Thursday, 29 January 2009

Irony and idiocy - the UK Labour camp

The current government's breathtaking ignorance and stupidity never ceases to amaze me, I will shut down this blog when I can no longer point out the rank incompetence and stupidity of the fools in charge on a regular basis, somehow I believe this day will never come, it's just a gut feeling I have.

The economic recklessness and incompetence of this government is currently coming home to roost, as the IMF predict that the UK is to be the most severely affected of all developed countries we should be asking ourselves why? Fat Gordon will continually call the recession a 'global problem', pretending we could have done nothing differently, when in reality he knows that we could have built a much better roof for when the storm came to town.

On the subject of health and the NHS, this government's lack of joined up thinking is demonstrated so regularly I have genuine difficulty keeping up with it, we are bombarded with so much incompetence that it becomes hard to know where to start looking. A recent example has been the health secretary Alan 'postie' Johnson threatening hospitals with fines if they do not get rid of all mixed sex hospital accommodation.

So the government is threatening fines for something that it has caused with its own top down policy making. Hospitals up and down the country have been rebuilt with PFI contracts over this government's reign of terror, strangely as our population goes up and our elderly population expands alongside this, our bed numbers have been falling and falling. Hence the pressure on beds is immense and hospitals simply do not have the spare capacity to afford the luxury of mixed sex wards even if they wanted them.

So not only did these PFI contracts result in a cutting of service capacity by a reduction in bed numbers as private firms fleeced us for as much as they could get, but hospitals have been left in ridiculously expensive contracts which have resulted in many other essential services being cut. The great irony of all this is that the banks that provide a lot of the capital for PFI projects are the very same banks that us, the tax payer, has bailed out to the tune of several billions pounds.

Now not only are we are keeping the banks afloat, but at the same time the very same banks are in effect lending our own money back to us at extortionate rates. This could only happen in Gordon's Britain, and while our big financial institutions are allowed to get away with murder the mighty CMO, Sir Liam Donaldson, is nannying us even more by saying that anyone under 15 should not drink any alcohol at all. Well it's much easier to get a fat civil servant to spout some garbage than actually take on the big business that is arguably one of the root causes of the rise in alcohol abuse in the UK, the mighty supermarkets. Gordon wouldn't want to take on his friends who own the supermarkets though, they help fund his 'party'.

ps at least we can trust Lord Darzi not to cosy up to the private sector behind closed doors before deciding how policy reform is to be planned

Wednesday, 28 January 2009

New Labour's NHS Legacy

The following list is taken from a GP who has written of the people that she has been emailed by in her local PCT. The list speaks for itself, it tells the tale of the incredibly inefficient and wasteful bureaucratic mess that this government has created in the NHS. There are now more PCT managers than primary care doctors in many areas, there are people with titles that make no sense and the output of their jobs often amounts to even less. Here we have Kafka's PCT list:

* Communications Assistant
* GP Directorate Manager
* PA to Medical Director and PEC Chair
* Assistant Director Commissioning & Informatics
* Medical Directorate Administrator
* Strategic Programmes Director
* Primary Care Manager
* Public Health Project Manager
* Primary Care Commissioning Officer
* Long Term Conditions Administrator
* Resuscitation Educators
* Communications officer (media & campaigns)
* Senior Primary Care Commissioning Manager
* Long Term Conditions Commissioning Manager
* Commissioning Officer
* PA to Head of Urgent Care
* PA to Primary Care Commissioning
* Head of Urgent Care
* PA to Director of Commissioning & Informatics
* Head of Clinical Quality (Commissioning)
* Lead for Quality of care in care homes and End of Life Care
* Locality Manager - Children's Community Service
* Admin Support Primary Care Commissioning
* Information Governance Manager
* PA to Commissioning
* Public Health Strategy Manager
* Acting Co-ordinator (Substance Misuse)
* Liaison Officer
* Senior Administrator & Project Support
* Primary Care (GP) Support and Development
* Commissioning & Information Directorate
* Public Health Nurse Consultant
* Primary Care Development Manager
* Intermediate Care Coordinator
* Chief Executive
* Communications Officer
* Acting Deputy Chief Executive
* Director of Strategic Development
* Associate Director of HR
* Assistant Director of Information
* Primary Care Development Manager
* Clinical Governance Admin Support
* Knowledge Services
* Director of Primary and Community Services
* Public Health Analyst
* Public Health Intelligence Team
* Administration Support Officer
* Sexual Health Commissioning
* Service Development and Market Management
* Commissioning Project Officer
* Mental Health Commissioning Team
* Temporary Clinical Quality Administrator for Primary Care Independent Contractors
* Primary Care Support and Development Manager
* Clerical Officer
* Senior Administrator & Project Support
* Primary Care Commissioning
* Assistant Directors Commissioning & Informatics
* Core Learning Administrator
* Employee & Organisational Development Team
* Long Term Conditions Administration Officer
* Public Health Administrator
* Sexual Health Development Manager
* Clinical Governance Administrator

I hope the government are proud of their achievements. As front line clinicians struggle to meet yet another raft of top down targets, it is amazing that such a wasteful bureaucracy continues to proliferate in such fashion at the time of a recession. Mind you with leadership like we have at the top, with billions burnt on the basis of a stupid whim, who can be surprised that billions continue to go up in smoke producing so little end product?

Saturday, 17 January 2009

Honest noble Lord Darzi on the surgical checklist

One thing this government and its minions could not be accused of is reinventing the wheel and then claiming it as their own invention. For example we all know that Lord Darzi was the first man to ever use laparoscopic surgery, even though he was born in 1960, he has magical time travelling powers, the man is simply a great surgical pioneer, he would never be described as a politically minded brown noser who happens to have published a lot of papers.

This week Lord Darzi has been talking about a 'surgical checklist' that the World Health Organisation (WHO) have come up with:

"Health Minister Lord Darzi, who played a role in developing the checklist, said: "The beauty of the surgical safety checklist is its simplicity and - as a practising surgeon - I would urge surgical teams across the country to use it.

"Operating theatres are high-risk environments. By using the checklist for every operation we are improving team communication, saving lives and helping ensure the highest standard of care for our patients.

"The amazing results from the global pilot puts this beyond any doubt." "

Thanks for that honest and full description of the situation Lord Darzi, you really are a man of great integrity and honour, you wouldn't possibly be trying to spin things to enhance your own importance would you? Are you reinventing the wheel, again?

The study has many limitations and is poorly designed for one, even the paper admits a lot of this, something the media fail to mention, very strange that, the BBC just describe it as being a 'startling' phenomenon. In fact the study took eight hospitals from eight very different countries and made the assumption that this sample can be representative for any hospital in any country in the world, it doesn't stop there though, in the four hospitals from the wealthier countries there was not a statistically significant difference in complication rates in three of the four hospitals. While the hospital from the UK, St Marys, recently made on of the biggest errors in medical history by removing a women's healthy gallbladder for no good reason, I believe the great Lord is an honorary consultant there too. There are other flaws that the paper explains in the discussion section. It becomes rather obvious that drawing conclusions from this study and applying them in blanket fashion to the whole NHS is just plain stupid.

If you listen to Lord Darzi then it appears that the checklist is a revolutionary idea, in fact all good hospitals in the Uk will already be doing everything on the checklist For example where I work it would be considered bad practice to not be doing the routine checks on the WHO's list. Lord Darzi however has not been defending the fact that many hospitals are well above introducing a checklist when they already have the checklists in place!

He has been concentrating on blowing his own trumpet, pretending that this research is ground breaking when it is not, and spinning the agenda of the government that involves continually belittling what others have done well before him. He made no attempt to reassure patients that many hospitals in the UK are already doing these checks, he deliberately pretended that this checklist was revolutionary and in doing this a lot of people will get much more anxious than they should about surgery in the NHS.

Lord Darzi has gone from being a surgeon to a politician, he has no interest in responsibly getting the facts of a an argument across in the best interests of science or people's health, he is just keen to further his own political career by blowing his own trumpet whenever he has the chance. A responsible scientist would try to emphasise the grey areas and the limitations of various pieces of research, an irresponsible politician goes away from science by spinning only one agenda that is not based on the scientific evidence. Lord Darzi is no more than a politician dressed up in a fake surgical gown.

Sunday, 11 January 2009

Centralisation is not necessarily better

All that glistens is not gold and all that is centralised is not better, two facts that I'm sure many of you would agree with. The strange thing that I've noticed in recent years is how the government is very keen to centralise things which are better done locally, while they are keen to keep things local when they should be centralised, these poor decisions are sometimes just down to stupidity, on other occasions more cynical motives are lurking.

The fact that any doctor has to get a CRB check every time he/she changes NHS Trusts speaks volumes for the complete lack of joined up management of this problem, this should not be happening. I know people who are having more than one of these criminal record checks every six months, it's a complete pain in the arse for the doctors and a massive waste of NHS money. Occupational health checks are also all done locally and there is no way of easily transferring one's records between NHS trusts, this is something that would be perfectly suited to a centralised system, alas the strife continues for NHS staff who have to put up with the ridiculous bureaucracy every single time they move between hospitals.

Trauma is an example of something that should not be centralised en masse, by this I mean that it is important to keep local hospitals open with functioning AE departments and a surgical capability to deal with trauma, it is not wise to centralise all trauma care. Some aspects of trauma should be centralised, the evidence and common sense indicate that major poly trauma patients do much better in specialised trauma units, that's hardly a surprise. However there is not the evidence out there to say that centralising all trauma to specialist centres, while shutting local hospitals and opening more minor injury units manned by under trained 'practitioners', is a good idea.

Health care decisions are rarely simple, decisions regarding individuals and policy frequently involve the balancing of various complex risks, one solution is rarely perfect and risk free. For example centralising all trauma will result in certain benefits, especially for the sickest poly trauma patients, however the fact that a lot of minor trauma will no longer be seen by a doctor with some experience will certainly result in some harm. Weighed into this argument, one must also consider the fact that our Ambulance service and transport capabilities are simply not able to provide the capacity to support more and more patient transfer miles which the further centralisation would inevitably involve.

Our health care system is moving more and more towards the huge inequalities of the American system, the case of trauma care is a salient example. In the US if one is lucky enough to get to a big trauma centre then you'll get great care, however unfortunately for the patients nothing much exists of a size that is in between these huge centres and the tiny cottage hospitals staffed by a handful of staff who are simply not used to handling anything remotely challenging. Overall one gets the distinct feeling that on average the American patient may well not be that much better off, and remember their transport to the specialist centres is considerably better than ours.

The problem is that once one heads towards more centralisation, it becomes very very hard to stop, it's a bit like the point of no return. This is because once a local hospital starts to lose certain specialist surgical services such as trauma and orthopaedics, it's AE department becomes less backed up and less sustainable, the house eventually crumbles. I have personally seen examples of this locally. In this way a good local AE department is lost, and replaced by a group of useless 'minor injury units'.

I say 'useless' because they can at best do very little more than a GP, however they are frequently manned by staff who lack the expertise to know what is simple and what is not as a GP can. I have first hand experience of seeing old and frail patients grossly mismanaged by staff who have been thrown way out of their depth. How on earth can one assess head injuries safely without being able to do a neurological exam properly, it cannot be done, these units are just plain unsafe at times.

The problem is that you will only find what you look for and when our new centralised centres are assessed I'm sure they'll provide an excellent standard of care. However no one will be looking for the cases which have been mismanaged by the minor injuries units that would have been properly sorted in a hospital AE department, no one will be measuring the harm done by delays in transporting patients between units when many of these trips could have been avoided in the past by having more expertise kept that little bit more locally. This government wants to dumb things down and save money, so a few superficially shiny specialist centres will look good as propaganda despite the fact that less people will actually get to see a doctor following their trauma. All that is centralised is most definitely not gold.

Monday, 5 January 2009

The rotting system - the Ambulance service

The following piece is from a doctor who has had a lot of first hand experience with the management structures that control our ambulance service. His years of experience and exposure to the problems mean that he can neatly and eloquently describe just how the politicisation of the process is damaging to patients:

"Having recently been binned as a medical adviser to an ambulance service, I might shed some light on events: Paramedics are being encouraged by some management teams to avoid conveying patients to hospital. A good way of doing this is to send a single-manned car instead of an ambulance. This stops the clock ticking and helps achieve the 8 minute target and provides a barrier to conveyance of the patient.

Hospitals are unpopular with ambulance service managements because the ambulance is delayed by the need to drive to the hospital which takes time. On arrival at the hospital, there is often delay due to the ED managers blocking the patient's acceptance until they can be sure that the patient can be processed within the target time. Also, the ambulance then has to drive back from the hospital, which also takes time.

Much more efficiently, if the patient is not conveyed, the ambulance becomes instantly available for the next category A call and the 8 minute target is more likely to be reached for that one too.

Of course, the hospital and PCT managers are not going to discourage any behaviours that result in fewer attendances at the ED.

The classic paramedic training does not equip the paramedic to make an assessment with a view to recommending non-conveyance. The doctors who constructed that course were wise folk who knew that it is much more onerous to declare a patient fit than to send them for further investigation. In a 16-week course that includes a 2-week driving course assessment skills at the necessary level could not be taught.

More recently, extended care practitioners (ECP) have emerged. They do a six-month course having already shown themselves to be in the top group of paramedics. Some are nurses. So this is an add-on course for people who are already experienced, say 3 to 5 years in. ECPs usually work in single-manned cars and they have a limited formulary. In the pilot scheme in Bristol, they seemed to be safe, but they took responsibility for their decisions and it was not a course in high pressure selling of the "say at home" option. Their work was audited.

The episodes described here and the one in Brighton (see "paramedics arrested" topic in the "air your views" forum are simply disgraceful and indefensible practice from bullies in green overalls.

It is essential that each and every incident be reported, because patients are incredibly vulnerable and ignorant of the care they OUGHT to be getting. Only doctors, nurses and conscientious paramedics can make any impact on this. All paramedics have to be registered with the Health Professions Council and they accept complaints in the same way as the GMC.

My favourite incident is that of a friend of mine who was a paramedic in the LAS. He was sitting at home watching the rugby with a can of beer, waiting for his wife to return (A & E sister). He suffered a sub-arachnoid bleed and realised what was going on. He called an ambulance and staggered to the front door to open it and then collapsed. The crew arrived and stepped over him and decided that he was some kind of drunk. Eventually, after he pleaded with them, they dragged him out to the ambulance, grazing his foot on the way, and dumped him at the hospital as a "****ing drunk". He was thus put into a cubicle and left until he fitted, after which he was scanned and sent to ********. The only slight relief is provided by the fact that it was the same crew that attended for his transfer, this time intubated and ventilated. That was in 1988, so it really is time we did something about this type of behaviour!"

The words above make it very clear that this is a systematic problem brought about largely by the mismanagement from the top. The vast majority of paramedics are excellent and brilliant professionals, however the system is rotting in such a way that it is dragging everyone down with it, the small minority of dangerous paramedics will be made more dangerous by the political pressures that they are subject to. It should also be pointed out that the ambulance service is currently massively over stretched with its staff fighting a losing battle, unless capacity is increased by a massive increase in investment.

Most importantly it is not appropriate to offer patients the option of not going into hospital in certain situations, it is very easy to hide behind the cloak of patient autonomy when trying to defend reckless practice, however when someone could well have sustained a serious injury and need urgent medical care it is best to encourage them into hospital rather than pretending it would be reasonable to stay at home to help with the government's meeting of meaningless politically driven targets.

Saturday, 3 January 2009

The management must take the blame

It's hardly fresh off the press, but the fact that so much money is being continually wasted on paying extortionate rates for agency/locum staff is incredibly sad. The Times wrote on this last year and at that point at least a billion pounds a year was being spent in this manner.

This year's news if full of more of the same. Apparently at the same time thousands of nurses are fleeing for a better quality of life abroad. This is just plain stupid for so many reasons. The blame should be laid firmly at the door of the short sighted fools who have the power to change this, these fools can be found either centrally at the Department of Health or locally at a hospital near you.

This is not just a problem for nurses, the very same problem exists for doctors, it's just because of the weakness of our union hospitals routinely run short of doctors without bothering to even hire in the agency staff, hence nowhere like the money is spent on agency/locum doctors I would suspect, despite the demand being pretty significant.

This problem could be avoided by some very simple measures and it would also improve the conditions for everyone working in the NHS, leading to better performance and staff retention. It's amazing what could be achieved by proper planning and treating people well, as opposed to bullying the intimidating to get what you want.

The solution would involve employing more staff than one actually needs, assuming everyone stays fit every day of the year, because the current system of employing the bare minimum is bad in terms of safety and bad in terms of staff morale. In fact it is much cheaper to employ a couple of extra nurses/doctors full time to cover for sickness and other absences than it is to employ the bare minimum, then hire in the expensive agency staff when people inevitably get sick. Also remember that people are more likely to get sick and stay off work if they are less well backed up at work in terms of having a bit of slack in the system.

I have seen the solution work very well abroad, extra doctors work for short periods where they only cover other gaps in the rota, it means that all the rotas are fully staffed all the year round, everyone stays happy and nowhere is dangerously short staffed. Contrast this to the situation in the NHS where there is no slack at all to cover for junior doctor absence, meaning that patients suffer due to the lack of continuity and that doctors become exhausted because they are constantly doing the job of two or three.

It's hardly rocket science is it. One can plan for the fact that a certain percentage of staff will be away from work a certain proportion of the time because of sickness et al, hence one can employ a certain percentage of extra staff to cover these very predictable absences. This keeps everyone happy and provides a better service for patients.

However it just doesn't seem to happen as we have a management hierarchy with the combined brainpower of a Land Rover squished hedgehog. It would involve planning ahead, making some simple calculations and the hardest thing of all, actually working with people and cooperating with staff to achieve a goal. The management of the NHS would rather spend a billion to save a hundred million, they would rather bully than cooperate, and for this reason things keep going backwards. No wonder doctors and nurses are fleeing the NHS in droves.

Thursday, 1 January 2009

Honesty in an NHS manager

A PCT manager by the name of Caroline Davis has been caught admitting the exact nature of her job with the PCT as a 'assistant director of strategic partnerships':

"I now live in Dover, where I work for the NHS, bull*****ing for a living, no change there then."

The rather honest comments were stupidly put up on Friends United by Caroline, whoops. Dr C also picked up on this rare moment of honesty from an NHS manager.

It's one of the saddest facts of recent years of government health reform, the billions have rarely got anywhere near the front line services, invariably the money is intercepted by one of the many layers of inefficient bureaucracy that stifles the provision of health care in this country.

PCTs have expanded at a rate faster than an obese chocaholic at Easter, in many areas they now have more managers in the PCT than doctors in the same area. The government has knowingly and deliberately presided over this mass expansion of bullshit peddlers in order that it may serve as a smokescreen for the cynical privatisation of the NHS that has been going on at the very same time.

Tales like this from the Jobbing doctor are commonplace in the NHS these days, the government is happily building numerous facilities often funded with PFI money which are simply not needed, their aim is to undermine good local services and feed their buddies in the private sector. It's no wonder that basic compassion is going out the window at the same time, numerous people are being encouraged to do things for which they are simply not trained, whether it be nurses being encouraged to become managers rather than rewarding proper nursing, or pharmacists having a crack at playing toy town doctors. How about we stuck at doing what we were trained for and we set about cutting back the overgrowth of pointless stifling bureaucracy, then things might be slightly less disastrous.