based on the large amount of available data’.

Applying the mantra that ‘all screening causes harm; some does good, and some more good than harm at a reasonable cost’ is something we collectively need to mindful of when considering both individual and population screening. And as for direct to consumer genetic testing…well that is another whole can of worms that we will be discussing in our Spring 2020 reviews! 


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