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INSIDE HEALTH

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Programme 6.

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TX:听 29.10.13听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 HELENA SELBY

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Porter

Coming up in today鈥檚 programme: Exercise and depression - exercise is often held up as an alternative to pills and talking therapies for milder forms of depression, but do the benefits live up to the hype?

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And does this ring any bells?

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Clip

It just looked horrible.听 Instead of being pinkish they were sort of a yellowish brown, it was sort of musty unpleasant colour.

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And which nails were affected?

听

I think all of them but the big toes were the worst.

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Had you tried covering them up?

听

Well I didn鈥檛 expose my feet very often.

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You hid them?

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Yes.听 I didn鈥檛 like people seeing my nails.

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Porter

Fungal nail infections - I am sure you鈥檝e all seen the ads urging people to seek treatment. But which treatment is best - and do any of them actually work?

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And getting in to see a GP - how one doctor is harnessing technology to make it easier.

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But first the call for all children under five to be given free supplements to combat vitamin D deficiency. Current recommendations advise that parents should give children under five supplements of the so-called 鈥渟unshine vitamin鈥� but most don鈥檛, and deficiency is now widespread leading to a resurgence of rickets. Nearly half of all young children in the UK have sub-optimal levels of Vitamin D. England鈥檚 Chief Medical Officer, Professor Dame Sally Davies, hopes the move to provide vitamins free to all families will boost uptake.

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Davies

Healthy Start vitamins, which offered at the moment to children who are in poverty or socially excluded or at risk, actually have Vitamin D in them but unfortunately the take up is very low and it鈥檚 not working.听 And there鈥檚 a Birmingham University study which is absolutely excellent where they gave them universally the vitamins, got a dramatic reduction in symptomatic Vitamin D deficiency and improved matters by nearly 60%.听 So clearly a universal offer can catch the people it needs and that鈥檚 not surprising because Vitamin D deficiency isn鈥檛 just in poor people, it鈥檚 people with pigmented brown black skins, it鈥檚 in people who are covered up too much or use sunscreen a lot and the further north you get the more likely you are to be Vitamin D deficient.听 So a universal offer would mean that we鈥檇 see less Vitamin D deficiency.

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Porter

But what鈥檚 actually different about this?听 I mean looking at the NHS website, the Department of Health already recommends that every child under the age of five has Vitamin D supplements unless they鈥檙e given a fortified formula feed, is it that they鈥檙e free?

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Davies

The difference with the Birmingham study was twofold:听 One it was free and two, it was given to the mother when she visited the clinic or the health visitor came to her so she didn鈥檛 either have to pay for it or go out and cash in the script and that makes it much easier and that meant the uptake was bigger.听 And as you and I both know vitamin drops or tablets made for this sort of use cost pennies.听 So we need to check it is cost effective but looking at the Birmingham study I suspect it will be but NICE are going to do that review.

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Porter

Why do you think current uptake on the existing recommendations that parents should be giving this supplement to their children anyway, it鈥檚 not the sort of thing that midwives and doctors are mentioning very often is it?

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Davies

Well clearly our mothers are not hearing it, whether that is that they鈥檙e not told, I haven鈥檛 done a study to be sure but they鈥檙e not hearing it and some of it is just the hassle of going out to the chemists to buy them.听 So the easier we make it the more likely children are to get it, the less problems and disease we鈥檒l see in children.

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Porter

Professor Dame Sally Davies. Well Inside Health鈥檚 Margaret McCartney has been listening to that. 听Margaret, do you tell your patients to give Vitamin D to their children?

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McCartney

Yeah, I have to admit this is all within the remit of the health visiting service and health visitors are often the first point of contact for healthy children under the age of five who are getting advice.听 And the current advice, and it has been the advice for, it has to be said, really some time, is that all infants and children aged between six months and five years if they鈥檙e not having half a litre, 500 mils, of formula a day, which is fortified with Vitamin D, should be getting the little vitamin drops with vitamins A, C and D in them.

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Porter

But you and I know that the vast majority are not and part of that鈥檚 because Vitamin D鈥檚 sort of fallen off the radar a bit hasn鈥檛 it?

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McCartney

Yeah and I think we all remember how you had to swallow your cod liver oil in the morning and I think it has changed, it was something that was very much in focus and now it鈥檚 a bit less in focus.听 But I think over the last few years there鈥檚 been an awful lot of publicity attached to Vitamin D but of course we鈥檝e seen an awful lot of hype about Vitamin D as well and how many things it鈥檚 purported to treat or cure in adults.听 So I think we have to find the middle way 鈥� there certainly is evidence that many of us in the UK are deficient, it鈥檚 very difficult to get everything from your diet and from sunshine but I think we shouldn鈥檛 be overhyping the effects of it.

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Porter

But Margaret, do you think handing them out for free will boost uptake, presumably so?

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McCartney

Yeah and as Sally Davies says there is this study from Birmingham that said if you give free vitamins to all children you do reduce the amount of children with symptoms relating to Vitamin D deficiency.听 But what鈥檚 really interesting was that that study showed that only 17% of children took up the vitamins after they were offered for free.

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Porter

But there鈥檚 still a lot of inertia to overcome 鈥� 17% uptake is still pretty poor.

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Stay with us Margaret as I think you will interested in our next item.

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Now here at Inside Health we are normally trying to clear up confusion among the general public, but this week it鈥檚 doctors who seem to be confused following the publication of a new review into the evidence behind advocating exercise for people who are depressed.

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The recent publication of analysis by the evidence based Cochrane Collaboration led to very different conclusions in the medical press - ranging from suggesting exercise was as good as antidepressants, to the other extreme that there really wasn鈥檛 much evidence that it helped at all. But who was right?

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Gillian Mead, Professor of Stroke and Elderly Care Medicine at the University of Edinburgh, led the Cochrane review - so is exercise an effective treatment or not?

Mead

It depends how you interpret the data and I think this is one of the difficulties in this area.听 If you look at all the evidence together it suggests that it does help a bit, if you look at just the high quality studies they actually suggest that it probably doesn鈥檛.听 So it depends very much on how you interpret the data and what your question is in the first instance.

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Porter

You mention that overall that it helped a bit, can you quantify a bit?

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Mead

I think that鈥檚 a very difficult question and the effect size that we used in the review is called the 鈥淪tandardised Mean Difference鈥� which Cochrane reviewers would understand but it鈥檚 actually quite difficult to interpret for people who are not familiar with the methodology.听 But roughly speaking that would equate to a six point improvement on a depression scale called the Beck Depression Inventory which ranges from nought to 63.听 So a score of nought would mean no depression, 63 very severe depression.听 So you鈥檙e looking at perhaps a six point difference on that scale.

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Porter

And how does any benefit compare to other interventions such as antidepressants?

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Mead

In our review we looked at trials that had compared exercise with antidepressants and we found that there was no difference between the two in terms of benefits.听 But I have to say that there was only a small number of trials so we can鈥檛 be absolutely confident about the results.听 Similarly we looked at trials comparing exercise with psychological therapies and again we found similar sorts of benefits but again small number of studies so we can鈥檛 be absolutely sure.

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Porter

Because you can interpret that two ways can鈥檛 you, you can say well look here we are exercise is as good as antidepressants and it鈥檚 as good as psychological interventions or you can say actually antidepressants and psychological interventions and exercise don鈥檛 have much in effect, none of them have much in effect?

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Mead

You could do, although if you look at the Cochrane reviews of antidepressants for depression there is much larger body of evidence, so I think we can be more confident that antidepressants have an effect than we can be that exercise has an effect.

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Porter

It must be very difficult looking at this sort of evidence because the groups of patients being studied are often very different, the degree of depression might be different and then we鈥檝e got to quantify what we actually mean by exercise?

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Mead

Absolutely, the trials recruited people from a wide variety of sources, so some, for example, just recruited patients who were undergoing treatment by a psychiatrist, so had severe depression and other people recruited patients from the general population by using a cut-off point on a scale, so these might not be people with particularly severe depression.听 As you say exercise can come in many different forms and the trials used a wide variation of exercise interventions.听 Some of them were more intense than others and some lasted longer than others, so it鈥檚 actually quite difficult given all those variable factors to be absolutely sure what the answer is.

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Porter

People, both the general public and doctors, like myself, often turn to Cochrane for a definitive answer, is this something we should be offering, is this something I should be doing.听 Are you happy that we鈥檝e done enough research in this area to investigate a link between the two?

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Mead

I think we do need more high quality studies.听 There are several studies that we identified that are currently on-going and we will need to update the review at some point in the future when further data are available.听 So I think it鈥檚 an area where we do need more evidence still.

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Porter

Professor Gillian Mead and Dr Margaret McCartney has been listening to that. Margaret, it might come as a surprise to many listeners that we鈥檙e having a debate about this, after all depression is in current guidance 鈥� we should be offering it to people who have depression 鈥� is that a mistake?

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McCartney

No I don鈥檛 think it鈥檚 a mistake but I think it鈥檚 an uncertainty.听 So I think we are lacking in really good quality evidence that would let us be pretty definitive to patients about whether or not this would help them.听 I think it鈥檚 really important as well to separate out two things, one, is that sometimes we can recommend that a patient does exercise who has depression and the second thing is whether or not the NHS should organise classes or groups to facilitate the increase of exercise among people who are depressed.听 And I think some of the controversy that鈥檚 been about, for example, the British Medical Journal鈥檚 study which was published last summer in Bristol and Exeter found that setting up a scheme to refer patients to to increase their exercise wasn鈥檛 very useful but unfortunately often the media coverage that resulted from that was a lot of people feeling quite upset and offended that the exercise that they felt helped them with their mood disorder was no longer recommended or they were being told that it was somehow a bit useless.听 So I think there鈥檚 two separate things in there.

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Porter

The pragmatist in me says well so what if exercise isn鈥檛 brilliant at helping people with depression, it has myriad other benefits and there isn鈥檛 really a downside is there?

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McCartney

Yeah, so I mean exercise is good for us, we know that there鈥檚 lots and lots evidence that says you鈥檙e likely to live a longer better quality life if you鈥檙e able to partake in regular exercise, so that鈥檚 good.听 The problem is when you recommend it to someone who鈥檚 got depression.听 There鈥檚 a couple of things that do concern me.听 First of all that people might make the wrong decision based on inadequate evidence about whether or not to use exercise as a treatment for depression.听 But the second thing is that when you鈥檙e depressed it can be really hard to motivate yourself to do things and exercise is one of those things that it can be very hard to motivate yourself to do.听 And if you were to choose exercise as your intervention to try and help with your mood, if you鈥檙e not able to do that that in turn might make you feel even worse about yourself, which is of course not the situation that you really want to open someone to when they are depressed.

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Porter

Professor Gillian Mead said we basically need more research into this area to come up with a conclusive answer.听 Looking at all the vagaries involved can you ever see a day when we鈥檙e going to be able to say it works or it doesn鈥檛 work?

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McCartney

Yeah, I think probably and I think one of the things that would be really useful to do is to categorise people with different kinds of depression.听 So mild to moderate depression is quite a different thing from a very severe depression and I think the strategies you might want to use to help someone would be quite different.

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Porter

Thank you very much Margaret - and there is a link to that review by Cochrane into the benefits of exercise in depression on the Inside Health page of the Radio 4 website.

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As we pointed out a couple of weeks ago as many as half of all people dispensed the most common type of asthma inhaler don鈥檛 use them properly, and our report on their misuse prompted a number of you to get in touch.

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Hughes

My name is Hazel Hughes, I am a pharmacist from Crewe with about 39 years鈥� experience on register.听 I did notice disappointingly there was no mention of pharmacists and the advice that they鈥檙e able to give about inhalers.听 Most community pharmacists have undergone extra training to be able to give advice and to demonstrate how to use inhalers correctly and effectively.听 If you鈥檝e been getting your medicine dispensed for three months at a particular pharmacy you can have a medicine use review, which involves a private consultation with the pharmacist to discuss how to use your medicines which includes inhalers to get the most benefit out of them.听 There is also a new medicines service where with a new medication, such as an inhaler, the pharmacist will enrol you on to the service, give you a demonstration of your inhaler and then follow up in a week and then about a month when you鈥檝e had a chance to use your new medicine to check you鈥檙e getting on with it alright.听 Giving advice on asthma inhaler technique is a service that鈥檚 provided in most community pharmacies every day and we鈥檙e very happy to do so.

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Porter

Well, we tried to do our bit too by posting a video on the Inside Health website of our guest Professor Mike Thomas showing how to use the various devices. A number of you e-mailed in to say that he had got one of the demos wrong. We have since edited the video so it鈥檚 OK now - and Professor Thomas has gone into hiding!

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Seriously though, it鈥檚 an easy mistake to make given the numerous devices that are out there - and if the Chief Medical Advisor to Asthma UK can get it wrong, what chance the rest of us? Particularly if we have never been taught properly in the first place?

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Another listener got in touch to tell us about her toe nails:

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Pam

I鈥檝e had a fungal toe nail infection since 2008.听 I think I got it from doing a lot of running which I was doing at the time.听 When I was running I was doing marathon training and running long distances and actually my feet got really, really damaged 鈥� my nails, particularly.听 So my toe nails would go black, then they鈥檇 fall off a few weeks later, so bits would just come off and then you鈥檇 just have the nail bed underneath where a new nail would grow.听 And I don鈥檛 think I realised at the time that that damage could actually be sort of a bed for infection I guess.听 So I鈥檓 pretty sure that the fact that at one point nearly all of my toenails fell off probably just exacerbated the problem and I鈥檓 left with the infection now.听

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It started on my little toe but then it started spreading to the other toes until eight of them were all infected and just got worse.听 My two big toes seem to be okay for whatever reason but the other ones they鈥檙e just a bit crumbly and they鈥檒l thicken and it鈥檚 a bit gross.

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Porter

Fungi occur naturally on our bodies but thrive in warm, damp dark places like shoes. If you have healthy nails and a normal immune system, it鈥檚 hard for the fungi to get a foothold. But if your nails are damaged - creating a portal of entry for the fungus - or your immune system is compromised because of some underlying health issue, like diabetes, then infection becomes more likely. And if you are elderly you are likely to have both a lifetime of bashing your toes and a number of underlying health issues, so it should come as no surprise that around half of all people over 70 have fungal nail infections. Tell-tale signs include thickened, flaking or crumbly nails that are often yellowish brown in colour.听

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But what should our listener do about hers? To find out I went to Mile End Hospital in London to meet podiatrist Ina Farrelly.

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Farrelly

You鈥檙e looking at condition that isn鈥檛 going to kill someone, isn鈥檛 going to cause him any pain.听 It can be unsightly.听 Some people are more than happy to paint nail polish on it and cover鈥�

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Porter

Just cover it up.

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Farrelly

Yeah.

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Porter

But assuming they don鈥檛 want to cover it up, they want to get rid of it?

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Farrelly

They want to get rid of it 鈥� and lots of people do, I mean that鈥檚 that whole thing 鈥� fungi doesn鈥檛 sound very nice, so some people do want to get rid of it.听 There鈥檚 a few options available to you.听 One of the classics that鈥檚 available and has been available for about 15 years is a nail lacquer.听 Now it comes down to looking at the nail 鈥� if the infection is just kind of at the end of the nail and hasn鈥檛 reached down to the bit where your nail actually grows out of the skin you should be alright just using a nail lacquer.

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Porter

And this has got anti-fungal 鈥� just paint it on effectively?

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Farrelly

Yeah.听 The trick is you must make sure that you file right across the top of the nail so that the medication actually soaks in.听 And that鈥檚 the same with any home cure, whether it be tea tree oil or Vicks vapour rub or vinegar 鈥� and yep they鈥檝e all been recommended.听 Tea tree oil has anti-fungal activities and has actually got research to back up that it鈥檚 quite effective.

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Porter

But this is likely to work best for people who鈥檝e just got what we would call distil infection, so infection in the latter part of the nail, not down to the cuticle.

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Farrelly

Once it gets down to the cuticle you鈥檙e really looking at a need for oral medication and this is where you get medical people, like yourself and me, saying to people look you need a liver function test theoretically before you have that done.

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Porter

These are strong medicines, so can have an effect on your liver.听 I鈥檓 getting the impression and it鈥檚 an impression I鈥檝e got before from speaking to lots of my other colleagues that oral medication听 is using a sledgehammer to crack a nut and we鈥檙e not keen on it unless the patient鈥檚 desperate?

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Farrelly

Yeah, yeah if it鈥檚 a bloke and he wears boots all the time and he鈥檚 just come because his wife鈥檚 harassed him or someone鈥檚 said you should do something about that then you鈥檝e really got to question the validity of giving someone like that quite a strong oral medication for something that is more about social鈥�

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Porter

It鈥檚 cosmetic.听 Okay what are the odds of success 鈥� let鈥檚 assume you鈥檙e suitable for the nail lacquer, what do you tell your patients in terms of the likely outcome 鈥� how long will they need to treat for and what鈥檚 the chance of a cure?

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Farrelly

The most common nail affected is your big nail, so your big nail can take anywhere between a year and 18 months to grow from beginning to end and that鈥檚 pretty much how long you have to use the nail lacquer for.听 And if you get rid of it research indicates you鈥檝e got up to a 50% chance of recurrence because if you鈥檝e got in the first place it may be because you鈥檝e damaged the nail, you鈥檝e got other illnesses so then you鈥檙e predisposed to it.

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Porter

But what are the chances of getting rid of it in the first place?

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Farrelly

About 30% they argue.

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Porter

Right, so less than half are getting rid of it and if you do get rid of it there鈥檚 probably a 50/50 chance it鈥檚 going to come back?

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Farrelly

Yeah.

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Pam

The nail lacquer 鈥� you have to be quite strict and you鈥檙e supposed to use for a year and I have been disciplined enough to use it I think for twice a week for a year but it hasn鈥檛 made a difference, I may have missed some times and I think also as it started when I was running if you do do exercise more I just think because it鈥檚 a slightly damn environment it doesn鈥檛 get rid of it or it grows back enough.

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Porter

What about the oral medicines 鈥� are they more effective?

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Farrelly

They鈥檙e more effective yeah but not very鈥�

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Porter

It鈥檚 still 50/50?

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Farrelly

Yeah because you have to take them for about a three month course.

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Porter

So if you catch it really, really early, filing and tea tree oil otherwise the lacquer but if it gets established you鈥檙e on a bit of a 鈥� sounds like you鈥檙e on a bit of a hiding to nothing?

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Farrelly

Really yeah.

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Pam

I keep seeing these things that are advertised where it says you can have six treatments of laser treatment on fungal toenails, which I think sounds really, really intriguing and if it worked I would definitely definitely try that but I鈥檝e always wondered if there鈥檚 any actual evidence that laser treatment on them does work given most other treatments take so long to work, could it work instantly?

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Porter

Laser treatment, this is the latest boy on the block if you like, latest treatment to come along 鈥� is it any more effective?

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Farrelly

Well there is a research paper that I found where they had 40 patients that they used laser on and they followed them up and they found in this study that it produced an improvement in the cosmetic appearance.听 What I found interesting about that study is that they didn鈥檛 say they鈥檇 actually cured it, they said it made it look better.听 I couldn鈥檛 find any NHS authorities that are actually offering laser and I think that鈥檚 because most people at this point aren鈥檛 totally convinced or feel there鈥檚 enough research to back it up.

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Porter

It鈥檚 not something that the podiatric world鈥檚 getting excited about is what you鈥檙e telling me?

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Farrelly
I think that again it鈥檚 a cosmetic infection, if that鈥檚 what worries you and laser makes it look better then maybe that鈥檚 something you want to investigate but if you鈥檙e looking to cure it I haven鈥檛 found anything to support that.

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Porter

Okay, assuming I get rid of 鈥� I鈥檓 one of the lucky minority who get rid of this after many months, maybe 18 months, you said there鈥檚 a 50/50 chance of it coming back, is there anything I can do to change that?

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Farrelly

What you also need to do is you鈥檝e got rid of your fungal infection 鈥� congratulations 鈥� you need to be aware of the fact that you鈥檝e now got a cupboard full of shoes they鈥檙e sitting there full of fungi.

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Porter

So how do I get rid of that?

听

Farrelly

Well there鈥檚 varying things and most of them are sort of old wives tales but some of them work quite well.听 One patient I know put all his shoes in a plastic bag, sealed them up with bleach inside and left them there for eight hours to fumigate them.听 If you know someone that鈥檚 got gas sterilisation.听 My sister baked her shoes in the oven, I鈥檓 not recommending that, I鈥檓 sure it would wreck your shoes.听 Or you just buy new shoes.听 If you鈥檝e got canvas sneakers you could probably wash them in the washing machine.听 And you can try putting them out in the sun which might be a challenge to find in England but there you go.

听

Porter

Podiatrist Ina Farrelly talking to me in her clinic at Mile End Hospital.

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If you would like us to look into a health issue that is concerning you then please do get in touch 鈥� you can a send a tweet to @bbcradio4 including the hashtag inside health or e-mail insidehealth@bbc.co.uk

听

One perennial complaint we receive is how difficult it is to get in to see a GP - either during normal working hours, or at night or over the weekend. An issue that has been picked up recently in the debate about pressure on A&E departments. GPs are acutely aware of the problem, but like their local A&E departments, most are already running at full capacity - so how can access be improved?

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Well in Middleton, North Manchester a group of GPs think they may have a solution - using IT technology to blur the boundary between听 hospital and community, and out-of-hours GP clinics and normal surgeries. Dr Fred Thomason is working on a pilot to test the idea:

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Thomason

We are setting up an extended hours pilot within the town whereby patients will be able to book into clinics of an evening and also at the weekend which will be staffed by the out-of-hours provider but within that there鈥檒l be the possibility that the doctor who sees the patient will be able to access the patient record on a web based system now where the computers are accessible if you have a hosted server away from the practice you can actually access that really from anywhere and so it鈥檚 a possibility that an out-of-hours doctor can conduct an in hours consultation which is obviously beneficial to the patient.

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Porter

Is this something that鈥檚 only going to apply to patients who have urgent medical problems or is it something 鈥� I mean if I was away working from home and didn鈥檛 get back from my commute till half past seven would I be able to use this sort of extended hours?

听

Thomason

Yeah I think this is the kind of patient that we would be targeting with this service and we鈥檇 have to speak to practices and make sure that they use their common sense and they book that kind of patient into the service and not just fill up with people who could have come during the day.听 But we鈥檙e also extending the facility to A&E so the nurses who triage at the front door of A&E if they see a patient who they think may be more appropriately dealt with in primary care they鈥檒l say to them well there鈥檚 a four hour wait here but we can book you in a clinic in an hour鈥檚 time back where you live.

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Porter

How have your colleagues accepted this 鈥� do they think it鈥檚 a good idea?听 The concept of basically routine appointments in extended hours has always been a controversial one.

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Thomason

I think most general practitioners think that access is a big problem, it鈥檚 a day-to-day problem, the more we can do to try and solve it the better.听 And also the problem in A&E which has been in the press for quite a while 鈥� if we can improve the front door problem at A&E 鈥� people turning up who may not be entirely appropriate.听 But also we have a system which we鈥檙e piloting which allows us to track a patient through the hospital.听 So we can then plan discharges if we know where patients are and we call that our NHS tracker and Pennine, our local hospital, are very keen to put this into place.

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Porter

And how does that work?

听

Thomason

Well if a patient is admitted on to their computer system on the hospital, if it鈥檚 a Middleton patient, because that鈥檚 our pilot, they鈥檒l also be admitted on to the tracker system, it鈥檒l just be a few more keystrokes, and then if that patient is seen in A&E and discharged then that is recorded and it鈥檚 colour coded.听 If the patient is admitted up to the ward, they鈥檒l turn red.听 Once they鈥檙e getting towards the end of their package of care they turn yellow and then when they鈥檙e finally discharged they turn green.听 So practices will be able to go on that and see who鈥檚 in the hospital, where they鈥檙e up to and whether they鈥檙e ready for discharge.听 And that allows us to plan for discharges because what happens, and most patients who are discharged from hospital will verify this, that once the ambulance drops them at the front door they drop off a therapeutic cliff really, they鈥檙e in no-man鈥檚 land until the practice picks that up.听 And that may be three or four days later.

听

Porter

I was going to say it鈥檚 when the hospital lets us know and we may not know for a few days.

听

Thomason

That鈥檚 right and so we need that pre-planning information in order to set up services.

听

Porter

And there鈥檚 a very real risk, isn鈥檛 there, particularly with elderly frail patients, that they come out, that they fall off this 鈥� as you talked about 鈥� this therapeutic cliff and they just bounce straight back into hospital.

听

Thomason

Well that鈥檚 right and we鈥檙e trying to facilitate early discharges by this system and trying to free up hospital beds which will help the backdoor of A&E because patients cannot leave A&E to be admitted to wards because we鈥檝e no beds to admit them to.听 And so we鈥檙e trying to help with that.听 But actually if we can plan ahead 鈥� and we鈥檙e talking to our local hospital about the possibility that the hospital will share care with us for two or three days when an early discharge is made home and then if that happens, if we run into trouble, if somebody鈥檚 discharged early but maybe too early, then we can agree a protocol maybe where they would go back straight into the hospital ward that they were on previously.

听

Porter

And is this going to happen to all patients or do you have particular patients in mind?

听

Thomason

I think early discharges are probably patients that have been on the ward a day or two and they have a therapeutic regime set in place 鈥� maybe they鈥檙e on oxygen and they need to finish off a course of steroids or they鈥檙e on intravenous therapy and they just need a few days of that or they need occupational therapy or they need physiotherapy.听 Then they can come home and have all of that provided we can plan it and arrange it and there鈥檚 no gap in their care.

听

Porter

Dr Fred Thomason - and that pilot starts next week, and we will return to find out how they are getting on.

听

Just time to tell you about next week鈥檚 programme - the last in the current series - when I will be talking to a world expert about the best way to treat trigeminal neuralgia - a cause of severe facial pain. And we will be asking if a new way of diagnosing diabetes is up to scratch.

听

ENDS