Bravo Baroness!

I must apologise for being so lazy with this little blogging effort. I stumbled upon this blogging piece which links in two excellent pieces of opinion the government's disastrous White Paper. The Baroness's excellent piece has been repeated here:

"I can’t support the coalition plan for the NHS
by Liberal Democrat Peer, Baroness Williams of Crosby

Some of the health service reforms are valuable but the scale is too great and too many questions are unanswered. Being in a coalition government produces difficult dilemmas. I support the coalition agreement. I believe the coalition is necessary to tackle our immense financial crisis. But every now and then, a dilemma emerges that cannot easily be resolved. Such a dilemma for me is Andrew Lansley’s health policy.

I campaigned nationwide in the last general election on the basis of the Liberal Democrat manifesto, reiterating our strong commitment to the National Health Service. The coalition agreement, which promised “to stop top-down reorganisations of the NHS” and made no mention of insisting on competition, posed no problems. On reading it I felt the NHS was safe in David Cameron’s hands.

But a recent report by the candid and incisive Commons Health Select Committee pointed out big differences between the agreement and the subsequent White Paper, Equity and Excellence: Liberating the NHS: “The coalition programme anticipated an evolution of existing institutions, the White Paper announced significant institutional upheaval.”

As a Liberal Democrat parliamentarian, I am under no obligation to support policies outside the agreement. Indeed, I have a moral duty to the voters I asked to support us to find out exactly what Mr Lansley intends and its implications for the NHS. So I have a few questions.

But first let me say what is valuable in his proposals: the recognition that the NHS must become more efficient if an ageing population is to have good care; the joining-up of healthcare and social care vital to the wellbeing of sadly neglected elderly people; reducing bureaucracy, though it will be easier said than done; ending Labour’s often niggling interventions in professional judgments, which left a legacy of resentment. There is, however, an unresolved tension between an emphasis on good management for obtaining efficiency savings, and the plans for radically reducing NHS staff.

I have four questions: the cost of the reorganisation, the accountability of the new GP consortiums, the role of the private sector and patient choice.

The cost
What is the cost? The Government must reduce public spending from 2011- 2015 by £80 billion. If it can’t, its strategy will have failed. The NHS accounts for a third of England’s revenue budget and 11 per cent of its capital budget. It faces relentlessly growing demand.

David Nicholson, the chief executive of the NHS and now of the National Commissioning Board, noted in 2009 that the NHS must find £15-£20 billion in efficiency savings in the next four years. But he himself believes that “to do so will require clear and effective management every step of the way”.

Key to this is a 40 per cent cut in management costs. Already hundreds of managers have left Primary Care Trusts at a cost of about £1 billion. The impact of this is not yet known, but GP commissioning consortiums are bound to look for good managers, some of whom will be hired from outside the NHS. They are likely to cost more. Some 20 per cent of the savings will come from moving patients from specialised hospital care to treatment by GPs or nurses in the community.

The final 40 per cent will have to come from clinicians and hospitals, an estimated £2 billion a year. Such huge savings will almost certainly entail an element of rationing. Waiting lists for routine operations are lengthening, and in some cases they are being postponed or cancelled. As the National Audit Office observed: “Government reorganisations … frequently entail higher costs than anticipated”.

Accountability
What arrangements are there to hold GP consortia accountable for quality of care? Primary care trusts (PCTs) were accountable to Strategic Health Authorities and, ultimately, to the Secretary of State. They were overseen by local authority committees. Meetings were held in public and the minutes made available. The new consortia, responsible for about £80 billion, are not obliged to meet in public. Local health-watch groups may scrutinise them but have no power to hold them accountable. Suggestions for adding knowledgeable lay people, members of other medical professions such as clinicians or nurses and elected local representatives have come from many quarters, but it will be up to each consortium to decide for itself.

Accountability upwards will be to the Secretary of State via the NHS Commissioning Board, but the board has no powers of oversight.

The private sector
What are the Government’s intentions here? Private medical practices work closely with NHS colleagues and were encouraged by Labour to bid for contracts at a price determined by the NHS tariff. Competition for these contracts depended on the quality and effectiveness of service. There is a cap on the proportion of private beds in Foundation Trust hospitals, which varies according to earnings from private patients and is much higher in London. Last year the private sector treated 220,000 patients.

The Government is now preparing to remove the cap, renegotiate the tariff and require the National Commissioning Board to promote competition. This will open the door to competition on price, not just quality. Many clinicians fear that the private sector will skim off profitable routine operations, leaving expensive, complicated treatment to the NHS.

The body that will license health providers is Monitor, which oversees foundation trusts. Its chairman, David Bennett, wants healthcare exposed to competition like gas and rail. British Gas raised energy prices by 7 per cent last year, while making £700 million in profits. Since rail privatisation, the UK had paid the highest fares in Europe. Should this inspire confidence?

Patient choice
How does the Secretary of State reconcile this with the need for large savings? Mr Lansley puts great emphasis on the involvement of patients in their own treatment. That’s good but achieving it in practice is hard. Articulate and self-confident people are likely to benefit, but elderly or busy patients will have little basis for their choices beyond rumour or GPs’ advice. Choice must be balanced against the realities of a publicly funded service.

Underlying the debate about health is another about values. For some of us, health care is a public service, strengthened by partnership and co-operation, the model in most Western European countries. For others, it is a market in which price determines quality, the US pattern. A June 2010 study of 11 health systems by the US-based Commonwealth Fund said of the US system: “Compared with … Australia, Canada, Germany, the Netherlands and the UK, the US system ranks last or next to last on five dimensions … quality, access, efficiency, equity and healthy lives.” The NHS was the second least expensive per person after New Zealand, and came first on effective care, efficiency and cost-related access, and second on equity and in the overall ranking. Why we should dismember this remarkably successful public service for an untried and disruptive reorganisation amazes me. I remain unconvinced."

This is all absolutely spot on. The Liberal Democrat MPs who are supporting the White Paper should hang their heads in deep shame, they can have no excuses at all, they are selling their souls. There was also an excellent bit of journalism on the Channel 4 news tonight exposing some other problems with the proposed system, huge conflicts of interest indeed.

Politicians and managers expect NHS silver service

One thing that I have noticed as a bit of a recurrent theme during my time in the NHS has been the way that politicians and NHS managers expect to be treated like private patients on the NHS, they do not tolerate the treatment that normal 'mere mortal' patients receive, they insist on being treated differently, they want to be shunted ahead of the others, they do not want to ever wait for anything, they expect the silver service on the NHS and it tells you a lot about the kind of people that they are.

Obviously doctors and nurses themselves will generally get treated a bit differently by their colleagues, but it's the way that they so rarely push for it, they generally politely accept whatever they are given, the doctors and nurses are generally a very different breed to a medical manager or politician.

The NHS managers and politicians are often not the most pleasant of individuals, they lack manners and frequently bully their way into getting preferential treatment. They care not for the other patients that will be delayed by their own special treatment, they only think of themselves. I will obviously mention no names, but certain rather high profile individuals have bullied and threatened their way to an NHS silver service in recent years.

The worst thing about this is that these very same managers and politicians have often so frequently done absolutely nothing when front line staff have complained to them about the lack of resources, the long waits that patients are being subjected to et cetera. When their health is not directly affected they care not, they hide in their ivory towers and ignore the problems. However when their own health is on the line, they expect the rules to be broken, the normal service others get is not good enough for them, they will force the best for themselves at a cost to other patients. This kind of behaviour makes them hypocrites of the highest order and it really stinks. Obviously the image above of Tony Blair is nothing to do with the above article, it is but a pure coincidence.

Scottygate revisited - Needham shoots herself in foot

It was hard to miss the 'Scottygate' scandal of a couple of years ago; if you missed it then Dr Rant has covered a lot of it in excellent detail. Essentially various senior doctors in management positions used their power in a completely disproportionate manner and this resulted in a junior doctor being inappropriately suspended from work for a significant period of time. It was a classical case of the medicopolitical abuse of power.

One of the senior doctors behind this scandal was Gillian Needham. She has now felt the need to give her 'side' of the story, really she should have simply let sleeping dogs lie, instead she is amazingly trying to portray herself as the victim in the whole affair, while her lack of remorse and her complete inability to admit to having made a big mistake are unbelievable, it is quite simply beneath contempt.

The BMJ have also made a massive error in giving this woman the space with which to try to justify the unjustifiable, she deserves no sympathy from the BMJ's readership and she will not get any I am sure. Several letters are already flooding into the BMJ's rapid response section and it will not be very favourable for Needham. I have taken this excellent and eloquent response to Gillian Needham, it is written by a senior doctor who sums things up very nicely indeed:

"I fully expect that this message will be but one of the deluge that will flood your inbox over the coming days, but I was so incensed by your self-serving patronising and utterly complacent article published in the BMJ this weekend that a direct response was needed. You should be thoroughly ashamed of yourself, behaving as you do; like a petulant talentless teenager on a popular reality television show.

I will pass briefly over the gross affront accorded to retired doctors who you glibly dismiss and compartmentalise as having passed through a medical death by asking just from where do you derive this imperious arrogance and disconnection from reality?

The facts of this matter are, that by over reacting you precipitated a maelstrom which damaged the offending trainee far more the fleeting discomfort you experienced. It is of course very frustrating when something is in the public domain and as an office holder you cannot reply. Believe me I know this only too well, having managed a number of very high profile problems and having been misrepresented myself. Get over it; it goes with the territory. The true professional does not respond then, or ever after. Certainly never in a such a whinging, self serving way that can only ignite the original grievances again. You will certainly be further diminished by doing this.

You, and your colleagues in medical education perpetuated a disastrous re-organisation of post graduate training, introducing a system more akin to the Soviet era in its total disregard of the personal needs of trainees and focus on standardised production. You do not seem to appreciate that because of what you did, there are thousands of young men and women out there who have been permanently damaged by your slavishly idealistic and dogmatic attitudes.

You Madam are depised and loathed by these doctors whose development you and your colleagues let down so badly. The fact that you have published this account shows how little you understand that. Doubtless you will now be thinking about another intimate piece of disclosure to show how unfair you think the hostile response to your self-indulgent pleading is. Like the petulant teenager, you know no shame.

You brought the wrath of others upon your head by your overzealous and disproportionate reaction in the first place, and now you are doing the same by this ridiculous attempt at self justification. When will you ever learn?

Yours etc"

Hear, Hear.

Lansley the corrupt and the top down White Paper

It is worth repeating that Andrew Lansley is being bankrolled by Care UK in the week that the privatising White Paper is released for all to see. The fact that Mr Lansley's personal office was funded by 21,000 pounds from the chairman of Care UK stinks.

A great problem with the new system as imposed by the new White Paper is the fact that GPs will not actually have any power to select the best treatments for patients, even though the government are pretending this is the case so they can blame GPs when it goes tits up.

The new 'commissioning board' will force GP consortia to purchase the cheapest services, irrelevant of quality or sustainability. Essentially despite the government's pretence that clinicians will be in control of this new 'local' process, it will be a top down centralised process controlled by this Stalinist commissioning board. Even Polly Toynbee understands how damaging this whole process will be.

If you want a good service, for example a house built or your car serviced, going to the cheapest provider rarely makes sense. In fact as a consumer to make a sensible choice you need the insight to know who is trustworthy and reliable, so that you know that get the best service possible for your money. The government's new system is a joke, the cheapest services will have to be purchased by the consortia, and as we have seen with ISTCs the private firms will frequently provide a shabby dangerous service for the money.

If this system were to have a hope of working then the GP consortia would have to be free to make their own informed choices, sadly they are not, they will be told what to do from on high. This is no sensible bottom up market, it is a top down Stalinist shambles that is designed to hand lots of money to Mr Lansley's generous friends in the private sector, and in the process our hospitals will be destabilised and destroyed.

The White Paper - dangerous rubbish

The White Paper chitter chatter is high on the news agenda this week, the full version is due to be unleashed in a couple of days time and apparently it is not rain forest friendly as regards its paper consumption. That tells its own story, this latest 'reform', 'modernisation', 'shit storm', call it what you will, is extremely complex and it is not going to be light in the bureaucratic department.

It is yet more rapid change, and this comes with the inevitable reform fatigue, combined with an immense amount of money wasted on the new bureaucracy (reportedly in excess of 3 billion). It also puts a hell of a lot of money in the hands of Primary Care, Secondary Care is at its mercy and this is where the danger lies. Do not believe all the talk about better outcomes, this is just the smokescreen for the mass privatisation that is being ushered in undemocratically.

Competition does not necessarily drive progress. In fact as regards Secondary Care and hospitals, competition can be catastrophic. Hospitals function best as integrated services consisted of all the bits working effectively in cooperation with each other. As soon as private firms are allowed to cherry pick the easy bits of work, something that will be ensured by the new regulatory framework, then certain hospital services will be starved of cash and will be shut. We only have to look to the USA to see that competition and choice are far from the Utopian solution that certain politicians and academics would have us believe.

The end result will be the crumbling of our hospitals. An Accident and Emergency department cannot survive when a hospital loses its Obstetric cover, its Orthopaedic cover or its General Surgical cover. This is all fine for a patient who wants an elective hernia operation or an elective joint replacement, the problem comes when one has a life threatening infection, or a hip fracture, or an appendicitis, then you just want a good safe local service and if that is threatened, we are in very sticky waters indeed.

The BBC's Nick Triggle on Consultant 'overtime'- Crap journalism at its worst

There has been a lot of chatter in the news today on how much money some consultants are earning for 'overtime' work, and it stems from the BBC's Nick Triggle's shoddy journalism:

"Some consultants are making more than £100,000 a year in overtime payments from the NHS, the BBC has learnt. The sums - paid on top of basic salaries and bonuses - have been criticised at a time when the health service is trying to save money. Consultants have been accused of playing the system, but doctors said poor planning by managers was to blame. Overtime rates vary, but are often about £600 for four hours - treble what senior medics get for contracted work. Basic pay for consultants stands at just under."

Essentially the government promised a lot and couldn't deliver it without increasing the capacity of the system. To do this surgeons, anaesthetists and all the other staff had to be paid for doing this extra work, so that all the waiting time targets could be met. It is also key that none of this work is within their contracts, it is all outside the obligation of their consultant contracts, it is work in their 'free time', that is a more honest term for Triggle's 'overtime'.

It is certainly not 'overtime' as most people would understand it, but this is the story that the BBC's Nick Triggle's tries to spin to the reader. This is work which the NHS needed to get done and in order to get it done it had to pay the market rate.

Surgeons and Anaesthetists aren't going to work outside their contracted hours for much less, it may surprise Nick Triggle to know that in the private sector the very same consultants would probably be earning a hell of a lot more per hour than they are for this NHS 'overtime' work:

"Managers at Mid Staffordshire NHS Trust tried to reduce the rate for overtime for orthopaedic surgeons from £1,000 to £500 for a four-hour session. But minutes from official meetings showed consultants would be "downing tools" if they did so. In the end, managers had to compromise on a fee of £750."

This is down to simple market forces. If managers started offering way under what consultants can earn privately for extra work in their free time then they simply wouldn't do it, they are under no obligation to. It may surprise the dishonest or stupid Nick Triggle that Consultants can earn many hundreds of thousands of pounds for their private work, it can also be argued that they are underpaid in the NHS for the work they do.

The lame duck Alan Maynard is even brought in at the end of the article for a rent-a-quote to have a dig at doctors, maybe this bitter failed academic is just jealous of people who have a job they enjoy, I don't know. It remains clear that Maynard should be able to understand how the market forces he loves to go on about are at play with the pay for this extra consultant work, either he is stupid or dishonest like Nick Triggle.

It remains clear that this so called 'news' piece is just a rather lame misrepresentation of the reality of a situation in which a group of professionals are being paid a reasonable market rate for doing some extra work to clear the decks. Triggle and Maynard may like to think how much it costs to call in the plumber or the electrician at the weekend, they may also like to think how keen they would be to work extra weekends for their normal rate of pay? Mind you, I can't think of any reason for anyone needing Alan Maynard at a weekend, maybe that's why he's such a bitter individual? Either way, shoddy journalism all round I say.

New targets/Nurses beyond means- Same old for 2011

It does not surprise me to see a lot of the same old NHS junk repackaged and called something new under the new government. 'Targets' are being scrapped, but the new 'Targets', ie performance indicators, are coming in. Lansley keeps trying to pretend that these new targets are all about measuring quality but this is hogwash, they are just targets by another name, as soon as something is used as a performance indicator you change what you are measuring, another piece of the system is fiddled and you are back to square one again. For example the 4hr wait was never of any use in determining the quality of care or helping patients, it just showed how quickly a piece of paper could be filled in and a patient dumped on a new 'assessment' ward. The new targets will be more of the same, measuring something completely changes the process and that measure's meaning, something that stupid politicians and managers completely fail to appreciate.

Some rather interesting information and recent scientific research points to the obvious fact that the less training you give to autonomous practitioners, whether doctors or nurses or monkeys, the lower quality of service patients will receive. Some interesting research from Holland points to primary care perinatal mortality being higher than that in secondary care, something a midwife would never even dream of considering, it runs against their fundamentalist doctrine of medieval home births. Some interesting recent news on the danger in giving nurses power beyond their means has hit the headlines. I see this regularly at first hand, numerous under trained staff are given responsibility and autonomy way beyond the limits of their knowledge and training, the side effects in terms of patient harm are inevitable and regular. This does not just apply to nurses in dangerous extended roles, it applies to certain paramedics, other quasipractitioners and technicians, including health care assistants and other staff with minimal training.

Onto the topic of health care rationing, something I have no problem with as a general principle, we do not have infinite funds. However when this rationing is done in a way in which the non-medically trained are empowered to make clinical decisions that are both reckless and dangerous, then I am completely against it. Numerous PCTs have sod all cash and as a result are stopping all elective surgery that they deem to be of 'low value'. The problem is that a lot of these low value procedures are often rather essential and need to be done as almost an emergency, if not then the knock on costs in terms of patient morbidity and long term disability are far greater than the money saved it not doing a simple effective procedure. This is stupid short term NHS thinking at its best, so a new government, but the same old stupid top down rubbish spewing forth. I see more of the same for 2011.

Alcohol and harm

Having spent many a night or weekend seeing the carnage that results from the casual and excessive use of alcohol in this country, I have to agree with David Nutt, we really should be putting far more effort into taking on this huge problem.

One can watch his words here on the BBC, I am sure most of you will be infuriated by the pathetic interviewing from the BBC 'journalists', they clearly lack the brains or knowledge to adequately dismantle this topic for their viewers, typically woeful coverage of a scientific issue I'm afraid. I noticed this thanks to Dr Grumble's blog.

The BBC and the media in general are pretty damn rubbish when it comes to covering scientific matters for several reasons. Firstly their journalists lack the understanding of the issues and secondly their bosses want ratings, not decent accurate journalism. One only had to watch their recent Panorama program on the use of antipsychotics in dementia patients to see a complex issue poorly broken down and distorted by some shoddy journalism.

Anyway onto alcohol, it is a national disgrace that the government continues to do effectively sod all to take on the drinks industry. The most effective strategy for improving our dangerous boozing culture is to raise the minimum price of a unit of alcohol, the government continues to resist doing anything in this regard. A&E departments are routinely overrun with drunk patients, the long term health issues associated with alcohol are plentiful. I suspect the drink industry and the big supermarkets' power is part of the reason that the government is doing sod all of use again.

Ideologically driven failed policy - the White Paper

Dr Grumble has beaten me to it, this excellent article which neatly summarises exactly what the government's NHS white paper actually means is absolutely essential reading:

"Behind the technicalities, what do the government’s plans for the NHS really mean? Stewart Player and Colin Leys expose the reality of the health service white paper......"

Those who read this blog regularly will understand it well. The ideology behind it is so deeply flawed. The white paper just continues the same old flawed policy which the previous Labour government inflicted upon the unsuspecting public.

The introduction of pseudo-competition and the market has been shown to fail before, private firms invariably only do the easy work for a nice tidy profit, the left over work which is much less profitable and a lot trickier is left to the public sector, a public sector which I may add is being dismantled, it is so much harder for hospitals to work effectively when they lose essential working chunks of their arms and legs, as they are sold off to private firms. Commissioning is at the centre of this wasteful reform, a process which oversees the pseudo market and results in a hell of a lot of expensive and inefficient bureaucracy.

Critics of the article's authors, Leys and Player, love to simply claim that their writing is ideologically driven nonsense. The great irony in this is that the actual reform, the white paper itself, is ideologically driven nonsense. There is no decent evidence that any aspect of these reforms will spend tax payer's money more effectively in delivering health care, thus to criticise the white paper's critics for being ideologically driven is nonsensical, the white paper is evidence free, it is hot air, actually there is a lot of decent evidence which shows that various white paper policies have failed time and time again in the past. ISTCs, PBC, PFI, Choose and Book et cetera have been shown to be an ideological bonfire of tax payer's cash, there is no decent argument or evidence which says that the new white paper will be anything but more of the same needless incineration of tax payer's cash.

Cuts, cuts and more cuts

I have no problem with the reality of a recession and belts being tightened, this is just an inevitability and part of life. One thing I do resent is the fact that the last government spent so recklessly off the balance sheet in the form of various PFI schemes.

Numerous NHS Trusts around the country are now paying for the government's errors, they are having to service these PFI contracts and a disproportionate amount of money has to be fenced off to do this. These costs cannot be trimmed, the contracts were set in stone years ago, it is as if the government sold its soul and we are now paying the price, there is no going back.

So while essential services are cut, while patients suffer as PCTs restrict access to essential operations and medicines, it is ridiculous that there is no risk to the income of the private firms who have their hands in the NHS' till. These private firms and guaranteed their profit, they will get their money come what may. The system is all wrong, how can this be right when the blind old man with cataracts is not guaranteed a fix, or the limping old lady with a painful hip is not guaranteed a reasonably speedy operation?

Cuts to local government budgets for social care are going to compound this problem. We are already massively short of beds as it is, so with winter coming and money short, as well as our increasingly aged population, there are some very stormy times ahead.

Apologies, I am still alive

I apologise for my lack of posting recently, it has been for a mixture of reasons. Firstly I have been pretty busy having just moved jobs, secondly I have been generally disillusioned with politics and health care for the past few weeks and thirdly I sometimes just get a bit lazy. Maybe Dr Crippen's absence is part of the reason too, everyone in the medical blogosphere must miss his excellent writing and razor sharp insight into all matters health related.

I was having a quiet pint last night in a very pleasant pub and there was a certain book by 'Dr' Gilliam McKeith on a shelf there. A few of us began to browse through the aforesaid Dr's book and became rather obvious that it was full of complete and utter bullsh*t. It was very well produced from a publishing point of view, very shiny and well presented, enough to convince the ignorant reader that there may be some 'science' and 'truth' within. However when one skated beneath the surface it was clear that there was very little in there that was not based on the meanderings of a stupid fool.

So why am I rambling on about Gillian McKeith you ask? Well, it has motivated me to start making the effort to do a bit of writing again, I am fed up with the low quality rubbish that gets fed to us in the media a lot of the time, especially concerning science, medicine and politics. There are just so many uneducated quacks out there in so many different forms peddling useless rubbish to unsuspecting members of the public, and this culture is propagated by a lot of rather low quality journalism covering all matters scientific.

Anyway that's about it from me for today, I will try hard to cover a few health related matters with a decent amount of cynicism in the forthcoming weeks, there have just been so many health related issues in the news of late that it's been hard to know where to start. The government's ridiculously stupid white paper has been a big story, while the mismanagement of medical training and the EWTD has been another big one, the failure of 'minor injuries units' is also a story that I intend to cover in the not too distant future.

One massive contradiction in recent days has been the massive cuts that are taking place in the NHS throughout the UK in recent weeks, but at the same time the government is ring fencing the NHS' budget. Something quite clearly does not add up. Is this because various NHS Trusts have been saddled with massive bills for PFI deals and they also know that the new crackpot government reforms are going to see more and more money kept away from secondary care, then poured into the coffers of various government friendly private health care corporations? That would be my cynical explanation, billions are being ring fenced to pay for the stupid new rearrangement of the bureaucrats' deckchairs, while more cash will be squeezed away from the front line. New government, same old reforms taking us backwards, no change really.