Continuous Use of Combined Contraception

Thank you to our practice pharmacist Najla Salamsi for writing the blog post below.

She explains recent changes in the way that health professionals advise women to take their combined contraceptive pills, patches and rings. The take home message is that having a break from your contraceptive every month is not necessary. Women can choose to take their contraception continuously so as to not have a period at all (strictly speaking, it is a withdrawal bleed … not a period) - or for several months at a time, which allows them to choose when to have their period. Please read below for more information or arrange an appointment with Najla or with your GP should you want to talk about it some more.

Combined hormonal contraceptives (CHC) is a type of contraception that contains two types of hormones: oestrogen and progestogen.  These hormones prevent pregnancy mainly by stopping ovulation (the release of an egg from one of the ovaries). They also cause other changes in the body that help prevent pregnancy.  The three forms of CHC available include tablets “the pill”, patches applied to the skin and vaginal rings.

Standard CHC regimens

Combined oral contraception (the pill) The majority of COC in the UK is designed to be taken as 28-day cycles, with 21 consecutive daily active pills followed by either seven pill-free days or taking seven inactive tablets – known as a hormone free interval (HFI).  During this HFI, most women will have a withdrawal bleed.

Combined patch One patch is applied to the skin and worn for 7 days to suppress ovulation. Thereafter the patch is replaced on a weekly basis for two further weeks. The fourth week is patch-free to allow a withdrawal bleed. A new patch is then applied after seven patch-free days.

Combined vaginal ring One ring is inserted into the vagina and left in place continuously for 21 days. After a ring-free interval of 7 days to induce a withdrawal bleed, a new ring is inserted.

New guidance from the Faculty of Sexual and Reproductive Health (FSRH)

In January 2019, the FSRH released new guidelines suggesting that the withdrawal bleed that occurs during the 7 day hormone free interval does not represent physiological menstruation and has no health benefit for the woman.  Additionally, the FSRH advised that the 7 day HFI has the following disadvantages:

·         Withdrawal bleeding may be heavy, painful or simply unwanted.

·         The HFI may be associated with symptoms such as headache and mood change.

·         As ovarian suppression is reduced during the HFI,  errors in pill-taking (or patch or ring use) around that time could result in extension of the HFI increasing the risk of ovulation, and thus potential risk of pregnancy

As such, the FSRH have advised that women can safely take fewer (or no) hormone-free intervals to avoid monthly bleeds, cramps and other symptoms and potentially reduce the risk of escape ovulation and resulting contraceptive failure. The FSRH state that although such regimens are outside of the manufacturer’s license, the FSRH support their use and advise they are as safe and as effective for contraception as standard regimens.  Such “tailored” regimens involve:

·         Continuous use of CHC (no HFI)

·         Extended use of CHC (less frequent HFI); timing of HFI can be fixed or flexible

·         CHC regimens in which the HFI is shortened (the shortened HFI may be taken after each 21 days of CHC use or incorporated into an extended regimen).

If you are an existing user of combined contraception or are considering starting on it and would like to discuss this further, please book an appointment with the Practice Pharmacist or your GP.

For more information regarding the different forms of combined hormonal contraception, please access the following:

Repeat Dispensing

Repeat Dispensing is a time saving way of getting your prescriptions

If you or someone you care for uses the same medicines regularly, you may be able to benefit from using the NHS Electronic Repeat Dispensing (eRD) service.

This means you won’t have to re-order or collect your repeat prescriptions from your GP practice every time you need more medicine.


Mr Smith is on three regular medications - two for high blood pressure and one for high cholesterol. He used to have to go to the GP surgery every 2 months to request his medication. With eRD, his GP issued him with a year's worth of prescriptions to be collected every two months the pharmacy next where he works. He still sees his GP every year for a medication review and health check but now doesn't have to take time off work just to request and collect his prescriptions.



Ask your GP if you can use Electronic Repeat Dispensing (eRD). 

If your GP thinks that you could use eRD for your regular medicines, they will ask you for permission to share information about your treatment with your pharmacist. This will help your pharmacist to give your prescriber feedback about your treatment and provide you with useful advice.

Your GP or prescriber will then authorise a number of eRD prescriptions. This will be based on your circumstances and clinical need. These eRD prescriptions will then be supplied by your pharmacy at regular intervals.

Most commonly this would be 12 months' worth of prescriptions to be collected from the pharmacy every 2 or 3 months.


 Collect your first eRD prescription from your pharmacy.

You can choose any pharmacy that dispenses NHS prescriptions.


Next time you need more medicines, go back to your pharmacy.

Before dispensing the next issue of your prescription, your pharmacy will ask you the following questions:

·       Have you seen any health professionals (GP, nurse or hospital doctor), since your last repeat prescription was supplied?

·       Have you recently started taking any new medicines - either on prescription or that you have bought over the counter?

·       Have you been having any problems with your medication or experiencing any side effects?

·       Are there any items on your repeat prescription that you don’t need this month?

If you don’t need all of the medicines on your prescription, let the pharmacy staff know, so that they only supply the medicines you need. This will help to reduce waste and save the NHS money.


 When your pharmacy supplies your prescription, they will advise you to contact your GP practice to arrange for your medication to be reviewed and if it is clinically appropriate to issue another eRD prescription.

Your doctor or practice nurse may want you to make an appointment to see them before they will authorise more eRD prescriptions.



Vitamin D




Vitamin D forms in the skin when it is exposed to sunlight. It can also be obtained from some foods. It is important for forming and maintaining healthy bones, and is therefore particularly important for anyone growing – for example pregnant women and children. 

Most people should be able to get all the vitamin D they need by eating a healthy and balanced diet and by getting some summer sun. People at risk of not getting enough vitamin D are: all pregnant and breastfeeding women, babies and young children under the age of five, people aged 65 years and over, people who are not exposed to much sun (such as people who cover up their skin when outdoors, or those who are housebound), people taking certain medications, people who have darker skin (such as people of African, African-Caribbean and South Asian origin) and people with certain medical conditions.


The Department of Health advises:

For babies and young children:

  • breastfed babies from birth to one year of age should be given a daily supplement containing 8.5-10mcg (300-400 iu) of vitamin D to make sure they get enough

  • formula-fed babies shouldn't be given a vitamin D supplement until they're having less than 500ml (about a pint) of infant formula a day, as infant formula is fortified with vitamin D

  • children aged 1-4 years old should be given a daily supplement containing 10mcg (400iu) of vitamin D

You can buy vitamin D supplements or vitamin drops containing vitamin D (for under fives) at most pharmacies and supermarkets.

Women and children who qualify for the Healthy Start scheme can get free supplements containing the recommended amounts of vitamin D. See the Healthy Start website for more information.

For adults and children over 5 years old:

During the autumn and winter, you need to get vitamin D from your diet because the sun isn't strong enough for the body to make vitamin D.

But since it's difficult for people to get enough vitamin D from food alone, everyone (including pregnant and breastfeeding women) should consider taking a daily supplement containing 10mcg (400iu) of vitamin D during the autumn and winter.

Between late March/early April to the end of September, most people can get all the vitamin D they need through sunlight on their skin and from a balanced diet. You may choose not to take a vitamin D supplement during these months.

People at risk of vitamin D deficiency:

Some people won't get enough vitamin D from sunlight because they have very little or no sunshine exposure.

The Department of Health recommends that you take a daily supplement containing 10-25mcg (400-1000iu) of vitamin D throughout the year if you:

  • aren't often outdoors – for example, if you're frail or housebound

  • are in an institution like a care home

  • usually wear clothes that cover up most of your skin when outdoors

People with dark skin from African, African-Caribbean and south Asian backgrounds may also not get enough vitamin D from sunlight. They should consider taking a daily supplement containing 10-25mcg (400-1000iu) of vitamin D throughout the year.



Mild vitamin D deficiency usually causes no long term effects. It is very common, with more than half of the adult population in the UK having insufficient levels of Vitamin D. Most affected people either don’t have symptoms, or have vague aches and pains, and are unaware of the problem.

With prolonged deficiency the risk of getting osteoporosis is likely to be increased. Severe vitamin D deficiency in children leads to rickets, where the bones soften, and osteomalacia in adults. It may also be associated with some other long term conditions such as heart disease.



90% of our Vitamin D is produced in our skin in response to sunshine. The best way to maintain good levels of Vitamin D is through exposure to sunlight. Exposing your forearms and face to midday sunlight for 20 to 30 minutes 2-3 times per week from April to September is enough to achieve healthy Vitamin D levels that last through the year. People with dark skins need to spend twice as long in the sun to achieve the same effect. People with freckled or very pale skin should take particular care to prevent sun burn. It is important for everyone to use sunblock if they are going to spend longer in the sun.

10% of our Vitamin D comes from our diet. Oily fish (herring, mackerel, salmon, trout, sardines) is the richest source of Vitamin D with lesser amounts contained in dairy products and eggs.



NHS Camden GPs are now being asked to prescribe vitamin D only for patients who are deficient and not for people with slightly low levels or to prevent a deficiency. The reason for this is that there is no clear evidence that a slightly low Vitamin D level is associated with long term health problems yet the NHS was spending large sums of money prescribing Vitamin D to these patients. This money could be better used for treatments which have been shown to improve people’s health.

Vitamin D tablets or capsules can be bought from pharmacies (chemists), supermarkets, health food shops or online. It may also be labelled as Vitamin D3 or cholecalciferol. Look out for the ones with at least 20 micrograms (µg or mcg) which is equivalent to 800 units (iu) of Vitamin D.

All women who are pregnant or breastfeeding and all children between the age of 6 months and 5 years should take a daily supplement which contains Vitamin D. You do not a prescription to obtain these supplements. They can be obtained through the NHS Healthy Start scheme. Healthy start vitamins are FREE to those eligible for the Healthy Start scheme, and if not they can be bought very cheaply (about £1 per month for an adult)

Please see the website for further details.



If your Vitamin D level is higher than 50, it is considered to be normal.

Having a Vitamin D level  higher than 50 is not associated with long term health risks and, in most people, would cause no symptoms. You do not require any specific treatment.

If your Vitamin D level is between 25-50, it is slightly low.

You should try to boost your Vitamin D levels through eating Vitamin D rich food and through safe exposure to sunshine. If you want, you could also take a Vitamin D supplement, one can be bought over the counter. It is policy across NHS Camden not to prescribe Vitamin D supplements for patients with a slightly low Vitamin D level unless they have specific medical risk factors for long term Vitamin D deficiency.

Certain patients have specific medical risk factors which put them at risk of long term Vitamin D deficiency and they may be prescribed Vitamin D by their GP. 1 month after they have completed the course they should do another blood test to check their Vitamin D and calcium levels, and then discuss whether they need longer term Vitamin D supplements.

If your Vitamin D level is below 25 it means that you are Vitamin D deficient.

You should take the high dose of Vitamin D prescribed. 1 month after you have completed the course you should do another blood test to check your Vitamin D and calcium levels, and we can then discuss whether you need longer term Vitamin D supplements.



The blood test use to diagnose diabetes is called HbA1c. If your result is between 42 and 48, you do not have diabetes but this result is higher than expected and puts you in a category called “pre-diabetes”.

If you have pre-diabetes your blood sugar is raised beyond the normal range but it is not so high that you have diabetes. However, if you have pre-diabetes you are at risk of developing type 2 diabetes. Around half of people with pre-diabetes will develop diabetes within ten years. It is also thought that having pre-diabetes increases your risk of developing conditions such as heart disease, peripheral arterial disease and stroke (cardiovascular diseases).

There is increasing evidence that if pre-diabetes is treated, the progression to diabetes can be prevented. Also, it may be possible to prevent cardiovascular disease from developing. So, it is important to know if you have pre-diabetes and to treat it in order to reduce your risk of developing diabetes and cardiovascular disease. In general, the treatments for pre-diabetes do not involve taking medication.

NHS Camden runs a Diabetes Prevention Programme for both English speakers and non-English speakers. We  strongly recommend that anyone diagnosed with pre-diabetes finds out more about it and consider joining (you will need your blood test result and your NHS number in order to register):

The information and the videos from the link below are useful to understand more about pre-diabetes and your health:

Please do not hesitate to book a face-to-face or telephone appointment should you wish to discuss this further.

School or Nursery Absence Following Common Childhood Illness

by Dr Ellie Cannon

We are often asked how long you need to keep your child off school when they are unwell.

We have made a list of the common childhood ailments and the recommended time off school.  These are just a guide based on national recommendations from Public Health England to protect others in the school or nursery.

These times assume that your child is feeling well enough to go to school: so they are really a minimum time off. If they are feeling unwell or suffering with a temperature, they should stay off school.

Chickenpox Until all spots are have crusted over
Cold Sore None necessary
Hand, foot and mouth None necessary
Impetigo 48h after starting Antibiotics
Molluscum None necessary
Ringworm None necessary
Headlice None necessary
Roseola None necessary
Scarlet Fever 24 hours after starting Antibiotics
Slapped Cheek None necessary
Diarrhoea & Vomiting 48 hours after last episode of diarrhoea or vomiting
Flu Until recovered
Conjunctivitis None necessary
Glandular Fever None necessary
Threadworms None necessary
Tonsillitis None necessary

An American view of the NHS

Thank you to Dr Jason Hickel, a patient at the Abbey Medical Centre, for sharing his perspective of using the NHS as an American living in London.

The original article can be found here

Take it from an American - Britain's NHS is as good as it gets
JASON HICKEL 16 February 2015

As an American, I have followed the debate about the future of the National Health Service with curious fascination. I must say I don’t entirely understand why this has even become a question – why anyone seriously thinks that privatizing the NHS would be a good idea, or why we have to resort to citizencampaigns simply in order to keep it around.  As far as I can tell, the NHS is one of the best things Britain has going for it, and it would be a monumental step backward to let it go.

 I haven’t always held these views. Being on the left, I have long been committed to the principle of socialized healthcare, but, like most of my countrymen, I secretly suspected that such a system could never really work in practice. Before I moved to London in 2011, I had visions of the NHS as a quagmire of forms, queues, and long waiting times. These assumptions affect US progressives as much as they do devotees of Fox News: they’re in the water, part of the commonsense furniture of everyday life. Somehow we all end up believing that America’s private, for-profit healthcare system is our only hope, and without it we’re likely to end up dying while waiting in line for basic treatment. For most Americans, the specter of socialized healthcare – and of the NHS in particular – looms like the heavy shadow of Russian bureaucracy in a Gogol novel.  

I was forced to confront these assumptions when I made my first visit to the doctor, which I put off for a long time out of sheer fear.  I expected to have to take a train to some government complex where I would submit myself before a nameless bureaucrat behind a glass barrier in a brutalist concrete building. I literally thought this. So I was pleasantly surprised when it turned out that all I had to do was walk five minutes down the road to the nearest GP.

Upon arriving, I went straight up to the counter – no queuing required – and asked to register. Instead of the multiple page forms that I expected to fill out, which I had grown accustomed to completing every time I visited a doctor in the United States, I was presented with a single quarter sheet with the obvious fields: name, date of birth, and address. Nobody asked me for a health insurance card. Nobody asked if I would be able to pay. Nobody asked me for a British passport to prove that I was worthy of care. The edifices of my worldview began to crumble around me.

Fine, I thought: registration may be simple, but surely I’ll have to wait weeks for my appointment? Or even months? I was wrong again. I was given a slot that very afternoon.

I did have to sit in the waiting room, I’ll admit: for a sum total of 15 minutes. During that time, I marveled at the attractive display of public health information lining the walls – something I had never encountered in the US. It struck me, for the first time, that a publically funded healthcare system actually has an incentive to maintain good public health through mass education and preventative care. What a refreshing change from the perverse incentives built into the American model, which not only lacks this motive but operates according to the opposite logic: the more bad health there is in the population, the more money there is to be made from it.

My doctor was warm and professional, set up the referral and ordered my tests, and sent me on my way. As I passed by the receptionist at the front desk I felt almost guilty, and actually stopped to ask her if I needed to pay anything before leaving: surely there must be at least a small fee? She laughed at me. To this day, three years later, I still can’t get used to it, to the idea of health as a public good – it seems too humane to be true.

Some might rush to conclude that this surprisingly positive experience is probably due to the fact that I live in a posh white part of London. But I don’t. I live in Kilburn, and the clinic in question is adjacent to a number of council estates. The vast majority of the clinic’s patients are working class, and only about half of them are white.  The first-rate care I receive is the care that every resident receives, regardless of their race or class – as a basic human right, as part of the social contract, as a feature of the collective solidarity that Clement Atlee’s Labour government forged in the 1940s from the ashes of World War II.

And it’s not just that this clinic happens to be a good apple in a barrel of bad. I’ve been referred to specialists in other units – including large hospitals – on a number of occasions, and each time I’ve found myself amazed at the efficiency of the service.  At one point I was referred for a possible case of melanoma. I was seen by a dermatologist at the first break in my schedule.  So much for languishing in line for treatment.  Why so efficient? Because there’s a powerful incentive at work: the NHS saves money by catching cancer early.

And it’s not just life-threatening illnesses that call forth the best of the NHS. The mundane phlebotomy lab I had to visit recently at the Royal Free Hospital was run like a well-oiled machine, caring for fifty patients an hour at peak time without a glitch.  The system just works. We needn’t rely on anecdotes to prove this. The Commonwealth Fund recently released a report comparing the health systems of 11 highly industrialized countries. In the category of efficiency, the UK ranked number 1. The US, by contrast, ranked last. So much for the theory that profit stimulates efficiency. The UK also ranks well above the US in terms of timeliness of care, contrary to Fox News propaganda.

I suppose I shouldn’t be surprised; while living in the US I spent an astonishing amount of time waiting for appointments and sitting in receptions, even as a paying customer. I sometimes caught myself wondering if things might be different if I were able to pay more.

And it’s not just in the areas of efficiency and timeliness that the UK performs so well. It comes first in almost every other category – equity, access, quality, etc. – making it the best overall healthcare system in the world. As for the overall ranking of the US: dead last, again. The Commonwealth study didn’t measure bureaucracy, but I suspect that here too the UK would win handily.  While living in the States I was regularly frustrated by the amount of time I had to spend not just filling out forms, but reviewing costs, interpreting bills, paying fees, comparing coverage plans, and badgering my insurance company over the phone to shell out for their fair share (an obligation they routinely shirked).  

It’s no wonder that 30% of healthcare spending in the US is absorbed by bureaucracy – nearly twice the proportion that other industrialized countries spend. This is rather strange, given that the chief justification for private healthcare is that it suffers less bureaucracy. It turns out that exactly the opposite is true.

As for how likely a patient is to die for want of life-saving services: I wouldn’t choose to take my chances in the US, given that I’m not a millionaire. A close friend of mine recently discovered she had a fast-growing mass on her ovary that would lead to swift death if it wasn’t removed within the month. It sounds like a no-brainer, but before she scheduled the surgery she had to count the costs: her insurance company agreed to cover 80% (after much pressure from her doctors to get the company to cover it at all), but she would be responsible for the remainder – a sobering $40,000. She’s alive today, but she’ll spend many years working extra hours to pay off the loan she took out just to stay alive.

She is not alone. Millions of Americans are in debt due to healthcare costs, which is the number one cause of personal bankruptcy in the United States. In the UK we don’t have to face this terrible anxiety; it would be difficult for me to overstate how liberating this feels.

These are stories and statistics that I regularly wheel out during conversations with my American friends and family. And while they usually accept the evidence that I offer up (albeit somewhat grudgingly), they always insist that, sure, it sounds like a great service, but there’s no way it can be financiallyviable, right? But here again the evidence defies assumptions.  The Commonwealth study confirms that the cost the UK pays for delivering the best healthcare in the world is less than any other industrialized nation: only $3,405 per capita. The most expensive healthcare system, by contrast, is the US, at $8,508 per capita – more than double the UK, while delivering much worse results.  

Critics of the NHS claim that we can’t afford to pay for it; but the truth is that we can’t afford not to.

These data tell a clear story. But ultimately it’s not the extrinsic values of efficiency, timeliness, and low cost that make the NHS great. The NHS is great because it’s built on the principles of solidarity, universality, and equality – and because it is staffed by people who believe deeply in its basic moral mission. It is for these reasons that, when the NHS was founded in 1948, the Minister for Health Aneurin Bevan famously proclaimed that it was “the most civilized step that any country has ever taken.”

Yet, tragically, the present government is doing its best to dismantle the NHS, with the ultimate goal, it would seem, of replacing it with the US model. The Health and Social Care Act of 2012 put an end to the mandate for the state to provide comprehensive healthcare to every resident of England free at the point of use, and has allowed for-profit companies to buy up huge chunks of the NHS (£10 billion worth of contracts have already been handed out since the Act was passed).  The Tories know the US system performs worse on every conceivable count, but they are willing to go there anyhow: the healthcare market-in-waiting is just too juicy to leave untapped.

Bevan knew that the NHS would face opposition from powerful private interests, but he was hopeful that it would prevail: “The NHS will stand,” he said, “as long as there are those who will fight for it.” Many Britons are doing just that. But, thanks to skillful government subterfuge, the vast majority do not even know that their cherished healthcare system is under threat, and many others don’t understand what it’s like to live with the dysfunctions of a private alternative.  It’s sometimes hard to realize how good something is until it’s taken away from you. To England, I say, take it from an American: what you have is as good as it gets, and it’s worth defending. Your civilization depends on it.

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Would you like to improve your sleep?

This month, our health blog highlights the common and distressing problem of insomnia. We welcome guest author Dr Hugh Selsick, Consultant from the Insomnia Clinic at University College Hospital.  Dr Selsick writes:


“Insomnia can be a very distressing disorder, and has a huge impact on quality of life. However, it is very treatable and, while medications can sometimes be helpful, the best long term treatment is cognitive behaviour therapy for insomnia. This is an effective, evidence-based treatment that teaches patients practical techniques to sleep better. Although many people worry that their insomnia is caused by some defect in their brain or a physical problem, this is very rarely the case. In the vast majority of patients with insomnia it is the anxiety about insomnia and unhelpful sleep habits that drive the insomnia. Therefore by changing these habits and managing the anxiety it is possible to improve sleep greatly.


Unfortunately there is very little good information available on how to sleep well. Sleep hygiene advice, while useful, is rarely sufficient to make a significant difference. And very often the common sense things that people do to improve their sleep in fact make it worse. For example, if one has insomnia it can actually be a bad idea to go to bed at the same time every night. But what is important is to get up at the same time every morning.


It is important to stress that effective insomnia treatment takes time. People have often developed unhelpful sleep habits over years or even decades and it can take a few weeks or even months to correct those habits. But with the right techniques, and some persistence, insomnia can be beaten!”


We are grateful for Dr Selsick’s permission to show a video of him discussing insomnia at an education event for Camden GPs. The talk is a practical and fascinating resource for doctor and patient alike on different ways to approach the problem of poor sleep:

12th Sept 2013 UCLH/Camden CCG ENT Event for GPs. Re-posted with permission. Thanks to Dr Selsick and to  Dr Jo Frank, UCLH education programme lead.