Tuesday, 24 March 2009

Remedy survey reveals the truth about MMC

A recent Remedy survey has shown the devastating impact that Modernising Medical Careers (MMC) has had upon patients, doctors and their families. The results are not surprising but are still very important as none of the powers that be have ever looked for any feedback or comment from doctors on MMC.

It is strange that in an NHS with so much bureaucracy and pretend feedback that organisations such as the Department of Health, PMETB, the Deaneries and the BMA have never asked any meaningful questions about MMC. If you do not look for something then you will not find it, also if you hide from something then you are also a damn sight less likely to encounter it.

Amazingly despite the stated aims of MMC being to improve patient care and postgraduate medical training, 78% of all respondents say that patient care and postgraduate training is worse than previously. Very few (just 1%) could comment on MMC positively.

Sadly MMC is but the tip of the iceberg of failing and destructive healthcare reform, it is also true that this failing government healthcare policy is also only the tip of another even bigger iceberg, the one that represents this government's general failure in all it touches. Whether it be the riding roughshod over our civil liberties or the never ending empowerment of various Kafka-esque state agencies, this government treats most people with no respect, and if you treat people with no respect and showpeople no trust then you know what you can expect in return.

Monday, 23 March 2009

Cancer mortality unchanged and more targets

It is obvious that the government's grandiose inefficient top down schemes don't work very well, another example of this has been the government's 'Cancer plan', yet another superficially catchy plan backed up with more targets that appears not to have worked. Blanket targets that force patients to be seen within a certain time frame irrelevant of their actual clinical need are ways of robbing Peter to pay Paul.

The only way to improve our cancer mortality figures is to scrap the targets and continue to sink money into capacity on every level. This doesn't only mean quicker surgery by more operative capacity, it means more radiotherapy capacity, more capacity of adjuvant therapies like chemotherapy, easier access for GPs to diagnostic services and more capacity in the specialist clinics and in radiology departments. It would take a hell of a lot of money to drag us back into line with the rest of Europe on this one after so many years of relatively underspending.

Simon Caulkin's quite magificent article in the Guardian brilliantly exposes just how foolish the government's approach is to these complex problems:

"Target-driven organisations are institutionally witless because they face the wrong way: towards ministers and target-setters, not customers or citizens. Accusing them of neglecting customers to focus on targets, as a report on Network Rail did just two weeks ago, is like berating cats for eating small birds. That's what they do. Just as inevitable is the spawning of ballooning bureaucracies to track performance and report it to inspectorates that administer what feels to teachers, doctors and social workers increasingly like a reign of fear."

You can read the rest of this excellent critique here, it really is a fantastic piece of journalism:

"They even propose a health warning: "Goals may cause systematic problems in organisations due to narrowed focus, increased risk-taking, unethical behaviour, inhibited learning, decreased co-operation, and decreased intrinsic motivation." As a glance at Stafford hospital would tell them, that's not the half of it."

Wednesday, 18 March 2009

'Individual management failures'

The headlines surrounding Staffordshire General Hospital have been hitting the news in the last few days and it is hard to see how anyone could not be outraged at the appalling standards of care 'provided' there. Gordon Brown was answering questions on the subject at lunchtime today and he kept repeating the words 'individual management failures' while ignoring repeated criticisms of the NHS' dire central management which imposes the market from Whitehall and the top down target based system that is arguably to blame for problems like Staffordshire General's.

Others have covered this story already. Dr C points out that anyone pointing out these kind of glaring failures in care is likely to be labelled mentally ill by the GMC, such is a whistleblower's fate in the NHS. Dr Grumble points out how the idiotic target based system encourages the prioritisation of political imperatives over clinical ones leading to junior doctors being bullied by managers into ignoring the clinical priorities of patients. Dr Rant points out where the blame should lie. The Witch Doctor cleverly points out that the 'leaders' which this government is so keen to marginalise are probably the only people who could dig the NHS out of the deep pit which the politicians have been digging for so many years.

Alan Johnson and Gordon Brown are living in cloud cuckoo land. While some hospitals do manage to provide high standards of care, it is despite the government's central megalomania, not because of it. The problems in Staffordshire General stem from No 10, the DoH and the top. The government's top down control freakery and brutal imposition of various brainless reforms is the cause of problems like this. The management structure of the NHS is centrally driven and top down, there is no room for feedback, no room for local decisions, it is do as the government says or die, quite literally in some cases.

It is no coincidence that patients were killed in both Maidstone and Staffordshire as a result of Trusts prioritising their finances over patient care. Both hospitals were trying to gain Foundation hospital status, hence they wanted to save money and meet targets, whatever the cost in terms of patients being slaughtered. The government has killed these patients with its systemic mismanagement of the NHS. The market has been their top priority and imposing this from the top has come with the obvious costs attached. There is no doubt that the governent has created this environment in which finances are prioritised ahead of patients' lives.

Gordon Brown and Alan Johnson have the blood on their filthy hands. These are not individual management failings, these are systemic failings as a result of a Stalinist system that forces managers to prioritise the government's wishes ahead of patients' clinical needs. The government's explanations for these deaths do not cut the mustard, it is simply not good enough to try to pin the blame on individual managers. The blame lies with a cynical and corrupt system that is set up to meet the short term propaganda gathering needs of politicians, local managers are frequently in a no win situation as they are forced to meet political targets rather than improving the process of clinical care with their hospital.

Gordon Brown's stupid words in defence of his targets sum it all up beautifully, he claimed that no reasonable person would deny that cancer patients should be seen within two weeks and that AE patients should be seen within four hours. Actually Gordon I am reasonable and there are many situations when it is very reasonable for minor injuries to wait many hours for treatment, as if there are moribund patients needing resuscitation in the same AE department they must be the number 1 priority and the sore big toe or the itchy buttock can damn well wait.

Targets do not improve patient care, only extra investment and a consequent increase in capacity can do this, the targets are a bit like robbing Peter to pay Paul, improving care for one condition invariably results in someone with another condition suffering. All the managers in Staffordshire General were doing was responding to the pressures of a system that had been put in place by central government, if they had some local autonomy then it would be fair to blame them, unfortunately they did not. The government has created this dangerous clinical environment, it is they who should be up in court charged with murder.

Friday, 13 March 2009

Alan Johnson: liar or just plain ignorant?

Anyone who works in the NHS these days, well pretty much anyone, can tell you that Alan Johnson is extremely innacurate with the following statement that is documented on the record in Hansard:

"There is no question but that it has been challenging to work towards full compliance. The NHS has over 46,000 doctors in training at any one time. Incidentally, there is no vacancy problem, as the hon. Member for South Cambridgeshire (Mr. Lansley) suggested. On the last set of figures, we had a 95 per cent. fill rate; there is absolutely no vacancy problem anywhere in the country that I know of. This is a service that by its very nature has to operate for 24 hours a day, seven days a week. Trainee doctors need to train and work in as many medical disciplines as possible to become good doctors. Hospitals have had to make dramatic changes to how staff work. So, yes, it has been difficult, but it is simply not true to say that the NHS is ill prepared to achieve full compliance by August this year. We have provided substantial financial support to the NHS to help it to meet the requirements of the directive—£110 million in the current financial year, rising to £310 million for the year to come."

Either Mr Johnson is incredibly ignorant of what is going on in his own department or he is telling big fat porkies. For many reasons there is a staffing crisis at many junioir doctor levels in the NHS, numerous rotas are being run short of multiple staff members, meaning that doctors are missing out on training and patient care is suffering.

A recent survey of surgeons in training showed that over 50% of surgical rotas were significantly short of staff, and this is not an isolated problem for surgery, it is occurring across the board and it is not good for anyone. Doctors are getting overly tired covering the gaps while patients will be getting less continuity of care, as well as less time dedicated to their various problems.

The blame for this lies with the government thanks to their stupid reform that has led to non-EU doctors being kicked out, all doctors changing on the same day every year and hundreds quitting the NHS due to their great disillusionment. This is all compounded by reducing working hours thanks to EWTD and the fact that the BMA are doing nothing about this serious problem. NHS Trusts cannot find locum cover to fill these gaps, while even if they can it is very expensive and wasting a lot of money needlessly. Well done Mr Johnson et al, you have shafted a generation of doctors and now the patients are suffering too.

Thursday, 5 March 2009

You get what you pay for, less training more mistakes

With kind permission from the author I have reproduced the following tale to show how quite simply less training leads to more mistakes and a lower quality of care:

"Not so long ago, in a land not far from here, a young boy awoke one morning with a painful tummy.

"Daddy!" he cried. "My tummy's hurting."

The father looked down at his dear son and said, "Don't worry, O son, for I know a Wise Woman who will be able to cure your pain. Let us go and visit her."

And so, the family made haste their travel to the local Walk-In Centre, where the friendly nurse greeted them with a warm smile. "Come in, and tell me all about it," she said. And the young boy proceeded to tell the Wise Woman of his painful tummy."This is nothing to worry about!" she declared in a very wise and motherly way. "Be gone, for your pain is due to a virus."

The Wise Woman did not need to examine the young boy, for she had been on a "couple of courses."

The family thanked the Wise Woman for her great wisdom and made good their journey home.2 days later, the post-mortem report concluded that the boy had died from a perforated appendix.

The morals of this story are that:

1: When you assess a patient, you often have to examine them.
2: If you do not know how to examine a patient, you should not be assessing them.
3: Sometimes it takes a few disasters before mistakes in policies are addressed.
4: Nurses, as with doctors, have a duty of care to their patients. If that duty is breached and harm results, then they are NEGLIGENT.
5: After a few civil cases, nurses in WICs will realise that they are on their own, in a failed policy.
6: The public should be fully informed when consenting to treatment: "You get what you pay for."

Wise words. I am not pretending doctors are perfect, far from it, however less training results in worse care, it's very very simple.