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GP Access, Telehealth, ICU, Sewage

Duration:
28 minutes
First broadcast:
Tuesday 24 July 2012

Do you have trouble getting an appointment to see your GP? If so, you are not alone. A Department of Health review from 2009 suggested that as many as 200,000 patients a day struggle to get a consultation with their doctor. And a quarter of those who want to book an appointment in advance simply can't. One Inside Health listener emailed us to ask why some surgeries seem to only release appointments on the day - a bit of a telephone lottery - and others do allow for some advance booking. Chair of the the Royal College of General Practitioners Dr Clare Gerada offers some insight.

Monitoring patients in their own homes - telehealth - is one of the latest developments in general practice.
The government hopes that the technology will help at least 2 million people over the next 5 years, saving the NHS more than a billion pounds. The £2,000 black boxes measure blood pressure, blood sugar levels and blood oxygen - information that's then sent over the internet to a medical professional. But the project to monitor patients with long term conditions like diabetes, heart failure and breathing difficulties hasn't got off to a good start and GP Margaret McCartney questions whether it will ever live up to the hype.

The most seriously ill patients in hospital are looked after in Intensive Care - where they are given life-saving treatment and support with vital bodily functions like breathing. To help staff relieve anxiety - and enable staff to carry out procedures like inserting breathing tubes - patients are often sedated. Dr Chris Danbury from the Royal Berkshire hospital in Reading says it's important to get the level of sedation right - not too little and not too much. One consequence of the drugs and environment can be hallucinations and flashbacks - with some patients reporting dreams of being abducted by alien space ships. Specialist outreach nurses in Reading - like Sister Melanie Gager - are skilled at offering strategies to overcome this - including follow-up visits to the ICU for both patients and their families.

Now that summer has finally arrived for most parts of the UK, if you are planning an outdoor swim then there may be hazards lurking in the water. Heavy downpours result in the release of sewage into the sea from overflow pipes - which can affect water quality for a couple of days. Inside Health reporter Anna Lacey met Pollution Control Manager Dr Robert Kierle on the banks of the river Axe in Weston-Super-Mare - and Surfers Against Sewage who are offering a free text service to alert would-be bathers about local measurements of any pollutants.

  • The beach at Weston-Super-Mare, Somerset

    The beach at Weston-Super-Mare, Somerset

    Holiday-makers flock to the beach - but is it safe to swim?

  • Seafront, Weston-Super-Mare, Somerset

    Seafront, Weston-Super-Mare, Somerset

  • The Pier, Weston-Super-Mare, Somerset

    The Pier, Weston-Super-Mare, Somerset

  • Programme Transcript - Inside Health

    THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.


    INSIDE HEALTH

    TX DATE: 24.07.12 2100-2130

    PRESENTER: MARK PORTER

    PRODUCER: PAULA MCGRATH


    Porter
    Hello in today's programme: I don't want to appear a spoilsport, but now that the summer has finally arrived, if you are planning an outdoor swim then you should listen to what Anna Lacey has discovered for Inside Health about hazards that could be lurking in the water.

    Telehealth - technology that is supposed to help at least two million people over the next five years, and save the NHS more than a billion pounds, but the project to monitor patients with long term conditions in their own homes hasn't got off to a good start. Margaret McCartney questions whether it will ever live up to the hype.

    And I visit an intensive care unit to learn more about sedation - and discover why so many seriously ill people dream they are on space ships run by aliens.

    But first: Do you have trouble getting in to see your GP? If so, you are not alone. Improving GP Access and Responsiveness - a Department of Health review published in 2009 - suggested that as many as 200,000 patients a day struggle to get a consultation with their doctor. And a quarter of those who want to book an appointment in advance can't.

    Inside Health listener Lisa is one of them and has e-mailed us to ask:

    Lisa
    Why do some surgeries use conventional appointment systems - i.e. you phone in and are told when the next available slots are so you can book accordingly - when so many others seem to have switched to a new system of only releasing appointments on the day. This means you can't ring on a Monday to make an appointment on the Friday. You have to ring up on Friday morning - along with everyone else - and by the time you get through all the appointments have gone! And how can I give my employer notice if I can't pre-book?

    And who better to answer Lisa's question than Clare Gerada, Chair of the Royal College of General Practitioners.

    Claire, this call on the day system's been causing grief for some time. Tony Blair famously promised to do something about it when he was cornered by Diana Church, a member of the BBC Question Time audience, and that was back in 2005 but it's still with us. What's the rationale behind it?

    Gerada
    Well the rationale behind the call on the day is it's called advanced access and what it's meant to be - if I can give an example - it's meant to be the same rationale as when you go and buy petrol for your car. So the idea is you buy petrol when you need it and there's never a queue or there might just be one or two people in front of you so you don't need to book well ahead, you should turn up on the day, as long as there are enough access points, i.e. petrol stations, you should be able to get the petrol. But the problem is, using that analogy, we actually probably don't have enough GP appointments, if the truth is known, mainly because we don't have enough GPs and of those GPs that are doing the work what we have now is a massively increased workload due to the ageing population, the complexity, the access points and now you're as likely to find your GP in a walk-in clinic or even a supermarket or a physiotherapy service. So advanced access worked within limits and what we now need of course is a mix and match. I would want to book my appointment three weeks ahead, of course I would, I'm a busy person as many of your listeners are. I must say though that of the people that do book their appointment ahead a quarter of them, on the whole, don't turn up, so that's a lot of wasted appointments. We also have needs for children to have to be seen on the day and emergencies have to be seen on the day.

    Porter
    But actually I'm quite relieved for the time off and so it's not completely wasted, because I'm normally catching up.

    Gerada
    Yeah Mark but the other day I did a surgery where eight patients didn't turn up, I didn't need that time catching up, I was actually pretty angry because of the people that could have seen me.

    Porter
    But there are moves afoot, I mean including for the Royal College of General Practitioners, to extend consultation times so that we can try and do a better job, presumably that's going to make the problem worse?

    Gerada
    It is, it's already is extended, the average consultation length now is about eleven and a half minutes. When I qualified, and probably when you qualified, it was around six minutes. Every patient I see now is equivalent is to that patient seeing five different specialists because over the last 20 years we've moved more and more care outside hospital, so I give a joke that actually the GP now does everything other than open heart surgery. So we've moved more and more care outside hospital, the patients listening to this will know that, so it's very unusual, for example, even for somebody with heart failure to go to hospital, let alone some of the more complex things such as chronic airway disease, depression. So we are doing more and more. We're also - we've got an ageing population, most of the population who are older have lots of different diseases, not just one, so the workload is massively increasing and we need to address this but unfortunately because of that your listener can't get an appointment to see her doctor.

    Porter
    Do you think there's a culture amongst GPs that we actually put some obstacles in the way to reducing access because obviously if we're overworked as it is the last thing we want to do is have our doors fully open and everybody pouring in?

    Gerada
    Access and continuity go hand and hand and continuity means being able to see your doctor when you want to. Now...

    Porter
    Increasingly difficult these days.

    Gerada
    Increasingly difficult. Now amongst the young they tend to just want a quick appointment, in and out, they don't really mind who they see, but certainly once you're ill and have a chronic illness you want to see your doctor. We don't put barriers in but the barriers are there - the barriers are there because unless we sleep in the surgery we can't work any harder. And again we need more GPs spending longer with their patients in their communities and if we don't get more GPs then I'm afraid the NHS will cost a lot more but it also won't be able to deliver the care that it should be.

    Porter
    What can she do - her surgery or one of the surgery's she uses obviously uses this system - it's driving her to distraction, she's not getting anywhere with it, I mean should she register her disquiet? I mean if you look at the patient surveys they say everyone's happy but at ground level that's not the case.

    Gerada
    Well they don't say they're happy about access actually. What she should do is probably ring up the practice manager. We tend to reserve between a third and a quarter for on the day. We have looked at this mathematically over 20 years...

    Porter
    Has there been any work looking at allowing patients to book their own slots, for instance going online and having a look at the calendar and putting their name in?

    Gerada
    Oh yes and many practices allow that, they allow you to book online.

    Porter
    Does it work?

    Gerada
    It does work, one of our practices has online booking. Yes it does. The same thing though around about 20%-25% of patients who book ahead don't turn up for all sorts of reasons. There have also been experiments to allow patients to determine how long they might need with their doctor, so to book a five minute appointment or a 10 minute appointment or a 30 minute appointment and that works really, really well, patients on the whole know how long they'll take with their doctor. I do have a fantasy though, Mark, that one day I'll be doing tweet deck general practice.

    Porter
    We need forward thinkers Clare, but I suspect consultation by Twitter may be some way off - he says hopefully. Dr Clare Gerada thank-you very much.

    And Lisa, an insider's tip - no matter how much your surgery may insist you can only call on the day, even the most determined disciples of advanced access routinely keep back appointments that can be pre-booked days in advance. But you may have to push a bit.

    Clare Gerada's desire to offer consultations via Twitter may be fantasy - at least for now - but other new technologies are changing the face of healthcare, and changing it fast. Monitoring patients in their own homes - Telehealth - is the latest development in general practice.

    Two thousand pound black boxes that can measure parameters like blood pressure, blood sugar levels and how well oxygenated someone is, are being installed in peoples' homes and sending required info over the internet to the GP or nurse looking after the person. The aim is to improve the standard of care for people with long term conditions like diabetes, heart failure and breathing difficulties.

    And it seems to work. The results of the world's biggest randomised controlled trial into Telehealth -the Department of Health funded Whole Systems Demonstrators study - prompted Health Minister Paul Burstow to announce in a press release earlier this year that: "Telehealth could save the NHS up to £1.2 billion over five years. And that it will revolutionise personal care, improving the lives of three million people, increasing independence and dignity, as well as reducing time spent in hospital."

    Wow, it sounds great ….so why isn't GP Margaret McCartney impressed?

    McCartney
    They've put out lots of numbers without providing the full data. Now if a drug company did this we would quite rightly come back to them and say show us the numbers, this is not good enough. And I think almost criminally these numbers went out in December and we've only now actually seen the full published results which are quite different from what the Department of Health has been putting out and they don't reflect the numbers that they've been hyping for us.

    Porter
    Well looking at some of the conclusions that they drew from this same press release, they were talking about a 20% fall in emergency admissions amongst people who were using this technology, 14% fewer admissions to hospital, 8% reduction in costs - I mean they're pretty significant figures. What you're saying is they've been cherry picked?

    McCartney
    Absolutely, so, for example, where they're saying that Telehealth saved lives, when actually you look at the numbers the authors are quite clear that the change in death rates between the groups that used Telehealth and didn't were not significant when adjusted for baseline. And they also said that we cannot conclude that Telehealth reduces secondary care costs over 12 months. So again they came out and they said look we're not sure that this has done anything much to saving money at all.

    Porter
    We're also joined Nick Goodwin, who's senior fellow at the King's Fund, a charity dedicated to improving healthcare. The King's Fund take on this Nick?

    Goodwin
    Well I think taking the wider picture we need to find a way in which we can support people with complex long term conditions to live longer more independent, more healthier lives at home because we know a lot of people end up having to go for an unnecessary hospitalisation or indeed end up as a person within a residential home community who wouldn't really need to be there. And we think actually it would be far better to organise this better around the home and Telehealth is one part of that solution because it enables individuals to manage their care more effectively at a distance from hospital and most people who have used it and where it's worked well would suggest it's significantly improved their lives.

    Porter
    Margaret, do you have a problem with Telecare per se, the idea is sensible is it not?

    McCartney
    I do not think for one moment that Telehealth is a magic bullet and I'm concerned that we're moving towards gadgets, buttons, numbers when actually we should be talking much more about personalised healthcare and actually about frontline staff and helping them to care for patients better. And I'm very concerned that the Telehealth movement is putting a gadget in that's not been proven to help and we're extrapolating numbers here far beyond what the trials have been capable to do. I mean when we actually look at the Telehealth Demonstrator Trial it wasn't just Telehealth that was used in the intervention group, it was also health education, so how do we know it was the Telehealth devices and gadgets that actually helped, we do not.

    Goodwin
    Margaret, I agree with you. I think - I think 90% of the issue here is not actually the technology, it's about the way we go about managing individuals better in the community, how we support them to manage their own self-care, so whether it is education, whether it is provision of care coordination or nursing care support in the home, whether it is enabling them to get faster access to community services so they don't fall into crisis - these are the sorts of things that allow people to stay independent and healthy. And Telehealth and Telecare, as I've always suggested, and also the King's Fund suggested, is just one of those tools that might be used to support that process.

    Porter
    Let me put another fly in the ointment here. Let's assume that the technology or the support that goes around it does have some useful effect, it has to be used to have that useful effect and one of the problems that we're having at the moment they're actually having to pay GPs to get people referred on to the scheme because the uptake's been so poor. If the doctors don't want it, the patients don't want it does it matter if the government wants it?

    McCartney
    Well can I just say that I think one of the reasons why doctors don't want to get involved with this is because they've read the evidence on it. And there was a paper in the Archives of Internal Medicine earlier this year which said that people who were using Telehealth were far more likely to die, 14.7% in the intervention group compared with 2.9% in the control group, and I think it's quite right that doctors are sort of saying well look let's put the brakes on here, is this a good thing for my patients or could this potentially have harmful effects, is it diverting resources, is it placing too much faith in what these numbers can tell us?

    Goodwin
    Margaret, you are - you are - I mean I think you are misplacing where the evidence is. I think you're right that people are suspicious of the evidence and so on but I think the majority of the evidence in this field shows that the technology based applications, whether it is internet based applications or simple telephone based advice, can be incredibly effective in supporting people quite safely.

    McCartney
    But GPs have been using - but GPs have been using the telephone as a fundamental tool for decades.

    Goodwin
    Well have they? GPs are not necessarily arguing against the technology, they're arguing against a new type of care in which they with their community partners working and nurses and maybe social workers developing new packages of care to manage individuals better in the home environment. And we know that GPs - we know that GPs have found it quite difficult to move into Telehealth, they've also found it quite difficult to support and develop new ways of working with these other staff and I think there is a more fundamental question here that goes beyond the technology.

    McCartney
    No I completely disagree.

    Goodwin
    I think they're buying the technology, they haven't skilled up the staff to use it, people haven't bought into this new way of working and as a result of that the kit is lying on shelves and not being used and it's been quite expensive. You need to have simultaneous innovation in the way we deliver health and social care systems as well as the innovation of the technologies to support it.

    Porter
    Margaret?

    McCartney
    Well the evidence is that this has been overhyped beyond all really all reasonable [indistinct word] and until you actually sort that out there's no point in starting to say all our troubles would be rescued by technology. Think about how much we pay carers - we pay them a pittance to do incredibly hard front line work continuously looking after patients in their own homes to try and prevent them going into hospital, to try and provide them with all those difficult to do personal care needs. We treat these people - minimum wages - we treat them very badly, we don't invest heavily enough there. And if we're going to say that other troubles would be rescued with having a Telecare pack which is going to support the Tele healthcare industry let's look at who actually is caring for people and actually put our resources where our mouths are, rather than keeping thinking we need something new and different, why don't we do what we're doing but better?

    Porter
    We must leave it there - thank you both very much - time will no doubt prove which one of you is right.

    Now from black boxes in the home, to the most high tech medical environment of them all - the intensive care unit. It is a strange place where patients, thanks to a combination of their illness and the painkilling and sedating drugs that they're given, can exist in a twilight environment, an environment that can come back to haunt them.

    Dr Chris Danbury is an intensive care physician at the busy 11 bed unit at the Royal Berkshire Hospital in Reading which looks after a typical mix of patients.

    Danbury
    They can be accidents or people have had cardiac arrests - like footballer Fabrice Muamba. Our average length of stay on intensive care unit here is about two days but there is a significant number of people who stay here for an awful lot longer and the longest patient that we've had on intensive care since I've been at the Royal Berks is about three months.

    Porter
    Presumably you have to deal with patients who are in a lot of pain, so pain relief is one of your important aims?

    Danbury
    Absolutely. It's a combination of pain relief and also putting them into a state where we can actually give them the treatment that is necessary for them. So we now use very short acting painkillers like remifentanil and also hypnotic agents to sedate patients and an example of that would be a drug called propofol.

    Porter
    And you're needing to sedate them why - is it for their sake, so they don't know what's going on or is it for your sake so it's easier to look after them?

    Danbury
    We're sedating them for one of two reasons. For instance if you have a cardiac arrest, if your heart stops beating, then once we've got it going again we need to rest the brain for two to three days afterwards. And the sedative drugs that we use in that case will stop the brain from working and allow the brain to recover. The other major reason for giving people sedation is when you become critically ill you often become agitated and difficult to talk to and explain what sort of treatment that you need and so we need to give sedative drugs in order to allow that treatment to be given to them.

    Porter
    When you're looking at the level of sedation how do you ensure that you get it exactly right, because I presume no two patients are exactly the same?

    Danbury
    That's correct. We use a continuous infusion of the sedative drug and on this unit we use the Richmond agitation and sedation score. The score ranges from minus five to plus five and a normal individual walking around would be a score of zero, a negative score is sedated and a positive score is agitated and we generally target a sedation score of minus one.

    Porter
    So in practical terms what does that mean for the patient, what are they experiencing, are they aware of everything that's going on around them?

    Danbury
    Yes and that's the intention. We want them to be at a level of sedation where they can lay down memories, they can be aware of what's going on around them but they're not distressed or upset by any of the treatments that we're giving them.

    Gager
    My name is Melanie Gager, I'm a sister from intensive care at the Royal Berkshire Hospital and my main role is to run the follow up clinic. We only - at the moment - follow up patients here with a length of stay of four days or more in intensive care and so we follow them up on to the wards, where we would discuss their short term memory of the experience and also then when they get discharged from hospital we invite them back to intensive care and that's usually two to three months after discharge.

    Porter
    What sort of recall do they have of their time on here - they've been on strong painkillers, they've been sedated do they remember much?

    Gager
    That's variable, it depends on how they are sedated and how long far but also it is determined by their pre-admission - the reason why they came to intensive care - their memory of that. But a lot of people in general do not remember that much at all.

    Porter
    Which is, I presume, probably quite a good thing is it?

    Gager
    You would think so but our experience is that perhaps it isn't because what they try to do is make up the story of why they're critically ill and so whilst Dr Danbury alluded to the fact that we do sedate our patients their mind is not necessarily sedated, so they are laying down memories and so from the sounds and the noises and the smells they try to make sense and make a story of what's happened to them while they're sedated.

    Porter
    And do many of them have unpleasant memories, do they get flashbacks to what happened?

    Gager
    Yes, so we have a proportion of our patients that have hallucinations, nightmares, intrusive thoughts, flashbacks - all of those things combined or singularly.

    Porter
    And when you say hallucinations can you give me some examples?

    Gager
    There are common themes to hallucinations, so many patients will recall being on a spaceship and they will often see their relatives or nurses as aliens. There are other issues where patients feel that they're all at sea because of the motion of the bed that they're on. Some persecutory nightmares have been where they're tortured and tied down but we think that's because of the nature of what we do and how we do it.

    Porter
    And these can be pretty graphic presumably, quite intrusive for some people?

    Gager
    Oh absolutely and patients can recall them very vividly, very clearly forever actually, we have patients from 10 years ago that can still tell those nightmares and hallucinations now.

    Porter
    And the suggestion is that using too much sedation can actually make that worse?

    Gager
    I don't think you can just put it down to totally sedation, it's probably - there's a complex issue there regarding what their critical illness is in the first place as well as in combination with sedation.

    Porter
    So how do you help them deal with that?

    Gager
    Our role is to listen, to normalise - to say this is a normal response to an abnormal situation and the body's trying to make sense of what's going on. So what we do is we kind of relive the story for them, so we bring them back and we expose them to intensive care, they have one to one visits where we go through their story with them.

    Porter
    So your job really is to try and help them get those memories in sequence, get them in perspective if you like?

    Gager
    And also I think it's about recognising the impact that it has on them and so their memories and hallucinations are real to them, they may not be factual but they're real to them.

    Porter
    And what happens at your later follow up, what sort of things do you go through?

    Gager
    So at clinic we would talk through the patient's story, we'd invite relatives along and we would try to explain exactly what happened at that point and then if they needed on-going referrals to anyone else we would do that. But after that we would bring them back to the unit and what we do is encourage the patients and the relatives to come together and we relive the story together because there are two sides to every story - the patient will have no real memory and therefore they get an understanding of what the relatives have been through but equally the relatives will then understand the terminology and the complexities of the treatments that the patients received.

    Porter
    Sister Melanie Gager from the ITU at the Royal Berks in Reading.

    Don't forget if there is something that is confusing you that you would like us to look into then you can e-mail me via insidehealth@bbc.co.uk or send a tweet to @bbcradio4 including the hashtag insidehealth.

    Time now to step outside and enjoy the arrival of summer - but be warned if you fancy a dip, the months of rain have had a detrimental effect on the quality of the water, as Anna Lacey discovered when she met Pollution Control Manager Dr Robert Kierle on the banks of the river Axe in Weston-Super-Mare.

    Kierle
    What all this heavy rain has meant over the past few weeks and months is that we've had an unprecedented amount of water washing over our fields and our streets carrying dog mess, livestock waste and everything into streams, into rivers and carrying that out to coastal waters. So as we've got here with the River Axe draining a large agricultural catchment behind us it is going to have a big impact on bathing water quality.

    Lacey
    So what's in this water then Rob that might be causing a problem?

    Kierle
    Well this River Axe drains a large area of agricultural land just behind the Weston-Super-Mere on the Somerset levels and the main concern I have is the amount of pathogens - bugs, bacteria, viruses - that are coming from livestock waste that's draining into the river and going out to sea. But when you're looking generally across Weston-Super-Mere there are a number of these overflow pipes from the sewers, called combined sewer overflows, and a combined sewer takes in the rainfall that runs off the streets and off our houses and into the drains and it also takes the human waste away from the homes but you'll also get dog mess. For example it's something like 6,000 tonnes of dog mess are deposited on the UK's streets every day. So you think in a small resort with a lot of dog owners who aren't responsible and aren't cleaning up after them that gets washed into the sea, that is going to have an impact on bathing water quality.

    Lacey
    But it's obviously not just Weston-Super-Mere that has these overflow pipes, so give me an idea of what the picture is on beaches throughout the UK.

    Kierle
    We actually found out there's 31,000 of these intermittent overflows allowing raw sewage to go out to the environment and that's 31,000 right across the country - coasts, inland, in England, Scotland, Wales and Northern Ireland.

    Lacey
    Combined sewer overflows are mostly active in winter but during summers, such as this one, with heavy rain followed by sunny weekends, sewage in the water can be a much bigger problem.

    Cummins
    The closer you are to a major population, and we've got a big town right on the beach here, then the more at risk you're going to be from these combined sewer overflows.

    Lacey
    Andy Cummins is the Campaign Director for Surfers Against Sewage.

    Cummins
    I mean on a day like today people want to go in the sea, even around the UK where it can still be a bit nippy. But what we're concerned about is on beautiful sunny days like today there can still be a problem associated with the raw sewage coming out of these combined sewer overflows.

    Lacey
    And where's the problem on this beach here in Weston-Super-Mere?

    Cummins
    It's a couple of hundred metres to my left or if you're not on the beach with us it's to the South West but it's still in an extremely popular part of the beach, maybe because it's a little bit further away from the car parks and the main town and the hustle and bustle.

    Lacey
    And do you happen to know how this beach has fared so far this year with all the heavy rain?

    Cummins
    It's done terribly bad, to be honest, I mean we've had 10 spills already from May 15th and we've still got pretty much half of the bathing season to go.

    Lacey
    What kind of health problems can occur as a result of that?

    Cummins
    Well there's a long list and I suppose the most common is the ear, nose and throat infections, which can be uncomfortable but it can get dramatically worse extremely quickly, so there's the gastroenteritis which you wouldn't wish on your worst enemy, there's Ecoli 0157H which can survive 30 days in seawater, hepatitis A which can be found in human sewage, again can survive 90 days in seawater. And the list goes on and on. What we don't want to do is scaremonger and get people away from the sea, what we do want to do is make sure that they go in the sea at times that are appropriate and they have at least as small a chance as possible coming into contact with some of these nasties.

    Lacey
    But why are we putting sewage, however dilute, into the sea in the first place?

    Bardon
    So this is where the raw sewage from Weston-Super-Mere first arrives at the sewage treatment works.

    Lacey
    Ruth Bardon works for Wessex Water.

    Bardon
    They take this excess water and here at Weston-Super-Mere it can be 30-40 times more than the normal sewage flow which is received at the sewage treatment works. So we need an outlet into the environment at a less sensitive location rather than flooding people's properties, roads and amenity areas.

    Lacey
    So you're saying that if it wasn't put into the sea it would be coming up your plug hole, back out of your toilets?

    Bardon
    Yes exactly, that's right. So this is deemed the least risk option and better for public health.

    Lacey
    For now at least these overflows will be fact of life on our beaches. But Rob Kierle from the Marine Conservation Society has a simple rule to keep you and your family safe.

    Kierle
    The World Health Organisation actually advises that if there has been a rainfall event in an area that you shouldn't go into the water for at least 48 hours. It's applicable wherever you go and it's a good rule of thumb actually, if you have had a bad storm just wait a couple of days before you go into that water and then the risk of catching an eye infection or an ear infection or a stomach bug are going to be massively reduced.

    Lacey
    And back on the beach, Andy Cummins has a more high tech option.

    Cummins
    Well the only service, as far as we're aware, in the world that can give you real time water quality information is Surfers Against Sewage's sewage alert service and what this does - the sewage alert service will send you a free text when a combined sewer overflow opens and discharges raw sewage in real time and then you've got the information to make an informed decision for yourself. We feel it's really important you get the message then you can know before you go.

    Porter
    Andy Cummins ending that report by Anna Lacey and we have a link to that sewage alert on our website bbc.co.uk/radio4. And I should point out, not least because my wife's family comes from Somerset, that this is problem faced by many of our beaches and rivers, and by no means peculiar to the River Axe and Weston. And that World Health Organisation advice applies when you are abroad too.

    Just time to tell you about next week's programme which will be devoted to the liver - particularly the impact of our waistlines on the organ, and a novel approach to gauging the number of people infected with hepatitis C. Should everyone between the ages of 45 and 65 have a one off test? Join me next week to find out.

    ENDS

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