Monday, 28 April 2008

Money burning Direct

The following short passage comes courtesy of an anonymous contributor to, a doctor who was involved in the set up of NHS Direct and who clearly experienced the grim reality of New Labour's top down tinkering with the health service:

"I was involved in the set up of NHSD on the national clinical steering group - our job was essentially to try to limit the potential damage caused by the torrent of ill informed directives coming from the No.10 policy unit.

It was a fascinating introduction to the interface between politics and health care. I was eventually "invited not to re-apply" for repeatedly posing the question - What advice are we giving the callers and is it any good?

It was made very clear to me that NHSD was a great success and therefore such questions could not be asked. It cost about £230M to set up and must have cost at least as much as that again since.

So far as I know there is has been little serious study of its safety or effectiveness nor any serious attempt to measure value for money.

No one really knows the answer to your questions and my personal view is that is is pretty harmless and pretty useless, it certainly has not lived up to any of the grand claims made for it at the outset. As you well find out most people working in other parts of the NHS hate it with a vengeance, believing it to be inept, inefficient, generating work for others and probably dangerous."

At best NHS Direct is a benign waste of money, at worst a dangerous waste of money, the truth is probably somewhere in between. What this does demonstrate rather nicely is the way in which short term political gains have been prioritised over the short and long term public interest by some greedy control freaks at No 10. Money wasting short term gimmicks are now the normal response from No 10, the dis empowerment of professionals continues as important decisions are made by career politicians with no knowledge in the areas in which they are so keen to make these big decisions.

It is no coincidence that Clostridium Difficile continues to run riot in England. Several factors that have been key in this rise have been as a direct result of political meddling in the NHS; these being bed occupancy rates, a lack of capacity to isolate patients, the excessive movement of patients due to politically driven targets, a shortage of nurses to do the basic nursing and dirty hospitals partly because of the short termist privatisation of NHS cleaning services. Of course the people making the decisions, the big cheeses in No 10, will never take any responsibility for their actions and the sage will continue. That's progress for you according to the Supreme Leader.

Sunday, 27 April 2008

Expensive half baked quackery

The NHS really is the envy of the third world, as doctors in training see their pay slashed and free accommodation withdrawn, the under trained are being rewarded with huge salaries given their minimal levels of training.

Physician's assistants only have to train for a fraction of that of a doctor, while entry is far less competitive and rigorous. However after a couple of years training and a dumbed down diploma one of these PAs can be earning well over 40 grand. It beggars belief.

This is while patients on the wards are left short of basic nursing care because proper hands on nursing is undervalued in comparison to clip board wielding managing and playing with fisher price stethoscopes on dumbed down quacking courses.
Whatever happened to having different training for different roles? Why is there this ridiculous need to merge all health care workers into one pseudo fabric of competency based mincemeat?

It seems that many people without the necessary knowledge and training feel happy to have a crack at the role of a doctor these days. Bizarrely the most highly trained of the health care workers, the doctors, are not allowed to apply for these nurse practitioner or physician's assistant posts. Why is this bizarre and nonsensical one way street being constructed? The Witch doctor explains this situation nicely:

"There is A New Cult being generated by this government: A cult that attacks professionalism: A cult that undermines intellectual capacity: A cult that is attempting to sway this nation into worshiping competency rather than the excellence that professionalism continuously strives to grasp: A cult that is attempting to turn health care into a commodity in order to generate a market share. The government has complex reasons for promoting such a cult. The Witch Doctor believes what this government is doing is very short-sighted and in the long term will be very damaging for the future health, knowledge base, and ultimately the freedom of this nation."

Indeed there is, and this new cult is a massive danger to the progress of our society. Short termist power grabbing and economics are the motives for policy that is spitting on the professions. Dr Grumble highlights some salient John Tooke quotes that make for some rather interesting reading:

"The results of role substitution experiments are not particularly well publicised, but when they have been conducted they’ve tended to reveal that the role substitutor for the doctor is no more cost effective and indeed in some cases less cost effective than the doctor doing that role. And the real reason for that is that a role substitutor may be able to follow a protocol, but unfortunately human beings and human disease don’t conform very neatly to protocols and that gets forgotten."

There are pressures from Europe to change our training in a way that meets dumbed down European standards as regards consultant level standards, this is dangerous as our health system is very different to other in Europe and by trying to conform a lot of damage will be done. This top down megalomania has gone far enough, it is time that we, the professionals, rallied against this catastrophic erosion of high professional standards.

The public need to be educated to these evils before it is too late, health is not a simple commodity like coal; doctors require large amounts of knowledge and a lengthy training for very good reason, their job is complicated and if it continues to be farmed out to the ever growing army of quacks, then the service will continue to be dumbed down and reduced in quality. What is the good in producing more and more coal, if the coal is of lower and lower quality? Not much I reckon, but this is the end result of a top down system motivated by pure greed.

Saturday, 26 April 2008

The sinking ship

One big problem that no one in the medical establishment has even dared to think about addressing is the European Working Time Directive (EWTD). The phrase 'head in the sand' comes to mind when describing the attitude of the government, Royal Colleges, PMETB, BMA and other institutions to the EWTD.

By August 2009 all doctors in training will have to be compliant with 48 hour a week rotas. The Surgeon has published a piece detailing what a failure the pilot introduction of these new EWTD compliant rotas has been. Not only did the new 48 hour rotas result in poorer quality training for the doctors but it also resulted in a large majority of doctors feeling that patient's care had been compromised by a lack of continuity.

The naive proponents of MMC believe that their revolutionary new methods of training, consisting of lots of paperwork and lots of hot educationalist waffle, will increase the quality of training so much that a reduction in hours will have no effect on training. Any trainee on the ground will tell you how dumb this approach is, as the reduced hours has resulted full shift rotas replacing older more training friendly rotas, while there is far more cross cover than ever before, meaning that more time is spent doing mundane admin as opposed to the juicy training bits of the job. I won't comment on the paperwork burden, other than to say that chopping down trees only trains lumberjacks.

EWTD in its current form will further worsen patient care in an already fragmented service that lacks any continuity of care, and it will arguably worsen the quality of training even further in a system which is not giving enough exposure or experience to trainees as it is. Firstly training doctors need to realise that if we are to remain highly skilled professionals then we must remain apprentices in our trade and we cannot allow our hours to drop yet further. Secondly we must force those who represent us to listen to our views, and those who represent us must then force those in government to listen. If we do not, then the effects of EWTD could be quite catastrophic.

Sunday, 20 April 2008

Wake up and smell the Coffey

The privatisation and destruction of the NHS continues apace, the government has one intention, to open the market up to big profiteering multinational corporations, and it is patients that will be bent over and shafted in the process.

The stupid and cynical one size fits all reform threatens to result in the closure of numerous excellent local GP practices up and down the land. These new plans will result in the needless waste of millions in paying for shiny new polyclinics, when the money could be far better spent supporting the primary care services that are already in place.

In fact the medical evidence is overwhelming that the loss of continuity for patients will be quite harmful to their health. While the increased centralisation will result in longer trips and yet more inconvenience for the elderly and disabled, stretching an already overloaded transport system even further.

One GP seems strangely keen on these reforms, and has backed all New Labour's destructive reforms over the years, he speaks today in the Independent and mentions no conflict of interest. His name is Tom Coffey and he has very strong links with the Labour party, strange he didn't mention that in the Independent, some would call this unethical, cynical even, I can think of other adjectives.

It seems that this is not the first time that the delightful Dr Coffey has backed his party's noble reforms that he claims will help the poor, I am sure they'll be just as helpful just as cutting the 10% tax bracket has been. Labour seem to be rather keen to shaft the poor these days, they are now a rather corrupt party that is funded by big business, whose interests they represent ahead of the poor and deprived.

This dangerous agenda backed up by the sham Darzi consultation is a disgrace, it is only about the overly equitable access to the health care market by private corporations, it is nothing to do with improving access for patients. In December 2007 the Department of Health ordered PCTs around the country to start making plans for these new private clinics, their minds were made up long before the consultation process ever started as Freedom of Information requests have revealed.

In typical fashion the consultation process is stage managed and none of the important details are ever revealed until it is far too late. Is it time to withdraw from the consultation process, as otherwise the government will use our lack of withdrawal to represent our consent to this malignant program of wanton destruction a la MMC?

My heart bleeds Mr Bully-imic

The lovely politician John Prescott has long been known to be a fat bastard, he has now revealed that his is also a bulimic, and strangely this amazing revelation comes as he releases his inspiring autobiography 'Pulling No Punches', what a coincidence.

It is rather ridiculous in my opinion that the most corrupt and malignant politicians expect us to show them sympathy when they come out as suffering from mental illness, in a way they are trying to hide behind the politically correct shield of 'mental illness'. It reminds me of Alastair Campbell coming out as a depressive, when he expected massive sympathy for his woes.

It is the likes of David Kelly that deserve our sympathy, not Campbell and Prescott. Do vindictive, dishonest, cruel, corrupt and selfish individuals merit sympathy from the public when they choose to come out as the sufferers of mental illness, even if we assume that their claims are entirely honest and well motivated? I think not.

I have about as much sympathy for the likes of Prescott and Campbell as I would for Adolf Hitler if I found out that he was suffering from manic depression during his last days. As humans we are defined by our actions, not our hollow words, and in some cases corrupt and dishonest actions can have knock on effects on one's mental health. If these people had considered other people in their lives a bit more and if they had acted more morally throughout their careers then I would have sympathy for them, as it is I struggle to have any sympathy at all for their ilk. My heart will not bleed a drop for the fat bulimic New Labour bully.

Thursday, 17 April 2008

No common sense in the market

Why do we sometimes reach a point where everything around us seems rather foolish, and it's almost as if the walls are caving in but one doesn't quite know how to go about stopping the impending collapse? That's how I feel about the NHS and medical training at the moment.

The government have cunningly attacked the medical profession and our professionalism on so many fronts that they have split us up into numerous ineffective little camps. We have not had the power or organisation to unite as one in order to prevent the government's plans for piecemeal privatisation.

My everyday experience of hospital work helps convince me that the ridiculous payment networks and bureaucracy that have been assembled over recent years are so awfully thought out that they cannot possibly be good for anyone involved. The staff on the ground really want to the best for their patients, but over time they get ground down by the stupid protocols and the highly complicated internal markets that have been forced upon them from above.

I wonder why can't a hospital just get some money from the government and be left to spend this money as it sees fit? Would this really be worse than the intricate network of payments that currently take place that mean money is shuffled back and forth while the needs of patients are forgotten, and most importantly doing proper work is frequently disincentivised by the artificial gradients. The whole internal market has simply not been thought through, and it appears to me that the damage can increase exponentially as more hair brained managers come up with new market based solutions to problems that have been caused by the market based approach.

I could waffle on about the catastrophic idiocy of Darzi and his polyclinics, Brown and his penchant for PFIs but the theme remains the same, this government believes only in improvement that is driven by the excessive use of power from the top. There is a massive irony here, as when Alan Johnson states that choice is a means to an end, how on earth can improvement come about when choice is nothing but a sham and an illusion? The only choices being made are being made by the government, they choose the path that we must choose, there simply is no other option. I am still standing in the same place and the walls are still collapsing, which way to turn?

Tuesday, 15 April 2008

Lame ethics

Medicine is dumbing down, the apprenticeship is being replaced by less shift work, as old fashioned learning methods are replaced by politically correct self directed methods. Everyone must be complimentary to everyone else, pointing out that something is just not good enough is no longer allowed. Students and juniors are cotton wool wrapped like never before, as it becomes harder and harder for those who really want to learn to get the valuable experience that they so badly want and need.

This story perfectly demonstrates the dumbing down and the abdication of responsibility that is happening far more often than it used to. A Foundation 1 doctor, this is the grade formerly known as house officer (PRHO), was asked by a nurse to pop a venflon in (to site an IV). This doctor then called her registrar because they could not do this task. The registrar went along and asked this F1 doctor if they had tried to do this simple task, the F1 replied that she had not. When asked why she had not, she tried to defend her lack of effort by saying that it would be ethically indefensible for her to put a patient through any pain when the registrar was more likely to be able to succeed with the task. The registrar replied by politely stating that ethically she should think of all the patients that she is going to treat in the rest of her career, they will be relying on her skills that she must develop during her training. She then grudgingly had a go, failed and burst into tears.

Of course I have a little sympathy for the aforementioned F1, however venflons should be bread and butter after a few months of house jobs, and even if the patient is particularly tricky then a junior should virtually always have a go before calling for senior help. Maybe I'm just biased, but I get a feeling that junior doctors are getting less and less experience than ever before. MMC was meant to remedy this, however it appears to do the very opposite, the combination of MMC and EWTD have led to most junior doctors working full shift rotas these days. This means that the continuity of care is affected which impacts upon training and patient care, while juniors are often busier with menial administrative tasks which means that they have less time to experience the useful bits of their job than in days gone by.

I have more experience of the surgical specialties and the current environment is most definitely shafting surgical training. I have to also say that I do come across many more trainees who are incredibly committed and motivated to learn, as opposed to the work shy clock-on-and-off shift workers. The new system does unfortunately encourage the latter's approach, and I must add that GP trainees are somewhat more likely to be part of the latter group as they have no interest in proving themselves to hospital consultants as they their path to GP-land is assured.

What's the solution to all this woe? Well a 48 hour week is certainly not the way to go. I like the idea behind Remedy's Barbados plan, as trainees must take the initiative if we are not to become a cohort of deskilled shift workers. MMC and the competency based lunacy that goes with does nothing to deal with these grave problems with training. Two things can be modified, either the service can be lowered in quality or the way the service is delivered must be changed. The empowerment of a whole raft of health care practitioners (HCPs) is changing service delivery but also reducing the quality of the service, while also having grave implications for the sustainability of the service, as if the consultants of the future are massively deskilled then this could have dire implications in the long term. I do reckon though that trainees must push to work longer hours otherwise not only will patients suffer the effects in both the short and long term, but we will not become as good a doctors as we once hoped we would.

Thursday, 10 April 2008

The wonders never cease

It's getting better, it's our best year ever, but is it really? If these things were true then why would the majority of staff be so disillusioned with life and so frustrated at the poor standard of care that they see delivered left, right and centre.

As Dr Crippen points out, why would 25% of student nurses be quitting before the end of their training? After all nurses are not paid that badly, there must be something else at play here. Maybe it's to do with traditional nursing not being valued, and that there is now much more reward in becoming a bullying clip board wielding nurse manager.

74% of staff think they are not valued by their employers

25% think NHS trusts do not see patient care as their main priority - 29% are undecided

78% think the communication between staff and managers is poor

The Healthcare Commission has found out a few interesting facts, three of which I have reproduced above. The facts all fit with one explanation of events. Typically the managers like to pretend that the communication problem is the fault of clinicians, anyone who has worked on the ground will tell you that the problem stems from managers refusing to listen to staff because they have no power to do anything other than enforce what has been ordered to them from 'above'.

'Above' is typically the Department of Health that is lead by Gordon Brown and his cronies. Hence what hope have local managers got when they either enforce the DoH's orders or they listen to local opinion, thus ignoring the DoH's top down command and making it hugely likely that they'll be out of a job pretty damn soon. 'Stalinist' is an over used adjective but it describes the NHS very well indeed, Barry Monk describes three clinical cases very neatly that perfectly encapsulate how our government's top down control freakery has produced an incredibly useless Stalinist end product. This is progress, somehow I think not.

Tuesday, 8 April 2008

The modernising NHS

Through the eyes of a junior doctor,
progress can sometimes seem a very funny thing.

We are more competent,
but we are less experienced and less skilled.

We are more valued,
but we are less well paid and more expendable.

We work less hours,
but the inane paperwork makes up for the lack of practical experience as if by magic.

Training is better than ever,
but even students are not spared the dumbing down and over-emphasis on soft educationalism.

The government is taking responsility for training,
by telling trainees to train themselves and pay for it too.

We are optimistic for the future,
but in reality we have no job security and morale is at an all time low.

Patients are safer than ever before,
but the under trained are empowered and the medically trained harder to find.

Training standards are pushed to higher and higher,
but the proper training and qualifications are no longer needed for jobs of great responsibility.

The NHS is better than ever before,
but its harder to see an appropriately trained doctor than it used to be.

Sir John Tooke's review is provisionally great,
but the government are going to ignore it all and brush it under their bulging carpet.

Selling off the public services will be great for the economy and the service provided,
just as it has been with the Royal Mail and the railways.

Gordon and Sir Ara have our best interests at heart,
corporatising and dumbing down health care so that it can be privatised will be good for us all.

Sunday, 6 April 2008

Gordon's spendthrift nation

The short termist policy that has been employed so negligently by Gordon Brown from his early days in office right until the present day are like a ticking time bomb, it is only a matter of time before the monumental explosion occurs.

There are very few areas in the public services in which assets have not been mortgaged up to the hilt in a tragically stupid and short sighted manner. NHS Trusts up and down the country are being financially crippled by having to service ridiculously expensive PFI deals. Valuable buildings and land have been sold off at cut price rates, as public services have moved to cheaper areas for short term gains. Our pension funds have been negligently raided by the irresponsible supreme leader Gordon Brown.

We have already seen the impact of the global credit crunch caused by irresponsible work in the sub prime mortgage market. Gordon Brown is recklessly ignoring repeated warnings about the state of the UK economy as this spendthrift policy continues; when the time bomb explodes Gordon will not be able to deny that he was warned, he has been warned time and time again.

Politicians like Gordon Brown need to face up to reality. It would indeed be very nice if we could have everything we wanted all the time, but life isn't like that, and by trying to provide more than we can practically afford Gordon is sacrificing our future security for this short termist slash and burn. Gordon is pawning the TV to buy another bag of smack. Gordon is one selfish power hungry gawping fatty who is happy to risk all of our futures for his own short termist political success. I wouldn't look so happy if I were you Gordon, your time is almost up.