30 December 2008

Compassion in the NHS

One of the good things about being older is that you can remember how things used to be. There is the strong risk of the rose-tinted retrospectoscope and you can't go back to check on your memory or show youngsters how it used to be but you can be pretty sure of some things.

Dr Grumble did a ward round on Christmas Eve. He doesn't usually do a ward round on a Wednesday but his junior staff wanted him to. The timing of the round was their idea. They were worried about the long weekend. So was Dr Grumble. He never likes these long holiday periods for patient care. The worry of the managers was very different. The Grumble hospital has been very full. The possibility of running out of beds over Christmas was frightening them. But it never seems to happen that way. For all sorts of reasons the pressure is off at Christmas time. Nevertheless Grumble thought it was his duty to try and get patients home for Christmas. You might think patients would like that. But you would be wrong. For the lonely Christmas is the loneliest time. The second patient Dr Grumble saw did not want to go home for Christmas nor the third. And so it went on.

Dr Grumble can remember what the consultants of old would have done. They would have been compassionate. They would have invited these lonely people to stay for Christmas Day and we would have had a great big turkey. A real turkey. And Dr G's consultant would have come in on Christmas Day and carved it. We would have had a nice party and presents would be flying in all directions.

But those days are long gone. Dr Grumble had to ask his staff why these patients were still in hospital. The was no reason. Not a real reason. It was just that nobody had had the heart to send them home. Except, that is, Dr Grumble. He wishes it could be otherwise. But you can't turn the clock back. And we must have the beds.

29 December 2008

Second life

Would you like to have a second life? Dr Grumble would. This life has been good to Grumble. But he would like another one. He's not sure what he would do with it. Perhaps something similar only better. And it would be nice to be born into the era of the internet - though having these things to discover towards the end of his working life has been a great excitement for Dr Grumble.

Dr Grumble went to one of those peri-Christmas parties yesterday. It was full of old farts. Dr Grumble is of the old fart era. One of the old farts (a nice old fart actually) began talking about new technologies. Dr Grumble mentioned he had a blog. The old fart seemed surprised. Why? Blogging is not difficult. It's certainly easier than writing a letter. Do the old farts not realise this? It seems they don't even read the blogs. But then Dr Grumble's children don't either. Are we there yet with blogging? Has it gone as far as it is going to go or can we expect more? It's hard to know. It's difficult to see where some of the new web-based technologies will lead us. Sometimes Grumble thinks we are trying to push it too far.

But none of this was the purpose of this post. The purpose of this post was to ask what you people out there think of Second Life. Dr Grumble, being an old fart, is not really into Second Life. He knows what it is. He knows how it can be used for medical education. Research protocols have even crossed the Grumble desk relating to the use of this sort of simulation for education. But Dr G has not yet dipped his toe into the water. Will Second Life become an important part of our lives? It clearly is already to some. Will it become important in medical education? Will we stop going to international conferences and just wander around in Second Life where we will make friends and meet experts from around the globe? Some people seem to think so. What do you think?

28 December 2008

Back to basics

For most of us it is difficult to complain. If Dr Grumble were to take the trouble to complain about something, which he rarely does, he would probably try and start with a compliment about the service. If you are going to complain it is nice to give credit for the things that went well and this might also lend some credibility for when you put the boot in.

Dr Grumble has just read an account by a patient referring to 'good care' at Leeds General Infirmary. By this the patient means the medical treatment was good (which it probably was) but the 'care' was plainly appalling. The patient refers to 'poor facilities' (which they probably were). It easier to criticise facilities as opposed to people. But Dr Grumble thinks there were staff failings. Full bedpans and urine bottles left everywhere may have something to do with facilities but whatever facilities you have these things do not empty themselves.

"Could we nudge them into doing better?"says Paul. No Paul. They need more than a nudge. We need a return to good old fashioned nursing. And we don't need to do away with hierarchies we need to bring them back. We need somebody with status in charge. Somebody who is revered. Somebody who is accountable. Somebody who takes pride in the ward and the staff and ensures that everybody does a good job. We need to do away with the endemic sloppiness that has insidiously crept into our wards. We need to do away with the no-blame culture and get people to do their jobs properly. We need to bring back the benevolent dictators who used rule the wards with a rod of iron. Good basic nursing needs to return. It needs to be valued. It needs to be respected. It needs to be rewarded.

27 December 2008

"Wrong kind of misconduct"

In October Remedy, smarting from the catastrophe of the medical training applications system (MTAS), instructed their lawyers to write to the General Medical Council (GMC). Essentially the allegation was that the doctors in charge of MTAS had fallen below the high standards required and that the GMC should investigate.

The GMC has now rejected the call for an enquiry. According to the GMC:

i) the alleged misconduct is not relevant to the fitness to practise of these doctors, and

ii) allegations of deficient performance must be concerned with poor performance in a clinical setting.

Dr Grumble knows nothing about the law but he can read. Below is a cut and paste job from the judgment relating to the case of Professor Sir Roy Meadow:

....... "serious professional misconduct" is not statutorily defined and is not capable of precise description or delimitation. It may include not only misconduct by a doctor in his clinical practice, but misconduct in the exercise, or professed exercise, of his medical calling in other contexts, such as that here in the giving of expert medical evidence before a court.

Could the GMC's decision have more to do with expedience than the letter of the law?

Remedy and their lawyers believe:

• that the GMC rejection on such shaky grounds is at best absurd and at worst unfairly protective of an unimpeachable elite

• that there are unhealthy double standards of accountability between the profession and its leaders

• that it is the duty of an organisation like Remedy to step up and restore accountability to that leadership

• that a clear precedent needs to be set pour encourager les autres

• that far from being an issue from the past, unaccountable leadership is an ongoing problem for the profession which needs to be addressed immediately

They have some good points but if they want to take this further they will need to raise a lot of money. Lawyers don't come cheap.

For more on this issue visit Remedy.

25 December 2008

Happy Christmas

Dr Grumble wishes all his readers and fellow bloggers a Merry Christmas.

23 December 2008

From litter tsar to patient safety

Logins from the paradise of Necker Island have led Dr Grumble to suspect that no less a person than Richard Branson reads Dr Grumble. It could though be just his minions but Dr Grumble likes to think it is Sir Richard himself.

Sir Richard has been proclaiming on MRSA. Now Sir Richard is not a great expert on MRSA so why should we listen to him? He was not a great expert on litter but that did not stop his being appointed litter tsar though Dr Grumble cannot remember him solving that problem either. But, since Sir Richard reads Dr Grumble, he may have more knowledge on MRSA than we give him credit for. And his great friend Peter Emerson is a doctor and, of course, so is his daughter, Holly. Dr Grumble has met Holly. But that was many years ago when she was something of a tomboy.

So where did Sir Richard get his latest idea on how to tackle MRSA? Could it have been from Dr Grumble?

Spoof or not?

Can you believe that one of these videos is a genuine video from the Department of Health? Can you tell which one?

Is it number 1 or number 2?

What a way to market Connecting for Health and the electronic care record. Presumably even the actors were embarrassed.

22 December 2008

Can you spot madness? Let's Hope so.

Do you think this man is mad? What are the signs? The vacant grin? The confabulation reported in the press? The impending spillage of his coffee? Or his plans for dementia training for GPs? Which of the above is the key to the diagnosis?

21 December 2008

Managing uncertainty, ambiguity and complexity

Do you know what a doctor does? Probably you think you do. Quite possibly it seems a fairly simple job. The patient goes to the doctor. The doctor is highly trained. The doctor knows what is wrong with the patient and delivers the appropriate treatment. What could be easier? But it is not really like that. Even apparently simple things are not really like that. When one of the Grumble children injured his ankle and had to be carried home by his friends it might have seemed likely that it was more than a sprain but Dr G did not know and nor did Mrs G. When he continued to fail to weight bear Mrs Grumble took him to A&E. No fracture apparently. Then it was back to the orthopaedic clinic. Now why do you think that was necessary? There he was seen by a registrar who was dismissive even though he still could not weight bear at all. That would have rung alarm bells even to Grumble. But there was no fracture - apparently. Then the consultant came in. He pressed on one spot and poor young Grumble leapt into the air - or he would have done if he could have leapt. And he ended up having to have his bone screwed together. How could this have happened? Were all the doctors up until that point incompetent? It happened because even orthopaedics, even whether or not a bone is broken is just not that easy. The A&E doctor would have been very junior and, despite years of training, the SpR had had insufficient experiential learning. The consultant got the diagnosis in seconds because he had seen it all before. He had the mileage.

Move now to the GP's surgery where the poor doctor has to deal with absolutely anything that is thrown at him or the physician's clinic where clinical problems that the GP cannot fathom may be referred. The problems there are even worse. Sometimes it can be easy. Dr G remembers as a student being impressed when a patient whose fingers were clubbed came in with an abnormal chest radiograph . Within moments the consultant was as certain as he could be that the patient had lung cancer. The young Grumble might have been impressed but that one was easy. Often it is not like this. The outpatient clinic can be a real struggle. Sometimes the history has to be wrestled from the patient. Sometimes the history gives few clues. Sometimes there are too many clues. Easy it is not. And if you don't know what is wrong from the history, the examination is unlikely to help either. The mental effort you have to put in is substantial. A busy clinic is draining.

The managers of MMC failed to realise that medicine is difficult, that extensive experiential learning is essential and that it is not just a matter of acquiring competences and getting boxes ticked. Many cases are grey. Many cases are ambiguous. And, as patients get older and older, many more are complex. Doctors need to think on their feet from first principles. They need to cope with not always knowing what is wrong with their patient. They need to cope with ambiguity and complexity. They need to help patients and their relatives who cannot handle the uncertainty. None of us likes uncertainty.

Unfortunately those responsible for the management processes in the health service have also failed to realise just how difficult this all is. Not only has medical training degenerated into a tick box thing but the management of patients has headed the same way. ACS protocols are now the order of the day for every sort of chest pain. It's a wonder this approach is not killing people. Perhaps it is. But nobody worries if the protocol is followed. And, if it can all be protocolised, we do not actually need doctors at all. That anyway is how the thinking was going. But that's because few away from the coalface recognised what an enormous issue the management of uncertainty in medicine is and few at the coalface wrote about it. Yet every real doctor will known of the ambiguities, the complexities and the fogginess that forms an integral part of the practice of medicine - whether you are an orthopaedic surgeon, a GP or a grumbling physician.

While doctors have always known this, they haven't said much about it because they really didn't think they needed to. It has been obvious to us. It has been obvious we are needed. It has been obvious that we need to learn from sheer experience and that no course or simulator can make up for lack of experiential learning. But as the mistakes have gone on being made from those in charge who know so little we have now had to tell them what doctors actually do. It's sad this was needed. It is a statement of the bleeding obvious. But Sir John Tooke was right to ask for it because those in charge do not seem to understand the bleeding obvious. Well done, Sir John.

19 December 2008

It's busy

Across the UK the demand for emergency hospital care has been exceptional. Elective work has been cancelled. One London hospital is said to have had to resort to piling up the patients in the endoscopy suite. Ambulances have been queuing outside hospitals waiting for beds to become available. That's no way to treat people needing emergency care. But we are in difficulty. The Secretary of State has had to announce that we do not have a crisis which is what Secretaries of Sate say when we do have a crisis. Yet there is no 'flu epidemic. There is no epidemic of anything. Some 'flu and a bit of norovirus in some places but nothing remarkable. If we have a crisis now what is going to happen when we do have an epidemic?

Why has this happened? It is because NHS beds have been cut and cut. Between 1984 and 2004, the number of hospital beds in England fell by 31 percent, from 211,617 to 145,218. That is a loss of 66,399 beds which is about equivalent to a city the size of Guildford. It's no wonder we are in trouble. Whatever the Secretary of State says.

Money that could have gone to front-line acute medicine and an adequate supply of beds to enable proper bed management has gone to the government's pet projects. Unfortunately the government is keen on supporting black holes.

Potty policies on polyclinics

Here's what Frank Dobson has to say in relation to setting up a super surgery at a London teaching hospital:

There may be a case for polyclinics being set up in under-doctored areas, but this area has some excellent GP practices. The whole idea of setting up polyclinics is to shift services away from hospitals into the community. But this proposal to set up the polyclinic at the hospital was potty

Why can't we have a proper informed discussion on these things? Politicians vowing to 'quash resistance' is not the way forward. Pulse has the story.

14 December 2008

Christmas presents you don't want

Very occasionally Dr Grumble sees a patient with gonococcal septicaemia. As it happens he saw one recently. Dr G was quick to spot it. The junior doctors were not. It was not in their differential. They have probably never seen a case before.

Alcohol and office parties mean that the season for this sort of thing is about to get into full swing. Below's a little ditty for the revellers.

You can also find it here. With thanks to NHS behind the headlines.

13 December 2008

The Bloggers' Bond

Dr Grumble knows the identity of only one of the anonymous UK medical bloggers. There was a time when Dr G felt that he wanted or needed to know who these people were. Now he is content to know them just by their blogging names. It would be sad not to know that you actually were or had been a friend of one of these people and that is why Dr Grumble did eventually unmask himself to one particular top medical blogger. As it turned out it seems we do not know each other. But that doesn't matter because we are blogging friends.

People learn to trust you by your blogging. That is how they know you. They feel that they are thinking in similar ways and that earns you some respect in their eyes. One blogger told Dr Grumble something that was very personal, something that was very hard for her to talk about. Perhaps it was something she did not mention much, if at all, to people closer to her than Dr Grumble. Dr Grumble was touched and flattered. It brought home to him the closeness of the blogging fraternity. To some extent he even wonders if anonymity can bring a frankness and closeness that is more difficult in a face-to-face encounter.

The blogging community is getting even closer because we are now communicating with each other away from the blogs in emails. Dr Grumble's email address is not even on the blog. It never has been. Somehow it has got around and he is being included in some email discussions which are addressing important issues. There is something very wrong when medical bloggers feel there is a need to conceal their identity from each other and discuss things like freedom of speech and the undermining of free thinking. And whether there is somebody in some senior position with a sinister objective or whether the goings-on are all cock-up rather than conspiracy.

Dr Grumble has worked outside the NHS. He has seen a lot of what is happening in the NHS happening elsewhere. It is a phenomenon driven by a blind management mantra that is sweeping the world. Some of what these people spout is nonsense but it is difficult to tell them so. In the summer Dr Grumble read a book about markets. Like most such books it repeatedly extolled the virtues of markets. Dr Grumble accepts that there was quite a lot of truth in the book but he does not approve of the uncritical worship of markets. Dr G has always taken the view that markets have their weaknesses. An earlier post on this very topic was never published. Grumble thought that even the blogging fraternity might not be ready for his views. You see, not so very long ago, it was heresy to suggest that those people in the City who run markets were not actually creating anything useful for society. But that is what Grumble was saying to himself along with criticism of bankers and their unwise lending. A few months later and Grumble's avant garde thinking is already passée. Everybody is thinking the same way. It's an odd world. Why was nobody prepared to speak out before?

In the management book Dr Grumble read there was criticism of doctors and other professionals with their cartels or closed shops. The implication was that this prevents the market working and that what you need is deregulation to allow the market to be opened up to all comers. This, of course, is the standard mad mantra. This was the rotten thinking that led to the banking crisis. This is the very same catechism that is being followed as healthcare assistants replace nurses and nurses replace doctors as they are propelled up the skills escalator. These malignant innovations have all come from the management gurus. But these smart-clad know-alls do not actually know all. We all know that they know very little. But nobody ever calls their bluff. It's like the City and the bankers. We all knew but nobody ever said anything.

The regulation of doctors is there to protect the public not doctors. Just as the regulation of banks should have protected the public. Medicine is not just regulated to prevent non-doctors doing a doctor's job. Cosy cartels are not what it's about. After all the regulation even prevents doctors doing doctors' jobs. What does this riddle mean? Well, Dr Grumble could not just set up as an NHS GP. Nor could a GP become a Dr Grumble. When Dr Grumble goes to his GP he wants to know he is seeing a doctor who has been trained to do the job. Perhaps Joe Public thinks any doctor who has been through medical school would have enough knowledge to be a GP but it is not the case any more than a GP could do a heart transplant. And for heart transplants you do not just need a surgeon. You need an anaesthetist and intensive care doctors and even physicians to tell the surgeon that a transplant is the only way forward. And there are lots of highly skilled nurses and technical staff needed all along the way. Each has their own expertise. Each has a vital and important role. Each task needs the right person for the right job. There's nothing new about this (Smith, A). So why are the malignant management gurus telling us otherwise?

As for markets in medicine, Dr Grumble is not at all sure that they work. The public may like more and more tests and scans and screening and be prepared to pay but that is not necessarily good for them. Yet in a market system there may be pressure for high tech solutions. And if you are a doctor being paid for providing high tech solutions then high tech solutions is what you will get whether it is good for you or not. That's the way of the market.

So who is driving the rotten thinking that pervades our organisations? Where does all this nonsense come from? Why is the same madness appearing everywhere? How can it be that so many are singing from the same rotten hymn sheet? Who is responsible for pedalling these insidious false beliefs? Are we being taken over by some mad malign evil sect? Sometimes it seems like it. It really does.

12 December 2008


You would think that receiving financial compensation for some sort of injury or illness would be a good thing. Dr Grumble is not sure it always is. Sometimes all the wrangling that goes on is distressing. The only certain winners are the lawyers. Sometimes even doctors win. Some of Grumble's colleagues made a lot of money from the miners' compensation. There were those that appeared in court and there were the jobbing doctors that assessed the claims. All got good money. They were paid lawyers' rates. Had Dr Grumble had the right expertise (he is unwilling to say whether or not he did) he would not have helped. He had the strong impression that too much money was being spent on the process and not enough on the victims. It seems he was right. A vast industry had grown up around the compensation scheme. That could never have been right.

Two-thirds of the claims cost more to administer than the cash paid out and some claimants are still waiting for the money a decade after they put in the claim. Others died before they got the cash.

As Dr Grumble has been implying compensation is not always a good deal for the victim. Sometimes despite every effort they end up with nothing or a derisory sum. On the other hand one of the best things you can do for a patient is give them money. It's rare for a doctor to have much influence over this but it does happen. Here's a letter Dr Grumble received from a grateful patient some years ago. Identifying details have been removed but otherwise it has been reproduced warts and all.

Dear Doc,

I hope you are well and and happy in your new career [The patient went to great lengths to track Grumble down].

I am now 65 years old and want you to know the best help and advice in my life came from you, "Well beyond the Call of Duty."

I know the DSS pestered you for reports on my condition and you did a fine job on my behalf. [Dr G was precise and honest.] To give you some idea what this means to ratbag and myself, if we have visitors we can buy extra milk and a few cakes without being short the following week ; and the best of all not to dread Christmas when we could only buy a few cheap crap presents. Now I feel good. We can buy everyone a crap present but affordable.

It took 5 years but you will be pleased to know the following. On turning down my claim for "industrial injuries" they said I had only been exposed to a minimum amount of ................. and by chances of probability it was not the cause of any problem. [Dr G thought this was nonsense and with something of a heavy heart because of the long haul and uncertainty of the outcome he advised an appeal.]

I appealed on both these points and won. In February of this year I was awarded £27-50 a week FOR LIFE and £8089-40 back pay. WOW! Ratbag and I felt we had won the pools. There was however a few pound short from my award and when I went to the XX Board on another matter I told them of this and "Will my luck never end", another £36-62 PW and £1132 back pay.

As you can see, I've had £9221-40 lump sum and am now on £64-12 per week. With my pension on top of this, I shall soon be paying income tax (can't wait).

When ratbag goes to the Post Office every week she asks if I want her to pick up Doc's money - this is how we both think of it because, without you, this would never have happened and both of us are so grateful to you.

I know you will be pleased your work on our behalf turned out so well for us so there is no need to reply to this letter (can't read your writing anyway). I will put my address on the rear of the envelope and then I will be sure if they don't return it that you have it.

Many thanks and best wishes to you and yours.

Of course Dr Grumble replied saying how happy the letter had made him. It really did. The letter had a profound effect on Dr G. It contributed to his returning to clinical work. Another terribly sad incident had contributed to his leaving. But that's another story.

07 December 2008


Doctors are often accused of talking in jargon. The implication is that they do this on purpose in order to create an aura of importance. They are also accused of concealing information from patients by using words they do not understand. Sometimes Dr Grumble feels the same about managers. Even the garage man uses terms Dr Grumble cannot understand. Quite often actually. As he writes Dr G's car has a broken spring of some sort somewhere. Dr Grumble really does not understand the function of this spring. The garage he goes to is a bit upmarket so you speak to a smart man in a suit instead of a bloke in overalls with an oily rag. Dr G feels more comfortable chatting to the mechanic. He's not sure that the smart guy has any idea of what the spring does. It is like one of Grumble's patients getting an explanation of what has gone wrong with his body from a hospital manager. Most of them wouldn't have a clue.

Sometimes Grumble hasn't got a clue as to what the managers are on about. One manager he knows (she is actually quite good) strings management buzz words together into totally incoherent emails. They really are quite incomprehensible. To Grumble anyway. By comparison doctors are really quite good. Dr Grumble has never ever heard a doctor talk about a patient haemorrhaging. Perhaps they do in the US. Perhaps not. But in the UK if blood is pouring out of a patient we call it bleeding. There is a simple English word for it and that's what we use. Curiously, patients often seem to use the word haemorrhaging. Where they pick this up from Dr G has no idea. Is it from the TV? There are plenty of examples of doctors using simple words when longer ones would sound grander. Would you believe that the gastroenterologists have a journal called Gut? And respiratory physicians have, yes, Chest. You can't get much simpler than that. There are others like Bone and Eye and Big Toe. OK. Not Big Toe.

One of the delights of the English language is that you often have the choice of several words that mean the same thing. You can close the door or shut the door. Close and shut mean the same thing. But there is a subtle difference between the two. Close is more upmarket. Odd that. How does Grumble know? He just does. Anyway it is nice sometimes to have a choice. It's the same with medical language.

If you have a blog you probably have some love for language. Dr Grumble certainly has. So do other medical bloggers who even address the wretched split infinitive. Dr Grumble is happy to split infinitives if it sounds right. He's going to tentatively give you an example. There you are. That was it. Quite painless. Not too bad really. But perhaps it is not surprising that Grumble failed his Use of English exam at school all those years ago. He has always split infinitives. And just look at all those sentences a few lines up with no verbs. And two sentences in a row beginning with and. Even one beginning and ending with and. Yes. They were right to fail Grumble.

Of course technical jargon has a function. There are words that Dr G uses that have no simple English equivalents. To do other than use the technical terms would require cumbersome circumlocution. C'est la vie. But management buzz words do get Grumble down. Especially if they are just strung together meaninglessly. The other day one of the young girls put in charge of old Grumble came with some good news about uplift. Dr G took a risk. He put on his best bewildered look and asked what she meant and told her that he had only heard this term in the context of mammary suspension. She was, of course, delighted that she knew a word that Grumble could not understand. She apologised and simplified her language so that old fart Grumble could comprehend. Grumble knew all along, of course. But he didn't let on. Dr Grumble, you see, has played buzz word bingo. If you want to play too click here for a bingo card.

30 November 2008

am Klo

Dr Grumble tries to keep his past under wraps. It's too identifying. But, for this post, he is going to have to reveal that, for a short while, he worked in Germany. Dr Grumble still takes German lessons. He is now in the advanced class. But he rarely goes to Germany any more. Mrs Grumble is not keen on Germany.

It was very many years ago that Dr G worked in Germany. The building where he worked is now derelict. But Grumble remembers it as if it were yesterday. One thing he remembers is the toilets. The Germans are very clean. Perhaps obsessionally so. Dr Grumble's German teacher thinks there is a historical explanation for this. Whatever the reason cleanliness is important to Germans and you cannot criticise them for that. Their lavatories are clean too. But they have one very unusual feature. Dr Grumble refers to this as an 'inspection panel'.

All those years ago Dr Grumble pondered over this inspection panel. He called it an inspection panel as a joke and because he could not think of any other suitable term that would adequately describe this extraordinary feature. In those far off days you couldn't google and you could hardly go to a library and asks for a book on German lavatories. But now the wonders of the internet have revealed to Dr Grumble that he is not the only one who has been pondering the design of the German water closet. The Germans are great engineers. They could design much better toilets if they wanted to. But it seems they don't. They like their toilets just as they are. It seems that what Dr G jokingly called 'inspection panels' are just that. The Germans, apparently, like to inspect what they have passed. Now isn't that odd?

What has all this got to do with medicine? The answer is that the way people behave in different countries is very different. The NHS or GPs get blamed for poor cancer survival rates. But British people are a stoical lot and very different from German people when it comes to their health. Dr Grumble's evidence for this is weak (not that he has looked for any). But one piece of evidence is that most British people are not intent on passing their excrement onto a porcelain panel for inspection. And that could mean that we are less likely to notice if we have serious bowel trouble. Or it might not. It is an interesting possibility anyway.

Dr Grumble apologises for being a bit slow off the mark with this post but world toilet day quite passed him by.

One rule for the guilty another for the innocent

Dr ***** **-***** has been named as the locum paediatrician who examined Baby P two days before he died.

The doctor said:

"My professional career has been devoted to the care of children."

The boy's mother and boyfriend have been convicted of causing the baby's death. The law prevents them from being named.

Dr Grumble says:

The doctor's registration has been suspended. The doctor was a locum so, presumably, is now without a job and and has lost her livelihood

Dr Grumble says:

Somebody has to be blamed. It could be the doctor. It could be a social worker. It could be both. It won't be the government.

Did you know there are targets to reduce the number of children being taken into care?

Dr Grumble says:

Nothing at all.

24 November 2008

Sick certification

The GP bloggers are getting angry about the failure of hospital doctors to issue certificates. They write: This is NOT a rant against my colleagues in secondary care and claim we are ignorant or they imply we are lazy. So which is it? Dr Grumble thinks it is simply because we are provided with the wrong form. Here is the one some of us have been using. It only covers the hospital stay.

Here's a quote from the document linked to below:

Until now the Med 3 statement has been used very rarely in Trusts and in the whole of the NHS generally. There is widespread use of the Med 10.

As far back as 2001, Trusts were required to integrate a simple sickness certification procedure into the hospital discharge and out patient process. The reason was so that hospital doctors and consultants would not refer patients to a GP solely for the purpose of obtaining a sick certificate. At that time, it was estimated that 518,000 appointments per year could be saved for GPs plus 42,000 hours. Also, it would ensure a seamless service for patients upon discharge.

Issue date: September 06
[So it has only taken them five years.]

The problem is clear. It's not much to do with laziness. Filling in one form is much the same as filling in another. It makes no odds to Dr Grumble. But in the Trust where Grumble works there are, say, over 1000 inpatients and over 50 wards on more than one site. Getting the right pieces of paper to all these places is a challenge. This is a management failing. It needs a management solution. And it can be done. Filling in forms is a shocking waste of a GP's time and it won't take us any longer. We just need the right piece of paper. That's all.

23 November 2008

Quite Obviously Flawed

If you had asked Dr Grumble whether, if you were to set up a system of performance bonuses (QOF) for GPs they would meet them, he would have guessed that they would. The average GP runs a very tight ship. Practices are heavily computerised. Most patients GPs would need to see for their performance payments would visit their GP quite often. So all the GP would have to do to jump through the hoops and earn extra pay would be get organised and do what the system required. It could be something as absurdly simple as offering advice about smoking and diet or taking a blood pressure. Patients are still smoking and getting fatter and they must know that these things are bad for them - but there is some evidence that a doctor mentioning such issues can help so it may not be quite such a daft way to pay doctors.

How would you negotiate with government over something like this if you were the BMA? Dr Grumble had always thought that the BMA, being dominated by GPs and knowing that GPs would be good at jumping through hoops, would have kept their cards close to their chest in any negotiations with the government. That way GPs would get paid much more than the government had ever intended. But Dr Grumble has now learned that the BMA played with a straight bat. The BMA actually told the government that if you were to give GPs hoops to jump through they would do it. The government did not believe them. They estimated that GPs would only manage to reach 75% (NAO pdf - para 2.11) of their target payments. In fact they got 96.8%. As a result they were paid more than intended. They were paid for doing the job the government imposed upon them. They told the government they would achieve. And they did.

Of course GPs weren't paid for everything you could pay them for. Dr Grumble is not paid for quite a lot of things he does. That is professionalism. But now the Mail claims that GPs 'are ignoring elements of care such as compassion because they do not get extra cash for being nice to patients.' So how would the Mail deal with that unfounded allegation? Another box to tick? What the Mail fails to say, because they are acting in all of this as government rotweilers, is that if anyone is to blame for moving from a professional contract to a jump-through-the-hoops contract it is the government. All this comes, of course, from listening to management consultants who seem to think that people will work only for money and have no concept of professionalism. Professionalism is under threat. It is very sad.

Here in a comment to one of Sam's posts is Dr Grumble's spontaneous tribute to the professionalism of a state school headmaster responsible for educating Dr Grumble's three children. Dr Grumble is not sure he has ever really said thank you to him but he's sure Mrs Grumble has. Sometimes people do not treat professionals well. They think of them as public servants who should be beaten with sticks. The I-blame-the-teachers mentality gets Dr Grumble down. Dr Grumble has noticed when he has visited the schools where his children have been pupils how defensive the teachers can be. He has noticed how inconsiderately long some parents spend with the teacher. He can guess what is going on. These people who have not succeeded in producing successful offspring must be bludgeoning the teacher as if it is the teacher's fault. These imagined encounters always remind Dr Grumble of those relatives who seem to think that you are not going to do the best for their loved one unless they give you the third degree. But Dr Grumble trusts his children's teachers. And he makes a point of thanking them. Sometimes they look surprised.

22 November 2008

Why we need bloggers

One of the reasons Dr Grumble blogs is that he does not think that the truth is always told. Journalists rarely do their jobs as they should. They are lazy. They regularly churn out material that is spoon-fed to them. It's no wonder that they can be so hostile to bloggers. If they cannot do the job properly somebody else will. For nothing.

But it is even worse. Dr Grumble has come to the conclusion that newspapers are in cahoots with the government. Just how this happens is, to Grumble at least, unclear. There must be some sort of trading going on. But there is no doubt that it happens. The evidence is there again and again. Of course, you wouldn't expect a newspaper, if you can call it that, like the Daily Mail to be on board with a Labour government. Or would you?

18 November 2008

White elephants

Have you ever seen a white elephant? Dr Grumble hasn't. Not a real one anyway. But he has seen metaphorical white elephants. An example would be Concorde. Concorde used to fly over Dr Grumble's house. It made a distinctive noise. It was loud. But Dr Grumble still liked it. It generally flew over every day at the same time but always, if he could, Dr Grumble would look up to the sky and admire a beautiful white elephant. Some white elephants are worth Dr Grumble's share of the expense. Dr Grumble is not the only one who used to feel this way about Concorde.

Some white elephants are not worth paying for. But the nature of white elephants is that somebody will pay for them nevertheless. And that somebody is often Dr Grumble and the rest of the British taxpayers.

Do you know why white elephants are called white elephants? You can find out from wikipedia. Do you know which particular white elephants Dr Grumble is thinking about?

Pensioner power

Never underestimate the power of pensioners. Pensioners are patients more often that the rest of us. They experience the NHS more than most. Dr Grumble has seen many of them today on his ward round. At least one thanked him for the high quality care he had received.

There's a lot wrong today in the hospital. Too many patients. Too few staff. And not enough beds. But somehow we managed to give the impression to a pensioner that he had been looked after well. Probably he was. Other patients were not managed perfectly. Dr Grumble admits it. He is angry that his staff did not do better. Probably no harm has come from the mistakes that we made overnight. But it should not have happened. It might have been sloppiness. It might have been communication problems. Perhaps it was just one of those things. But it shouldn't have happened. A young septic patient with rigors should have had blood cultures. But he didn't. It is very basic. Dr Grumble is ashamed.

But on the whole we do quite well. And on the whole the pensioners are right when they say we look after them well. And they doubtless feel the same about their GPs. So when their local surgery is threatened or taken over without consultation they take action. And the action they take has more effect than any of Dr Grumble's grumbling ever has.

16 November 2008

How do diabetics fare in the NHS?

Diabetes can lead to a lot of potentially very nasty complications. Keeping track of diabetics to make sure they get what they need to minimise complications is quite a challenge. So how do we do in the NHS compared with other countries? Some idea can be found in the bar chart below from the latest Commonwealth Fund survey.

On this measure we are not at all bad. But can you believe that in the NHS 75% of adults with a chronic condition reported a medical, medication or lab test error in the past two years and in the US and Canada it is even worse? And these were just the errors that occurred outside hospital.

Richard Branson might condemn these figures but perhaps the errors reported are more equivalent to an airline losing your bags or landing gear failure than a pilot forgetting to put the landing gear down.

Google epidemiology

Have you ever wondered what the Google people know about you? They know who Dr Grumble is. They may even know he was a little off colour this weekend because Dr Grumble was searching to find out what were the active ingredients in the cold cure Mrs Grumble brought home from the local shop. As well as being able to guess that Dr G was a little under the weather Google can also do some real time epidemiology. When the long-feared 'flu epidemic arrives Google may well be the first to know. Here's how.

12 November 2008

Paice, Needham and Dr Scott

Read the latest here. Is Dr Grumble the only one who thinks that a great deal of time and effort is now going to be wasted on this whole sorry saga?

09 November 2008

Hospital 'worse than third world'

That's the worrying claim being made about Birmingham Children's Hospital based on this draft report (pdf).

06 November 2008


When Dr Grumble got into his car to drive home tonight he switched on the radio and thought he heard a familiar voice. The voice appeared to be describing a parathyroidectomy. Sure enough the voice was that of Richard Collins. When Mr Collins started work as a consultant Dr Grumble was already in post as the house surgeon to one of the other surgeons at the Kent and Canterbury Hospital. That was a long time ago. So surely by now Mr Collins should be retired. It turns out that he has retired. But he was called out of retirement to operate on a gorilla. You can read the story here.

02 November 2008

Up to expectations

The new computer system for St George's Hospital in South London is living up to expectations. Dr Grumble's expectations anyway. These stories are so commonplace they are no longer news. How is it possible to waste so much money? Who made the decision to waste money in this way in a meeting on a sofa - a meeting that we know existed but was not minuted? How can such decisions with taxpayers' money at stake be made with no proper record?

01 November 2008

Clinical engagement

'The idea of clinical engagement is a good one," says Dr Rant. Dr Grumble agrees. No more ranting and no more grumbling. Dr Grumble sees definite signs that in his hospital clinicians are becoming more engaged. It is tragic that the powers-that-be ever thought that successful healthcare could flourish without clinical engagement. It's insulting that doctors were considered to be just out for themselves and not enthusiastic about improving the ways they work. But let's not go on grumbling. Let's join with Dr Rant and welcome the concept of bringing back clinical engagement.

Lessons in bad behaviour

No. Not a story about Jonathan Ross and the celebrity culture though Dr Grumble does wonder if the use of his TV licence fee has been contributing to youngsters like Dr Scott not quite knowing how to behave. If the likes of Dr Scott want to behave like drunken teenagers that is their prerogative but do we need to pay large sums of money to people like Mr Ross to encourage this sort of behaviour on national television? And using Dr Grumble's licence money! Should Dr Grumble write to the BBC and complain? Or would that be a waste of time?

We all have some inherent idea of what is right and what is wrong - except, perhaps, Jonathan Ross. For example, hitting people is wrong. We are all agreed on that. Even, one would think, Jonathan Ross. So we all agreed that hitting people is wrong. Every one of us. Of course we are. Do our legislators agree? Amazingly they don't. Not yet anyway. Should Dr Grumble write to his MP again? Or would that be a waste of time? Like writing to the BBC who spend millions employing idiots.

The apparent futility of protesting has not stopped Dr Grumble. He has written to the BBC already. Nobody else need bother. (Grumble hasn't had a reply anyway.) But you might want to write to your MP about the other much more important matter. Or you could do nothing. Doing nothing would be easier.

25 October 2008

Sherlock Holmes

Dr Grumble's latest batch of medical students are very green. Very bright but no knowledge. Everything clinical is new to them. It's rewarding to teach bright students who know very little. The less they know the more you can teach them. It's like starting with a blank canvass and painting a masterpiece. Maddeningly Dr Grumble has his students for only a month. It's crazy, of course, but nobody listens to Grumble. He used to have them for eight weeks. In that short time if students and Grumble worked hard the rudiments of history taking and examination could be taught. The beginnings of a masterpiece could be created. Some of these students will end up much greater and more important than Grumble. Amongst them may even be the Lord Darzis of the future. And, hopefully, some really good GPs.

The job of teaching is important but there's little reward. Nobody in the hospital hierarchy really cares about how well you do your teaching. They say they do but they don't. Small group teaching is essential when it comes to clinical work but only the small group even knows you have done it. These days they report back online on the quality of the teaching. But sometimes they do not quite know how good their teaching has been. They do not know that the notes they write will forever be better structured than the notes of those who were not taught properly. They do not know know how those difficult questions were not to make them look stupid or to check their factual knowledge but to get them thinking in the right way to be a decent doctor. They do not know what they don't know, what they really need to know and where they are heading.

Eventually Grumble's students do realise what he was trying to do. Sometimes anyway. Just occasionally Dr G will get an email from a student or doctor thanking him for teaching that took place years earlier. Sometimes in these emails they explain that it was only later they came to realise the importance of the Grumble style of bedside teaching. This is Grumble's only reward. It's his greatest reward. It's the only reward he wants. Dr Grumble had teachers he appreciated, teachers he wanted to emulate. He hopes he thanked them.

Some years ago Grumble used to teach Japanese medical students. Don't ask why. Even Grumble does not know. They just turned up and Dr Grumble just taught them. He used to ask them who wrote Sherlock Holmes. They always knew. The home-grown students can look bewildered if you ask them a question like that. They certainly don't see its relevance. But it is relevant. In a way. Because the next question is about how Sir Arthur Conan Doyle got the idea for Sherlock Holmes. And the answer, which they rarely know, is from Dr Bell who used to teach Sir Arthur when he was a medical student. Dr Bell, like all physicians, was a detective. Sometimes he could tell what parts of the world his patients had visited and what jobs they were in. Dr Grumble can do some of this. It impresses students no end.

The other day Dr Grumble met a patient for the first time and told his students in front of the patient that he thought he had been in the army, that he had worked in the past as a coal miner and that the had given up smoking about six weeks ago. The patient dutifully confirmed all this. The students were visibly impressed. Dr Grumble thought that from then on they would be taking him seriously.

How did Dr Grumble do this? It isn't that difficult. Patients who call the doctor 'sir' have usually been in the armed forces, coal tattoos in old cuts are common in previous coal miners and if fingernails grow at 3mm a month it is easy to work out from the tar staining when the patient stopped smoking. Now doesn't that sound like Sherlock Holmes explaining his deductions to Watson? It's easy to see how medicine lay the foundations not only to a series of good books but also to modern detective work. As Sir Arthur says himself in the only surviving recording of his voice. The recording is a bit stilted and there is only a hint of the admiration and gratitude Sir Arthur showed for his teacher, Dr Bell, without whom there may never have been a Sherlock Holmes.

19 October 2008

Unforgivable, inexcusable and dangerous

‘I don’t think they care,’ was Hubby’s summation of the nurses' behaviour, 'I just think they are thick'.

Sadly, there are times when Dr Grumble has felt the same way. Read the story here.

18 October 2008

Computer chaos

Have you ever had your broadband connection fail? These days if that happens you feel really deprived. Dr Grumble got his connection on the very first day his local exchange was enabled. It seems ages ago but it was only a few years back. Now, if his connection fails he cannot blog, he cannot email, he cannot read the newspapers, he cannot bank, he cannot do his shopping and so on. We have become very dependent on computers. If you call in at the petrol station and the computers are down there is no way you can pay. If you are in a hurry and offer to leave them some cash they threaten to have you arrested. They can't even work out the change without the electronic till. In a very short time we really have become extremely computer dependent.

When it comes to computers the NHS is behind. In hospitals anyway. GPs, being empowered, have been ahead of the game. Primary care in the UK is heavily computerised compared with, say, the US. (UK 89% v US 28%). Why are hospitals so behind? There are various reasons but one problem is that they haven't been able to get on with the job because of all the national initiatives going on around them. When it comes to computing government has a bad record. Sadly there are no signs of improvement.

Some of the recent problems that have been encountered seem familiar to Dr Grumble. They arise from a failure to engage clinicians. Take the issue of smartcard sharing. Dr Grumble thinks this is unforgivable but he believes this sort of behaviour in the NHS to be rife. Only last week Dr Grumble was tentatively asked to give his login details to somebody else. He declined. People about to leave the hospital may agree and that is how they can be found to be logging in long after they have emigrated to work in the antipodes. These things happen all the time. And if you are a clinician it is easy to see why. It's even easy to see that it is inevitable.

What happens is this. A locum doctor arrives at 11pm on, say, a Sunday. Locum doctors tend to plug gaps out of hours so there is less than a 24% chance of the doctor arriving during normal working hours. He arrives without being sure of where he has to go or what he has to do. He takes over from a departing doctor who is keen to get to bed and he asks how to get into the computers in order to access the information he needs to manage the patients. Getting a smartcard is either not possible out-of-hours or nobody actually knows how it should be done. Just at this moment there is a cardiac arrest. The inevitable then happens. The smartcard along with the PIN is quickly passed to the locum who will leave it in a drawer for the morning. That's how it happens. There is no other way.

In reality it is much worse than this. In some hospitals multiple programmes are needed for patient care and there are multiple log-ins and passwords. They time out rapidly. Doctors in outpatients will look at a radiograph, then blood tests, then, say, the appointments system or a recent discharge summary, then there are a few tests to order. Each requires another programme with another set of log ins. By the time the next patient is in all these programmes have timed out. Logging in takes an eternity. If you tell people about this problem nobody listens or they don't want to listen because they will be responsible if computers are left idle and unauthorised people can get in. It is worse than this because you have to keep changing your passwords and they cannot be synchronised. Dr Grumble cannot even work out for sure how many hospital passwords he has on the go but it is at least eight and they keep changing.

Computing in the NHS is a dog's dinner. It needs sorting. One thing it doesn't need is any more money spent on it. What is needed is real clinical engagement.

One rule for them, another for us

We all love to hate politicians. There is one that Dr Grumble particularly hates. Can you guess who? You will have to guess if this blog is to become regulated. Below is what he says about his views on preserving his liberty to speak out:

"........I think it is in the interests of democracy to preserve the liberty of politicians to speak about current issues and public figures in expressive language that is all part of the cut and thrust of political debate."

Below is what he says about his views on preserving our liberty on the web:

"It is not just about copyright or intellectual property but [things like] taste and decency in the online world. The time will come to say what are the direct interventions [needed, if any]."

So it's in the interests of democracy to preserve the liberty of politicians to speak about current issues but the common man with a blog has to be regulated on the grounds of things like taste and decency. That makes sense. If you are a politician.

Watch out Dr Rant. There are words you use that Andy Burnham may find in bad taste. He wants to prevent people like the sensitive flowers in the deaneries from ever reading your stronger words. Could that perhaps be a good thing? Think. We can protect the delicate types in the deaneries from ever knowing what these words mean. It would be just like the good old days when these words were not even in the dictionaries so we couldn't ever use them and people could not possibly be offended.

12 October 2008

£50 billion

The government is going to have to borrow up to £50 billion to support the UK banks in by far the greatest banking crisis Dr Grumble has lived through. That is a simply vast sum of money. But it is a simply vast crisis.

So compare the greatest banking crisis in recent history with the greatest computing crisis in history - Connecting for Health. How much is that going to cost? Can you believe up to £50 billion? Perhaps you can't. Just think of this. If we had not had Connecting for Health, health care now would be, well, much as it is. And we would have been left with enough money to bale out the banks in the greatest banking crisis we have known. How can this be? Who created this crisis of computing? How can 50 million health records be costing £50 billion? It cannot be.

Just so you know

Open up the NHS to new healthcare providers

Whose policy is this? It could be New Labour's. It could be a Conservative policy. It's hard to guess. Find out whose policy it is here. And have a think about why it is that the policies of the major parties are these days so very similar.

Alan Johnson at the NHS Alliance 2008

Here is the speech made by Alan Johnson last year to the NHS Alliance. What do you think he will say to the assembled multitude in Bournemouth on Thursday?

Wasn't Bournemouth where Lord Darzi was booked for the GPs' conference? But he couldn't make it. He sent a video instead. That's understandable. He is busy.

It couldn't happen twice could it? No. It couldn't. Mr Johnson has a 45 minute slot. People would be disappointed. They might think he doesn't care. No. It couldn't happen twice. Not at the 'leading event for primary care.'

11 October 2008

No more intravenous cannulation

In some hospitals junior doctors are no longer allowed to carry out intravenous cannulation. Some have asked why the deaneries are not protesting about this? Dr Grumble has some bad news. There may be infection control reasons for these initiatives but this sort of thing actually comes from the deaneries. Dr Grumble became aware of these proposals recently and protested loudly. He protested to a senior personage in the deanery. He argued that putting in an intravenous cannula could be a life-saving procedure and that it was not a bad idea for the most junior doctors to get a lot of practice at it. So what do you think the response was? Did the senior personage show some sympathy for the Grumble view? Not a bit of it. She tore poor whimpering Grumble to shreds in a most dismissive way. They are powerful these people. Very powerful. She told Dr Grumble that he was old fashioned and out of touch with the way things are going. Junior doctors were not to be rushing around doing chores at the behest of tyrannical consultants. There was an unpleasant implication there about how she seemed to think Dr Grumble behaved. Now Dr Grumble would agree that junior doctors should not just be doing chores. But his junior doctors are still rushing around doing mostly purely administrative tasks. Those are the tasks that should be taken away from them. The things that could be done by a reliable clerk. But stopping them acquiring life-saving skills is plainly crackers. But nobody listens to Dr Grumble. He's not tyrannical enough. You can't argue with the deaneries. They have an agenda.

06 October 2008

It's not just doctors

Deb Acle over at the Jobbing Doctor has pointed out that the sort of things the government has been up to in the NHS it has been up to all over the place. Dr Grumble is aware of this. He has friends who are teachers and lawyers. When Dr G moans to them they chorus that the government is doing the same to them. There was a good example on the Today programme this morning.

If you are a doctor you may not have heard of Criminal Defence Service Direct. But it may sound familiar. If you are a criminal in trouble you used to be able to phone your very own solicitor. And you could have a face to face meeting with him. In future you will phone Criminal Defence Service Direct for advice. They won't come and see you. They will give advice. The advice may be from somebody who is not a solicitor. Does that sound familiar? You used to be able to have your very own solicitor come and see you but in future you will get somebody who is not a solicitor over the phone. The similarity with NHS Direct is striking. The common factor is that this has been imposed by the government according to the exact same formula dreamed up by policy wonks who have probably never worked as a solicitor just as those who advised the government on general practice have never worked as a doctor. The powers-that-be probably think it will be cheaper. Many doctors think NHS Direct was money down the drain. What do the solicitors think about Criminal Defence Service Direct? They certainly seem to think it offers a dumbed down poor quality service that their clients just do not like. And Dr Grumble would be surprised if it really saves money. Paying people to do a poor job rarely saves money. As Red Adair said:

If you think it's expensive to hire a professional to do the job, wait until you hire an amateur.

04 October 2008

Concentration and pluralism in the media

Dr Grumble does not want to lose his readers. So why does he raise the tedious topic of a Motion for a European Parliament Resolution on concentration and pluralism in the media in the European Union (2007/2253(INI))? What is there to fear from this superficially innocuous document? Prompted by a post from the Witch Doctor, today is the second time Dr Grumble has perused this impenetrable product of Brussels. He still finds it heavy going. The first sentence of the paper is the longest sentence Dr Grumble has ever read. Any document which has 23 paragraphs in a row beginning with the word 'whereas' cannot be intended for the likes of Dr Grumble. There are also six paragraphs in a row beginning 'having regard to'. Plainly this is not the sort of document a mere mortal like Dr Grumble could possibly summarise here. But he thinks he understands the implication of the words 'having regard to' and 'whereas'.

As Dr Grumble has already revealed he failed Use of English so he finds trying to explain the significance of these words a challenge. By way of illustration, here is a sentence written in the style of a Brussels bureaucrat.

Dr Grumble,
- having regard to the law on the welfare of animals,
A. whereas dogs are a man's best friend, it is recognised that they may foul paths,
1. Urges the EU to have all dogs destroyed.

The above example does not read well but, frankly, nor does the EU document. It is quite difficult to extract the meaning from Dr Grumble's short paragraph but what you can see is that where it says 'having regard to' and 'whereas' the scene is being set. There is some motherhood and apple pie stuff there but it is meaningless as the sting is in the tail. What this means is that all the nice talk in the EU document about the Human Rights Act and Civil Liberties is not at all reassuring. That's just the preamble. What one needs to look out for is their proposals. Here is just one:

The European Parliament,
9. Suggests clarifying the status, legal or otherwise, of weblogs and encourages their voluntary labelling according to the professional and financial responsibilities and interests of their authors and publishers; (pdf)

We already know that the EU has become very concerned about the political influence of bloggers. Taxpayers money has been spent analysing the effect bloggers may have had on the outcome of the Irish referendum. Is that proper use of our money? Would they have bothered if the result had gone the EU way? Why do they want to 'clarify our legal status'? How can you have a legal status if nobody knows who you are? Doesn't having a legal status inevitably mean loss of anonymity?

We can chat to each other in the pub. We can chat to strangers. We don't have to reveal who we are before we open our mouths. We could post anonymous pamphlets through letter boxes if we could be bothered. So why shouldn't we express our views in our personal blogs, anonymously or otherwise, without let or hindrance from the superstate European Union?

Blame the doctors

Dr Grumble has only just caught up with this weird story about payment for visits to the GP. This is not the patient paying the GP. It is the GP paying the patient. It all hinges on concern about differences in life expectancy between certain social groups. Dr Grumble has covered this topic before. Regular readers may remember that Dr Grumble has regularly been told the tale about how life expectancy plummets as you travel on the tube from Kensington to the East End. That anyway is roughly the story that gets trotted out. There is the strong implication that this is all the consequence of poor access to doctors and that we must roll out polyclinics to address this issue.

In Glasgow there is a 28 year difference in life expectancy between areas that are just 8 miles apart. Can this really be due to differences in medical care? Can this possibly make sense? Is the fact that in the worst areas of Glasgow they smoke and drink to excess, mash up and inject sleeping tablets, sniff glue, get fat, take little exercise and get involved in fights really the fault of the local GP? If you pay these people to go along to the GP is there any chance that they will change their ways or will they take the £20 and buy heroine?

Amongst the people who come to get their £20 there will be some who are overweight. If the doctor advises them to lose weight what is the chance that they will be able to do so long term? If he finds people who smoke will it be news to them that smoking is bad and they should stop? If he finds people with a high blood pressure would the sort of person who can't be bothered to go to the GP unless they are given £20 take the necessary pills reliably? If the doctor finds their housing is cold and damp will he be able to persuade them to pay for heating with the money they don't have? If they are single mothers with more children than they can cope with will he be able to persuade them that the contraception they didn't bother with last time might be a good idea? Or might somebody already have made that point to them?

Who is responsible for the creation of these deprived communities? Does the fault really lie at the doctor's door? Or could it lie at the door of Number 10?

03 October 2008

Standing ovation for Donald Berwick

Who is Donald Berwick? And why the standing ovation? Donald Berwick is from the US and he has been talking to GPs. And they liked what he said. So you can conclude that he is probably not from one of those big US healthcare organisations that are continually lobbying politicians to persuade them that the only way of sorting out the NHS is to move to a more American system. It's odd that the politicians listen to these people because the American system has failed. But unfortunately they do. They don't seem to listen to people like Donald Berwick. But GPs do. And they gave him a standing ovation. Was anybody there? What did he say? Was it something like this?

Sheinwald leak

If you are Britain's Ambassador in Washington one of your jobs is to brief the Prime Minister on American presidential candidates. You need to produce a frank pen picture. It's a bit embarrassing if it gets out. This time Barack Obama's pen picture has got out. Now why should that be of any interest to Dr Grumble? Well, the ambassador is Sir Nigel Sheinwald and Lady Sheinwald is a doctor. According the the newspapers she is an internationally renowned paediatrician. Dr Grumble thinks they just googled Dr Julia Dunne and guessed the rest. She always used to work in medicines regulation. Dr Grumble used to share his sandwiches with her alongside the tramps in a small London park in Vauxhall. It's strange how things change. Presumably Lady Dunne is now entertaining the great and the good in the British Embassy in Washington. No more sandwiches in the park. But Dr Grumble still eats his sandwiches in the park. Alongside the tramps.

02 October 2008

Wellington Avenue

If you live in Wellington Avenue in Aldershot and need a GP you would be well provided for. It seems about 18 GPs are based in Wellington Avenue. Could it be that there is a polyclinic there? Could they have closed a whole hospital and replaced it with a polyclinic? How much would that have cost?

Aldershot Centre for Health is among the first of a new wave of private sector provided one-stop health centres . As large as many community hospitals and up to 30 times bigger than a conventional health centre, it will provide front line healthcare for about 45,000 local people, as well as specialist services for around 250,000. (pdf)

So let's get this right. Eighteen GPs are now based in a Centre for Health which is as large as a hospital. It's 30 times bigger than an ordinary health centre and it provides specialist services for a quarter of a million people. And it has a CT scanner. What is this place? It's not a hospital. It not a GPs' surgery. Is it a polyclinic? Is it sensible?

How has it been financed?

The Wilky deal represents a highly innovative financial structuring. I’m sure other property groups will be very interested in the potential offered by this exciting new market. (pdf)

Dr Grumble also thinks other property groups will be very interested. After all it did cost £28 million of taxpayers' money.

A private clinic, airport, hotel and the 'Hilton Health Centre' - these are just some of the comparisons/comments made by patients when they have visited the brand new Aldershot Centre for Health for the first time.

Sounds good. But what about the old lady who wanted her own GP at the end of her road. Will she need to move to Wellington Avenue? Yes. That's it. Get all the old folk and disabled to move to Wellington Avenue and everything will be just fine.

Come to think of it the old lady could go on her bike.

Car parking is limited on site and there is a charge for on-site car parking. There are 50 covered cycle parking spaces provided on-site.

It's quite big (pdf) compared with the average GPs' surgery. In some pictures it resembles one of Darzi's virtual polyclinics. I wonder what the old lady thinks. Do you think she will appreciate having the CT scanner there? Just in case.

Private Eye

Anybody interested in the story of Dr Scott and related matters should read Medicine Balls on page 10 of Private Eye.

With thanks to Dr Aust who alerted Grumble to this article.

01 October 2008

Friends in high places

The GPs are whinging again. About polyclinics. Who makes this accusation? None other than the Primary Care Czar. Is he out of touch? Does he actually do any general practice?

    • Does he really fail to understand the genuine concern about polyclinics?
    • Does he really think that all doctors are interested in is pay?
    • Does he really think that traditional general practice can survive unscathed if the government puts all the resources into Darzi clinics?

Is he loyal to traditional general practice? Or could his loyalty lie elsewhere? Who knows? Perhaps he believes what he says. It's possible.

37 thousand

Dr Grumble has had to abandon his early morning work. The reason is that when he opened the patients' notes they were all empty. Some clerk somewhere has opened a new file on each patient. Not a temporary file but a new file. That means that each of these patients has two sets of notes. One set is completely empty. It also means Dr Grumble cannot make decisions this morning. Dr Grumble was so angry he told a passing surgeon. To Dr Grumble's amazement, according to the surgeon, a neighbouring hospital is even worse. There they have 37,000 sets of duplicate notes. It is simply not acceptable. It is dangerous. Dr Grumble used to put each empty set of notes into an envelope and send it to a manager to make his point but they got fed up with him. So he has now given up. Like everybody else.

28 September 2008


If as an experiment you put people in a room, give them an exam to do and then set the fire alarm off, the first thing they do is try to get more information. If there is no more information it is only those who have been trained what to do who take action. Nurses are particularly good. They are taught what to do when the fire alarms go off. They close doors and do all the things one should do in a fire.

Dr Grumble has spent much of his life in hospitals and but it was many years before he had any fire training. Inevitably he has encountered quite a few hospital fires. Many hospitals he has worked in have been old and poorly designed from the fire protection point of view. In some ways some of the newer hospitals have been worse. The hospital where Dr Grumble currently works has had some problems meeting the latest fire regulations. Dr Grumble has never thought that it would be possible to evacuate patients safely in the event of a major fire. The fire officer agrees.

Many years ago Dr Grumble worked in a hospital on the South Coast. It was old. From the fire point of view it was quite hazardous. To be fair the hospital authorities realised this and decided to have smoke detectors installed. They put one in the doctors' mess. Unfortunately the obstetrics SHO, a rather comely girl, smoked . Every night she would have a bedtime smoke and in response a horrible klaxon would sound.

In those days Dr Grumble worked a one in three rota. That meant that he worked ordinary working hours from about 8am to 7pm and he would also work every third night and every third weekend (day and night). It was tiring and you didn't get much sleep. So when Dr Grumble went to bed usually in the early hours of the morning he was often desperate for sleep.

One night at about 2am, just as he was trying to get some shut-eye, that wretched klaxon sounded. Even though he had the hots for her, Dr Grumble cursed the obstetrics SHO. He took two pillows and placed one over each ear. Then he bound the two tightly against his head with dressing gown cord. He didn't worry about how he would hear his bleep for emergencies. He was simply too exhausted. He lay on his bed with the penetrating noise of the klaxon somewhat dulled and tried to get some sleep. But it was never really going to work. And then through the muffled sound of the klaxon he heard somebody thumping on his door. Wearily he staggered to the door and opened it to find himself engulfed in acrid smoke. There was a real fire. He needed to escape. How would he get out? Dr Grumble was upstairs, the smoke was thick and downstairs it seemed even thicker. Then the lights went out.

Complete power failure in a hospital is rare. Dr Grumble can remember sewing up abdominal incisions by torch light but modern hospitals have generators that kick in very quickly in the event of a power failure. And then a worrying thought struck Dr Grumble. If he had no power quite possibly the intensive care unit had no power. And in the ITU there were several patients whose lives depended on there being power. Dr Grumble was the most senior person in the hospital. He needed to get to the ITU and see if they were in trouble. But how was he going to get down the stairs in the pitch dark and with all that thick acrid smoke? He took out a towel, quickly wet it, wrapped it around his head leaving a gap for his eyes and using his pen torch for light made his way down the narrow staircase keeping as low as he could to avoid the smoke. Fortunately he made it to the main corridor of the hospital. There there was more room for the smoke to rise and things were easier.

Already patients in beds were being rushed outside into the fresh night air. But Dr Grumble couldn't stop to help. He needed to get to the ITU at the other end of the hospital. He dashed there as fast as he could using all the little short cuts he knew from frequent cardiac arrest calls. When he got to the ITU gasping from a mix of exertion and smoke inhalation his fears were confirmed. The place was in pitch darkness apart from some torch light. The ventilators had stopped, syringe drivers were frozen and the nurses were bagging the patients. This did not look good. And then a wonderful thing happened. The fire brigade arrived. They were calm and professional. Just as Dr Grumble likes to appear in a crisis (even if he does not feel at all like that inside). But what could they do? There was no fire at this end of the hospital. The problem was just lack of power. But the fire brigade know about these things and they knew what we needed most. Light. And suddenly there was light. Almost immediately they erected bright lamps which enabled us to see what we were doing. Now it was just a matter of bagging the patients and somehow getting their drugs delivered. And then another miracle. Quick as lightning the fire brigade brought in a generator and somehow rigged it up to bring the power back to the sockets. Clever that. Dr Grumble was very impressed and very grateful. He was too busy ever to thank them. He thanks them now.

You may think Dr Grumble showed some dedication as did all those involved that night but he was not as dedicated as the radio presenter in the video below.


In the past 4 years according to Anna Walker of the Health Commission there has been a 20% increase in attendances at Accident and Emergency Departments. How odd. How very odd. Are people getting ill more often? Surely not. Perhaps there are fewer alternatives than there were. No. It can't be that. We now have NHS Direct and NHS Walk-in Centres. We never had those before. Or could it be that these new government initiatives make more work for A & E departments? Or could it be something to do with the new GP contract? Which is it Mr Brown? This is not something medical. There are no diseases that increase by 20% in 4 years. It must be something the government has done. So tell us, Gordon, what is it that your government has done that has made things so much worse? Dr Grumble would like to know. And could you undo what you have done please?

Leading from the front

Government should lead. Our government does not lead. It follows. It follows public opinion. You might think that is good. It is not. If you ask the public what it wants you will get different answers. The answers will depend on how you ask the question, when you ask it, which members of the public you ask and sundry other variables. The people you ask may not have thought much about the question so you may not get an informed answer. But that has never stopped this government consulting silly focus groups. People, who have never had a day's illness in their lives, are asked how health care should be organised. They simply don't know. They cannot be expected to know. It is not a criticism of them. It is a criticism of our government which seems to think that this technique is the way to win favour at the ballot box. It is not. And that is becoming patently obvious.

The principle applies to other aspects of government policy. For example, if you ask the public whether suspected terrorists should be locked up for 42 days you will get a yes answer. If you ask the public whether it is acceptable that somebody who might be innocent should be locked up for 42 days you will get a no answer. That anyway is what Dr Grumble suspects. It is not a way to formulate a sensible policy. And that is why we have this terrible law wending its way to the statute books. Dr Grumble thinks it is bad, his ennobled blogging colleagues think it is bad, even Stella Rimmington thinks it is bad. But the government goes blundering on.

Meanwhile intrepid Dr Grumble faces the threat of regulation of his blog by EU bureaucrats. One blog has gone already. What have they to fear from bloggers? On reflection maybe quite a lot.

27 September 2008

Instant feedback

Have you heard about the latest plan to give patients a PDA so that if they are not satisfied they can press a few buttons to record their problem in real time. The idea seems superficially very attractive. In the area of the hospital over which he has most control Dr Grumble sees that all the patients are given a questionnaire about their treatment. It doesn't actually help Dr Grumble that much. He knows what is wrong. It's getting it put right that is the problem. Data can help with that. If doctors complain the room is too hot or too noisy, managers take no notice. If you collect lots of data from patients and then tell them, there is a chance that something may be done.

The problem with all of this is the time it takes. The other day Dr Grumble asked his staff if his patients were happy. The answer: "We don't know."

"But what about the questionnaires?"

"We don't have time to look at them."

Dr Grumble knows though that his patients are happy with his service. Yesterday a private patient told him how good it was. Unknown to the private patient the NHS patients get identical care - except their breakfast does not come delivered by a smart flunky with paper doilies. Whether the breakfast is any better or not Dr Grumble has no idea but the NHS patients have occasionally made compliments about the breakfast so it can't be that bad.

One of the Grumble children has recently been an inpatient in an NHS hospital. He is a medical student so he has a little knowledge about how things should be. He was spontaneously complimentary about the nursing. Dr Grumble is quite critical about the nursing in his hospital. It's his job to be critical. So what hospital was the Grumble offspring in? Dr Grumble's very own. And what do you think the food was like? For the first time Dr Grumble can tell you. Dr Grumble sat his boy up to help him eat but immediately he became rather pale and sweaty. There were technical reasons for this which are irrelevant but it gave Dr Grumble a chance to taste the soup. It was not bad. By then the Grumble boy had recovered and the rest of the courses including a delicious pudding quickly disappeared apart from some potatoes and veg which Dr Grumble tasted. They were excellent. How they survived the system which brings the food to the wards Dr Grumble has no idea but they did.

Since then Dr Grumble has told this story to some of his patients and their relatives. Some of the relatives have also tasted the food just as Dr Grumble did. They are agreed. The food at the Grumble hospital is excellent. The average cost for inpatient food is less than £3 per patient per day. The catering staff deserve some praise. They work miracles. It's a shame Dr Grumble cannot name them.

Just as when Dr Grumble does his ward rounds, he has become distracted and gone off into a little anecdote when the purpose of this post was to address the concept of instant feedback. But the anecdote does show that workers at the coal face have constant instant feedback. Doubtless those that prepare the food taste it just as Dr Grumble has. You don't really need PDAs to know how good a job you are doing. Unless you sit in an office. Dr Grumble wonders how many times the Chief Executive has eaten food intended for the patients. Perhaps he has. Perhaps he should eat it every day.

Some time ago in the early days of the internet Dr Grumble was warned semi-formally that the hospital was scrutinising his use of the web. Everything he did was logged somewhere. That's a worry if you are a blogger. But the reality is that there is so much data being collected that it is difficult to really know what people are up to. There are ways of dealing with this but these days the miracle of computing means we all suffer from data overload.

The same is true of data related to patient care. While the Grumble staff are currently too busy to deal with all the data they collect on patient satisfaction, Dr Grumble gets weekly reports on certain areas of his clinical performance - in other words how well he performs against a certain standard. Graphs are provided showing in some detail the yawning gap between what he is doing and what he should be doing. This is just in one very tiny area of Dr Grumble's practice. Of course it something of particular concern to managers. It's just about possible to deal with but if they monitored everything Dr Grumble did to the same extent it would be wholly unmanageable. Nobody would have the time. Needless to say it's to do with a target.

So while this instant feedback from patients seems at first sight to be a good idea you need to remember that doctors and nurses are always getting instant feedback from their patients. It might have some purpose for managers who spend most of their looking at data on their computers or sitting through torpid meetings but for those of us bustling about the shop floor it is unlikely to tell us much that we do not already know. And even when Dr Grumble tells the pwoeres-that-be that something is very wrong it takes a long time for anybody to do anything about it. Sometimes even when you give them the data they just don't want to know. They have a poor sense of right and wrong. What is clinically important and what is clinically not so important escapes them. But they do know what a target is.