27 July 2008

A pause for thought

Dr Grumble has been away. Like Jobbing Doctor he is keeping his carbon footprint respectable. His annual sojourn away from the hustle and bustle of the hospital has been spent in the UK not so very far from the birth place of William Henry Davies. It gave Dr Grumble a chance to draw a big breath and think. It was almost like being on a retreat. There’s very little time for thinking in the NHS. We are all so busy. It’s not just those in the NHS. Everybody is so busy. Sometimes you need time just to stand and stare. There’s nothing new about this. William Henry Davies wrote the poem below long before Dr Grumble was born:

What is this life if, full of care,
We have no time to stand and stare.

No time to stand beneath the boughs
And stare as long as sheep or cows.

No time to see, when woods we pass,
Where squirrels hide their nuts in grass.

No time to see, in broad daylight,
Streams full of stars, like skies at night.

No time to turn at Beauty's glance,
And watch her feet, how they can dance.

No time to wait till her mouth can
Enrich that smile her eyes began.

A poor life this if, full of care,
We have no time to stand and stare.

But where is all this leading? What has Dr Grumble been thinking about? He has been thinking about something that has been perplexing him for some time. He has been wondering why doctors are getting such bad press. And he has come to the conclusion that it all comes from the government who are out to get us.

Some weeks ago Dr Grumble exchanged a few words with Thomas Stuttaford who, incidentally, is a real gentleman. Many will know Dr Stuttaford from his column in the Times. In passing Dr Stuttaford recommended a book. Dr Grumble rarely reads books so he likes to choose his reading material carefully. If somebody recommends a book Dr Grumble takes the view that they must have got something out of it and he has a policy of jotting down the details and putting it on his Amazon wish list. Then, when he is on retreat, he will order the book and start reading. The book Dr Stuttaford recommended was called The Triumph of the Political Class by Peter Oborne. According to Tom Stuttaford that was the book to explain what Westminster is all about. He was right. It has. It’s a book that demands to be read. It’s important. It accounts indirectly for some of what has been happening to doctors. But it is important to everybody.

There is only space here to whet your appetite. Dr Grumble would hate to give away the book’s punch line but the author does this himself in the introduction. The introduction alone caused the scales to drop from Dr Grumble’s eyes. Read the introduction if nothing else. The rest of the book argues Oborne’s case in detail.

So what is the bottom line to this masterpiece of analysis? It’s about how politicians are out to nobble us all. You knew that did you? But do you know the extent of these shenanigans and how they are all in cahoots with each other? If not, this book is for you.

Many moons ago Dr Grumble used to have a lively interest in politics. There were those on the left and those on the right. To some extent each had their own supporters. The left were for the workers. The right were for the toffs. But there was some overlap and genuine heart-felt arguments were put forward to support the views of each side. Now there’s the politics of the middle of the road. Politicians are more like managers than politicians. It’s as if they have all agreed, right and left, that the best way forward is somewhere just to the right of centre. There used to be talk of the need for clear blue water to distinguish the two major parties but this risked pushing those on the right further from the middle. If you were to analyse voter views you would presumably find a bell shaped distribution. And, of course, that is exactly what the parties along with their marketing cronies have done. They realise that to get votes it’s no good having clear blue water and policies two standard deviations from the mean.

That’s why politics has become so boring. Many doctors are clamouring for a change of government but will the others be any different? The answer is that they won’t. The same influences that make New Labour what it has become are at work on the alternatives.

The essence of the Oborne book is in the title. It is that the Political Class have triumphed. Right and left are in cahoots. They are out to clip the wings of anybody and everybody that gets in their way. They are just out for themselves. They have no concept of any sort of higher ideal. They have had a go at a lot of powerful groups. They have destroyed the Civil Service. That’s why quick decisions now get made on the Downing Street sofa. This never used to happen. It shouldn’t now. They have had a go at judges. Do you recall the many occasions when the likes of Blunkett, Reid or Blair have interfered with judicial decisions just to curry favour with the baying mob of Sun readers. That’s just not right. It’s not professional. Parliament too has generally been bypassed. Announcements are now made in the press. And the press have been bought as well. They’ve cocked a snook at the Queen. And while it doesn’t say so in the book, you can be sure that somewhere for some reason there is an agenda to privatise the NHS. Probably it’s something to do with money and party support. (If anybody knows Dr Grumble would be interested.) And, of course, the medical profession too has been consistently attacked by a manipulated press. The Political Class see doctors as a group with power and apparently believe that doctors are just out for themselves. They believe this because they move in that sort of world. They also believe that business people are the same and that standards in business are no higher than in politics. They use this belief to justify their own low standards. But, according to the book, this is not at all true. Standards in business are high and much of what politicians get away with would not be allowed in large companies. Business people have the same low opinion of the Political Class as the average doctor.

So that, in brief and with a few embellishments, is what Dr Grumble took away from the book. What Oborne describes is of momentous importance. It’s about the destruction of our democracy. It’s about the concentration of power in a clique of people with no experience of life outside politics. It’s about decisions being made without the normal safeguards that evolved over the last century. And it’s about appalling errors such as the Iraq war being made as a result. And, probably, it sets the scene for the impending destruction of our much-valued (pdf) primary care and our NHS and the constant attacks on our profession.

Why do we put up with the standard of service we get from our politicians?

A sign of the future?
Photographed by Dr Grumble himself.


As Dr Grumble was uploading this picture he was reminded that the opening hours for this US medical centre were not that great. This, of course, is quite contrary to what our government would have you believe. In fact, until their Verschlimmbesserung access to GPs in the UK must have been second to none. It is another theme of the Oborne book, which gives a number of examples, that information given to the press is quite often completely wrong and known by Number 10 to be wrong. While not mentioned in the book this has patently been the case for many of the unfounded accusations made against GPs.


Fx said...

Finally, one of you gets it. The NHS costs a lot of money. The government wants to dismantle it. Doctors resist this and so do their patients. Therefore the trust in and influence of doctors must be reduced by means of (1) deskilling doctors and upskilling nurses and (2) undermining of doctors' authority and influence through the media.

The sooner doctors come out of denial about this the better. Government really doesn't think about patient care - you're right, these are mangement decisions based on budget.

Voice from far away said...

Hi doctor G

I have just read 'Let the market rule. I would not like to see the NHS privatised but I also would not like it to go from bad to worth because of waste and mismanagement. I have a small business myself and know exactly what it means to be in trouble myself; during the Gulf war 1, I had to sub-let part of my prmises to support my cash flow, otherwise, I would have definately gone down. So, sometimes hard decisions have to be made to avoid catastrophy. I always understand macro economics by simplifying matters to the smallest denominator, find solution/s, then enlarge again to suit. However, the majority of docs on the net just crtique and never attempt to put forward solutions except rarely! I trust your opinion and would appreciate your input on what to do if you were boss? If the situation as is is not 'tenable'

Sorry said...

and pardon my spelling .. 'shame, shame, shame ..'

Dr Grumble said...

Voice from far away, Doc G regularly has the task of criticising scientific papers or applications for research grants. He has even had the job of dealing with applications for product licences from pharmaceutical companies. Despite the effort people put into these and in the latter case the millions spent it is always easy to criticise. Doing a better job is more difficult. So you have a point.

What to do if I was boss of the NHS is not something I can quickly answer. Perhaps I should do a whole post or series of posts on that question. It is not something that I have given a great deal of thought to because, frankly, nobody is going to take any notice. But when I see something happening that is obviously wrong it grieves me and I have to vent my wrath. Sometimes from the comments I see on blogs it is clear to me that what is obviously wrong to many who work within the health service is not obviously wrong to those outside. It is not even necessarily obviously wrong to those that work in other healthcare systems (such as in the US).

It is the obviousness of the wrongness of some of what is happening that may be what is leading to the frustration amongst doctors that is revealed by the blunt unconstructive criticism that you do see on the net from doctors. There is more thinking in the private doctors' chat rooms where the points being made are readily understood because of the readership. It is quite difficult to point out some of the basic truths of healthcare to those not in the business. I am not talking about medical things. I am talking about management issues related to medicine. It is easier to grasp some of these truths if you are a doctor.

For example if you put high calibre doctors into the community (GPs) and give them basic equipment and tell them to get on with it patients can end up with very cost effective care. If you put the doctors in a polyclinic with MRI scanners the scanners will be used. Patients will love it because they like tests. But it does not follow that they will be better off medically. On the other hand you do not want a system that is so starved of MRI scanners that you can never get one done when it is really needed.

If you pay a surgeon for doing an operation the patient is more likely to get an operation. But a system that restricts surgery to those that really need it is a good one. Even the NHS does a lot of useless operations. Surgeons like operating whether they are paid or not.

The NHS must give patients what they need (as opposed to what they want) when they need it. The old NHS was not badly structured to do this. The problem was that it was inadequately funded to deliver patient needs. Unfortunately government failed to realise that it was inadequate funding that was the main reason why the NHS was lagging behind other healthcare systems (the figures left little doubt about that). They misguidedly believed that GPs and consultants were on a gravy train and needed new contracts to lick them into shape. The government failed to realise how much out-of-hours work and work generally GPs were both delivering and managing. We had the best primary care in the world. Americans barely know what a home visit is. The same was true of consultants. The new consultant contract resulted in the colleagues I spoke to being paid more for doing less. The intention was to make us work harder – but they just didn’t know how much we were doing already - much of it for nothing.

These mistakes have been made. They cannot be undone. Providing 24/7 care 365 days a year was a responsibility GPs were glad to give up. But it was not good for patient care and it was not good for cost effectiveness. I don’t want to go back to my previous salary or my previous excessive out-of-hours responsibilities.

So it may not be very helpful to say so but Dr Grumble would not have made all these mistakes. He would have left consultants on a professional contract requiring them to do whatever was necessary to look after their patients in an open-ended way and he would have left the responsibility for out-of-hours medical care in the community with GPs.

Dr Grumble is a bit like the Irishman who when asked for directions says that if he was going there he wouldn’t be starting from here. That’s why Dr Grumble tries to stop the government making any more silly mistakes. Left to his own devices Dr Grumble would have put the extra money into the NHS without the new money-wasting initiatives. He thinks that would have delivered. If it had not a shake up would not have been unreasonable. One problem was that the government put the money in too late and put itself under pressure to deliver results quickly. They have shot themselves in the foot and seem now to be pointing the gun at the temples.

Voice from far away said...

Yes, but putting in more money without making sure it won't just be squandered in the system won't work either if the system itself is flawed to start with. Of course the sheer size of the NHS makes it very hard for anyone to reform, let alone undo the damage done by those who tried before them but did not succeed.

In a situation like this, remedy will have to include more reform which is unavoidable but it would produce good results if: 1- You have a person/s you trust is able to do the job. 2- you cooperate with them. There are no painless fixes in situations like this. I am sure you realize that.

Dr Grumble said...

Necessary painful fixes would include hospital closures. Dr G has lost count of the number of places where he has worked where there have been two acute hospitals neither with everything that is needed to deal with all eventualities in a sick patient when there should be one.

But whatever the system such fixes are politically impossible because there is always a public outcry when hospitals close. The public always want a hospital close by but they fail to grasp that if you are really sick, say, following a major accident you are better passing the smaller hospitals and going to a major centre where they have the full range of surgeons/facilities able to deal with everything ranging from your bones to your brain.

Interestingly at a meeting quite recently in a major hospital the consultant staff suggested to the management that a hospital should close. But closing any of the contenders would have caused a political furore in a marginal constituency. Also it is generally not allowed for hospitals to sell off prime sites and use the cash to build a bigger better hospital elsewhere.

There is no doubt that the old NHS system particularly with its focus on general practice has some considerable advantages and there is also no doubt that some things that are being mooted risk turning an essentially efficient way of delivering health care into an inefficient one. Unnecessary operations and investigations are commoner in some other systems. Even the NHS has traditionally done operations on a grand scale which have no good evidence base.

There are plenty of major changes which would save money and improve care in one. But privatisation and competition don't obviously seem to be the way to achieve this. However, according to the NHS chief executive (this is from the horse's mouth) some of these initiatives are just designed to shake things up. In that respect they might be a useful tool to effect change in the NHS. We shall see.

voice from far away said...

No need for the horse to talk Dr G :), if you have a small business, say your own private rooms in Harley Street, then you decided to borrow a relatively large amount of money to just do it up when you know the business will not pay back, then you are delibrately shacking your business with the intention of going bust. That's exactly what the previous government did, then waited till the point of no tryutn before handing over to the new guys. They are honest and they are trying but to the people, it looks as if they are the ones who are failing!

And, your post is right, any new government will not be any different, I am beginning to think 'better the devils we know.'

And, if I were boss, I would do something you suggested a long time ago, turn the majority of the NHS into a co-operative. However, it seems the situation has even passed this point.


Dr Grumble said...

if you have a small business, say your own private rooms in Harley Street, then you decided to borrow a relatively large amount of money to just do it up when you know the business will not pay back, then you are delibrately shacking your business with the intention of going bust.
These rules may work in Harley Street when you are milking the insured and those with money but the real problem with health care worldwide is that it does not really generate wealth. This was the rotten thinking that goes back to the very inception of the NHS. They thought that if you spent money looking after the sick there would be a pay back. There is some truth in this but mostly we are keeping people alive to spend their pensions or reach the old folks home.

That is one reason why health care is so very different from other enterprises.

The NHS is a big yoke round the neck of any government. That's why they want to get rid of it in so far as they can. As for payback they need political payback which requires them to talk up the NHS. But in fact they often knock it - especially the GPs most patients love.

There is no reason to think any other party would take a very different line with the NHS.

There are some changes empowering local managers in Foundation Trusts which may bear some fruit. Who know? But don't think it is all bad. There are some jewels in the NHS with some very hard working people.

voice from far away said...
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Magic said...

I woke up today to find that my blog 'undeleted itself!'

Amazing stuff!!

But then, this IS the story of my life!


Jobbing Doctor said...

Dear Grumble,

I have returned, and on the basis of your recommendation and as part of my increasing conspiracy theory mentality, this old socialist has ordered a book by Peter Oborne (a man who I would not normally give shelf-space to).

I hope that it will be a stimulating read.


Dr Grumble said...

Mrs Grumble had the same concerns. Dr Grumble was oblivious to the politics of the author (which are not apparent in the book).