General Practice in East Lothian, 1990-2000

Dr A Davies

I work in Tranent Medical Practice, which is situated in Tranent (six partners) and Ormiston (two partners). Tranent has a Health Centre with six surgeries and rooms for practice nurses, health visitors, midwives and community psychiatric nurses. Another wing of the health centre has a chiropody room and rooms for children’s clinics. The emergency overnight service for west East Lothian also operates from this wing.

In 1990, when Dr Kennedy retired, the practice changed its area, drawing in its area considerably, hoping that with more patients being closer to the health centre, there would be easier access for patients to the centre and so reduce the need for home visits. This has happened in Tranent and also in Ormiston.

Workload has increased. Nursing homes have opened in Pencaitland and Tranent. Now 100 quite unwell patients require four sessions (two hours) of GP time and additional emergency work. To balance this, overnight and weekend emergencies are handled by a co-operative of eleven practices (36 doctors) which covers west East Lothian. Haddington and Dunbar have their own arrangement. Later it may all amalgamate.

Work in surgeries continues, looking after ill patients, many of whom are discharged from hospital early on many drugs and who need a lot of attention. Use of day-surgery means increased vigilance and significant numbers of patients need readmitted. We are now involved in putting and maintaining people on anticoagulants, we are increasingly looking after patients on second line anti-inflammatory drugs who need regular monitoring. These items require many members of the GP team to be involved – receptionists, nurses and doctors.

Our area has a high incidence of heart disease and stroke and diabetes (national average is 2%, ours is 10%), and cancer continues with levels of lung cancer in women approaching that of men. Infections still cause great problems, not least the upsurge in resistance to antibiotics and the onset of new lethal bacteria like E coli 0157.

Mental illness is demanding more attention. There are now four consultant psychiatrists for East Lothian, one dealing with psycho geriatrics, mostly dementia. There is a move to deal with mental illness in the community. The consultants hold clinics in most practice premises and community psychiatric nurses are attached to small areas. GPs are prescribing more antidepressant drugs than ever before. The newer drugs are user-friendly and have good compliance rates.

Maternity work continues but with less input from GPs and more from midwives. Pregnancy is confirmed easily by urine testing and mothers are now referred to the only maternity unit in Edinburgh, the Simpson Maternity Hospital. The consultants run satellite clinics in the community. There is a small and consistent request for home deliveries; some GPs have no part in this. The midwives will handle these cases if deemed appropriate. Some mothers elect for domino delivery – delivery in hospital with their own community midwife, and then within a few hours, go home. Fathers are involved much more now, often attending scan investigations and delivery. Most GPs and midwives run antenatal clinics.

When mother and baby come home, midwives call every day until the 10th day. After that, health visitors call and advise, and then children attend surgeries for immunisations and child surveillance appointments.

Preventative work takes place as well – GP clinics for asthma, diabetes, ischaemic heart disease monitoring. Cervical smear test recalls take place every three years. There is monitoring of registers of diseases, for example hypertension and thyroid replacement therapy: practice nurses deal with this work. Our practice has 2.5 full-time practice nurses. Our patients are asked to go for regular breast screening by mammography from age 50.

Health visitors now give the childhood immunisations. Recent controversy about the link of childhood autism to the MMR vaccine is a problem. In Scotland, immunisation rates have not fallen much. Successes have been with the introduction of vaccines against Haemophilius influenza and Meningitis C.

After birth, some babies survive extreme prematurity and then have medical problems afterwards. In general, children are very healthy but there is a new incidence of asthma and severe allergies e.g. to peanuts.

Use of antibiotics has reduced in children. Most illnesses previously treated with antibiotics are viral and self-limiting.

School children are bigger and more inactive and less sporty. The diagnosis of attention deficit disorder and the subsequent treatment with Ritalin (methylphenidate) a close relative of amphetamine, is a worry. Even the experts can’t tell us how far into adulthood this treatment should continue.

Youth culture is an unknown area for many of us for the use of illegal drugs is greatly increasing. Intravenous heroin is being replaced by snorting or smoking, but cannabis, ecstasy, amphetamines and cocaine are easily available. Some patients in their late twenties have now been abusing drugs for 15-20 years. There is a definite incidence of long-term brain damage appearing.

The provision of eye care is offered by opticians who now have a system of direct referral to hospital for glaucoma; eye tests are free for anyone still in full-time education and pensioners. More elderly get cataract operations but waiting times for this operation are enormous. The use of contact lenses is widespread.

Dental care is more problematic. Many dentists no longer offer NHS care. Many patients never register with a dentist.

Foot care is provided free, by chiropodists, to pensioners and to others if medically necessary. There are now chiropodists in most surgeries or health centres.

Physical disability is less problematic and more is organised for disabled people, for example wheelchair access to public buildings and access to adapted taxis. Children often born with a disability are encouraged to stay in mainstream education with support but there are special schools. Disability through injury like paraplegia needs a lot of support and care. Sometimes respite care is provided but there is a shortage of places for respite for young, chronically disabled.

Older people are living longer and often alone. Their children are easily provided with housing so they don’t live together like they used to. Provision for this was expanded recently. There are lunch clubs and day centres in each village with added outings and activities. For frail and ill old people, day hospitals allow them to be assessed and investigated without being admitted to hospital. Social work now provides packages of care to enable frail elderly people to remain in their homes. Families do try to maintain their old folk in their homes but cannot leave their jobs and the need for care plans is great.

Alcohol problems continue, with much evidence of over-indulgence. It does seem to be unacceptable to drink and drive. All ages are involved. Alcohol is relatively cheap and easily available. Doctors and nurses spend much time dealing with alcohol effects on individuals and families. There is now an appointed community psychiatric nurse to deal solely with alcohol problems and counselling is available.

Tobacco use is still very strong. The youngsters take it up. More people are encouraged to give up smoking now and GPs are urged to use nicotine replacement items and urge attendance at smoking clinics. The government is beginning to back this.

Drug abuse is highly prevalent in youth, and support services are trying to stabilise some users on methadone replacement programmes. GPs and community projects are also trying this.

In summary, medical practice in the 1990s is expanding and is becoming more team-orientated to promote good health.