Tuesday, 30 June 2009

Head in sand doesn't make everything all right

Modernising Medical Careers (MMC) was allegedly the reform of medical training for the better, as many of us have since learnt the government lied about the real motives that lay behind this Trojan Horse of festering garbage. When everything when so spectacularly tits up back in 2007, the government had to pretend to act because things had got so bad that the media had started to take notice. In actual fact MMC had been doing damage to training for several years before 2007, the creation of the lame 'competency based model' of Foundation training and the useless application process for these jobs had already been about for several years by 2007.

After some excellent Freedom of Information ferreting I have managed to get hold of documents which detail correspondence between the Secretary of State for Health and the deputy CMO Martin Marshall on the topic of the MMC inquiry. I have highlighted some interested snippets for you to have a look at, taken from Martin Marshall's letter to the SofS:


....Whilst there have been successes as well as problems...

I understand the NAO are coming increasing pressure to undertake a review, either of the immediate issues with MTAS, or of the wider MMC program. I would hope that the announcement of an independent review would influence this decision, or at least its timing.

The purpose of the independent review would be to examine the framework and processes underlying the design and delivery of the whole MMC process and to make recommendations to ensure improvements for 2008 and beyond. This is likely to involve revisiting some significant issues but not to review the principles underlying MMC. These principles, to develop a competency based training program for doctors based on defined national standards, have widespread support amongst professional leaders.

The leading candidate is John Tooke... He is a committed educationalist, extremely well respected by the profession and more widely, and informal soundings suggest that he might be willing to accept the role if asked."

The above snippets are quite revealing. Not only do they show that the Department of Health has a remarkable habit of being completely unable to realise when it has made a mistake, but they only act when they are forced to by outside forces. The DoH appears to live in a permanent state of denial, completely unable to see just how incompetent their own actions are at times; they only ordered an Inquiry into MMC as they were afraid the NAO were about to nail them with a much more damaging review at a later date.

It is very revealing that the 'principles underlying MMC' were not to be called into question by this review, these were untouchable and allegedly already widely supported by our professional leaders, this all smells of fish to me. Interesting that the 'principles of MMC' seem to change every few days, according to the MMC website they are:

"One of the intended benefits of Modernising Medical Careers (MMC) was to ensure a transparent and efficient career path for doctors."

So much for that efficient transparency, MMC has reminded me far more of corrupt cock ups than anything else. The real motive of MMC was this:

"MMC aims to provide consistent national standards for training through better-structured and managed programmes with competency-based curricula approved by the independent Postgraduate and Medical Education and Training Board (PMETB)."

In reality MMC has resulted in a less flexible top down system which has done nothing but paper over the catastrophic effects of EWTD on medical training. Tons of extra paperwork and curricula will not help train specialists in less years with less hours per year, training cannot be purely competency based tick box numpetry, training must be common sense based and time based to a degree.

This government has dishonestly tried to force through the subconsultant grade with MMC, they lied to us and pretended that MMC was about better training and better patient care when it was about nothing of the sort. MMC was much worse than simply doing nothing as if nothing had been done we would have had to address the evils of the EWTD, as things stand the DoH and the government have stuck their empty heads in the sand and pretended that MMC would fix all our training problems including the EWTD. At the same time many new problems have been created by MMC including a lot of competency based damage to training and rain forests, an erratic and under performing Foundation training system, as well as numerous problems with various job application systems including an invariably useless Foundation scheme application system.

I've rambled on, mainly because it makes me very angry when people stick their heads in the sand and pretend everything is OK when it obviously is not. A lot needs to happen to fix this mess, the failings of competency based training and Foundation training need to be addressed fast before it is too late, maybe an NAO review of MMC would be a good thing to push for as well, while the EWTD monster needs to be taken on at some point. I don't have all the answers by any means, but the first step is to own up to the massive problems that exist, not living in arrogant denial like some choose to do on a rather regular basis.

Friday, 19 June 2009

Shambolic and unclear: Kafka's NHS

It's not hard to find diagrams like the ones above, the Internet is littered with examples of just how overly complicated the NHS' management structure and bureaucracy has become. It shouldn't take several textbooks and a few years of intense study to understand the way in which a health care system works (or does not as the case may be), the fact that the NHS is so hard to understand implies that it is a disorganised shambles with no clear chain of command. It should be so much easier to comprehend, but the government keep reforming, making things more complicated and shambolic.
The market argument is a complicated one, even a bottom up market would probably be more inefficient and bureaucratic than a well run state run system. However one can guarantee that a top down state run market system will be ridiculously inefficient and cumbersome. The diagrams above the the government 'newspeak' sum up the stupidity of the current process. Even people at the top are starting to see the light, and about bloody time too, it's just a shame that our moronic leaders like Tony Blair cared more for their own wallets than the nation's health. The lack of a clear chain of command means that the system is also incredibly dangerous as no one ever takes any responsibility when things go wrong.
The sad thing is that there appears little that we can do as cogs in our great 'democracy' to affect change in this regard. Labour copied all the flawed ideas of the Conservatives and then put them into practice from 1997 to this day, the Conservative would carry a lot of them on if reelected, while the Lib Dems never seem to oppose anything much with any vigour. The current economic situation and the future NHS spending cuts mean that we can expect to see front line services hit hard, while I am sure that the spending on bureaucracy, managers, PCT numpties, new incomprehensible reform strategies, management consultants, quangos et aliter would not be affected much.
It makes my blood boil. So much corrupt and cynical politics dressed up in nothing more than glossy bullshit. In the current financial climate it is a disgrace that money should be wasted in such a wanton manner. If I want to buy a load of bread the most efficient way to buy it is not to pass the money to the shopkeeper via four organisations and decide upon which loaf to buy by employing a cohort of idiots who then hire a group of management consultants to make the expensive decision for them, I haven't even started talking about how this NHS-style system would go about getting my loaf home; if I need a loaf of bread I'd go to the shop and buy it myself.

Thursday, 18 June 2009

Power without responsibility

It's a deadly combination, power without responsibility, as we've seen with MPs' expenses if people are allowed to do what they want with little fear for the consequences then they will behave quite appallingly and unethically. One of the best ways of ensuring high standards in any system is to ensure that those people who are making important decisions are made accountable for them, after all if something goes wrong and no one is at all accountable, then the same errors will continue to made time and time again. What relevance has this for the NHS, quite a lot I would argue.

I had the misfortune of encountering a rather arrogant and obnoxious radiographer the other day. Radiographers are the technicians who take XRAYs, CT scans et cetera. I have to say that most of the standard radiographers I come into contact with are very pleasant people. The problem is that as with all things in the NHS, radiology has started to be dumbed down, some radiographers have now been empowered to actually report XRAYs as 'reporting radiographers'.

Don't get me wrong, radiographers see a hell of a lot of XRAYs and are very good at spotting fractures, better than a lot of doctors in fact. Unfortunately they are not medically trained, they are not radiologists, meaning that they do not have the broad base of knowledge and training that enables them to think outside the box and think of rare pathologies. For this reason 'reporting radiographers' are only allowed to report a very small percentage of the XRAYs that are done. There is still a problem as what happens when a 'reporting radiographer' misses that rare abnormality that a radiologist would most likely have picked up, I get the distinct feeling that they would not be held to account as a radiologist would be.

Radiologists are notoriously cautious because they know how tricky interpreting XRAYs and other tests is, most of the time one can see the obvious answer straight away, however if one just jumps straight in without thinking one would never diagnose the subtle, rare and potentially career-ending-if-missed pathologies. Radiology is like a minefield littered with the occassional career ending mine, most of the time one will be OK skipping through nonchalantly, however if one skips for long enough one is sure to get blown to smithereens.

I have digressed. The point I was trying to make was that the rather obnoxious 'reporting radiologist' was so overly confident because they lacked the knowledge and insight to be aware of their own limitations, they were skipping through the minefield assuming that their luck would hold. The particular one I met chose to take a quick glance at the XRAY, then claim that it was completely normal and should never have been done. I kept quiet and didn't mention that a rather esteemed Consultant surgeon had a very good clinical grounds for performing the XRAY. This is power without responsibility in the NHS, it generates this rank arrogance in the ignorant, it creates a potentially lethal over confidence in those who do not have enough knowledge to realise their own limitations. I could move onto the tale of the osteopath who reports XRAYs and misses bone tumours the size of footballs, but I would want to get sued for insulting a quack would I?