BMJ praises Hospital at Night

The BMJ is a pretty ropey journal and if we're honest it wouldn't really be read by many people unless it was dished out free with membership of the BMA. Then if we're honest the BMA wouldn't be very popular if doctors had a decent union (that instead of trying to gain itself knighthoods and peerages for itself) that bothered to try to represent the interests of front line doctors.

The BMJ has recently come up with a load of awards in categories from 'Best Research Paper' to 'Excellence in Learning and Education', the full list of nominations can be viewed here. There are some very worthy nominations there, for example Ben Goldacre in the snazzily named category 'Health Communicator of the year'. However there are unsurprisingly some rather pathetic nominations that seem to have been done in a rather typical 'politically pleasing' manner. The nomination for the Hospital at Night team beggars belief and is factually incorrect for starters:

"Hospital at Night team: Skills for Health - Workforce Projects Team
The Hospital at Night (HaN) programme is a clinically driven and patient focused change programme which uses both a multiprofessional and multi-speciality approach to delivering care at night and out of hours. The programme enhances patient safety and outcomes and supports medical training and service delivery. The benefits of utilising HaN to training are:

• Exposure to the key management skills for early detection, management and support for acutely ill patients out of hours in a multiprofessional approach
• Enhanced utilisation of team competences
• Escalation of clinical issues with supervision and support from senior clinical staff
• Develops the capacity to deliver the junior doctor foundation programme curriculum.

They have conducted a comprehensive analysis of this project."

Interestingly the problems associated with the low staffing levels at night times in hospitals are not the fault of Hospital at Night (HaN), they are the fault of shift working and the EWTD which have resulted in hospitals being left dangerously short staffed with a real lack of continuity of care for patients. HaN is the government spin being used to paper over these gaping cracks.

HaN claimed it improved patients outcomes when it was first introduced, despite having no evidence that it did, it even wrote in big letters on its website 'better care'. Even recently the evidence on outcomes that it has is scanty at best and this evidence appears to have been misrepresented rather cynically by the HaN team.

The only report that has measured patient outcomes following HaN introduction is methodologically flawed and shows no results to back up the HaN teams claims, there were no statistically proven improvements following HaN's introduction. In fact there was an increase in 'the actual number of deaths' following HaN, however this is written off as being because of increased patient numbers, there are other explanations that they have not considered however.

The spin from the BMJ and the HaN makes it appear that all is wonderful thanks to the HaN scheme, despite the lack of any decent evidence to back these claims up, at best HaN has made no difference to outcomes or safety. Anecdotally if you speak to any doctors on the ground you will hear horror stories of nurses being empowered beyond their means, staffing levels that are dangerously low, doctors working outside their areas of expertise due to this short staffing and patients dying as a result of all this.

It's great that the BMJ are recognising these achievements of the HaN team, it speaks volumes for the way in which statistically insignificant evidence published on a government website can be spun in such a dishonest and irresponsible manner. Well done HaN team, I hope you're proud.

Dementia spinning

The Dementia story has been flashed all over the news today, if one believed the government then their gimmicky plans for earlier diagnosis will have a dramatic impact. Dr Grumble cleverly interprets the story here. The lobbyists claim:

"Research has shown that a brief four or five-hour programme of support and counselling at diagnosis can reduce institutional care by an astonishing 28 per cent or an average of 557 days compared with those not receiving such interventions. This is particularly crucial considering that much of the cost associated with dementia results from expensive care home provision."

In actual fact the abstract of the research that the lobbyist is spinning is:

Mittleman, M.S., Haley, W. E., Clay, O.J., & Roth, D. L. (2006). Improving
Caregiver well-being delays nursing home placement of patients with Alzheimer’s disease. American Academy of Neurology 67, 1592-1599.
The purpose of this study was to determine the effectiveness of counseling and support intervention for spouse caregivers in delaying time to nursing home placement of persons with Alzheimer’s disease and to identify the mechanisms through which the intervention accomplished this goal. A randomized controlled trail of counseling (6 sessions of individual and family) and support (support group, ad hoc telephone counseling available) was compared to treatment as usual for 406 spouse caregivers of community-dwelling patients with AD over a 9.5 year study period. Patients who spouses received the intervention experienced a 28.3 % reduction in the rate of nursing home placement compared with treatment as usual. Median time to placement was 557 days. Improvement in caregivers’ satisfaction with social support, response to patient behavior problems, and symptoms of depression collectively accounted for 61.2 % of the intervention’s beneficial impact on placement. The authors concluded greater access to effective programs of counseling and support could yield considerable benefits for caregivers, patients with AD and society.

Even from quickly skimming the abstract one can see that this is not a study about just early diagnosis and a brief support programme, it is a long study over almost ten years in which carers were given a lot more counselling and support than they would otherwise have been given.

This quick case study is the perfect example of the way in which the modern media and lobby industry operates. Scientific evidence is spun by non-scientists and manipulated into saying things for which there is simply no evidence. It makes headlines for the government to launch its gimmicky new early diagnosis centres for a relatively small amount of money but they are the equivalent of pissing in the wind; as if there is not a substantial investment in carers, care homes, support systems for carers and other facilities then the point will have been completely missed and the urine will continue to fly into the carers' faces.

The PCT list: New Labour's NHS legacy part 2

Following on from the original list, courtesy of a kind GP I have been updated that the initial list was not nearly comprehensive enough. Here goes, it's a bit of a mammoth beast, be warned, here are the lists of the job titles of those working in a few other subsections of the very same PCT (I have had to shrink the font due to the great length of this list):

* Acting Purchasing Team Leader
* Acting Supplies Manager
* Acting Supplies Support Team Leader/Trainee Buyer
* Action On Smoking Coordinator
* Active Lifestyles Development Officer
* Admin Assistant
* Admin Support Officer (Commissioning)
* Administration Officer – Supplies
* Administrator – Health Promotion
* Administrator, PA To Associate Director of Clinical Standards
* Administrator/PA Dental Services
* Assistant Business Accountant – Business Development
* Assistant Director – Communications
* Assistant Director - Corporate Development
* Assistant Director – Equality & Diversity
* Assistant Director Clinical Quality, Commissioning/ Deputy Director
* Assistant Director of Commissioning & Contracting
* Assistant Director of Finance (Commissioning)
* Assistant Director of Finance (Financial Management)
* Assistant Director of Finance (Financial Planning & Performance)
* Assistant Director of Public Health Training & Development
* Assistant Director Patient Safety & Clinical Governance
* Assistant Financial Accountant
* Assistant Management Accountant – Business Development
* Assistant Management Accountant (x3)
* Associate Director
* Associate Director of Public Health
* Breath Test Coordinator / Receptionist
* Business Development Manager
* Business Manager – Public Health
* Buyer – Purchasing Team
* Cancer Screening Coordinator
* Cardiac Network, Services Development Manager
* Chair (x2)
* Chief Executive
* Choose & Book Lead & Development Facilitator
* Citizens Advice
* Claims And Litigation Manager
* Clinical Governance Manager
* Clinical Quality Administrator
* Clinical Quality Coordinator (x2)
* Clinical Quality Manager (Care Homes)
* Clinical Receptionist
* Commissioning
* Commissioning Choose & Book Officer/ Commissioning Officer
* Commissioning Improvement Manager
* Commissioning Information Performance Manager
* Commissioning Lead For Younger Adults Physically Disabled
* Commissioning Manager
* Commissioning Manager CHD/Diabetes
* Commissioning Support (Temp)
* Communications Administrator
* Communications Assistant (FOI, Media & Campaigns)
* Communications Officer (Media & Campaigns)
* Compliance Support Officer
* Consultant – Public Health (Clinical Effectiveness)
* Consultant In Dental Public Health
* Continuing Care Case Manager
* Continuing Care Manager/Clinical Lead
* Continuing Care Network Lead
* Continuing Care Nurse/Care Manager
* Continuing Care Secondment
* Corporate & Legal Services Support Officer
* Corporate Services Manager (x2)
* Counselling Administrator
* Director of Clinical Quality & Nursing
* Director of Commissioning & Informatics
* Director of Corporate Strategy
* Director of Dental Services
* Director of Finance And Performance
* Director of Health Promotion
* Director of Human Resources And Organisational Development
* Director of Public Health
* Directorate Secretary - Public Health
* Domestics Supervisor
* Driver & Admin
* Employer Adviser
* End of Life Programme Facilitator
* Exercise Recommendation Coordinator
* Finance (x2)
* Finance Assistant – Financial Management
* Finance Assistant – Financial Services
* Finance Assistant – Treasury Management (x2)
* Finance Assistant (Temp) (x2)
* Finance Assistant (x5)
* Finance Manager
* Finance Manager - Patients Monies & Charitable Funds
* Finance Officer (x2)
* Finance Officer, Treasury Management
* Finance Officer–Financial Management–Treasury
* Finance Team Leader
* Finance Team Leader – Treasury Management
* Finance Trainee
* Financial Accountant – Financial Management
* Financial Team Manager – Treasury Function
* Free Nursing Coordinator
* Funded Nurse Care – Lead Nurse
* General Office Administrator (x2)
* General Office Administrator/ Physical Activity & Obesity Adviser
* Head of Cancer Commissioning
* Head of Clinical Quality (Commissioning)
* Head of Clinical Quality, Primary Care Independent Contractors
* Head of Commissioning Improvement Team
* Head of Corporate Governance
* Head of Disability Services, Children, Young People & Disabilities
* Head of Financial Management
* Head of Financial Planning & Performance
* Head of Information, Commissioning
* Head of Long Term Condition Programme
* Head of Practice Based Commissioning Finance
* Head of Primary Care Finance
* Head of Professional Development (Children's Services)
* Head of Professional Development (Community Hospitals)
* Head of Rehabilitation & Intermediate Care
* Head of Speech And Language Therapy
* Head of Strategy & Planning
* Health Improvement Officer
* Health Improvement Specialist
* Health Promoting Schools Adviser (x2)
* Health Promotion
* Health Promotion Admin Assistant
* Health Promotion Driver/Admin Assistant
* Health Promotion Service Administrator
* Health Trainer Programme Coordinator
* Healthy Business Adviser
* Healthy Schools Adviser (x3)
* Healthy Workforce Nurse
* Highly Specialised Podiatrist
* Hotel Services - Catering
* Infection Control Champion Programme Facilitator
* Infection Prevention & Control Educator (Nursing Homes)
* Infection Prevention & Control Nurse Specialist
* Infection Prevention & Control Team Leader
* Infection Prevention & Patient Safety Clinical Specialist
* Learning Coordinator – Health Trainers
* Long Term Conditions Administrative Officer (Commissioning)
* Long Term Conditions Commissioning Administrator
* Long Term Conditions Commissioning Manager
* Long Term Conditions Manager
* Management Accountant – Rehab & Intermediate Care Services
* Management Accountant (x4)
* Medical Director/PEC Chair
* Medical Secretary
* Medicines Management Technician (x2)
* Men’s Health Programme Manager
* Non-Executive Director (x7)
* Nurse Practitioner – Rapid Response Nursing Team
* Office Manager (Public Health)
* Operational HR Business Partner
* Orthopaedic Screening Secretary (x2)
* PA (Temp)
* PA (x2)
* PA Older People Advisor
* PA Public Health
* PA To Assistant Public Health Director
* PA To Associate Director of Clinical Quality (Commissioning)/Deputy Director
* PA To Associate Director of Communications & Associate Director of Corporate Development
* PA To Chair And Chief Executive
* PA To Director of Commissioning & Informatics
* PA To Director of Finance And Performance
* PA To Director of HR & Organisational Development
* PA To Director of Public Health
* PA To Directorate of Corporate Strategy & Trust Board Support Officer
* PA To Health Improvement Specialist
* PA To Medical Director/PEC Chair
* PA To PH Specialist Pharmaceutical Manager/Research Manager
* PA/Admin Support - Corporate Strategy
* PA/Secretary – Public Health
* PALS & Dental Temp
* PALS & PPI Manager
* PALS Information/Admin Officer
* Physical Activity & Obesity Advisor (x6)
* Physical Activity & Obesity Programme Manager
* Physical Activity Diet And Obesity Coordinator
* Physical Activity Programme Manager
* Physical Activity, Diet & Obesity Programme Manager (Men's Health)
* Podiatric Consultant
* Podiatric Specialist Registrar
* Podiatrist
* Podiatry
* Podiatry Reception
* Porter (x2)
* PPI/PALS Officer (x2)
* Primary Care Administrator
* Primary Care Lead Pharmacist (x2)
* Primary Care Locality Manager
* Primary Care Support & Development Manager (x2)
* Professional Development & Patient Safety Officer
* Professional Development Lead
* Professional Development Lead (Community Hospitals)
* Project Lead Community Nursing Services Development
* Project Worker – Action On Smoking
* Public Health
* Public Health Analyst
* Public Health Partnership Manager
* Public Health Secretary
* Public Health Training Network Administrator
* Public Health Workforce Manager
* Receptionist (am)
* Receptionist (pm)
* Receptionist/Telephonist (am)
* Receptionist/Telephonist (pm)
* Research Assistant
* Research Manager
* Research Officer
* Resource Library Manager
* Schools & Young People Team Coordinator
* Screening Manager For Long Term Conditions
* Secondary SRE Adviser
* Senior Buyer – Contracts Team (x3)
* Senior Buyer – Purchasing Team (x2)
* Senior Commissioning Officer
* Senior Dental Nurse
* Senior Financial Accountant
* Senior Management Accountant (x6)
* Smoking Cessation Adviser
* Specialist Community Public Health Nurse/Stop Smoking Advisor
* Specialist Pharmaceutical Adviser For Public Health
* Specialist Registrar In Dental Public Health
* Specialist Stop Smoking Advisor (x8)
* Specialist Trainee In Public Health (x2)
* Staff Podiatrist
* Stop Smoking Adviser (x7)
* Stop Smoking Facilitator
* Supplies Manager
* Supplies Support Officer (x3)
* Support Manager For Continuing Care
* Support Officer, Prescribing & Meds Management
* Support Pharmacist
* Support Services Manager/PA To Director of Health Promotion
* Systems Assistant (x2)
* Systems Manager
* Team Leader Stop Smoking Service
* Telephonist (am)
* Telephonist (pm)
* Temp Continuing Care
* Temporary Secretary
* Tobacco Control Project Worker
* Tobacco Control Worker
* Tobacco Control Worker/Outreach Worker
* Trainee Buyer
* Training
* Workplace Health Coordinator
* Workplace Health Project Worker

and

* 5-A-Day Coordinator
* Acting Team Manager – Specialist Team – Speech & Language
* Admin Support (Primary & Community Services)
* Admin Support Officer (Commissioning)
* Admin Support To XXX
* Administrator For Locality Mgr, Adults & Older People – Community
* Assistant Accountant (Sure Start/Commissioning)
* Assistant Clinical Director - Medical Directorate
* Assistant Complaints Manager
* Assistant Director - Integrated Governance
* Assistant Director – Strategy
* Assistant Director Commissioning & Contracting
* Assistant Director Medicines Management
* Assistant Director of Finance (Provider Services)
* Assistant Director of Information & Mental Health Commissioning
* Assistant Director of Planning
* Assistant Director of Planning & Programme Support
* Assistant Director of Public Health Clinical Effectiveness
* Assistant Financial Accountant
* Assistant Head of Adults & OP
* Back Care Advisor
* Chlamydia Screening Admin/Secretarial
* Chlamydia Screening Programme Coordinator
* Chronic Disease Management Nurse
* Clerical Officer
* Clerical Officer – Corporate Strategy
* Clinical Advisor
* Clinical Placement Facilitator
* Commissioning Lead Provider Services
* Communications Manager
* Communications Officer (Publications & Websites)
* Community Rehab Team
* Complaints Manager (x2)
* Complaints Support Officer
* Consultant In Public Health (x2)
* Continuing Care Nurse/Care Manager (x2)
* Continuing Care Secretary
* Database/Course Administrator
* DATIX Officer
* Day Unit Receptionist
* Environmental Manager
* Estates Project Manager
* External Communications Officer
* Finance
* Finance Assistant (Temporary)
* Finance Officer
* Fire Safety Advisor
* Fresh Start Advisor
* Fresh Start Advisor (Public Health)
* Fresh Start Pregnancy Advisor
* Fresh Start Specialist Advisor
* Funded Nursing Care – Assessment Nurse (x2)
* Governance Information Manager
* Governance Officer
* HCA (x2)
* Head of Adults & Older People
* Head of Complaints
* Head of Finance Provider Services
* Head of IM&T Strategy – Provider Development
* Head of Integration
* Head of Learning Disabilities Commissioning (Health)
* Head of Organisation Development And Core Education
* Head of Planned Care
* Head of PPI/PALS (x2)
* Head of Risk Management
* Head of Urgent Care
* Health & Safety
* Health & Safety Administrator
* Health & Safety Assistant
* Health & Safety Manager
* Health Promoting Schools Advisor
* Health Promotion Administrator
* Health Promotion Assistant (pm)
* Health Referral Administrator
* Health Referral Administrator – Public Health Department
* Healthy Schools Advisor (x3)
* Hotel Services
* Hotel Services Administrator
* Hotel Services Assistant Manager
* Hotel Services Manager
* Housing & Health Strategy Manager
* HPS Coordinator (Public Health)
* HR Advisor – Operation Business Partner
* HV Manager
* Infection Prevention & Control Nurse
* Information Officer (x2)
* Integrated Governance Administrator
* Integrated Governance Officer
* Interim Human Resources Manager (Temporary)
* Intermediate Care Coordinator
* Intermediate Care Pharmacist
* Intermediate Care Sister
* Intermediate Care Team Leader
* Knowledge Manager (x2)
* Knowledge Services Manager
* Learning & Development Manager
* Learning And Development Facilitator – Core Learning
* Library Technician – Knowledge Services
* Locality Lead Rehabilitation And Immediate Care
* Management Accountant – Specialist Rehab Services
* Medical Directorate Administrator
* Medical Secretary
* Medicine Management Programme Facilitator
* MTS Trainee
* NPfIT (x3)
* NPfIT Admin Assistant
* NPfIT Project Manager
* NPfIT Project Team Leader
* Office Administrator
* On Secondment to XXX
* Outpatient Physio, OT & MSK Services Lead
* PA to Assistant Director of Commissioning (x2)
* PA to Public Health Dept. Director And Public Health Consultant
* PA to Public Health Strategy Managers
* PA to XXX (x2)
* PA/Commissioning Officer
* Pharmacy Technician
* Physio
* Physiotherapist, Intermediate Care Team
* Podiatry (x2)
* Prescribing Advisor
* Prescribing Support Advisor
* Prescribing Support Technician
* Primary Care Commissioning Officer (x2)
* Project Manager – PCT Provider Services Commissioning
* Project Worker
* Provider Development – Locality Manager
* Provider Development – Urgent Care & Inpatients – Locality Manager
* Provider Services (x3)
* Public Health Project And Campaigns Officer
* Public Health Trainee (x2)
* Receptionist /Telephonist (x2)
* Secretary – Complaints Team
* Senior Financial Accountant – Financial Management
* Senior Management Accountant – Business Development & Reference Costs
* Senior Management Accountant – LTC & Community Nursing Services
* Senior Management Accountant – Specialist Services, Capital/LIFT
* Senior Public Health Strategy Manager
* Senior Public Health Strategy Manager (Tu/Th/F)
* Senior Rehab Support Worker
* Sexual Health Development Manager
* Site Services & Admin Manager
* Smoking Cessation Advisor (x2)
* Specialist Registrar In Public Health
* Specialist Services Manager
* Speech & Language Therapist (x6)
* Speech & Language Therapy Assistant (4)
* Speech & Language Therapy Manager (Adults)
* Speech & Language Therapy Support Worker (Admin)
* SRE Project Worker - Primary
* Team Leader Physiotherapist Out-Patients Physiotherapy
* Team Manager – Speech And Language Therapy
* Temp PA to XXX
* Unison
* Weight Management Coordinator

Be warned, this list is not anyway near the whole PCT staff. I would also emphasis that several of the jobs on the list are jobs which involve a fair bit of clinical work. However the vast majority of these jobs are managerial and involve either no or very little clinical component, what about the need for a 5-A-day coordinator!. This list is New Labour's NHS legacy, it is the incredibly top heavy management structure that is bringing the country to its knees, it is wasteful, it is inefficient, it is foolish, it is unproductive, it is so very New Labour.

When I talk of money not getting through to the front line, this is what I talk of, and remember the hospitals also have their own management staff, the GPs have their own managers locally, the SHAs and Department of Health are full of more managers too, this list is but the tip of the immense iceberg that is sinking ship NHS.

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

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?

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.

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.

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.

http://www.telegraph.co.uk/news/newstopics/politics/lawandorder/4030456/Paramedics-arrested-after-ignoring-dying-man.html

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.

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.

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.

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.

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.