Tuesday, 29 September 2009

Monkeys for management, the NHS rot

As we all know money is in short supply, the government has frittered away billions on brainless ideological schemes in many policy areas, this is especially relevant to health and the NHS. Who can forget the billions that have gone on management restructuring every two years (SHAs/PCTs), PFI schemes of appalling value, C&B/PBC (the market), Darzification and Darzi's privatisation of general practice et cetera.

The lack of understanding of medicine and health care in general is excellently shown by this chunk the article in the Telegraph:

"Sixty per cent of activity which now takes place in A&E departments should happen in community clinics within five years, the document says, along with 55 per cent of outpatient treatment. Thirty per cent of outpatient appointments will be stopped altogether. Managers say not all appointments are necessary, though many doctors argue it is impossible to know in advance which patients do not need to be seen. The number of diagnostic tests carried out will be cut by 15 per cent, while the amount of surgery will be reduced by seven per cent."

This statement exhibits a rank lack of intelligence and a rank lack of understanding of medicine. Shifting work out to lame little community clinics does not work, not only do the under trained staff at these units have no idea what they're doing but they often end up referring most stuff onto other services anyway, they do not have enough knowledge and skill to actually properly sort patients out.

Just because nothing is done at an out patient appointment it does not make this appointment unnecessary, a lot of appointments involve patients being reassured and adequately diagnosed by a specialist. Not all flood defenses are necessary, does this mean that those manage our flood defenses will go about deciding which ones to remove before the next floods hit us? Of course not, this is the logic of morons. With medicine becoming every more sub specialised it is inevitable that referrals will increase as it becomes harder and harder for generalists to adequately manage in subspecialities which are becoming ever more complex with new treatments becoming available of which they know very little. In modern medicine patients are also becoming more empowered and knowledgeable, this will also drive up referrals to specialist services.

The idea of reducing diagnostic tests and surgery in this context is also completely nonsensical. In the modern day drives to cut diagnostic tests will probably lead to more litigation and hence increase costs, while as medicine becomes more complex and subspecialised, it is inevitable that diagnostic tests and surgery will need to increase. As imaging develops we are constantly finding new indications for surgery which are proven to be effective, you simply cannot aim to reduce diagnostic tests and surgery in this context, it is utter lunacy.

The layers of bureaucracy are now proliferating. Various uneducated ignorami at the DoH, SHAs and PCTs are wasting a massive amount of money in trying to increase efficiency with stupid policies that try to directly reduce referrals in a top down manner. This is done by creating more administration to regulate clinicians in an Orwellian manner, telling clinicians not to refer is plain stupid, clinicians do not refer for fun, they refer when they think the patient will benefit from a referral, so top down interventions to reduce referrals are actually in conflict with good medical practice, it encourages bad and arguably dangerous medicine.

So millions and billions are now being wasted on various crack pot schemes that aim to save money by effectively stop proper medicine being done. In this way money is wasted enforcing bad practice and bullying clinicians. This is a blatantly Stalinist system at work, it is a disgrace. Many of us have now seen first hand examples of this kind of logic at work in the workplace, PCTs are now refusing to pay for certain hospital services that patients need, the demand doesn't just go away if you refuse to pay for something, fiddling the hospital out of money doesn't make certain ailments disappear.

The current system sees various bureaucracies fighting each other, there is no cooperation which would result in efficiency savings, PCTs are fighting hospitals for money, the DH is clawing back money from PCTs, and then finally the government will cut the money off at the source. In the meantime patients will not magically get better, their illness will not just go away. Fiddling the books helps no one in the long term.

The government and our administrators would do better to look reality in the face, in an NHS in which administration costs have almost tripled in a few years thanks to their endless tinkering they would do better to stop the rot, stop the top down artificial market, get rid of the PFI deals, stop wasting money on management consultants that tell them to sack clinicians and hire more management consultants, stop the reforms that are increasing the waste and inefficiency. Start thinking about the needs of patients, start trying to meet their needs as best you can and stop hiring more administrators to increase the efficiency of the system, this is akin to pouring petrol onto a fire in order to put it out.

Saturday, 26 September 2009

ISTCs and the disgraceful wasteful marketplace of doom

As with many recent government health reforms that have revolved around ideological nonsense and the enrichment of various groups with close political links, there has been no effort from the start to monitor the safety or performance of ISTCs from the very start. It is only thanks to some excellent local units that we are starting to discover just how much damage has been caused by these devastating reforms. This is without doubt only a small iceberg tip.

It is worth reading the full article and observing just how poor the record of these ISTCs is. The ISTCs have shown to be doing joint replacements that are failed at a rate of around 20% at three years, this is about twenty times the national NHS average rate, this is blatantly negligent and it doesn't need a statistician to tell one this. It is worth noting that this bodged surgery is costing the NHS a fortune to put right, add this to the fact that the ISTCs are often getting paid way more than the NHS for the same work. They are dangerous and bad value for money, the market is a clear failure in this context. The DoH is as always in complete denial as it is just pushing through ideological rubbish at the expense of patient care:

"Patient safety is top priority with all contracts with the independent sector. The Department of Health requires all Independent Sector Treatment Centres to have robust policies and procedures in place. All ISTCs operate under standards monitored by the Care Quality Commission, the independent health watchdog. The CQC... have not raised concerns with the Department about the safety of ISTCs."

What a lie and what a cop out. Like many new government reforms such as Walk in Centres and the contracting out of OOH (out of hours) work to private firms the effects in terms of patient care have not been monitored at all, it is a national disgrace. For example at ISTCs they are employing ' consultant' colleagues from other EEA states and many of these consultants have never worked in the UK before. They will, therefore, be working outside their comfort zone. They are often appointed with nothing like the formalities of an NHS Advisory Appointments Committee and sometimes appointments have even been agreed over the 'phone without any interview or meeting. This is dangerous practice and should be a risk management ' red flag '. Many of these consultants are not members of the respective UK academic college and are working in isolation from UK colleagues.

Millions of pounds of cash are still being dished out to ISTCs and there are simply not the systems in place to monitor just what they are doing in terms of harming patients. This is unacceptable, when those at the top of the political tree keep going on about standards and governance, why are these expensive unregulated disasters still being rolled out? Any changes to care delivery should be rigorously piloted and monitored to ensure that standards are not being compromised, this simply has not happened for the plethora of awful reforms we have seen in the NHS in recent years.

Whether it be your paramedic refusing genuinely sick people trips to hospital having been empowered by a short dumbed down course in being a doctor, your EEA GP with a limited command of English being flown in to do GP OOH work for a cost cutting private firm, your walk in centre quack pretending to be a GP and mobilising their Fisher Price (TM) stethoscope after a two week course in medical diagnosis or your EEA Orthopaedic specialist having a go at joint replacements in an ISTC with techniques which they have never done before, there is no excuse for this erosion of standards. The damage done is very hard to quantify as there has been no attempt to monitor the impact of any of these changes to practice, some things like Orthopaedic outcomes can be more easily eye balled retrospectively as has happened with the Cardiff ISTC but the vast majority of outcomes are almost impossible to measure without well though out prospective analysis, something it appears the government has avoided at all costs because it knows that this marketisation is doing harm to patients. The dumbing down continues.

Tuesday, 22 September 2009

Supermarket medicine

I apologise for my recent lack of activity, unfortunately life has dealt me a busy hand of late and far too much time has been spent working and in my car. Currently a porcine sore throat means I am feeling rather pathetic and tired, my energy levels are flagging.

It's hard to keep up with the news, there is just so much utter rubbish spouted from various media orifices that it is very hard to know where to start one's dismantling from. Certainly Andy Burnham's recent disingenuous ideas are as good a place as any to start, Dr Crippen has hit the nail on the head yet again:

"The demand is insatiable, and the only way the government can cater for it is by dumbing-down the service and moving towards a 24/7 "medical supermarket"."

The sheer nonsensical nature of the continued NHS reform beggars belief, the same failed ideas continue to be tried out again and again and again. It is no surprise that they continue to fail miserably. With the recession rolling on and debt levels high, cuts will inevitably be made in the places in which they will be felt the most. The real motives are hinted at here by Dr G.

The weak reporting of the the poorly explained entitity of 'misdiagnosis' really got my goat this week. The 'BBC investigation' was dramatic and breathtaking in the BBC's minds, in reality they showed nothing new but were rehashing and sensationalising the work of others. Strange that the beeb didn't mention how anyone can have a crack at diagnosis these days, just a few weeks with a toy stethoscope can give you the power these days.

I bet the useless NHS empire of bureaucracy that is made up by the DoH/SHAs/PCTs will not be trimmed, the front line services will be the ones to suffer as the aforementioned lame duck organisations waste money hiring management consultants and employing more idiots in trying to increase efficiency. Idiots will always try to improve efficiency by hiring efficiency officers to oversee efficiency reforms, a better management strategy would be to cut the ineffective rot out of the system. The problem is that the inefficient rot is running the show and as a result the NHS is doomed.