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Skip to 0 minutes and 11 seconds So we’re very happy today to be at Ash Trees General Practice Surgery, which is part of the UK National Health Service and is located in Carnforth which is near Lancaster. And today we’re with Dr Andy Knox, who’s one of the partners at Ash Trees. And we’re going to be talking in general about the flu, and the things that Andy sees on a day-to-day basis as part of his general practice as a doctor here. So Andy, we just passed through a very busy waiting room on our way here. So you must see an awful lot of patients during this time of the year. So what proportion of them do you think have cold or flu symptoms? That’s a good question.

Skip to 0 minutes and 55 seconds If we were to compare data from earlier in the year– so yesterday morning I was the triage doctor. So every patient who feels they need to be seen talks to a doctor in this practice. And we decide how quickly they need to be seen and by whom. If you looked in the summer months, we probably took between 70 and 80 calls of a morning. Yesterday we took 127. So that’s a massive increase. And the only thing we can really attribute that to is respiratory disease, particularly influenza and cold-like symptoms. So in kids, that would be RSV and increasing bronchiolitis.

Skip to 1 minute and 28 seconds In adults, we’re definitely seeing a major increase, so potentially a quarter increase on what we normally deal with in the rest of the year, which when you don’t have any increase in staff for the flu season, actually puts a huge burden on a practice team. So I should mention also that we’re filming this in very early December 2015. So it’s not officially the start of the flu season yet. And yet you mentioned that you have an enormous increase in the number of people with respiratory diseases. And you mentioned RSV, or respiratory syncytial virus, and the main symptom of that is bronchiolitis, which is an inflammation of the bronchial, which is quite low down in the lungs.

Skip to 2 minutes and 8 seconds That mostly occurs in children. It does, particular effecting under two-year-olds. And the problem with it is, is there’s not particularly any treatment for it apart from oxygen. And you’ve just got to always play a very importantly managed clinical game with the parents to work out, is this child able to be managed at home, or do we need to admit them? And it’s often a very fine line. And it sometimes clearly depends on the parents own feeling of confidence and what they feel competent and confident to manage themselves. So if the child or infant is clearly needing oxygen, than that would quite clearly be something that needs to be dealt with in a hospital.

Skip to 2 minutes and 43 seconds And that would be the point at which you would transition them into a hospital. Absolutely. So leaving aside that the children who may often have respiratory syncytial virus and bronchiolitis as a result of RSV, when it comes to adults, what are your diagnostic criteria, first of all, for distinguishing something which you think is genuinely influenza as opposed to a cold of varying degrees of severity? And is there a point at which you would feel the need to require a hospital test for an adult, or even to send that adult to hospital? So I think there are three different things that we need to distinguish. One, first of all, is how sick is the patient?

Skip to 3 minutes and 24 seconds And for us, that is the differential between just a cold and full-blown influenza. There are loads of people who will have snotty noses, who will have some sinus symptoms, who will maybe get a bit of a mild headache and a slight temperature up and down a bit, but just generally feel a bit off. But that’s not flu. In flu, you’ve really got a full package of significantly high temperature, really severe malaise, myalgia feeling really achy and cold through the body, the swinging pyrexia. You’ve got people with severe headaches, glands up, everything. But actually, when you examine them, you don’t find any clinical signs of a bacterial infection. The thing you’re particularly looking to rule out is pneumonia.

Skip to 4 minutes and 6 seconds So when you tap on their chest, and when you listen to their chest, it’s beautifully clear. There’s no bubbling. There’s no crepitations. There’s generally not even any wheeze there. They just feel absolutely dreadful. And I think there’s just a degree in the symptoms for us that is the differential between common cold, full-blown influenza. And then it’s to do with how much that person can cope with, and how severe their symptoms are, and maybe what else they’ve got going on with them as to whether or not we would ever go for a swab, or ask for a definite diagnosis of influenza from the hospital. To be honest, probably in the last two years, I haven’t asked for one.

Skip to 4 minutes and 45 seconds I’ve seen plenty of people with influenza. But have I felt the need to actually get an official diagnosis? Actually, the clinical diagnosis has been sufficient. And with some good communication with the patient, and them understanding what’s going on, and how long those symptoms are like to last for, and what they should do, and what they should look out for, the vast majority of times we can manage that without any need for further investigation. However, when the swine flu outbreak was a possibility– Yes. Back in 2009. We had a full action plan in place. People were having swabs very regularly.

Skip to 5 minutes and 20 seconds We were starting oseltamivir, because we knew that was the potential that things could go wrong, and get far worse far more quickly and we needed to hit them with the right antivirals straight away, because we didn’t want to have the epidemic or pandemic situation. So I think when we knew those kind of– when we knew the kind of strains we were dealing with, we were prepped and ready. But actually, with that intelligence hasn’t being coming to us, and the vast majority of times people get over influenza on their own with the right kind of support and management at home.

Skip to 5 minutes and 51 seconds People who are on things like DMARD (Disease modifying antirheumatic drugs) medication, people who are immuno-compromised, or are just generally frail and unwell, we are watching them like hawks. So we’re assessing them. We’re saying, hey, look. This is probably influenza. Probably going to make a recovery. But if you’re getting worse in the next 24 hours, 48 hours, we want to know. We’re on their case, at those times, we might be taking swabs, sending them off to the virology lab, and finding out if they need some oseltamivir or something else to support them. Or, has it become a bacterial infection, where we then need to work with them and give them antibiotics? So I saw a lady literally last week.

Skip to 6 minutes and 28 seconds She had been to the out-of-hours provider 48 hours earlier on the Saturday. She had been diagnosed with influenza. She was feeling more breathless. She was feeling really quite unwell, came to see me Monday morning, and clearly had a pneumonia. Admitted, actually she went on to intensive care, spent two days in intensive care, came out, made a brilliant recovery. Brought me a nice box of chocolates to say thanks. And that pneumonia would have been a bacterial secondary infection, probably rather than something caused by influenza.

Skip to 6 minutes and 56 seconds And the differential diagnosis of it depends on, as you said, looking for evidence of spread of infection to the chest, and the sounds that you would make on that, or listening with the stethoscope on the chest. Absolutely. So do you find that– we talked about some prescribing anti-viral drugs then. Do you find in general that there’s a lot of people that expect to be given antibiotics for colds and flu nowadays, or are the general population reasonably educated that they know the difference between a virus infection, where they ought not to expect antibiotics, and a bacterial infection, where antibodies might work? I think there are two things happening.

Skip to 7 minutes and 35 seconds One, we are as a surgery and as a health economy in this area working really, really hard to get messages out there about self care and self treatment. So if you sit in our waiting room for long enough, you’ll see on the screen loads of messages about antibiotics and not overusing them, and the things they do help, and the things they don’t help. And I think when you feel awful, you want something to be done to try and help you feel better. And if an antibiotic might help, people feel like they want to take them. And so often we’ll take a call from someone who has classic cold-like symptoms or influenza-like symptoms. And then they want something to help.

Skip to 8 minutes and 11 seconds And they ask, will an antibiotic help me? But actually, once you talk it through, and you explain the difference between a virus and a bacteria, and what works against viruses, and what works against bacteria, and actually how phenomenal our own immune system is, even in bacterial illnesses– 60% of chest infections will get better without an antibiotic– and actually allowing people’s own immune systems to do the job for them, especially if they’ve got supportive vaccination behind that as well, then hopefully they change their mind and don’t want it. But part of the job is on us, to do education, and to help people recognise when they do and when they don’t need treatment.

Skip to 8 minutes and 45 seconds So that brings us again to our next subject, which is prevention via vaccination. So every year you have to get vaccines out, at the very least to your vulnerable target population. So what are the mechanics behind this process? How early in the year do you have to start preparing for at risk getting vaccines– Really early.. So our flu campaign will end in a few weeks time. So we will have vaccinated the vast majority. We hit our numbers very hard every year. We are really, really passionate about providing as many vaccinations in the community as we possibly can. We really believe in it. We know there’s an accumulative effect on the vaccine.

Skip to 9 minutes and 21 seconds So one year the more influenza vaccines you have, the better protected you’re going to be because of the different strains that occur through the different years. But we will start planning for next year’s flu campaign as early as February. And we will have to then get our order in from the government. We have to order a certain number of vaccines in. We have to make sure we’ve got the numbers in to hit the children who need them, to make sure that all our elderly over 65 have got them, and then everyone in a disease group, who needs one as well. So we order enough for everybody.

Skip to 9 minutes and 52 seconds And then we push really, really hard to try and ensure as many people as possible come in for those campaigns. And last year, and I should mention that we’re filming this in early December 2015. So I mean by last flu season I mean the 2014/ 2015 one. Last year, we were forecast to have a very bad influenza season. And that was partly because the H3N2 virus had mutated away in a rather different direction to expected. The official vaccine was reckoned to be very poorly protective. And all the indicators were there that we would get hammered. And did that happen in your experience? We were hammered. We were really hammered last year.

Skip to 10 minutes and 34 seconds Unfortunately, because of that mutation, if you look at the burden, the crisis that happened in A&E from Christmas through to New Year, when I think the flu really began to just kick in then, the stories were all over the newspapers. The Health Secretary was in disarray, didn’t know what to do. The pressure that came on general practice and A&E departments as a result, people queuing right out the doors of A&E– and then on top of that, we know that deaths were significantly higher last year compared to any other year. I think we saw an increase of 143,000 deaths compared to previous years and what was expected.

Skip to 11 minutes and 7 seconds So getting the mutate– seeing that mutation, or not quite getting the vaccine right has huge implications. So getting the vaccine right is absolutely vital in terms of the cost and the welfare of our population. So there’s been some interesting research recently on the cost of vaccination versus the cost of those who are not vaccinated. So what would you be able to tell us a bit more about that? Yeah. It’s a really interesting study. It’s done by the World Health Organization. And it’s reported in PubMed and The British Medical Journal, The BMJ. And what it did, it took a retrospective case analysis over the last five or six years.

Skip to 11 minutes and 46 seconds And it looked at what has been the cost burden of vulnerable populations, those who had the vaccination compared to those who did not. And what they found, the burden on general practice was enormous. So for people who had the vaccination, the cost of appointments at a GP was around 27 million pounds a year. If you then took people who were vulnerable but did not have the vaccination, the cost of their appointments to the general practitioner rose to 112 million pounds. So that’s a massive difference. We’re talking nearly 100 million pounds difference.

Skip to 12 minutes and 23 seconds And on the hospitals, we see 142 million cost burden for those who are vulnerable and had the vaccination compared to about 167 million for those who should have had the vaccination, but didn’t. So vaccination programmes make a massive difference in terms of cost savings to the NHS. We save money big time. And we save burden on hospitals. We save staff morale. We save everything if we vaccinate better. Because the more people who are vaccinated, the less they will use the health service in that very difficult period of the year anyway. So you see a lot of people, as we’ve said, every year. You probably see more people with colds and flu than the average member of the population comes across.

Skip to 13 minutes and 6 seconds So you’re clearly very exposed to these viruses. Do you find that you’re own burden of disease is elevated to having entered general practice as a profession? It’s a good question. What’s interesting is, I think I’m hardly ever ill. But when I moved areas– so I moved here three and a half years ago from Manchester. In Manchester, I can’t remember having time off in several years. But when I first went to medical school in Manchester, I felt like I was ill the whole time. I feel like I probably went through virus after virus, after virus. You spend a lot time in bed recuperating, feeling sorry for yourself.

Skip to 13 minutes and 41 seconds But you have to get back on the wards because you have to fulfil your time criteria. So you can’t really afford to be off. But actually, you build up a real immunity to stuff, because you’re in contact with it all the time. And maybe you’re a little bit ill now and again, but majorly unwell, not so much. But when I moved here, suddenly I think I met viruses I’d never met in my life before. And I remember getting this full-blown influenza for the first time in many, many years, and shivering my way through Christmas, and feeling absolutely horrendous, and very, very unwell. But actually, since that three years ago, I’ve again, not had a day off.

Skip to 14 minutes and 16 seconds So you’re getting your own form of vaccination, which is vaccination by encountering live virus. I think that’s true. Plus, I make sure I have my vaccination. As well. As well, of course, yeah. So thanks very much, Andy, for taking your time out of your busy practice. There’s dozens of people waiting outside to see you. So we’ll let you get back to work. And thanks very much for having us today. Thank you.

In the Front Line

In this video, I’m joined by Dr Andy Knox, a general practitioner in the National Health Service in the UK, who talks about life in the front line, dealing with the flu and daily medical general practice.

As you listen to Dr Knox, try to think how many of the things he says, serve to bring together the various strands that we’ve studied over the last two weeks. The reason we study viruses is fundamentally that they cause disease. The doctor’s surgery is the place where all of the science is, in the last analysis, judged.

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This video is from the free online course:

Influenza: How the Flu Spreads and Evolves

Lancaster University