NICE - protocol driven monkeys

Recognising the sick feverish child is something that even the experienced paediatrician can get wrong from time to time, it is not easy by any means and requires a great deal of training, expertise and experience. General Practitioners have a solid training base to prepare them for the paediatric component of primary care, with several months of paediatrics as medical students and exams in paediatrics, followed by exposure to paediatrics in A/E and in specialist paediatric jobs. However there is probably a good argument that more rapid modern training may leave some fresh faced GPs a little unprepared in paediatrics.

NICE think that paediatrics can be put into a protocol, they think that proper training and experience can be replaced by a glossy colourful flow chart. NICE are cretins. NICE have come up with a traffic light system for recognising and managing the sick feverish child, and it perfectly demonstrates the nonsensical nature of these stupid protocols. Dr C has already humourously taken a glance at NICE's work, but I couldn't resist joining in.

Apparently if the child 'appears ill to a healthcare professional' then this is a red light sign and the child must be referred to a paediatric specialist. The 'appearing ill' part of this is completely subjective and open to interpretation, it shows that the protocol is of no use unless the person using it has the proper training and experience to know what 'appearing ill' actually is. Any doctor who does regular ward work will tell you that they are frequently called by nurses to see patients that the nurse thinks are 'very unwell', but when one arrives, the patient is sitting there eating dinner while watching the football on the box. There is a massively subjective element to this kind of judgement, and this makes a mockery of these kind of protocols.

'No smile' is an amber light, so if your 4 year old's football team lose a game and has a bit of a sniffle, and then you don't see a smile then you better get on the phone to NHS direct pretty damn quick. 'Wakes only with prolonged stimulation' is only an amber light, I'd be pretty scared about a feverish child who was that drowsy. There are other bits of nit picking I could do but you get the point.

These flow charts and protocols are useless. The protocol on its own is of no use, it requires the intelligent interpretation of an experienced doctor to be applied correctly, but the experienced doctor has no use for such a protocol. QED. This BMJ piece points out several flaws in the NICE approach for dumbies:

"This is a major concern because the most solid evidence for recognising clinical severity in febrile children in primary care is a global assessment by an experienced clinician.......To improve the care of children with feverish illness in primary care we should be offering less telephone advice and more opportunities for a prompt clinical assessment."

Precisely, the solid evidence suggests that there is no substitute for a properly trained experienced clinician, clipboard wielding numpties working to protocol cannot do the same job. If the government and its stooge agency NICE really wanted to improve the management of sick children, then they should be improving access to experienced doctors who can see these children in person. However currently we have far too much protocol driven nonsense administered by telephone and health care professionals working to protocol in an attempt to make up for inadequate levels training and experience. That's the way Stalin's NHS works, the bureaucracy proliferates exponentially and functions to limit the actual work done on the front line, more and more money goes to trying to avoid doing work, while less and less money gets through to the front line. In the end there will be no doctors and nurses and no hospitals, just a big brother speaker system eternally broadcasting words of reassurance to the people:

"Comrades, there is not time to be ill and there is no such thing as illness in the world according to the supreme leader. Anyone caught faking illness will be punished. And rest assured we are keeping a close eye on you, the Party's eyes are everywhere I assure you........."

Incoherent logic - dumbing down standards

This post seemed to attract rather a lot of reaction; a lot of this reaction was rather agressive, incoherent and based on rather shaky logical foundations. Anyone who reads this blog regularly would know where I stand on this issue, but for some reason some people keep missing the points that I'm trying to make, so I thought I would stir these mucky waters again, but before I get started I'd like to make a few things clear.

Firstly the cause of this problem is the government, in a deliberate attempt to weaken the medical profession's monopoly on doctoring, they are breaking this monopoly by empowering a variety of HCPs. The reason for this is that HMG want to privatise the NHS and with a strong medical profession this would be impossible, hence the dumbing down. The same dumbing down is also taking place amongst doctors as the government also want to weaken the power that hospital specialists hold, hence the introduction the GP with special interests (GPwSI). The GPsWI is not trained to anything like the level of a specialist, often only doing a short course with no exams or assessments, but in our brave new NHS and a market of pseudo choice PCTs will happily ship work away from hospital specialists to save money. The end product for this will be a low quality privatised set of Walk in Centres and polyclinics, while a lot of excellent local hospitals with specialist services are shut. The inadequately trained PA (Physician's assistant) is another example of this shoddy dumbing down that has been brought to us from the other side of the Atlantic.

Secondly I am not criticising all HCPs. The vast majority of HCPs work very hard, and are excellent at what they do, while several of the extended HCP roles are not problematic in their nature.

Thirdly I am not criticising the motivations of any HCPs, even if working in inappropriately empowered roles, they do their best and sometimes do not have enough insight to realise when they may be well out of their depth. The blame for this lies with the government's cynical reform.

Some nurse practitioner posts (such as this example, this example and this example) perfectly encapsulate the inappropriate kind of empowerment that I want to highlight. There has been a state of denial as regards protocols being used, but this can leave us in little doubt that Dr Crippen's comments about protocol driven care are correct:

"Working autonomously to a high standard of clinical care and utilising decision support software you will assess, diagnose, and manage or advise individuals contacting the Out of Hours Clinical Assessment Unit."

Read through the job description and it is pretty clear what these kind of roles involve, it is not a nursing job, it is not a narrowed field of specialism; it is a job that would previously have required a medical degree and a significantly broader and higher level of training:

"Competently provide evidence based advice/treatment for individuals accessing the service and discharge same, or refer to another clinician within primary or secondary care, as indicated and appropriate

Practicing autonomously and using knowledge, interpersonal, history taking and assessment skills, critical thinking and professional judgement, provide competent clinical assessment for individuals presenting with undifferentiated, undiagnosed and sometimes complex conditions.

Make judgements on a range of complex issues, which require analysis, assessment and diagnosis and implementation of care."

Amazingly many of these nurse practitioner jobs, in which the job description makes it pretty clear that they will be doctoring independently, require virtually no qualifications beyond a nursing degree, it is shocking. The inconsistency shown in the different job specifications shows just how disorganised and haphazard this reform has been, no one knows how qualified a nurse has to be before they can be allowed to have a go at doctoring. By doctoring I am referring to what is conventionally termed doctoring, which is diagnosing and treating varied and unpredictable problems in an unsupervised manner.

These jobs are general roles in which one would be expected to take a history from, examine, investigate and manage patients independently, and sometimes very sick patients as the job description makes clear. Medical training and gaining a medical degree involves a far more in depth training in basic sciences such as anatomy, pharmacology and biochemistry than any nursing qualification. Medical training is also aimed at producing a doctor to do doctoring, while nursing training is not. Of course doctors are far from perfect and there are bad eggs out there, but this is not justification for empowering people with less education and training. I have written about the lack of evidence behind certain schemes of empowerment before, here, here and here.

Medicine is also a grey area, no one is perfect and there are only degrees of safety in any system. However this does not mean that the change in the shade of grey cannot be noticed, it most certainly can. The empowering of those with far less training and far less thoroughly assessed skills can only reduce the quality of care provided. That is not to say that some of these dangerously empowered HCPs don't do a good job, some do, but on average the quality of care provided will be less than before when more training and education was required. The amount that the standard of care is reduced can be debated, however to claim that empowering those with far less training and education makes no difference is akin to insanity in my eyes.

The justification for the empowerment of the under trained is 'competency based training and assessment'. Junior doctors have come to learn how useless competency based approaches are, and how they encourage minimum standards and stifle excellence. They can also be used to pretend that training is adequate when it clearly is not, as competency is seen as a black and white entity, not the grey entity that it clearly is. The same pretence is being used in medical training, as competency based methods are used to pretend that working hours and experience are having no effect on the end product of training. The competency based model sees trainees suddenly morph into different beings once a form has been filled in.

The infamous NHS 'skills ladder' is another attempt by the government to dumb down standards by empowering those with ever decreasing levels of skill; only John Tooke has realised precisely how treacherous this path is, and is seeking to properly define the role of a doctor. The government will try to resist the Tooke review's recommendations for this very reason; Tooke is standing up for proper standards and high quality doctoring, while the government want cheap trash.

When advocates of the empowerment comment on events they often ignore the questions posed and appear to be in a state of complete denial, however they occasionally let the truth slip out as in the quote below:

"My local Trust also has what they call NP's, junior NP's etc working in the local WIC's. Many of these nurses only have their original nursing qualification, many with limited nursing experience and a 4 week clinical skills course to supposedly diagnose and treat, so yes they are sh*te! they are taught history taking using the medical model, regularly used in secondary care, so again will write similarly to the doctors."

Nurse practitioners in the roles I have described above are not as good as their medically trained equivalent. The same logic applies to physician's assistants who work completely unsupervised after their short period of dumbed down training and to GPwSIs who are doing work that was previously done by a properly trained specialist. If the under trained HCP is highly supervised then they cease to be good value for money, but on the other hand if they are allowed to practice unsupervised they they are not as good as their medically trained equivalent. In other words, a castle built on sand will never stand the test of time compared with one built on solid rock foundations.

As I have described above the dumbing down of standards is gathering apace, the amount of education and training required to practice medicine independently is decreasing by the year, I am just amazed that some people have the audacity to claim that this will not have any effect on the standard of care provided. By this logic, training and education could be reduced to zero and anyone could then be free to have a crack, and this is clearly an absurd idea. The language of medicine is being eroded, terms including 'clinician', 'consultant' and 'practitioner' have been pirated by the new brigade of HCPs. This dumbing down has gone far too far already, and frankly none of the defences of this shoddy reform cut the mustard. HMG, stop empowering the ignorant, then you might make a bit of progress. It seems that this government doesn't want excellence or progress though, they would rather have a bunch of remote control protocol-led machines that can be easily manipulated to do exactly whatever the Supreme Leader so desires.

MMC inquiry rolls on

I apologise for not covering the recent Health Committee sessions, my mind has been erratically hopping from random topic to topic of late in a kind of angry frenzy. The 4th session saw the big cheeses from the Royal Colleges attempting to distance themselves from what they saw as the DoH's mess. Carol Black was a little limp, but Bruno Ribiero appeared to have a large quota of balls and admitted the Colleges could have done more to stop things going as badly wrong as they did. In this regard at least Bruno had the guts to take his fair share of the blame, unlike Carol Black whose weak defence of that infamous letter didn't really convince at all. It was made clear that the DoH was ominously stalling over Tooke and this must not be dropped.

The fifth session saw the idea of NHS Medical Education England (NHS:MEE) discussed by Professor Rubin, with the idea being that education was taken more seriously with its own ring fenced budget. DoH cronies didn't seem too keen on this idea with comments like this uttered in response claiming that NHS:MEE would 'fracture the relationship between service and education’. In my mind if cronies from the DoH like Sian Thomas see NHS:MEE as a bad idea, then it is most probably a very good idea as it would stop the government buggering up education by prioritising short term service needs over the long term service and high training standards. Interestingly Prof Rubin was not convinced by Foundation training, while apparently

"The Health Select Committee has not scheduled any further oral evidence sessions as part of its inquiry into MMC and MTAS. However, it is possible that another session may take place after the Department of Health publishes its formal response to the Tooke report at the end of February. A final written report from the committee is not expected until after Easter."

I hope the Department of Health are kept well away from future medical job application processes and the following quote hardly fills me with glee:

"The Department of Health is in the process of establishing a number of pilots in order to rigorously test a variety of new methods for recruiting and selecting trainees for specialist training. The aim of this research is to review the effectiveness of the different selection methods and processes being piloted, their appropriateness in a variety of circumstances and their impact on applicants and selectors. It is intended that the findings from this research inform planning for current and future medical recruitment"

It is good to use solid evidence as a base on which to change policy and implement change. However the deliberate manufacture of shoddy evidence to fit a politically driven plan is not a good idea for the future of medical training and job application systems. Like many lame duck studies conducted by the DoH to fit a political glove, the kind of evidence crafted is likely to never make it into even the lamest of peer-reviewed journals; in my eyes until proper solid evidence is obtained for a new process and then accepted formally by the medical profession following proper consultation, the old tried and tested CV and interview should be continued until further notice.

I have to say I am very impressed with some of the recent comment in blogosphere on this hot potato of a subject. Chez Sam's has been on the case energetically, an excellent piece that brings these issue in the perspective of the dreaded and useless 'skills escalator'. The Witch doctor has been in good humour and is impressed with Bruno Ribiero, I just wonder whether there is a hint of romance in the air there? Some commentary on the events that I have also described, and I particularly love this quote from Bruno Ribiero. It encapsulates the feeling that many of us doctors in training have, it sums up the complete and utter frustration that we feel towards the stupid patronising competency based assessments that we have to manipulate our way through day in day out, medicine is an apprenticeship and not a stupid protocol-led tickey box load of old manure, well said Bruno:

“When I applied for Medical School in 1962 I had no idea whether I was going to be a surgeon, a physician, or a gynaecologist – being a doctor was all that mattered. Interviews were designed to establish whether you had the qualities and vocation to become a doctor. This was not about ‘touchy-feely’ qualities, but whether you had the ability to care for your patients.

Putting patients first before all else should be your aim in life.

Vocation like compassion is now seldom referred to as a reason for going into a healing profession.

Doing an apprenticeship so that you boss could assess all your qualities, good and bad, has given way to competence assessment in an attempt to define what is often indefinable in a professional.”

NHS Employers - you should be ashamed

NHS Employers have threatened Remedy UK with legal action, for what I hear you ask? For providing an excellent resource for doctors who are trying to find a job for this year. So NHS Employers is trying to restrict doctors' access to job information, how on earth is this in the best interests of patients?

It isn't. The only explanation is that NHS Employers are cretinous idiots of the highest order. The job application process this year has been an utter shambles, with very few jobs for thousands of highly skilled applicants. Applicants have found the process very stressful indeed as they have had to search high and low for hidden job advertisements, and then had to fill in numerous lengthy and verbose application forms while working long shifts at the same time.

Now NHS Employers are working against the interests of doctors and patients by preventing Remedy from helping doctors find out which jobs are on offer, it seems that the clunky NHS jobs website has been made to look a little outdated by Remedy's slick efforts:

"NHS Jobs, a key resource for job information is run by NHS Employers. From the makers of MTAS, the discredited application service used in 2007, comes another difficult to navigate and slow website. Remedy Jobs aimed to provide another route to navigate these jobs, with a simple chronological interface rather than a search engine requiring esoteric search terms to be used to access some jobs. This is achieved using an automatic web spider similar to that employed by Google. "

No wonder the NHS is in a mess, it is being run by a bunch of first class morons. Rather than thank Remedy for providing a valuable service, they are threatening them with legal action. This bunch of muppets have carried on from where they left off last year, they must be really proud of their achievements:

"This year is perhaps more disastrous than last year. Hundreds of members have reported problems accessing their web-mail from work. Application forms have been taken offline before closing dates have been reached. Application websites have been slow and unresponsive, echoing the experiences of MTAS 2007. Application forms submitted by email have been "lost"."

Anyone feeling generous?!?

Just out of interest, I have nominated myself for a blogging award, and if anyone feels like joining in with this little experiment on blogging 'autocracy' then feel free to vote for the fancier here:

http://www.bloggerschoiceawards.com/blogs/show/39709



ps I nominating myself is against the rules then I apologise, these kind of awards things are a bit of a joke in my opinion as it just comes down to who sings loudest anyway, just thought it would be an interesting experiment in singing loudly

pps please nominate Lord Darzi's NHS blog as the worst blog of all time

A little birdy

I had a dream the other day, being the strange individual that I am, I had eaten a large amount of Stilton before retiring to my bed. They say cheese before bedtime gives you strange thoughts and dreams.

A vision appeared to me. It was the year of darkness 2007, it was around the time of MTAS and a voice was whispering faintly:

'What if the BMA had decided that MTAS should be legally challenged, would the government have stood a chance in court? MTAS was weak and would have fallen like a pack of cards. Remedy were too small and not seen to be the voice of all doctors that the BMA are seen to be.'

'What if the reasons for the BMA's lack of legal bottle had been not to do with the legality of the process, but instead to do with vested interests and protecting those who dwelt on important BMA committees?'

'Well then, the BMA would have been deliberately ignoring its members' interests to protect its own. This would be indefensible.'

What an interesting dream. If this little birdy is to be believed then the BMA's actions were completely indefensible. I just wonder sometimes, what really happened behind closed doors.

The DoH bulldozer grinds on

So much for Darzi's review having a thorough and open consultation process, it seems that yet more reforms are being rail roaded through with the claimed backing of the Darzi review, before the consultation and the review have even finished. Following news of the plans for more private WICs up and down the country, it turns out that this is a nationwide initiative, it is entirely top down from the DoH and it is completely non negotiable:

"This is a national initiative for ALL PCTs. It's is in the Darzi interim report and the PCT Operating Framework. The time scale is set nationally and is not negotiable. Our delivery of this is being performance managed by the SHA."

This quote comes from documents leaked to the fancier by a PCT mole near you. This article highlighted exactly how Darzi is seen my ministers, as a compliant yes man with no autonomy to do anything that would displease the party, as Alan Johnson states:

"This work has not been subcontracted to Ara. He is not producing an independent report that will be left on a shelf gathering dust. He is doing this as part of a team. He guards his independence, but he develops his proposals in discussion with us, and recognising our settlement in the comprehensive spending review." Brown appointed other non-politicians to a "government of all the talents", known in Whitehall by the acronym Goat. Some went off message and had to be reprimanded. Johnson says: "We don't have a goat problem in this department. Our goat is tethered."

This is an admission of the truth about Darzi and his sham review, Darzi is just a pawn in the cynical game of PR that the government are playing in trying to pretend that educated medical opinion is behind their agenda of destructive and expensive privatisation. This is dishonest and a disgrace, as Dr Rant says:

"We have a centralised bureaucratic monolith that is not giving anyone, be they doctors, patients, managers or politicians or taxpayers, what they want. It costs a lot yet no one gets value, or feels valued by this system. It’s a miserable monopoly."

Not only do we have a centralised bureaucratic monolith, we have a centralised bureaucratic monolith that is run by dishonest manipulative scumbags of the highest order. Democracy to them means doing whatever they want to further their own self interest once they have been elected, they do not feel the need to represent the people that elected them in the slightest. This has been demonstrated yet again with the scandal of the EU 'reform treaty, the EU constitution dressed up in bog roll, that is being forced through without a referendum that we were promised; it's more than a little reminiscent of Labour's promises to scrap and internal market and not to privatise the NHS. If anyone from the DoH does read this blog as part of their intelligence gathering role, then it would be ironic, as intelligence is needed to gather intelligence, so you're onto a bit of a loser there I'm afraid.



ps sign up to the petition above at http://petitions.pm.gov.uk/polyclinics

Links grow stronger

Following the news that Patricia Hewitt is to cash in on her inside knowledge of DoH and government machinations with an advisory role at Boots, it appears that there is yet another example of just how close the links are between the Department of Health and the network of big health care corporations that are currently feasting on tax payer's cash. Ramsay Health Uk are a private group with significant interests in the NHS:

"Ramsay Health Care UK runs one of the largest Wave One Independent Sector Treatment Centre contracts on behalf of the NHS, which saw the development of nine new NHS treatment centres from Cornwall to Newcastle. In 2007 Ramsay were also awarded a large Wave Two contract to provide elective surgery to NHS patients in Cumbria and Lancashire. Ramsay also offers NHS services at their 21 acute hospitals as members of the Department of Health’s Extended Choice Network."

It turns out that yet another person with experience of working at the DoH is being employed for their insider knowledge, Ramsay Health even admit this openly:

"Dr Peskett joins Ramsay from the Department of Health’s Commercial Directorate where she is currently Deputy Medical Director, on secondment from Keele University since September 2006.

Jane Cameron, Director of Clinical Services for Ramsay Health Care UK, said: “I am
delighted that Dr Peskett will be joining us to help continue our excellent record of clinical governance across our UK operations. As our NHS services continue to grow, Dr Peskett’s experience at the Department of Health will be a great asset to our company.” "

The government thinks that these kind of cosy arrangements will result in better value for money for the tax payer and better services. I think not.

Ferreting through medical news and blogging - 1

The way health care is run is going to change rather dramatically over the next few years, and there doesn't appear to much that the general public can do to stop it, short of strapping oneself with explosives and taking a trip to the DoH headquarters in Whitehall. The government is intent upon a campaign of wanton destruction, having wasted billions on the internal market, the stage is now set for dishing out yet more juicy contracts to the altruistic private sector. The links between government and business are as close as ever, but I'm not quite sure that they'll be working in the best interests of the general public. It's hard to be very sure of what exactly they are up to, as various firewall-like defense mechanisms such as the Freedom of Information act mean that information and consultation are kept to an absolute minimum, until the next dastardly scheme has arrived on one's doorstep, and by then it is too late.

There is some positive news from Lancashire with a PCT pulling out of a CATS deal with Netcare due to its extremely poor value for money, I just wonder how much compensation Netcare will get for their efforts though. I remember reading in the Telegraph at the weekend that the new tendering process for private firms building schools meant that as much money was spent tendering as was spent on the schools themselves, showing the rather obvious downside of using private competition in the public sector. The NAO has also looked at the overall value for money that the public sector has extracted from PFI deals and unsurprisingy found PFIs to be poor value for money. Shockingly, a large number of UK trained physiotherapists cannot find work in the NHS following graduation, and this is despite there being unacceptably long waiting times for physiotherapy up and down the country. It shows what happens when political needs are given precedence over clinical ones, billions are wasted on ideological reform while patients are left to fend for themselves.

Virgin is set to enter the primary care 'market' in 2008, one wonders whether their health care will be as outstanding and reliable as their trains? One thing that is sure though, is that they will put their shareholders first, and this may have rather grave implications for NHS patients. Virgin health care are keen to point out the care is still 'free at the point of delivery', this couldn't be called privatising primary care then could it? On a tangent, it seems that top down orders have resulted in PCTs trying to suppress the reality of Practice Based Commissioning. Interestingly 'The survey shows only 12% of GPs feel PBC has improved care', so while primary care must be overhauled because only 90% of patients are happy, billions will continue to be wasted on a scheme that appears to be an unpolishable turd.

In the blogging world Sam points out the important job that Remedy are currently doing for juniors, this is especially relevant now with Remedy's job update site being a lifesaver for many doctors struggling through a rather disorganised and shambolic application process this year. Congratulations are in order for Barry Monk, I would disagree with him slightly in that the pinnacle of his career would be winning a seat in parliament at the next election, fingers crossed of course. More good work from the Witch Doctor too, showing us just where 'retail medicine' will lead us, and it ain't pretty. Dr Grumble has sensibly supplied a link which can help all of us medical bloggers avoid trouble with our musings, blogging about work is certainly a very grey area; I deliberately do not mention anything to do with my daily work as I want to keep well away from this grey area. I cannot believe that anyone could get in trouble for having political opinions, Labour has not quite turned Britain into Iran, yet. Pay peanuts, you get monkeys, Dr Crippen hits the nail firmly on the head, the NHS can't even afford peanuts though with so much money being wasted on ideological gimmicks.

I have already commented on Dr Ray's interesting deconstruction of Labour's NHS tactics, this is perfectly demonstrated by Alan Johnson's rather ominous absence from the public eye. This tactic of avoiding criticism and open debate has been used more and more frequently by Labour of late, call me a cynic, but I think it's a sign of a regime that knows it is forcing through unpopular policy and is just trying to minimise the commotion surrounding their antidemocratic reform. Front point has not been in action for a while, but this piece on the importance of the continuity of care is particularly relevant in the context of the government's push for more Walk in Centres and Polyclinics. Henry North links to this fantastically amusing piece from Bloggerheads about SOCPA, could the government really be 'authoritarian and stupid', and maybe they are reading and planning new laws to punish people who even have the audacity to call them 'authoritarian and stupid'? Straying off into non-medical things, the Policeman's blog has been on top form keeping an eye out for government newspeak and more gaffes from the Labour loudspeaker that goes by the name of Toynbee. Just to finish with something medical, Dr Crippen tells the sad tale of Luke Solon, a junior doctor who typifies the sad waste of talent that Labour have presided over in the health service; what a waste indeed:

"Yes I'm sad to be leaving some great colleagues and a job that has both tremendous highs (to go with the recent soul-destroying lows) but on balance I am relieved not to be entering into the mad scramble for jobs this year and for the first time in a while I am optimistic about the future. I'm on nights at the moment, being ordered around by "Outreach Nurses" and hassled by A&E to meet their 4 hour targets."

ps please email the ferret fancier for anything you feel should be included next time and it will be considered

Z - the whisteblowing scandal

Victoria McDonald of the Channel 4 news has kindly allowed me to reproduce some of her comments on the Dr Z case, which Victoria covered excellently on Channel 4, the news report can be read and viewed here. There is also an excellent summary here, on the Scientific Misconduct blog.

"There are so many appalling aspects to 'Z's case, not least the gagging order which means she cannot speak and we were extremely restricted in the way we could report this case.

When I asked what had happened to the consultant who had sent 'Z's medical information to her employers, I was told by Addenbrooke's that he had had his knuckles wrapped.

This is what the apology read in open court says: "In deciding to place the Claimant on special leave, the First Defendant (Huntingdon PCT now Cambridgeshire) was wholly misled by information provided by a third party. It should not have relied on that information and should not therefore have placed her on special leave. The party who supplied the information has since unreservedly withdrawn the implication and apologised publicly.'

Hmmmm... And 'Z', who according to a statement she handed out after the case, has had her career curtailed. This has, she writes, caused absolute devastation to both my professional and personal life and to my family.'

Is there not someone who can help her back to medicine, help her make up for the five lost years?"

It's a shocking case. The cancer registry element to it also thrown up some very interesting questions, questions that everyone needs to think long and hard about because they have important implications for us all. If the state is given increasing powers to gather information, information which may be used to benefit society, how far should the state be able to go in gathering this information? Can the state simply ignore the individual's rights and freedoms as what it is doing is for the greater good?

I am sure we all have our own ideas about these kind of questions, as our answers define who we are and how we see the world. I would add that we must be pretty careful in giving the state extra powers for these 'ends justifying means kind of problems'. This is because the state is not the most trustworthy of beings, and more and more evidence of the state's slimy nature is revealed from one week to the next. The use of anti-terrorism laws to prevent peaceful protest being one prime example of the state abusing its position of power to suppress fair dissent.

Dr Faustus should have been more careful before he signed away his soul to the Devil, and I think that we should be very very careful before accepting that the state should be able to ignore the rights of individuals in going about its regular business. The state should have to work hard to gain our consent for its schemes, and we will be happy to give our consent when we can see that a scheme is in our best interests; then when we can see that the state is up to something fishy, we can withdraw our consent. In this way the state's powers can be kept in check. However if we lose our ability to consent, then the state's power will snowball and that does not lead to a pleasant outcome for us all.

Medical blogging- a crossroads?

I happened upon this rather enjoyable piece of the Witch doctor's the other day and just wanted to reiterate what was said. As most of you know Dr Grumble spoke here of the reasons behind his withdrawal from blogosphere. Quite a few interesting comments were made at the time, and I have just noticed that sadly Dr Grumble has removed his blog as a result of fears for his safety. Dr Grumble is spot on with this comment, the NHS cannot take constructive criticism and this is a huge problem that holds back progress:

"We are all new to blogging. Inevitably we have made mistakes. In my view the NHS cannot take constructive criticism (because it sees criticism as not being constructive). If you intend to criticise the first priority is to keep your identity secret. Without anonymity your comments and thoughts are stifled by concerns about what the averse consequences of your free thinking might be. Stifling honestly held opinion is not a healthy thing to do."

I would urge anyone that has time to read Dr Grumble's eloquent words here, his thoughtful and articulate commentaries will be considerably missed in my opinion. I am not one for conspiracy theories, but explanations for government policy reforms frequently revolve around perpetuating the self interest of politicians and their political parties, and our political system has been shown to be not entirely free of corruption.

The Witch doctor wants us to play a game of joining the dots. It does not take a PhD in logical thinking to come to a rather sinister explanation that Dr Grumble was hinting at. The government cynically and deliberately reduced the responsibility that doctors take for their patients with the new GP contract, this was done by offering a pittance for out of hours work that GPs could simply not afford to take on. This has left a gap through which the 'Britnell bulldozer' can be forced through, as more and more of routine NHS work can be farmed out to the major health care corporations. The dodgy links between politicians and business as regards the health care beggar belief, Patrica Hewitt being the latest to cash in on her political status with a job 'advising' Boots.

The government will pretend that this ideological reform is not privatisation, this is a lie, it is. In fact Labour and Blair were elected on an anti-privatisation ticket in 1997, which makes this agenda of destruction all the more galling, it is fundamentally antidemocratic. Some would argue that as we have elected these people, this is democracy; I would argue that our politicians have a responsibility to represent the best interests of the public, and that going back on promises is rather the opposite of what is meant by 'democracy'. The privatisation is particularly galling because it is an inefficient use of our money and the service could be much better if money was more effectively spent on the 'NHS', and not filling the pockets of corporations close the HMG. Dr Ray nicely hits the nail on the head with this piece that neatly deconstructs Labour's cynical war.

The thing that infuriates me most about all of this is the complete lack of open and honest policy making, and an NHS culture that is completely resistant to constructive criticism. The public could get a fantastic health system for relatively little if the government chose to work with people, to cooperate with the experts, if they chose to listen and respond to criticism, rather than silencing and intimidating those who speak out. That's why I intend to continue blogging and sticking it to them, and it is also good to see Dr Crippen back waging war again.

The Britnell Privatisation Challenge - coming from a PCT near you

The NHS is closer resembling the Soviet system of the 1960s as each day passes, and one man who is rather involved in giving Stalin-like orders from the top is a chap called Mark Britnell, his unpleasant bullying has been noted in blogosphere before.

The ferret fancier has got hold of leaked PCT documents which show that the government, in the form of the Department of Health's Britnell, are ordering PCTs to start opening a swathe of privately run Walk in Centres up and down the country. Importantly this is being done in the most top down antidemocratic manner possible, as this has been done without consulting the public adequately, without consulting the medical profession and is to be done even in areas where there is no problem with accessing GP services.

This sick twisted ideological reform is called the 'Britnell challenge' by PCT monkeys in the know. Darzi's review is being used to back this agenda up, even though the sham consultation process has not yet been completed. In Oxfordshire there is hardly a problem with access, as you can see:

"•National GP Patient Survey 2006/07

•In Oxfordshire responses of 46% to the access survey were received compared to 47% average for NHS South Central PCTs and 44% nationally

•In Oxfordshire 94% of people reported that they were satisfied with their ability to get through to their doctor’s surgery on the phone compared with 86% nationally

•In Oxfordshire 90% of people who tried to get a quick appointment with a GP said they were able to do so within 48 hours compared with 86% nationally.
•In Oxfordshire 88% of people who wanted to book ahead for an appointment with a doctor reported that they were able to do so compared with 75% nationally
•In Oxfordshire 92% of people who wanted an appointment with a particular doctor at their GP surgery thought they could do this compared with 88% nationally
•In Oxfordshire 84% of people said they were satisfied with the current opening hours in their practice, the same as the national average "

While the educated local opinion realises that this top down enforced reform is not a sensible use of NHS funds:

"Everyone locally seems to agree strongly that it is both damaging to the local NHS and a waste of resources - but the managers feel unable to resist DH central instructions to introduce competition in order to make us extend opening hours."

The privatisation will be done using the Alternative Provider Medical Services route (APMS), a contractual route through which PCTs can contract with a wide range of providers to deliver primary medical services that are tailored to local needs. The PCT run procurement of these APMS contracts has not always been that transparent or competitive, I can't imagine that this will change. The PCT's documents show clearly that there is no choice in this reform agenda, they must obey Britnell or else:

"•During 2008/09, all PCTs will complete procurements for new GP-led health centres providing convenient access to GP services"

The DoH are not as clueless as the PCTs, but they are far more cynical and corrupt. It is just such a waste of money to be forcing ideological reform upon the public in this blanket and short sighted way. Oxfordshire is a great example of how just stupid the DoH are. Patients are remarkably happy with their GP services here and there is simply no need for this costly reform, but the PCT have to follow orders from Britnell and his boys. I thought this quote taken from the end of the PCT's slide show summed up just how dumb this all is. The blind are truly leading the blind here, the head of the PCT's commissioning presented the questions below as the final slide of his sermon; really someone who is in the process of changing the way primary care is run in his region should have some idea of the answers?

"•What would ‘best’ look like?
•Who do we need to work with in developing Primary Care Strategy?
•How would we know we have got ‘best’ services? "

Aneurin Bevan would not be turning in his grave, he would be locking and loading his double barrelled shotgun and making his way rapidly towards the DoH's headquarters.

MTAS 2008 - a pile of poo

No matter how good the application system was this year, it would not make up for the problems that have been created with the rushed and shambolic implementation of MMC (Modernising Medical Careers). Unfortunately the application process appears to be far from perfect, and this is making a bad situation even worse.

The failed rushed reform has resulted in far too many doctors competing for an exceptionally small number of training posts this year. Nothing could fix this situation, it is something the government could temper to a degree by increasing training numbers, but their incompetent reform has made the situation irretrievable before MTAS 2008 even started.

Many doctors are going to emigrate or quit medicine over the next few years, the numbers have not been massive as yet as many are hanging around to compete for the last few training numbers, but over the next few years this number of ex-NHS doctors will number several thousand in wasted talent.

The huge applicant to job ratio has led to a farcical situation of Deaneries trying to limit the number of applications in several ways. Firstly they have limited the number of days on which it is possible for applicants to get hold of an application form, thus applicants have to keep their eyes peeled on a daily basis otherwise risk missing out on a job entirely. This has also lead to local trainees being tipped off by Deaneries as to when they will be releasing their application forms, hardly fair to all is it. Secondly there are stories of Deaneries deliberately blocking external emails to cynically limit applications, Ram Moorthy of the BMA explains:

“This is outrageous. Doctors are being denied vital career opportunities. It’s utterly bizarre to be told you can’t have an application form for a job before the deadline has passed. We’re concerned that this is a cynical attempt to reduce numbers of applications.”

This is hardly the way to ensure that all applicants are treated fairly. Some Deaneries are also running online applications, meaning that applicants have a strict deadline within which to submit but the slow nature of the computer systems means that it is taking hours of frustrating toil to fill in. It seems that very few lessons have been learnt. There are also rumours that despite Tooke's push for uncoupling, many Deaneries will be offering out run through posts at ST1 and ST2 level. I really despair.

The saddest thing is that this whole mess was so very preventable, unparalleled levels of rank incompetence have been shown by the likes of the DoH in railroading through their ill though out politically motivated dross. It is quite sickening that the architect of this dismal failure, Liam Donaldson the CMO, is still in his job, demonstrating just how unaccountable this bunch of contemptible creatures are.

Unconvinced

Dr Crippen is back and an interesting discussion has begun already, as a result of an initial post on the events surrounding a patient with chest pain. To me it looks like that ambulance staff took far too long mincing around with a patient who clearly needed to get to hospital asap:

"The ambulance then sits in the car park for eleven minutes (just over)."

Dr Crippen also highlighted the nonsensical protocol driven aspect of getting an ambulance to a patient, it appears that the people who have the job of prioritising the transport have very minimal medical knowledge, this can result in very sick patients waiting at the expense of much more trivial problems. I have certainly experienced this first hand on several occasions, as transfers from one hospital site to another seem to carry a low priority for these protocol driven automatons, meaning that patients in extremis can be left on a knife edge for much longer than necessary. In fact Tom Reynolds, in his response to Dr Crippen points out yet another example of how managers with minimal medical knowledge are able to put an unfair pressure on events, an unfair pressure that then results in unnecessary delays in sick patients reaching hospital:

"We are told by our management and training to do ECGs on chest pain patients. If we take a patient like this to hospital without an ECG, the hospital will look strangely at us. If we don't document a *very* good reason for not doing an ECG then we can expect to be asked some pointed questions by our management."

Tom Reynolds does make a strong argument for doing ECGs on patients with chest pain which I do tend to agree with, however the explanation of merely 'doing an ECG' does not explain some of the obstructive delaying tactics used by a increasing minority of ambulance staff. I have heard of several cases where patients with unstable angina with normal ECGs have been very inappropriately managed by ambulance staff, in one case instead of being taken to hospital the patient was dropped of at the GP's surgery and another ambulance had to be called. I have lost count of the number of stories, several of which I have had first hand experience of, in which ambulance staff have dangerously questioned the opinion of experienced GPs, resulting in patients nearly dying or having their arrival at hospital dangerously delayed. A pregnant woman with severe abdominal pain which turned out to be an ectopic, a man with an MI who had to drive himself in as ambulance staff refused, old ladies who were unable to weight bear with fractured necks of femurs left at home having being given a single dose of morphine; these are all examples of shocking bad practice that cannot be defended. I therefore think the problem of arrogance does not lie primarily with GPs. Of course GPs are not perfect by any means, however medico legally would these ambulance staff have a leg to stand on in court if they were found to be questioning the medical opinion of GPs? I think not.

I found the next two quotes particularly revealing, as they showed up some rather gaping problems in the ambulance service that should be addressed:

"It's frankly irresponsible to have a system that can't take account of the assessment of a doctor on the scene to grade a call into anything other than "blues and twos" response or "whenever". Generating a blues and twos response puts other road users and ambulance crews at risk. This is acceptable when life is, or might, be at immediate risk, but when a doctor says "it's urgent but not that urgent" there ought to be a way of grading the response appropriately."

"The only other observation I would add is that when you were transferred to the 999 'pathway' with a patient presenting with chest pain then your call became an "A" cat response: we need to get someone to your surgery within 8 minutes (doesn't matter who - the station cat will do provided he can press the 'at scene' button) . Trouble is, in my service at least, you end up with me; the good 'ol solo responder. Once I arrive, the clock stops and we could all be waiting for hours for that 'back-up' ambulance. You remember, the one you actually needed in the first place. So to kill time (and to avoid being disciplined) I'll do an ECG and fill in the paperwork and we'll probably have time for a game of cards or two while we wait. At the end of which you'll be hopping mad and well behind with the surgery list. I usually suggest that the GP might like to complain."

"If you want to get an ambulance person ranting just mention ORCON, it's the '8 minute' target that was dreamt up by the government based on an out of date bit of research concerning cardiac arrests. A lot of the problems in the ambulance service, in my opinion, are based around this 8 minute target. Think of it as a QoF equivalent, only it causes more life threatening mismanagement of resources. Like sending out the station hamster, or leaving #NOF on the floor for three hours..."

Again we see how a target, based on out of date evidence and implemented by idiots with no medical knowledge and no ability to foresee how the target will result in changes to the dynamics of the system, can result in ludicrous acts of fudging the system with patients being no better off, if anything they are frequently worse off. The vast majority of ambulance staff do a very good job under exceptionally tricky circumstances, however the increasing empowerment of management with no clinical knowledge has definitely resulted in unfair pressures being applied to try to prevent hospital admissions, and this puts ambulance staff in an impossible position at times. If they disobey management they risk censor, but if they try to prevent appropriate admissions then patients will suffer, it would be an impossible job even with a medical degree and years of medical practice.

It's a hallmark of our Stalinist regime that instead of doing the work that needs doing and treating the sick, the government is instead putting it's efforts into bullying staff into making decisions for which they are not adequately trained, in an attempt to reduce the workload of the system. I just wonder if a patient had chest pain following trauma, would the ambulance staff still be obliged to do an ECG? If they were then it would show the ludicrous nature of these blanket rules, as this patient would simply need to be shifted to hospital as damn fast as possible, an ECG would add precisely nothing.

Who needs doctors?

A lot of information can be gleaned from having a quick butcher's at NHS Jobs, one can see just how advanced the role of nurse practitioner is becoming in certain areas and how the faulty logic behind these schemes works or doesn't work as the case may be.

Starting here with the 'Triage nurse practitioner', so how is someone without proper medical training going to do this job safely; "full competency based training will be provided to support development within the role". Competency based training has become the hallmark of the dumbing down of medical standards, proper qualifications and exams are no longer needed, all that is needed is a bit of on the job 'competency based assessment'.

Moving on to the 'Orthopaedic nurse practitioner', from the job description one learns that this specialist nurse is to 'provide expert orthopaedic clinical knowledge for the multi disciplinary team.' One wonders how on earth the nurse can do this, when they have taken no postgraduate exams in surgery or orthopaedics? Is the nurse meant to have magically osmosed 'expert' knowledge just from being around orthopaedics for a while? Many of the other jobs of this orthopaedic nurse practitioner are very simple mundane jobs that could be done by junior doctors, and I can tell you than junior doctors do not get paid £34,092 - £43,105 for a 37.5 hour week.

Strangely there are quite a few nurse practitioner jobs up for grabs in our wonderful Walk in Centres. These nurse practitioners have quite a tricky job on their hands, one could even say that this kind of job used to only be done by those with a proper medical degree:

"· To receive patients with undifferentiated and undiagnosed conditions in a unpredictable environment

· To work autonomously and give holistic assessment/ interpretation of results/ treatment/ advice resulting in discharge or referral of patients as appropriate.This requires wide range of expertise underpinned by competency based framework"

No surprise here then, this dangerous dumbing down is underpinned by a 'competency based framework', that typical excuse for this unjustifiable dumbing down. A few years ago people would have laughed at me if I had suggested that any old registered nurse should be let loose to do this kind of job diagnosing and managing medical problems in a completely unsupervised fashion. It's too late to laugh now, it's time to be very afraid indeed, there is no need for a medical degree and years of supervised practice, all one needs now is a nursing degree and a 'portfolio of evidence'.

This country has gone stark raving bonkers. We have thousands of junior doctors who will be out of training come August, in fact we already have thousands our of proper training; and at the same time nurses are being dangerously empowered to do the jobs of doctors, jobs that these junior doctors could do much better, and for a significantly smaller amount of cash. Ridiculously at the same time wards are dangerously short of proper nursing staff, meaning that patients are left wallowing in their own filth and hospital acquired infections are left to run amok. Ironically many nurses on the wards have been replaced by Healthcare Assistants, I wonder how long it will be before an experienced HCA is allowed to have a crack at diagnosis?

(I was inspired to write this little rant because I overheard a nurse on the ward bragging about her new job as 'Orthopaedic nurse practitioner', she was delighted that she was to get her own office with her name on the door, she also boasted about the fact that she was now going to be prescribing drugs. It was the way that she boasted about her new responsibilities, like a child boasting about their birthday present, that shocked me; she just saw everything as a bit of fun, there was no sense of the increased responsibility in her chatter. This is the way the role of nurse practitioner frequently works, nurses are handed jobs beyond their means and the buck does not stop with them, they get all the bonuses but none of the pitfalls of this extra responsibility. It is unaccountable dumbing down gone mad. Trust me, you would not want to hear the stories from the coalface of how unprepared these practitioners are for their extended roles.)