Night’s Watchmans and the White Walkers - Game of Thrones

"... and winter is coming" are the ominous words first uttered by Eddard Stark, Lord of Winterfell and Warden of the North, in the opening scenes of Game of Thrones. Such words were well heeded by Napoleon in Russia in 1812, if not by Hitler in 1941, and now, in a similarly invasive, if less violent, context, by health custodians of the NSW Far North Coast in 2017.

The Northern NSW Local Health District (NNSW LHD), in conjunction with the North Coast Primary Health Network, local Aboriginal Medical Services and General Practices, is on a quest before this year’s winter sets in.

Each April/May sees a spike in patients attending general practices to receive influenza, pneumonia and other vaccines. Many practices attempt to cope with this increased load by running clinics for their most susceptible patients. Most Aboriginal people and all people aged over 65 qualify for free vaccinations.

Patients with diabetes or chronic conditions that affect the lung, heart and immune system are at greatest risk and should receive the age appropriate influenza vaccination. All pregnant women are encouraged to have the free vaccine. It is safe in pregnancy and protects not only the mother but also the newborn in the first six months of life.

Workers who get influenza may expect to have a number of unpleasant days of illness, and to lose time from work, with symptoms such as high fever, myalgia, headache, runny nose and coughing. Yearly vaccination greatly reduces this risk. Those too pressed for time to get to their general practice can be vaccinated at some chemists for only a small fee.

A frustration for many GPs is vaccine refusal due to the oft heard complaint that the vaccine ‘causes the flu’. Patients are quick to label autumnal allergic symptoms and minor viral illnesses as post vaccination influenza and make the false assumption that a temporal correlation indicates a causal association.

Side effects from vaccination are rare and, apart from fainting young males, are mostly confined to soreness around the injection site or low-grade fever that settles in 24 hours. Since the Australian flu vaccines contain no live virus it might be worth checking with patients on their understanding of how these vaccines work.

It is important that GPs practice, and are seen to practice, what they preach. All health professionals in contact with patients should be immunised and many general practices will pay for all their staff to be immunised.

The autumnal vaccination season is soon followed by increased presentations for many viral illnesses. Outbreaks of influenza start in June and peak in August. They are associated with lost productivity in the healthy, with significant morbidity and mortality in the very young and old. These severe cases stress the resources of local hospitals and major outbreaks can be devastating.

Older patients will often have prolonged hospital stays from the complications of influenza. This ties up much-needed beds and has a cascading effect through the hospital system with bed block in the wards causing similar problems in the emergency departments. It even ties up individual ambulances for hours on end. These issues have been well documented and publicised for North Coast Hospitals in recent years.

The Winter Strategy addresses this aspect of the problem by aiming to better manage those at greatest risk of hospital admission. It is a four-pronged strategy focussing on:-

  1. Identification by GPs and the hospital EDs of high risk patients,
  2. Increasing patients’ capacity for self care management,
  3. Improving access to medical attention before the condition deteriorates to the need for hospital admission
  4. Out of hospital care through increased services from community and LHD chronic disease nurses, home visits by GPs (and possibly GP nurses) and Hospital in the Home.

Better communication between all groups within the primary and secondary health sectors is the key to delivering this program, which builds on the work done in 2015-16 in the North Coast Integrated Care Collaborative. Reorganising services to be more patient focussed takes time and effort and will extend well beyond the 2017 winter.