Tuesday, 30 December 2008

Empowering the ignorant and intimidating the intelligent: Labour's NHS

It's that time of year again when everyone tends to feel a bit under the weather, it's cold and miserable, the germs have been multiplying over Christmas and people are just waiting for winter to bugger off, so it's been no surprise that numerous hospitals up and down the country are packed to the rafters. Labour have intelligently cut the number of beds in the country steadily over the last ten years, this is despite the fact that our population is expanding and becoming more elderly in its make up. GPs have been receiving emails similar to this one from their lovingly patronising local PCT monkeys:

"Dear Colleagues

Unfortunately the hospital is on red alert which means that they have no available beds at present and they are doing everything that is possible to free up any available capacity. As a result of this, any referred patient may well have an extended wait on a trolley before a bed is found for them.

We fully appreciate that GPs are working very closely with their PBC consortia in order to work as effectively as possible in order to manage more patients safely within the community. At this time we would ask you to re-consider the following before a decision is made to refer any patient for an admission:

Please inform the patient of the likely delay on a trolley so that they are prepared and that it doesn't come as a shock to them"

This kind of message is completely pointless, it's as if managers think GPs deliberately send in patients to hospital for no reason, yet when bed pressures are greater they can suddenly cut down on these unnecessary referrals, what patronising idiotic twaddle.

Then again it's very much the New Labour mantra that patients should be treated in the community, however it doesn't really go alongside improving the quality of care because hospitals are very much necessary for managing sick patients, doing this in the community is either dangerous or incredibly expensive in comparison. Have Labour ever heard of economies of scale?

GPs and doctors in general are also being bullied by their lovely managers into following NICE guidance, which sort of makes a bit of a mockery of it being 'guidance'. Given that NICE guidance often works against the best interests of patients and misinterprets the scientific evidence, it's not as if we should be following a lot of NICE's crap little protocols anyway. It's just another example of doctors becoming less like independent professionals and more like agents of a sinister bureaucratic state.

Medical training is another thing that's going awfully well too, good old MMC means that everything is amazingly so much better than before. It's almost like alchemy, as even with less hours and experience doctors are now magically going to be better than ever before. Once PMETB said that training was now competency based and not time based, it's as if magic came to town and all those training problems went away, unfortunately common sense also went out of the window and we're all doomed, doomed I say. Apparently the GMC don't think that those who forced through the destructive and dangerous training reforms should be held to account, I just hope Remedy can force them to do their job properly, rather than protecting their buddies in their ivory towers. The GMC's logic appears sadly lacking, no surprises there then.

God medical blogging can be depressing, I'm naturally not a pessimist by any means, it's just everything that this government does is so negative and destructive. They have no intention of working with people, all they want to do is bully people and force through their corrupt agenda of privatisation. The doctors are their enemy because they are independent intelligent professionals whose autonomy threatens the government's reform agenda, the government wants a compliant cohort of worker drones who will do as they are told, follow the government protocols and let big business tuck into the NHS pie. Nothing else could possibly explain the drive to empower the ignorant and put patients at risk, while obstructing the hard working professionals who hold the system together. Ho hum and happy new year.

Sunday, 28 December 2008

Bad Science and a merry christmas to all

I was fortunate enough this year to find a copy of Ben Goldacre's Bad Science on my stocking, since I've had the misfortune of working for a portion of the Christmas period I've found time to turn a few pages of this fantastic book. It really is a pleasure to read.

His analysis of Gillian McKeith is reason enough to buy the book on its own, there's no doubt as to the danger that this kind of ignorant pseudoscience poses to the general population who are often not informed enough to know any better. Take this little extract from Gillian McKeith's website, her symptom of the day is:

"Backache or low back pain

Low back pain invariably involves a degree of dehydration and extra water helps most people in a few days. It is also a call for more Boron and Magnesium in the foods you eat along with Vitamin D and the B Vitamins; B1, B12 and B6."

Personally I find Gillian McKeith to be remarkable stinging pain in the rear end, almost like an anal fissure, it's nothing personal Gillian, I just find you brand of pseudoscience particularly offensive.

Interestingly if you search the medical literature for 'magnesium' and 'back pain' then one gets one paper of interest. Interestingly this study found that 'Plasma magnesium was slightly reduced after the supplementation', so I wonder where this talk of more magnesium comes from? Gillian McKeith's derriere perhaps?

Also if anyone gets inspired to drink lots of magnesium containing antacids a a result of reading Gillian McKeith's advice then I suggest they think again, this may be rather bad for your bones. As regards Boron there is nothing in the literature on this bizarre McKeith claim. In fact Gillian when you say 'You are what you eat', things couldn't be further from the truth, millions of year of evolution mean that we can break down what we ingest and convert it into much more useful bits and bobs.

Anyways I digress, Ben Goldacre is a rare example of someone writing about science who actually has a scientific education and background; sadly the media is full of arts graduates who who have no scientific background or education who feel sufficiently empowered to comment on all matters scientific as if they were experts, they lack the insight to be able to see just how foolish they appear to those with some scientific knowledge and understanding. In fact I remember debating this very point with a broadsheet journalist last year, he/she insisted that a science correspondent didn't need to have any scientific education, something that only an arts graduate with no understanding of science would have the nerve to say.

The BBC's shoddy journalistic standards continue to astonish in this manner, only a few days ago they were presenting a case of 'cortical blindness' as being a new undiscovered phenomenon, it may sound exciting to the lay person to present the old as new, however it's just lazy journalism not to research a story properly and to present something that was discovered over 30 years ago as being discovered this year. This is hardly a one off example, it seems to be routine for the BBC to misinterpret a poor quality study from a dodgy journal in order to spin their own agenda these days. Anyways I am ranting, I'll leave you in peace for now, happy new year and here's to the greater exposure of quacks and bad bad science.

Sunday, 23 November 2008

Pulse nails the lazy Mail

There is a certain sense of irony in me reproducing a Pulse article here because the article neatly mocks the Daily Mail's lazy and sensationalist journalism, I just think it's such a damn good piece that it deserves to be spread as widely as possible:

"Cancer, global financial crisis and all wars 'are GPs fault', Daily Mail claims

GPs' newspaper of choice, the Daily Mail, has stepped up its crusading message with three stories which set a new standard in GP bashing. It couldn't be pay negotiation time could it?

Today comes the news that out-of-date GPs are sentencing thousands of cancer sufferers to death because they're failing to diagnose their illness in time. I paraphrase only slightly.

In the story, headlined '10000 Britons die needlessly every year as GPs with out-of-date training miss vital cancer symptoms', based on an eminently reasonable Cancer Research UK report, Mail reporter Daniel Martin writes 'GPs too often miss symptoms or do not send enough patients for tests.'

He goes on 'In some cases their training is simply out of date. The report says some people are deterred from seeking treatment by the difficulty of getting an appointment.'

Predictably the article doesn't miss the opportunity 'failure of GPs' comes despite their pay 'soaring to more than £100,000 a year'.

What guff. The nub of the Cancer Research report, that there is too little public awareness about cancer symptoms, meaning many victims do not see their GP until it is too late to save their lives, is mentioned but only as a throw away point - seeming less important as a factor than getting an appointment with a GP.

One would think the Mail, with its vast numbers of middle-aged, female and elderly readers slap bang in the highest cancer risk groups would focus more on this aspect. No, of course not. Because there's no easy target there. Too much explaining to do.

Moving on, yesterday the Mail's bait was the Kings Fund report on PBC. How did on earch could it carve an angle out of something as desperately drab as PBC, you ask. Easy. It's that 'GPs 'waste' 100m NHS fund set aside for local care'.

Apparently, family doctors are simply pocketing cash set aside to improve local services or routinely commissioning themselves to do it.

Of course, as GPs know there are enough problems with PBC to make your eyes bleed with frustration, but...that'd take too much explaining. Rubbish managers? Too dull. Dreadful bureacracy? Boring. Ill conceived scheme in the first place? Too complicated. GPs pocketing your hard earned money? Gotcha!

Our 'favourite' story though, for its sheer absurd, laughable, OTTness is 'GPs are focusing on patients who bring in bonuses'. Now there might be a fair point in the report that conditions not in the QOF don't get the same focus as those that are.

The QOF an incentive scheme. If you incentivise something, it gets more attention. That's life.

But it's the third line in the story that's the killer. So brazen. So shameless.

GPs 'are ignoring elements of care such as compassion because they do not get extra cash for being nice to patients.'

Why didn't the Mail just come right out and say 'GPs are money-grabbing, heartless bastards who would mug you in the waiting room for a quid and are really hoping you'll die so they don't have to waste their time on your pathetic existence' and get it over with?

So why is the knife being plunged in further and twisted harder this week? The week the Government's pay negotiators put forward a below inflation 1.5% pay recommendation for GPs.

Might Mail editor Paul Dacre have had a chat with his good pal and former chancellor - the man who signed off the GP contract that has embarrassed his Government ever since - the Prime Minister?

I really wonder how close the brown nosing Mail hacks are to the politicians that feed them this misguided propaganda? Certainly it's very strange how so many useless schemes that have been crafted from faeces by this Labour government are then blamed on the workers such as the GPs who are forced to put them into practice. It's the brainless Whitehall managers and bureaucrats who run the shambles that is called the NHS that are to blame, not the hard working clinicians on the ground.

Wednesday, 5 November 2008

The King's Fund - an 'independent' body

I am a terrible cynic so I have never paid much attention to the ramblings of the King's Fund, however I am sure that many neutrals get sucked in by the pretence of this Fund being such an 'objective' voice of reason. As many other so called 'independent' bodies it isn't really anywhere near as independent as it first appears, much like virtually all other so called 'independent' think tanks which are run by a small gang of cronies with blatant vested interests such as IPPR or the Fabian society.

Invariably these 'independent' bodies are run by people who are casting their divine judgement on things in which they have never been remotely close to the coal face, it typifies the way in which a lot of the country is run so badly by idiots who have no understanding of the reality on the ground. The King's Fund claims that:

"The King's Fund is an independent charitable foundation working for better health, especially in London"

The Who's who of the King's Fund makes rather interesting reading too. Strangely the NHS' commissioning boss Mark Britnell is a senior associate, the man who controls the NHS' purse strings, no conflict of interest there then. Private Eye alerted me to this fruity little story. Britnell sat on the DoH interview panels ahead of the selection of the King's Fund and Co consortium as one of seven eligible for contracts to boost the skills of PCTs in spending their 75 billion on world class 'commissioning'.

Britnell co-authored the NHS Plan in 2000 with Alan Milburn, while two of the plan's other architects also sit on the King's Fund management committee. These are Tony Blair's former health adviser amd now UnitedHealth UK boss Simon Stevens and Dr Penny Dash, ad adviser to McKinsey and Co of private equity and independent health care provider fame. As the Eye has revealed the private links to the King's Fund do not stop there, Dr Rebecca Rosen is the medical director of Humana, a huge US health care firm, and she is also an senior associate of the King's Fund.

So when the King's Fund talks of opening up the health care system to yet more competition and private providers, with yet more needless bureaucracy, should we believe them when they talk of their remarkable independence and integrity? It appears the DoH is rapidly becoming a privatised branch of Whitehall and that little they do is in the best interests of the general public, they seek to satisfy their private masters first and foremost.

Friday, 31 October 2008

GMC referral and more

"We have requested that some of the senior doctors be investigated for their role as managers integrally involved in the introduction of this. We have asked the GMC to investigate whether their professional and managerial actions and conduct in relation to SSR/MTAS fell seriously below the high standards that are expected by the profession, as laid out in ‘Management for Doctors’ and elsewhere, and whether their deficient performance, and their failure to meet the published GMC Guidance for Doctors in management roles, was so significant that their actions would amount to misconduct and/or deficient professional performance and would impair their fitness to practice in this managerial field of work under section 35C of the Medical Act 1983 (“the 1983 Act”)."

Remedy UK have written to the GMC to request that the senior doctors involved in MTAS, SSR and MMC be investigated for their actions. The full details of the request can be read at the Remedy UK website in full here.

I can only say 'hear, hear' in response, it's not about being vindictive, it's about ensuring that those in charge of the big schemes and reforms are aware that they must behave properly in their roles, it is simply not good enough to say 'lessons have been learnt' and for nothing else to happen.

Those who failed so many people so very badly with MMC and MTAS must be held to account, not only to restore people's faith in the system but in order to go about preventing more disasters like this happening in the future. It does seem that some lessons have been learnt, however it is also abundantly clear that other have not, for example the woeful application system for the Foundation job schemes does look rather similar to the failed MTAS methods.

Whether the GMC will do anything about this is another matter altogether. Many have rumoured just how close the GMC bigwigs are to certain members of the medicopolitical establishement, and for this reason it would appear unlikely that someone living in the house of cards would start blowing a gale. Stranger things have happened though.

Monday, 27 October 2008

PCT referral schemes scrapped but fishy smell lingers

It appears that despite the best attempts of several PCTs to introduce sick cash incentives for GPs to refer less patients to hospital, they have been thwarted by the government who have come out against these schemes:

"It is clearly essential that they do not in any way undermine - or be constructed in a way that could be perceived as undermining - the GP's overriding clinical and professional duty to provide the best care for each individual patient."

The DoH has said something sensible for once. It seems that the government had come under pressure as a result of a Telegraph investigation into these PCT schemes, however I did break the details of the Torbay scheme myself in the middle of last week, every little helps I guess.

One thing that should be emphasised though is the reaction to these schemes from GPs. Although a lot of GPs were concerned about the unethical incentives contained in these schemes, a lot of GPs did quickly sign up. In fact the Oxford LMC (Local Medical Committee) signed off on the scheme despite predicting the negative press coverage, while the Hampshire LMC passed it by 14 to 11 votes. I am slightly disappointed that more GPs didn't tell their PCTs to stick their unethical cash where the sun don't shine.

Another strange aspect to all this is the fact that Mark Britnell, the NHS' director of commissioning, made it appear that he and the DoH knew nothing of these schemes until the Telegraph had alerted them:

"We are grateful to The Sunday Telegraph for raising these three incidents and we have asked strategic health authorities to look at their local incentive schemes with PCTs, to make sure patients are getting the most appropriate care, and to make sure the relationship between the GP and patient is not undermined."

It seems strange that PCTs up and down the country were all rolling out these incentivised referral schemes at exactly the same time without the DoH or Mark Britnell's knowledge, it would be a wonderful coincidence if they had all thought up such similar schemes independently wouldn't it? It all smells very fishy to me.

Thursday, 23 October 2008

Sick PCTs incentivising patient death

The ferret has just found of one PCT that is sinking to new unethical depths in the incentivisation of medicine, it certainly would not surprise me if more than one PCT was indulging in this depraved behaviour. The national media has already noticed the unethical incentives offered by numerous PCTs in trying to get GPs to refer less to hospitals, clinical need is being thrown out of the window as the bean counters take over the NHS. In a new PBC scheme in one PCT the following are allegedly 'indicators of access to personalised and effective care', and GPs are being paid to reduce emergency beds, emergency admissions, out-patient referrals and alcohol related admissions, while they are being paid to let more patients die at home. These are the PCT's 'vital signs' that it intends to pay GPs for fiddling, amazingly the fools at Torbay have left the full document on their website, it may not be there for too much longer:

-Emergency bed days per 1000 patients
-Admissions for ambulatory case sensitive conditions per 1,000 patients
-Proportion of all deaths that occur at home
-GP referrals per 1,000 patients
-Rates of admission for alcohol related harm per 1,000 patients

(note- ACS conditions include life threatening problems such as angina, COPD, gangrene, perforated or bleeding ulcer, asthma and many more killers)

I find it hard to comment on this scheme without swearing but I shall nonetheless try. PCTs have already unethically started schemes up and down the country that reward GPs for reducing referrals, irrelevant of clinical need. The Mail calls the PCTs 'sick' and I am inclined to agree with them on this. The new incentivised vital signs detailed above reward GPs financially for reducing referrals irrelevant of clinical need, for reducing hospital admissions for life threatening conditions and for ensuring that more patients die at home. This is not just unethical, I think the PCTs are encouraging GPs to break the GMC's clear guidance on the duties of a doctor, there could be severe consequences for both the PCTs and the GPs if they accept these sick schemes:

"-You must make sure that your conduct at all times justifies your patients’ trust in you and the public’s trust in the profession.

-You must act in your patients’ best interests when making referrals and when providing or arranging treatment or care. You must not ask for or accept any inducement, gift or hospitality which may affect or be seen to affect the way you prescribe for, treat or refer patients. You must not offer such inducements to colleagues."

These PCT schemes are an utter disgrace. They demonstrate that the health service is being run by bean counters who have no understanding of the role and responsibility of being a doctor. Any doctor taking part in these schemes should be ashamed and could well be in grave trouble with the GMC, interestingly I wonder whether anyone with a medical degree has been involved in coming up with these ideas at the DoH or in the SHAs? It does emphasise the way in which doctors can be accountable for taking part in sick schemes like this, while medical managers are seemingly immune from ethics and codes of conduct, they can encourage bad clinical practice and they just don't care for the potential consequences in terms of patient harm.

Modernising Scientific Careers

Amazingly enough this is no joke, MSC (Modernising Scientific Careers) is upon us, so what exactly is MSC?

"The Department of Health's Modernising Scientific Careers (MSC) workforce programme is designed to ensure flexibility, sustainability and modern career pathways to address the needs of the future NHS."

In government speak this means 'unflexible, unsustainable and dumbed down pile of manure' and it deems a bit similar to the ideas behind the disastrous top down failure that has been Modernising Medical Careers (MMC). There is emphasis on a framework that appears to focus on competencies and centralisation, the government seems to be obsessed with these ideas despite the fact that their track record with them is of Eddie the Eagle quality:
  • introduce an integrated career framework encompassing all disciplines and employment groups within the workforce based on roles and function and linked to transferable skills and competences
  • clearly identify pathways for progression and transfer, supported by learning and development providing enhanced opportunities
  • provide national consistency and maximum flexibility to support local service delivery, the expansion and extension of current roles and the emergence of new roles.
Guess who is MSC's Programme Director? None other than the larger than life Shelley Heard, one of the key figures behind MMC, and my, what a success she made of that. NHS Employers must have had their work cut out to fight off the competition for her signature, well that or maybe they bribed her with a lifetime's supply of Ginsters. One wonders precisely what qualifies Shelley Heard for her position, is it her compliance with government ideology that has been proven by her years as a postgraduate Dean or is it her rank incompetence?

This government is pursuing the very opposite of excellence, their obsession with top down control and centralising everything in sight is so destructive that it's hard to put into words, they are completely unwilling to trust anyone to get on with their own jobs, hence more and more is run from the centre by corrupt government friendly numpties who will do anything the government says in order to hang onto their job or get their OBE. Hence the long term interests of the country are ignored time and time again, as the short term interests of brain dead politicians and their hangers on are served. The compliant incompetent are put in charge, while the educated experts are dis empowered as they may dare to disagree with the government's Stalinist approach, no wonder everything is turning to turd brown.

Wednesday, 22 October 2008

GPs sailing close to the wind

The screening for certain disease has had massive impacts upon our health, for example cervical cancer, however screening is only appropriate should certain criteria be satisfied. A number of factors should be considered before screening for a particular disease, they are nicely summarised by the WHO here. For an example of a cancer that it is pointless, arguably dangerous, to routinely screen people for, then take Ovarian cancer.

Firstly the blood test for the tumour market Ca-125 is a waste of time, it is not particularly sensitive and very non specific. Secondly screening with ultrasound scans is also dangerous, as for every cancer detected several women will undergo pointless diagnostic surgery which has obvious risks attached (estimates of this number are 2.5 to 60 women needing surgery for every cancer detected). There is also no decent evidence that early detection of the cancer will reduce mortality. Interestingly even in the high risk groups there is no evidence that screening is of benefit in terms of median survival and overall mortality:

"Although there is interest in identifying and screening these very high-risk women, there is no evidence that screening benefits this group in terms of median survival or overall mortality."

So overall screening for ovarian cancer appears foolish at best, unethical and reckless at worst. So when I hear that some GP practices are sending letters to their older female patients to advertise the screening for ovarian cancer by a certain private health firm (Health Screen Clinic or Health Screen First Limited as they are technically known) I get a little hot under the collar. This is unethical at best and given that they are sending out the private health firm's propaganda with their letter, it is sailing very close to the wind indeed. This has already recieved coverage in the national press, so why are some GPs still pestering their patients with this private firm's propaganda against the advice of the BMA?

In fact the private health firm recommend screening for people with only one first degree relative who has been affected, they are also using the rather useless Ca-125 blood test which costs the patient are rather significant amount of money. I see this behaviour from the private health firm as scaremongering, they are trying to scare a vulnerable group of patients into spending their money on screening themselves for a disease, that even if detected may not result in any improved survival. The GPs are complicit in this. In the GMC's duties of a doctor it states in the probity section:

-you must not put pressure on patients to accept private treatment
-you must not exploit patients' vulnerability or lack of medical knowledge when making charges for treatment or services

These GPs would struggle to defend their position in front of the GMC. Not only do they stand to gain financially by leasing their rooms to this private firm, but also they are distributing this firm's factually inaccurate propaganda to their patients. I am not sure if this is an isolated example, it may well be going on in many other areas, and I would be very keen to know if this is the case. Interestingly the BMA's advice makes it clear that GPs know that they should be steering well clear of this particular firm, the wind is indeed close, maybe too close for comfort:

"The GPC has asked LMCs to warn all practices in their area of the significant risks they take should they involve themselves with this company and its current business model.

  1. The practices could be deemed in breach of their GMS or PMS contract for breaking regulation 24 in relation to fees and charges, as they are receiving an indirect fee for their involvement in letting this private company screen their patients. The level of involvement in the company’s operations and the payment of a fee for rent, means that this goes beyond any allowance to rent practice space to an individual practitioner or company as permitted in the Premises Directions.
  1. The practices are in breach of the Data Protection Act. They hold patient data as part of their NHS contract. It was never intended, and patients are not aware or indeed have consented to their personal data being utilised for the purpose of advertising private services.
  1. The practices could be deemed to be in breach of the GMC’s Good Medical Practice (probity guidance) and therefore may be open to ‘fitness to practice’ procedures."

Monday, 20 October 2008

Unethical, scandalous and downright dangerous

It always amazed me just how poor the national press are at picking up on the rank mismanagement of the health service by the various organisations that are so good at getting most things so very wrong. It's no surprise that the NHS is so badly organised because the management structure is virtually incomprehensible to even those that work within it, consequently no one is in charge and no one takes responsibility for anything; the structure is also subject to incessant politically motivated tinkering, so that even when people have become accustomed to one dysfunctional structure, it is changed to yet another.

Primary Care Trusts (PCTs) are great examples of this rank waste and routine incompetence. They began as small and actually reasonably functional organisations that worked closely with local clinicians, however what they have matured into would make even Frankenstein's mother ashamed. They are now huge bureaucratic disasters, frequently there are more PCT managers than local GPs, and the job titles that are on offer at the local PCT would shock even the mighty Kafka. For example the Oxfordshire PCT started as six people, it has now proliferated into a monster that employs more than 2,500 people.

You would think that a body that employs so many people and that controls so much tax payer's money would employ a few highly trained experts in public health, so that they could efficiently go about spending their money in evidence based manner. You would be wrong, the PCT is made up of numerous people who have very little understanding of medicine and certainly no qualifications in public health. Have a look at some of the useful 'world class commissioning' posts on offer here.

Sadly PCTs do not work alongside hospitals and clinicians to try to improve health care for patients, they expand their own monstrous bureaucracies because they can, while the money that funds their expansion has to be cut from other budgets that fund essential local services such as hospitals. Hence as the PCT proliferates, more and more short sighted managers are employed to run schemes that are set up to deliberately starve good local health care services of cash. This vicious cycle continues, PCTs expand as local services are cut, that's the good old NHS for you, power to the uneducated and minimally trained PCT manager, and this is power without any accountability or responsibility.

A cracking example of the PCTs continued drive to stop paying hospitals for work that needs to be done is demonstrated by this scheme that actually pays GPs not to refer patients to hospitals, I kid you not. Unsurprisingly this scheme has been slated by local clinicians and patient groups, so what did the PCT have to say on this, something convincing? hardly:

"We have got significantly increasing rates of referral into secondary care providers. We're not sure why, so we're trying to understand why."

So referral rates are going up, so rather than trying to work out why this is happening, the ingenious PCT managers have decided to encourage GPs to refer less, they don't seem to care that the vast majority of these referrals are likely to be clinically necessary, they just want to reduce referrals and don't care if patients die in the process. I also understand that the PCT is so poorly run that they don't actually know what the correct referral figures are, a little birdie told me that the PCT's figures are laughably inaccurate. So not only is the PCT threatening patient safety by ignoring the clinical need of patients, but their dodgy decision making is based on the most dubious of figures that are being interpreted by people with no detailed understanding of clinical medicine. Lunatics taking over the asylum I hear you say, personally I think that's a little harsh on the lunatics.

Sunday, 12 October 2008

The dustbin of training

Whatever one chooses to prioritise can have massive knock on effects on other things, many of which are completely unforeseen. It's similar to engineering, when you change a certain property of something deliberately, it may alter other properties that you did not expect and it may have a quite catastrophic effect. The Titanic is a great example, supposedly unsinkable, however as we know it's design left it open to massive disaster.

The government's butchering of the health service to satisfy short termist political demands has had so many devastating knock on effects. Few politicians would have predicted the untold damage that the blanket Accident and Emergency 4 hour wait target would have had. AE is now no more than a glorified triage service thanks to the 4 hour target. The best way to improve AE care would have been to increase AE capacity so that a high quality service could have been developed to attract more talented doctors and nurses. Instead the 4 hour target has created a triage service that drives the best staff away and that has no incentive to sort out patients properly. The 4 hour target and the unnecessary excessively rapid movement of patients has also been a rather key driver in the rise in certain Hospital Acquired Infections (HAIs).

Likewise the current top down bullying from the DH to enforce the 18 week target. Superficially it seems like a sensible idea, however when one learns of the unforeseen side effects in does not seem too clever. A lot of patients simply do not need to be turned around in 18 weeks, they have minor problems that are causing them only minor symptoms, often a bit more time waiting is good for some conditions, it can result in a lot of them going away during the waiting period. The worst aspect of this target is that it is not clinically driven, for example the patient who is living in agony and needs a joint replacement quickly cannot be prioritised as well as they should be, as there are numerous other patients with much milder symptoms who have to be turned around within the 18 weeks. The 18 week target has also led to a culture of fiddling the statistics, as if there is no increase in capacity then no more work can be done anyway.

The long term sustainability of the health service has never been at the top of the government's agenda, they only care for the next election, much like our economy, it's no surprise that we meandering down sh*t creek without a paddle in this regard. Our economy has been run in an incredibly unsustainable short termist manner, we are now seeing the rather significant side effects of this stupid policy.

Training is a key if one hopes to sustain a high quality health service, no wonder the government has completely ignored training in recent years, all the policy has been directed at improving superficially gimmicky statistics to spin their network of dishonest propaganda. The current thrust at increasing output has seen trainees struggle to get the experience that they so desperately need to become the high quality doctors that they want to be. In surgery for example Trusts are under so much pressure to increase output that the training of tomorrow's surgeons is no priority at all, trying to get operative experience in this climate is not easy at all.

The government has also taken power away from the independent professional bodies, the Royal Colleges, and handed a lot of unaccountable power to useless organisations like PMETB and the GMC. Training posts are now ten a penny, the training content of jobs is not regulated properly, meaning that trainees are woefully inexperienced for their grade. Medicine is no longer the apprenticeship that it once was, the educationalists and politicos have far too much say in the training process, their emphasis on waffle and paper chasing have done nothing to improve training. Nursing training has also been subject to a same ridiculous politically correct forces, the loss of the apprenticeship has seen standards in training plummet.

The emphasis is also not changing. The short termist policies are the drivers, and training is still being left to rot. Darzi's review does nothing for training, the establishment of NHS MEE is just a token gesture, it is simply a powerless advisory body that will be made up of the same old government friendly cronies who have overseen the disasters of MMC and MTAS. Hospitals are invariably run by jumped up morons with clip boards who care nothing for the quality of care provided, they simply have certain top down government objectives to satisfy or else, and if the quality of care and good training get in the Trust's Stasi's way then they will trample over them. There are rumours this week that first year doctors are not being allowed to put in IV lines due to 'infection control' concerns, if there was an example of the lack of joined up thinking that our short termist politicos have forced upon us then this is it. The economy is crumbling, as is medical training, and this is because the politicians care only for today and never tomorrow.

Saturday, 4 October 2008

A system built by lunatics

I am possibly being a little kind in describing those that continue to tinker with the structure of the NHS as 'lunatics', there are other words that better fit their misguided actions. It is tricky to get across the sheer stupidity of the way the system is run to people who peer into the goldfish bowl from the outside. Although I reside within the bowl I shall try to describe it for someone who is looking in.

Lord Darzi's recent NHS review talked a lot about improving quality, and we know when the government talk a lot about something they invariably are about to do the exact opposite, just like the NHS constitution in fact. This NHS Review also talked a lot about reform being locally driven and patient centred, this was just as central government ordered Lord Darzi's portacabins to be erected in every PCT so that the old and vulnerable would have to walk that bit further to see their varying not so local doctor; in fact they may no longer be able to see a doctor, this government seems intent on empowering anyone to do jobs that used to be done by people with lots more training and medical degrees, quality, err, anyway that's another story.

In surgery the government pays hospitals for the operations that they perform, this initially sounds sensible, however when one probes beneath the surface it is far from sensible. This is because the tariff system was not thought through, they forgot about numerous surgical procedures, meaning that the most complicated and specialist surgical procedures frequently result in the same remuneration as the most simple and straightforward procedures. This is results in the big specialist surgical centres routinely losing money as they are taking on the most complicated, expensive and unrewarded work. These big centres of excellence dared to point out to the hair brained managers that the payment system was stupid, the managers just said that the specialist centres were inefficient.

Meanwhile ISTCs are paid for work they don't even carry out, and a lot of their work appears to be slightly shoddy to say the least. The tariff based system doesn't even work for the NHS alone, as centres that carry out lots of bad, quick and cheap operations will make lots of money, while centres that carry out lots of tricky specialist work well but expensively are being driven out of business. Take fractures of the neck of femur for one example, if one treats this with a bad and arguably negligent operation which is also cheap then one can make a lot of money, however if one carries out a good total hip replacement in some patients one will start to make a lot less money. The same goes for many other fractures, where fixing fractures badly with cheap materials is much more profitable than fixing fractures well with expensive devices.

I'm sure you get the point, the system is barmy, it has been created by morons who were obsessed with the gimmick of the market who understood nothing of the clinical practice of medicine. It results in market forces pushing standards of care lower against the best interests of patients. As I have been rather frantic at work recently I haven't had much time to read, but I always try to find time to read Dr Grumble, he has a wonderful knack of being able to succinctly sum up the daftness of the NHS we live and work in.

PCTs sum up the daftness, they used to be small organisations, they are now huge bureaucratic monsters which are run by people who have no understanding for what they throw money at. It is simply amazing that people with no medical training are allowed to spend thousands of our money on evidence-light health initiatives without a public health doctor in sight, it is as barmy as a country being run by ministers who are shuffled around so frequently that they barely have time to learn the name of their new department. The more they talk of quality, the more you should feel very very afraid.

Monday, 22 September 2008

Ambling into the abyss

Apologies for my recent lack of blogging, have had my finger in many a pie recently, shame not many have been particularly fragrant, that's the NHS I guess. Quite a lot has been going on as regards the infamous Dr Scott, he's now back at work but at what cost, only time will tell I feel. I certainly feel that the abuse of power that appears to have gone on in this case is merely the top of the iceberg on this intimidatory front.

The medical hierarchy seems rotten to the core. Many a doctor has been subjected to this kind of disproportionate venom in recent years, frequently the suppliers of the venom are remarkably powerful people bullying people with much less power, and those with the power do not seem to be particularly accountable for their actions.

A recurring theme throughout the failed reforms of MMC and MTAS has been just how unaccountable those in positions of power have been, no one will take responsibility and no one takes the blame when things go tits up. Hence the same people remain in their ivory towers running the dismal show. Darzi's review is simply a game of rearranging the deckchairs, it's not the formation that matters, it's the fact that our deckchairs are bloody useless.

There is a hell of a lot more to this Dr Scott story than one might imagine, I will leave the rest to your imaginations. There's a nice summary of events here, it doesn't fill one with much hope for the future. This is bigger than the odd individual for me, this is about a system that does not work, a few institutions have become far too powerful over time and they react to criticism in the only way they know how, with the iron fist. The problem stems from Whitehall and the tentacles extend locally to the Deaneries and centrally to the GMC.

The worst thing is that the behaviour of those in power goes against everything that we are taught to do as good doctors and it stifles progress so absolutely. Those who dictate the 'duties of a doctor' seem to think that they themselves are exempt from the same rules because they wrote them, they are hypocrites on high.

The clinician on the front line is so very accountable for his or her actions, as well as being an easy target should they fail to comply with the centrally enforced directives pushed onto them by small minded managers. Meanwhile the medico politicos and the managers are completely unaccountable for their own errors, this is no healthy state of affairs. However it does explain why those in power are so keen to crush dissent with so little regard for the law, they are desperate to keep hold of their positions of power, and they can see that if they are exposed for what they really are, then their time will most certainly be up. They are most definitely afraid and that is our best weapon.

Thursday, 4 September 2008

Obesity - it's all the NHS' fault!

There's always someone to blame for the obesity epidemic, except that if it's the fatties talking then they will never blame themselves and if it's central government then they will also never blame themselves. For example this overweight fatty thinks the NHS should take more of the blame:

"Yes, we are letting ourselves down by being overweight and it’s my choice what I eat, but if someone makes that big decision to access services, even if they are just a couple of stones overweight, the resources should be there."

Indeed it is your choice, I also agree that the resources should be there, however largely (what a pun) I do not mean NHS resources. This is because much of the money that is being thrown at anti-obesity treatments and resources is a complete waste, as there is no decent evidence that they will do anything to make our fatties less fat. The drugs are rubbish, and as for PCTs handing out slimming vouchers, don't get me started on that.

Most of the problems come from a complete lack of holistic management and policy making from central government. Where are our cheap and excellent communal sports facilities? Where is our excellent school sport and healthy school food? Where are our green open spaces? Where is our excellent public transport that would encourage us to walk a bit more rather than using the car for everything? Where is that cheap subsides and tax free fruit and veg? Where are the fast food grease pits that have been taxed more heavily to make profiting from heart attacks that bit more tricky?

You get the picture. Doctors can at best do very very little to help their fat patients, they can refer the fattest for bariatric surgey which is only a very last resort with significant morbidity and mortality attached, they can prescribe drugs that cost a lot and do sod all, or they can refer patients to services that also do sod all.

Unless people start taking more responsibility for their weight and stop blaming their genes, then we will just carry on getting fatter, by the way if it was all in the genes then we would have all been this fat fifty years ago. Also the government could also do a hell of a lot more to counter this growing problem in all areas of policy making, blaming the NHS and staff is utterly stupid as well as futile. This is a big systematic problem rooted in our rather short termist culture, and untiul we start to address the real underlying causes, this tide of lard will only gather momentum.

Sunday, 31 August 2008

The rise of the incompetent jobsworth

I obviously do not claim to speak for anyone other than myself, but for me Labour's reign has seem an utterly ridiculous empowerment of the ignorant and a continual belittlement of genuine talent and achievement. A lot of this has been undertaken in the name of 'equality' in a rather politically correct manner. It seems that knocking down the motivated while empowering lazy jobsworths is Labour's idea of great management. I'd argue that this approach is both inefficient and stupid.

The attitude demonstrated by this PCSO is typical for that of Labour's empowered ignorant, they tend to possess a very in-your-face aggressive streak that those with genuine intelligence and knowledge would never dream of revealing. They are completely unaware of their rank lack of training and expertise, they think that their title or position entitles them to treat other humans without any respect of dignity. They demonstrate quite succinctly just how power has the potential to corrupt so absolutely.

This agenda of dumbing down is not cheap, a PCSO is paid a very handsome wage, especially considering the lack of qualifications, training and competition for places. The same is true in other sectors, for example the health and legal sectors have also seen the properly professionals undermined at the expense of fulfilling a corrupt government reform agenda. The driving force behind this is not the unfortunate individuals who have been inappropriately empowered on the front line, it has been the unaccountable ever proliferating network of managers that have presided over this tremendously poorly planned waste.

Despite numerous management failings and programs of dangerous wasteful reform, those who have run the show in government and in the Department of Health continue to force their dross upon us and there seems to be very little we can do to stop it, short of organising a full blown military coup. The catastrophic waste is so beautifully encapsulated by the wasted millions of the NHS University, bear in mind that this is only the tip of the iceberg.

In the NHS those who prevent the show from going under have been those who have been routinely castigated and bullied by the management regime. It is the consultants, the GPs and the nurses on the front line who have had to take all the blame for various problems that should really be dumped at the door of their managers. The managers want all the power but will take none of the responsibility. The government is afraid of those with expertise who the public trust, so no wonder they hate the front line staff who do their best to care for patients when their hands are tied.

Some NHS managers do do a good job, however I am struck by the routine nature of bullying and similar jobsworth type behaviour that is shown by these managers to many of their fellow NHS staff. Good management should involve listening, accepting constructive criticism and working together with people in a cooperative manner to make improvements. NHS management involves ordering people around despite not knowing anything about the implications of one's orders, not listening to any criticism, bullying those who constructively criticise and then carrying on regardless of one's crass incompetence.

The point I'm trying to make is that it's not the fault of the under trained PCSO if he or she fails to do their job competently, it's the fault of the regime that has created a system that empowers the ignorant. Those who have changed the way the system works are completely unaccountable for their work. For example as regards HAIs (hospital acquired infections), the recent government decision to make certain potentially toxic antibiotics available over the counter flies in the face of the government's pretend attempts to combat C.Diff et al.

The medical profession has it's own malignant branch of this empowered jobsworth, and it seems that they frequently hide away from clinical duties, preferring to bully those on the front line by exploiting their many handy crony-based connections. I know I've significantly digressed from my original point, it's partly because I could rant on inanely for hours on this particular pet hate of mine.

I carry on because I love my clinical work, but it's incredibly frustrating to see progress stifled by such an incredibly backwards culture of top down bullying and incompetence from uneducated jobsworths. There's almost too much to criticise, so much so that the criticism is dissipated over a wider area, there are so many leaks in the NHS roof that it feels as if we're in the shower. The re branding of PCTs is the latest example of this foolish campaign of regression.

So if any of you jobsworths happen to be reading then I hope you realise just how much top talent you are forcing out of out public services such as the NHS. I recently encountered a very experienced and talented ex-nurse who had quit her job as a senior AE sister because she was so fed up with seeing the damage inflicted by the 4hr AE target. She loved her clinical work, however she was sick of seeing doctors bullied by jobsworth bed managers, she had had enough of fighting against this tide of empowered small minded incompetence. I just hope enough of us keep fighting, otherwise the outlook for out patients is not good.

Sunday, 17 August 2008

The NHS Stasi

There has been a lot of recent talk about a junior doctor who was suspended from work for comments made on a private Internet forum. On one hand it seems that our medical leaders cannot take a bit of banter on closed Internet fora, while on the other hand they are happy to nonchalantly wreck thousands of lives without expecting any punishment at all.

It is rumoured that the doctor's ridiculous suspension has been lifted, apparently some big media cheeses were sniffing around the story and this prompted some action from our esteemed medical leaders.

Dr Rant also remarks at just how unlikely it is that the likes of Liz Paice and her buddies will be investigated by the GMC for their cowardly acts which could be seen as a gross abuse of power by some.

Amazingly doctors such as myself have no choice but to pay almost 400 pounds every year to the General Medical Council. Some would say that the GMC selectively punishes various enemies of the state, so in this context is seems very strange that doctors have to fund yet another outpost of government?

It all makes Remedy UK's campaign to hold those behind MMC to account all the more important in my opinion, 1430 signatures so far, surely those behind this negligent reform should be punished? Or maybe swearing on a private Internet forum is more important in the grand scheme of things.

I'd better stop there, as I'm sure the Department of Health will be monitoring my words and telephone conversations using RIPA. Better keep quiet and sing Carol Black's praises then.

The GMC is great, they would never ever selectively punish doctors at the request of people that they are close to. MMC is great, modernisation for the sake of it is progress, even if it results in a terrible dumbing down of standards and the butchering of thousands of hard work professionals' careers. We do not live in a country in which the government continues to empower itself in a rather Stalinist manner, in a way that threatens the liberty of its citizens.

We live in a parliamentary democracy, we should be grateful, our politicians would never ever slip dodgy legislation through that spits in the face of freedom. Or would they?

Thursday, 14 August 2008

Walk in Centre comedy

I do not normally steal stories, however for this little Pulse gem I shall make an exception. Steve Nowottny tells us just how his trip to the Walk in Centre turned out:

"Pulse's senior reporter Steve Nowottny was impressed by the local walk-in centre. Luxurious, accessible, friendly. All the things you want the NHS to be. There was only one thing wrong. No-one could help him with his problem.

Pulse team blog
At Pulse I spend a lot of time writing about primary care. But as a young, fit and – touch wood – generally healthy journalist, it’s not every day I get to see it at the sharp end.

For the past three weeks though, I’ve been suffering from a low-level cough, and yesterday I finally caved in and decided to seek help.

The thing was, I didn’t want to go to my GP. After two years of covering extended hours, polyclinics and the rise of the commuter patient, I probably should have known better.

But I didn’t want to have to make an appointment, I didn’t want to wait and I didn’t want to have to stay at home.

So I went to the walk-in centre.

It turns out there’s an NHS walk-in centre just a ten minute bus ride from Pulse Towers in central London.

It’s a little hard to find, tucked away in a shopping arcade behind a railway station. But the sign in the window promised they could deal with coughs, and once inside it was a thing of a beauty.

Luxurious padded brown leather seats. Friendly receptionists. And best of all, just two patients ahead of me in the queue.

I sat and waited my turn. It took about ten minutes, and a nurse came to get me. She was very professional. She took my blood pressure. She took a detailed history. She listened to my chest.

But she was also very candid. I didn’t appear to have anything serious, but she couldn’t be sure, and wasn’t qualified to say.

My cough shouldn’t have lasted as long as it had (this I knew already). There was a small, a very small, chance it could be something serious.

TB was even mentioned. I could try some over-the-counter treatments, she said, and reeled off a couple of names.

But my best bet, she told me - and this was before we even started - was to go and see my GP.

I rather enjoyed my trip to the walk-in centre.

As one of those young professional patients Gordon Brown wants so badly to help and private companies are advised to target, I couldn’t help thinking it was everything the NHS should be.

I was able to turn up and be seen straight away. It was easily accessible and centrally located. It was beautifully decorated. I left feeling decidedly warm and fuzzy about walk-in centres, Lord Darzi, and the health service in general.

There's was just one niggling thing. The only thing it couldn’t do was help me with my cough. Or tell me for sure it was not something to worry about.

Tomorrow, I'm calling my GP."

This amusing little tale sums up just how unproductive this government's fiddling with the public sector has been. A lot of money has been wasted creating shiny and entirely useless gimmicks. At first glance, things look great, however the government has merely created a stage upon which it acts out this pathetic game. There is no end product for all the gloss. We have numerous empowered ignorami, but alas they can do nothing of use. The NP, the PCO et al, what a great waste of our money.

Saturday, 9 August 2008

Prof Paice - what a leading light

News has been circulating that a junior doctor has been suspended for comments made on a private internet forum. The exact ins and outs of this story have yet to emerge and I do not wish to comment more until more facts are known.

Moving on I thought I would share some golden nuggets with you, these nuggets are some of Prof Elisabeth Paice's finest comments in recent years. She obviously has a very high profile position and a lot of power in medical circles, these quotes show you just why MMC and MTAS have been such glowing successes:

"…one might have feared a tidal wave of applications, but that has not happened.
Obviously, people are targeting the post they want…they are spreading their
applications so that across the country people are getting applications in the
thousands, though not tens of thousands. Therefore, so far so good"

So Prof Paice thought MTAS was running smoothly in 2007, she also thinks medical education should be lumped in with everything else:

"Professor Elisabeth Paice of the London Deanery argued that creating an organisation dedicated specifically to medical education would make it more difficult to integrate planning and would isolate decisions about the medical workforce from their wider context: I would hate to see medical isolationism as the outcome of this and a step backwards from the integration of service strategy and financial planning, using medical education, if you like, as an enabler for service change and reform."

Hmmmm. MMC and 2007 were 'good for patients' apparently:

"Obviously, those people turned up elsewhere and are doing extremely well. It is good for patients that good people are all over the country, but it is very sad for individual doctors who perhaps have set their heart on particular placements. One of the outcomes is that people have applied for jobs and have got them but feel very distressed at the outcome."

Prof Paice is also a big fan of PMETB's standards and thinks that these are able to magically cope with EWTD's reduced training hours:

"With the European working time directive and so many changes in the health service the way we deliver training has to change; and we have to change the way in which we assess people so be more reliable and robust. A lot of this change is being driven,
rightly, by PMETB and the standards set by it."

She also squirmed when asked as to whether COPMED and the deaneries had been speaking with one voice:

"I think we have been speaking absolutely with one voice through what has been an extremely difficult time. It is correct that the experience has been different. If one asked whether this had been smooth one would get two answers, yes and no, but that is not the same as not being together in what we are trying to achieve."

MMC and MTAS are good for patients then. I stand corrected. The raft of unaccountable bureaucracies and organisations are all speaking with one united and representative voice. With the likes of Prof Paice in charge I find it very hard to understand anyone can dare to question the noble motives of our esteemed medical leaders. We are lucky to have experienced the glowing success of recent years, we should feel privileged to have been stroked by the hand of medico political genius that has been guided us to such fresh fertile pastures. It is just terribly unlucky that we all landed in a big cow pat and not on the lovely lush green grass than our medical leaders inhabit.