29 February 2008

Cloud cuckoo land

Sometimes Dr Grumble gets the sensation that he is in an unreal world where everybody with influence seems to be on a different wavelength. Take for example the latest initiative from Sir Liam Donaldson. This is what he says:

"Why should the health service, funded by the taxpayer, pay for the care of a patient that's had bad care?

Is this just intended as a soundbite for those with nothing between the ears or has Dr Grumble gone round the bend?

Sir Liam with a former civil servant.

Sir Liam's idea is that if something goes wrong (and he uses the rather bad example of MRSA) hospitals should not only not be paid to try and put the patient right but that they should be fined. He is going to recommend this idea to the noble Lord Darzi. But, really, how can this make sense? When things go wrong it's already enormously expensive for hospitals. If managers do not already realise this (and maybe they don't) will a fine really make them pay attention? And if you fail to pay a hospital for 'bad care' to spare the taxpayer the expense where does the money come from to look after the poor patient? Could it be from another taxpayer? Who else pays for care in an NHS hospital? Does Sir Liam understand how the NHS works or does he live in cloud cuckoo land? Or is he looking ahead to privatisation?

Dr Grumble is bewildered.

This post was first published on 17th December 2007. It has been republished it now because Dr Grumble was amused by this article about how much effort the civil servants in the Department of Health spend doing political spinning for their masters. One of the things they have been working on is Sir Liam Donaldson's wikepedia entry. You can see why. By the way it seems that the patients are beginning to understand what is happening to their health service. For Channel 4 clip click here.

28 February 2008

Shooting in the dark

As Dr Grumble arrived at work yesterday he bumped into Mr Pilkington in the car park. Mr Pilkington is a surgeon and arrives early, usually well before 07.30, and it's only on Fridays when the traffic is least heavy that Dr Grumble arrives at the same time. Yesterday Mr Pilkington was clutching five recently laundered white coats. "I hope you're putting those in the bin," joked Dr Grumble. White coats have, of course, been banned. Mr Pilkington is clearly not going to take any notice. He muttered something about the rot setting in when the hospital laundry closed. There's nothing new about any of this. White coats have always been fomites.

Dr Grumble is following the gallimaufry of new rules. As winter sets in, he has had a few comments about his short sleeved shirt. Hospitals tend to be hot but not consistently so and there have been times when Dr Grumble has shivered in his new attire.

The lifts in Dr Grumble's hospital are inadequate to say the least. Dr Grumble climbs the ten flights to his office each morning and on his way up he bumped into Dr Davey, a gastroenterologist. Dr Davey commented that Doc G had no tie. Ties too are now banned. Dr Davey is plainly another one who is not exactly content with the new dress code for doctors. Nor is Professor Parrot. Mr Bozek, a urologist, has even wondered if it is just another way of clipping the wings of doctors. Why the government is out to get doctors is puzzling. If you want to make the NHS the focus of an election campaign you ought to keep doctors on side. The public still trusts doctors.

There are many other workplaces where staff have to keep scrupulously clean. Dr Grumble has visited some. If, for example, you visit a pharmaceutical manufacturing plant you will be given a place to change, a locker and pristine white overalls. This is what Dr Davey says he needs for his endoscopies. Dr Grumble also performs endoscopies. When he was being trained he used to change into greens. There was a changing place and a locker. Now he just has a plastic apron. Some of the cases are highly infectious. Dr Davey wears his suit trousers and puts on a green top. He changes in the toilet. There's nowhere to put his valuables. In this garb he does 'topping and tailing'. In other words he pokes instruments down peoples' gullets and, well, up the other end. It's not, to Dr Grumble, pleasant work but Dr Davey probably enjoys it. It's not, by its very nature, clean work. Faecal material abounds. Some of it very probably occasionally gets onto Dr Davey's trousers. And then he goes to the ward and at the end of the day home to his newborn baby. It's not nice.

There seems to be a concerted campaign to blame doctors for MRSA and C. difficile. But how much is the government to blame? Who took away the ready provision of clean white coats? Surely contaminated clothes should stay in the hospital and be washed there and not taken out into the community? And who forced doctors to do safari ward rounds trekking from ward to ward because there was never enough flexibility to accommodate patients on the right ward? And who shoehorned extra beds into already crowded wards? And who is responsible for there being too few side rooms so that patently infectious cases cannot be easily isolated? And who is responsible for Dr Davey having to change in the toilet and wearing his suit trousers while dealing with faeces? And who is responsible for beds occupancy being so high that many beds have more than one occupant in 24 hours? If you were looking for a way to spread infection you couldn't find a better one. Skimping and cost cutting is costing us and our patients dear.

The solutions proposed by Gordon Brown's man at the ministry are about as effective as blowing against the wind. Dr Grumble wonders what evidence there is for them. He's not alone. Here's what the Lancet says:

So, on what basis did the Health Secretary make his recommendations? The working group resorted to “informed common sense”—a level of evidence just above guesswork.

Hospital infections are an important issue. We shouldn't be solving them by shooting in the dark.

This post was first published on 29th September 2007. Dr Grumble was concerned at the time about the government's silly initiatives tending to focus the blame for hospital infections on doctors. Since then we have had an even sillier initiative - the ludicrous deep cleaning that is costing us a small fortune. There are indications for deep cleaning but generally dirty hospitals is not one of them. They just require proper cleaning. The post has been republished to coincide with the latest news on C difficile deaths. The news is not good.

Drug name confusion

Platelets aggregating at the site of a wound.

Two or three years ago Dr Grumble was called to see a confused old lady on the ward. Confusion amongst old ladies in hospital is a common problem. The junior doctors were not too worried about that. But they were worried about something else - a low platelet count. The platelets were dangerously low. It was puzzling those looking after her. Now Dr Grumble is no haematologist but he does know where to start with problems like this. And he started with the drug chart. He went through the drugs one by one. He came across one he was not familiar with - you just cannot be familiar with them all. It was called hydroxycarbamide. "What's that for?" asked Dr Grumble. Nobody knew. "What is it?" Nobody knew. Nobody carries a BNF any more. That was one good use of the white coat but white coats are now a thing of the past. But we found a BNF somewhere and the BNF revealed all. Hydroxycarbamide is the new name for hydroxyurea. Hydroxyurea is used to lower platelets and the patient was taking it for essential thrombocytosis. Problem solved.

The culprit.

Changing drug names is not without risk. And it's especially problematic if the two names are really not very similar. Dr Crippen relates a similar problem here.

The real culprits.
This post was first published on 10th May 2007. Dr Crippen, it seems, is still having problems. By the way he is wrong about the spelling of 'fetus'.

24 February 2008

Why does the Sunday Times bludgeon doctors?

There's no doubt that doctors feel under assault. In the doctors' private chat rooms the ill feeling towards the government is palpable. The latest assault on GPs over their hours is just one example of many orchestrated attacks on the profession. What has been puzzling Dr Grumble is why the government should be out to get us. You cannot expect to achieve much in the NHS if you set out to hack off the key people you need for an improved service. Dr Grumble has twice now heard the Chief Executive of the NHS say how much can be achieved if you get doctors onside. Perhaps he can see the problems the government is creating.

Could it be that the government is trying to deflect its own inadequacies onto the staff of the NHS? To take just one example, it's plain that even NHS managers seem convinced that MRSA is a problem of the doctors' making and fail to recognise that bad management leading to too few side rooms, ludicrous bed occupancies and beds in general wards and even high dependency units shoehorned into tiny spaces has anything to do with it. If managers genuinely think this way, and they seem to, maybe the public is also taken in. Yet the public trust their doctors and are more likely to believe them than politicians or managers which makes the whole idea of constantly attacking doctors unwise, foolhardy even.

Another thing that Dr Grumble finds puzzling is that the government tends to talk down the NHS when they could be talking it up. Is the intention to soften people up for the privatisation that is on its way?

Dr Grumble still maintains that what the NHS really needs is funding to match that of similar nations. And perhaps bludgeoning doctors is the government's way of trying to get doctors to shoulder the blame for the inadequacies of the NHS. Perhaps then nobody will notice that spending on health in the UK is still lagging behind spending in other countries. The latest figures Dr Grumble can find are below. The curves look essentially parallel. We are just not catching up at all.

On the back of this manufactured failure of our National Health Service there is a concerted attempt to break up general practice as we know it in order to allow big business to muscle in and make big profits for shareholders. Examples of this are walk-in centres and private contractors bidding for local practices. Big business is waiting in the wings to replace the personal, high quality service we all know.

The personal nature of general practice is at risk. GPs know their patients, their problems and how they fit into their patient’s lives. Your GP may have been your doctor since you were a baby. He may well also be your children's doctor. He is your advisor, counsellor, confidante, advocate and friend. This personal relationship will not be possible with the new supermarket-type of GP the government seems to want.

Dr Grumble does not think this is what the public wants. And it baffles him that this is what the government wants. Next year will be the crucial year for ordinary people to fight for the National Health Service they love. But Dr Grumble thinks that within ten years general practice in the UK will go private. Some think it will be sooner. Unilaterally rewriting the GP contract is just the beginning.

This was first posted on 23rd December 2007 under the title Why does the government bludgeon doctors? Dr Grumble was moved to republish it as a result of being wound up by the continuing attack on doctors in some of this Sunday's papers. Journalists are lazy people who will readily write the story they are given rather than the one they should be writing. A top medical journalist has told Dr Grumble that some of the top papers are in hock to the government so there is more to this than just journalistic idleness. And that makes it even worse. Anyway Dr Grumble's famous informant (and you will all have heard of him or her) recommended a book to explain how it all works. Unfortunately Dr G did not have a pen with him but he thinks it might have been The Triumph of the Political Class by Peter Oborne. Has anybody out there read it?

17 February 2008

The truth about GPSIs

GPs have been very effective gatekeepers between primary and secondary care. It's one of the reasons why the NHS used to be the most cost-effective healthcare system in the world. But the government thinks that GPs have been wasting taxpayers' money by sending patients to hospital unnecessarily. After all, what could the hospital possibly have to offer that a GP couldn't deliver? Plainly, so government thinking seems to go, GPs have been just a little bit idle and have been offloading their work to the hospital. Just maybe, of course, GPs are not confident in every area of medicine. But that can be dealt with by a little extra training. And then you can call the specialist GP a GPSI (general practitioner with specialist interest).

Consultants have been somewhat sceptical about the value of such an approach. But that has not stopped the training of 1000 GPs in specialties with long waiting lists. Until recently this has taken place with little scrutiny. So what is the evidence for this approach? The NHS Service Delivery Organisation Research and Development Programme has funded two separate studies which assess the cost effectiveness of GPSIs.

The results come as no surprise to Dr Grumble:

  • The introduction of GPSIs did not reduce waiting times at the hospital clinic
  • The cost of GPSI clinics was always higher than the hospital (up to twice as high)
  • GPSIs were paid more than the hospital doctors
  • One consultant saw twice as many patients as the GPSI (a chance finding when a consultant replaced a GPSI temporarily)
Dr Grumble thinks it is time for a moratorium.

This post was originally published on 28th December 2006. It was intended as a warning about the government's efforts to move specialist care into general practice. General practice is a specialty in its own right. Patients are not cases with focused conditions to be managed by specialists. They are people with a range of problems. They present with symptoms. Palpitations might be a result of anxiety, cardiac disease, asthma treatment or an endocrine disorder. Sorting these things out is what the GP is good at. Knowing the patient makes it easier for the doctor and patients certainly prefer to see a doctor they know. As patients get older (and our population is getting older) they don't come with one disease suitable for one expert, they come will multiple ills best dealt with in one sitting by a generalist. Occasionally a particular problem will need the hospital but it really is not going to be cost effective to duplicate the resources you must have in hospitals in every shopping centre in the land. The government's GPSI initiative was the beginning of this plan (which has privatisation as its goal). Evidence quickly accumulated to suggest that this really might not be a cost-effective way forward but this did not stop the move towards polyclinics. But our government is not evidence-based. If it was we wouldn't ever have gone looking for weapons of mass destruction.

16 February 2008

Golden geese

How things have changed. GPs used to argue passionately that they were the ones that knew their patients and that they should be the ones if one of their patients fell ill to go out at night. Cradle to grave - that was the mantra. They knew each one of their patients as a person. It was a wonderful ideal but it was exploited. The government unwittingly exploited it with the old 24/7 contract that required too much of GPs. Even a doctor's spouse had responsibilities if the doctor himself was ill. Then the patients started exploiting it whipped up on a grand scale by a government unwisely increasing rather than damping down expectations.

Mrs Grumble (now an eco warrior) used to be a GP. The phone used to go at the Grumble home all evening and much of the weekend with helpful comments such as: "I want the doctor out." Sometimes it was 3 a.m. House calls in some countries are almost unheard of but in the NHS it was provided for free by individual GPs working very long hours. Mrs Grumble would go in the depth of night into the heart of Brixton (at the time of the riots) carrying a bag full of drugs. There was never any trouble. The doctor was known and respected. But it was tough with two young children at home and a husband who was working alternate nights (plus normal days) in intensive care. The government essentially got this service from GPs for nothing. With the new GP contract they killed a goose laying enormous golden eggs. Once you have killed your goose that's it.

This was originally published on 26th May 2007. Dr Grumble has republished it today following Lord Darzi's amazing comments [See addendum] about the doctor patient relationship. He says: "We need to separate that fantastic relationship between a patient and a doctor...." They've killed one golden goose. It seems the government is hell bent on killing another. It's quite extraordinary. But if you ask a surgeon how to organise general practice what do you expect?

Addendum (added at 14.10hrs)
Within hours of this being posted the comments correctly attributed to Lord Darzi have been inexplicably completely altered. How can that happen? The BBC accurately reported what Lord Darzi said but now they have fundamentally changed the meaning of what he said.

12 February 2008

Give GPs a break

Some decades ago when Mrs Grumble was a very junior GP she used to have to spend a working holiday in Lochgoilhead. It's not a very big place and there was only one GP. Going on holiday used to be difficult for a single-handed GP. You couldn't just abandon your patients. That's why Mrs Grumble had to do it. Quite a lot of pressure was put on her because otherwise the poor incumbent couldn't have a break. But now GPs can take a break - whether there is somebody available to do their work or not. These days, out-of-hours, it's the job of the NHS to provide a doctor. And here's how they do it in Scotland. It's not cheap. Not a very good deal for the government that new contract. The government just did not know how much GPs used to have to put themselves out to provide a round-the-clock service for their patients. Dr Grumble knew. But nobody listens to Dr Grumble.

This was originally posted on 7th January 2007 under the title Giving GPs a break. It's been reposted now in recognition of the latest government attack on GPs.

10 February 2008

I told you so

Regular readers (there are two) may be wondering how Dr Grumble got on over dinner with Lord Warner, Minister of State for Reform. Unfortunately, it seems that Dr Grumble might have upset him as the next day he announced his resignation. Anyway, the dinner was good. The great and the good were there - at least three lords and a baroness - all in their finery. Dr Grumble went in his best suit. Richard Horton came in his corduroys. When you're really well known you can do that. He amused everyone by introducing himself as working for 'a medical journal'.

Was this the problem leading to Lord Warner's resignation?
Lord Warner, of course, made a speech. That's what he does. It wasn't quite an after dinner speech, more a middle of dinner speech - between the lamb noisettes and the pear in muscat wine. He was introduced as being 'above average' which he is according to they work for you. One of Dr Grumble's readers would have been pleased because Lord Warner stated that front line clinicians, not managers, are the cornerstone of the NHS. In fact that's how he started his speech. Clever man. Get the audience onside from the start.

The surgeon who introduced the noble lord professed not to understand the terms 'plurality' and 'contestability'. Perhaps goaded by this, Lord Warner did set out on some definitions. He needed to. 'Contestability' is not in Dr Grumble's rather old dictionary nor his spell checker. As for 'plurality' it is defined but what does Lord Warner mean by this? Dr Grumble listened carefully. He is suspicious when words like these are used. Why use words to obfuscate? Dr Grumble's patients are never haemorrhaging, they just bleed. Of course, as Dr Grumble has already pointed out Lord Warner is clever so one can only conclude that obfuscation is exactly what the noble lord has in mind. And if obfuscation is what he wants that must be because the truth, the unobfuscated nub of his thinking, is not what he wants to convey to his listeners.

So let Dr Grumble cut to the chase. The words contestability and plurality in the context in which Lord Warner uses them essentially mean privatisation - though presumably Norman himself would never say so. It does not necessarily mean that the whole of the NHS is to be privatised but it does mean that the government wants to rid itself of as much of the ownership of the NHS and its staff as it can. Looked at from the government's point of view, this makes some sense. Public expectations of the NHS are rising faster than they can possibily be met. Health costs are running out of control - not, according to Lord Warner, just in the NHS but also in France and Spain where deficits run at £8,000,000,000. The over 85s that cost us so much are going to increase, according to Lord Warner, by two thirds. He didn't say quite how much that can be expected to cost but it will be something enormous. And the NHS staff will be amongst these elderly folk and that means pensions to pay. No wonder the government wants to divest itself of all these yokes. But will privatisation solve the problems?

The thing about a blog is that you can be ahead of the game. This post was originally published on 17th December 2006 and was entitled Plurality and Contestability. It takes longer to write a book. But a book outlining the meaning of obfuscated words that are being used in the NHS has now been published. It's aptly called Confuse and Conceal.

09 February 2008

Harming those on the side of the angels

If you are British and you are tried for an offence, you will not be found guilty unless unless the evidence points to your guilt 'beyond all reasonable doubt'. Despite this, many innocent people have been locked up or even hanged. We know this now more certainly than we ever did before because of the certainty of new DNA evidence. Why do we have such a system? It is to try and prevent such miscarriages of justice. We would prefer to have a few murderers going free than risk locking up innocent people. It also prevents governments abusing their power. But our government is now trying to get around this inalienable safeguard. The Americans have done it already in Guantanamo. There is this view around that if people are dangerous they should be locked away even if they cannot be shown to have committed any crime. We have the same in this country with attempts to get psychiatrists to lock away people who are bad and potentially dangerous but not ill - even if they have done nothing wrong!

Now it is errant doctors that they want to take out of action on the level of proof used in civil cases - the balance of probability. The curious thing is that all this stems from Harold Shipman who was a murderer and was and still would be tried under the ' beyond all reasonable doubt' standard that we should all hold so dear. The civil level of proof is designed for civil disputes between individuals where it is one person against another and the matter in question is a civil not criminal one. It is not appropriate for a misdemeanor of some sort. Doctors should not lose their livelihoods on a balance of probabilities.

Dr Grumble was on a train once and by chance found himself sitting next to a GP. He was on his way back to his practice having travelled a long way to try and help defend a colleague up before the General Medical Council. The doctor had been found guilty. The details of the case don't matter. What matters is that the people who best knew whether or not the doctor was a good one or not were not listened to. And that was the old system.

Not long ago Dr Grumble was asked to write a statement for the GMC about a colleague who had been called before them. An allegation had been made by a solicitor that the doctor in question had lost some notes. How for God's sake can a matter such as lost notes be taken so seriously? In any case, given the lack of secretarial support for consultants in many NHS hospitals, how can the doctor get blamed? No consultant has control over the number or quality of his supporting staff. As it happened the story had a happy ending and the solicitor was apparently made to look very foolish when she appeared as a witness. But doubtless the barrister defending my colleague didn't come cheap and he went through an anxious time. Things might have been different if he had been judged on the balance of probability.

The other problem that doctors have is that they have a great many encounters with a great many patients. Sooner or later one of thousands of patients may develop some sort of grudge against their doctor. Some of these patients may be mad, some bad and many may be just sad. Some may have a genuine grievance. But with so many clinical encounters that may lead to a complaint is it fair to judge a doctor on the balance of probability? If so, malicious accusations are bound eventually to succeed. This is just another example of government trying to protect itself rather than doing what is just.

Dr Grumble used to be a civil servant. He went on a special training course in Sunningdale to learn the key features which make a civil servant. He remembers the importance there used to be in separating the civil servant and his values from the politician. Dr Grumble wonders what the current Chief Medical Officer was taught on his course. Things certainly seem different.

Above is a picture of Sir Liam. Dr Grumble would not like to be one sided. If you want to read his views on applying the civil rather than the criminal standard to doctors you can read them here. But it is unlikely you will be able to make sense of them.

Here are the views of the BMA Chairman:

"It cannot be right, when a person's entire means of earning a living is at stake, to rely upon a balance of probabilities."
Here's a quote from a colleague who wishes to remain anonymous:
"The proposal violates what any civilised society would regard as elementary human rights (presumption of innocence and the right to a fair trial). It does so under the breathtaking assertion that these abuses are necessary to protect patients."

This was first posted under the title Standard of Proof on 12th November 2006. Dr Grumble was reminded of this post by the recent death of Dr Jeffrey Cream. Dr Cream was one of life's angels. But that did not stop the GMC from finding him guilty of serious professional misconduct. The professional conduct committee's chairwoman, Mary Clark-Glass, told Dr Cream that he had been "highly irresponsible"..... There was no appeal process. Dr Cream's reputation and merit award were threatened. He had to seek a judicial review in the High Court where the GMC ruling was described as irrational and perverse. Mrs Clark-Glass gets a mention here (it's worth reading) from none other than Ian Paisley Jnr.

08 February 2008

An excuse for a video

Most things in this world are in shades of grey. Stories of quality health care in the US abound. Make no mistake, the best of health care is found in America. Even Lord Darzi's Trust, excellent though it is, is not of the standard of, say, Johns Hopkins. So one could conclude, as our masters have, that US health care is better and that the NHS should be privatised. Dr Grumble has never taken this line but he does try to keep an open mind and he has recognised that the answer to this question may not be black and white.

That anyway was the Grumble view until today when he read this article. The article is packed with reasons why we simply must not take the private route for our NHS. They are too numerous to list here. Please read the article.

One of the hospitals in Lord Darzi's Trust.

But if you don't have time or can't access the article, here are a few bullet points:

  • For-profit health institutions cost more for less good care
  • Markets undermine institutions which do not tailor care to profitability
  • Commercialisation drives up costs
  • Poor performance of US healthcare should warn off other nations from taking the privatisation pathway

Here's a few more interesting points

  • Private health maintenance organisations recruit the healthy elderly by advertising on the bottoms of swimming pools (and other similar tricks)
  • The chronic sick got skimpy care and had bad outcomes
  • Investor-owned dialysis centres have a 9% higher mortality
  • Investor-owned hospitals spend more on managers
  • Over 30% of health care spending in the US goes on administration
  • Internal markets have increased administrative costs in the UK and New Zealand
  • In Canada the overheads of private insurers are 10 times those of public insurers
  • Overcrowded US emergency departments turn away one ambulance every minute
  • Seriously ill patients cannot shop around
  • The product of health care is difficult to evaluate
  • Health care costs bankrupt more than a million US citizens each year (despite being insured)
  • US mortality statistics lag behind most other wealthy countries
  • US clinical outcomes and patient satisfaction are mediocre
  • US costs per capita are about twice that of similar nations
  • Heart surgery on healthy patients leads to first rate surgical outcomes (they have done the trial in the US!)
Given this catalogue of reasons not to privatise our NHS why on earth are our political masters hell bent on taking this route? Now what do you think is the answer to that?

This post was first published under the title Is Private Really Better? on 2nd December 2007. Dr Grumble has republished it now mainly as an excuse to show you this video:

04 February 2008

GPs under attack - again!

Lord Darzi, who seems to be rather rarely graced with his new title by doctors, wants a more personal NHS. When Mrs Grumble was a GP she shared the on call with her partner and one other GP. Patients could telephone at any time of the day or night for all of the 168 hours there are in a week and one of the three doctors (in the week one of two) would be available. And telephone they did. Often Mrs Grumble would go out into the heart of Brixton to deal with the multitude of problems that were thrown at her. With two young children and a husband doing alternate nights (plus of course all the days and half the weekends) in an ITU it was tough. It was too tough. When she could Mrs Grumble found a less demanding job. It's no wonder GPs don't want to go back to that sort of commitment. But at that time British general practice was the envy of the world. GPs took pride in knowing their patients and being available for them out of hours. But gradually the phone calls from the public at the dead of night saying "I want the doctor out" went up and up. It was never going to last. GPs with high ideals struggled to keep it going. The final death knell was the government's new contract which destroyed the last remnants of this highly personal service. Where else in the world could you have expected your very own doctor to get out of bed to deal to your every need for nothing - or even for money? Yes, it had to end. And now the noble lord wants a more personal service. Something that has already, albeit with some justification, been thrown away by, not doctors, but the government. And how is the new lord going to bring back a personal service? He's going to do this with polyclinics. What could be more impersonal than that? Is this another new initiative that just hasn't been properly thought through? Or is this, as many think, a back door to privatisation? Cock-up or conspiracy? In the NHS it's usually the former. Dr Grumble fears yet another ill-thought-out reform.

A patient for the polyclinic?

Here's a letter from the Guardian which is reproduced for convenience below:

Ara Darzi plans to deliver "the kind of personalised care we all expect". But his proposals to develop 150 polyclinics in London are completely at odds with this vision. Enormous, distant health centres with vast numbers of staff and doctors are the antithesis of personalised care. It is inevitable that these plans will increasingly remove the right for patients to consult their own GP at a local and convenient surgery. Recently, Warrington primary care trust's plans to replace all GP surgeries in the town with six polyclinics proved massively unpopular and were shelved as a result of patient protest. While there is a national need for further improvement and investment in practice premises, the surgeon-minister's plans are spectacularly misjudged.

Dr Martin Breach

This was originally posted on 6th October 2007 under the title Polyclinics. Dr Grumble has released it again as GPs are being attacked once more. How can you improve on what Mrs Grumble offered her patients when she was a GP? What more in the way of personal care do patients want? Are drop-in centres for people who feel a bit iffy while at work really the best way of caring for them? Is that really what the sick need? Is it really a good idea to pick up a prescription from a stand-in doctor based in Asda?

The only people that are going to be able to stop the destruction of British general practice will be our patients. But do they know what is happening? Or have their minds been poisoned by the sustained adverse publicity being fired at GPs? Let's hope not.

03 February 2008

The Diving Bell and the Butterfly

A very long time ago Dr Grumble worked with some severely disabled patients. It was so long ago - more than a quarter of a century - that you are going to learn exactly where this was. It was Phipps Ward at the Southwestern Hospital in London. The hospital is no more. Even Google scarcely knows about Phipps Ward. Phipps Ward certainly never knew about Google. The patients in Phipps Ward came from all over the country and the one thing that characterised them all was that they required some sort of respiratory support. Some were unable to breathe at all unaided. Most were victims of polio. Some had other causes of respiratory muscle weakness. Still others had skeletal problems that interfered with their ability to breathe. Several patients could not move anything below their neck. One that Dr Grumble remembers well could just move a thumb and this enabled him to operate a Dictaphone which meant that he could earn a living running a business. It was a good living. He had a Rolls Royce ambulance that would take the iron lung that he was dependent on and this enabled him to go on tours of Europe. He died decades later of an unrelated cause. Its quite a challenge keeping somebody who has no respiratory muscles alive. The treatment in Phipps Ward was good. Phipps Ward opened Dr Grumble's eyes to how severely disabled people can have fulfilling lives. Dr Grumble knew these people well enough to ask them delicate questions about what they most missed about not being able to move. He thought that they might bemoan their loss of independence or their loss of dignity. Being dependent on others for everything including ones most intimate needs seems rather awful to Dr Grumble. But people who have been in such a state for years adapt and if you ask them what they miss they find it difficult to answer. Dr Grumble remembers one lady answering that she missed needlework. Dr Grumble has never even attempted needlework. These things make you think.

Doctors who have not worked with such severely paralysed patients may not realise that the lives of such people are not as bad to them as they may seem to others. But there are some truly dreadful states to be in - too horrible even to imagine. And that's where Dr Grumble's book recommendation comes in. The book is called The Diving Bell and the Butterfly and just occasionally, when it seems appropriate, Dr Grumble recommends it on his ward round. And just occasionally one of the junior doctors actually reads it. It doesn't take long because it's a rather short book. You can find out why here. All doctors should read it. Here's an email Dr G has just received:

Dear Dr Grumble, I just wanted to thank you for your recommendation of 'The diving bell and the butterfly', which I have just finished in one go (and have also just finished a box of tissues!). Best wishes, MF (I was one of the acute medicine SHOs at XXXXXXX Hospital from May to July)
It's sad that junior doctors don't expect to be remembered any more. But with shift work and consultants no longer working as they did in firms it's not surprising . Anyway Dr G did remember the SHO concerned and it was nice of her to send the email.

This post was first published under the title Book Recommendation on 9th September 2007. At that time Dr Grumble had no idea that there was a film on its way. Not an easy topic to make a film on. But it seems the film is a great success. Go and see it. Or read the book.

02 February 2008

The End of GPs

Here’s a case study from the Department of Health. Emily, a 28-year-old chiropodist, has a brain tumour. Most of the time she manages her medication herself; but when her condition deteriorates, she depends on her parents for care. This case study describes what happens to Emily over one particular weekend.

On Friday afternoon, district nurses from Emily’s GP practice arrive to set up a syringe driver for her. The next morning, a Macmillan nurse increases her dose of dexamethasone.

Emily’s condition continues to worsen, so her parents phone the out-of-hours on-call centre. Centre staff have no record of Emily. They contact her hospital, but the skeleton staff on duty at the weekend can’t provide any information.

In the afternoon, Emily becomes very distressed. An on-call duty doctor comes out to give her an injection of midozalam and a prescription for a further vial. He does not give Emily’s parents any information about her condition or arrange a follow-up visit, although he promises to brief the twilight nurses at the centre about her.

In the evening, Emily’s condition worsens again. Her parents call the on-call centre, but are told the doctors are changing shift. After a delay, it is agreed that Emily needs more midozalam, which takes over two hours to locate.

Emily’s father has to drive to a local hospice to collect the drug. He is kept waiting in a dark corridor where he can overhear staff talking about his daughter. After 30 minutes, he is told he is not authorised to carry drugs and sent home. Eventually, a doctor arrives with the medication in the early hours of Sunday morning.

Later, Emily’s parents, concerned that she will need more midozalam to tide her over until Monday, call the centre and ask for another prescription. They drive to collect it, and call several pharmacies to check that they are open and have the drug in stock. No single pharmacy can fulfil the whole prescription.

They get home in time for the weekend duty district nurses to administer an injection and recharge Emily’s syringe driver. Emily needs more pain relief but the nurses won’t increase her dose without authorisation. At midday on Sunday, her parents phone the on-call doctor to ask for a prescription for a higher dose.

Her father then drives to pick up the prescription, and drives on to another pharmacy to collect the medicine. The full amount is not available. He returns home and phones the on-call centre to ask for someone to come and administer pain relief. At 2pm, the duty doctor and district nurse return to administer an increased dose.

Mrs Grumble used to be a GP. Dr Grumble asked her how she would have managed such a patient all those years ago. She had no doubt how her practice would have done it. She and her partner would have ensured that one or other of them was available 24hrs a day – including at weekends. This is part of the vocational element of being a doctor. But it's not easy.

The Department of Health suggest that the solution is a care plan. But what might become the main problem in a dying patient like Emily cannot be predicted. It could be a fit, it could be an infection, it might be a pulmonary embolus or all sorts of other things. Whether to treat or how to treat is not a simple matter that can be laid out in advance. The management cannot be easily protocolised. These are not problems that can be solved with just care plans and motley staff who do not know the patient.

How can you manage the sick from here?

Why are things now so much worse now than they used to be? Could it be that the Department of Health had no idea how much work dedicated GPs were doing out-of-hours? Could it be that the new GP contract intended to push doctors' noses to the grindstone actually killed the goose that laid the golden egg? How can initiatives like NHS Direct possibly help with Emily’s problem? This is not something that can be dealt with from a call centre. What Emily needs is an experienced GP who knows her available day and night. It's a lot to ask of GPs but the best used to provide this. They saw high quality care of the dying patient as one of their most important duties. Dr Grumble is sure that many still do. His point is that the new way of doing things has not been conducive to high quality out-of-hours care. The same sort of thing has happened in hospitals with managers forcing doctors to go home whether or not the work is done.

A GP from the golden era. Now a thing of the past?

How can we ever get back the high quality out-of-hours service some of us used to have? If you have any ideas tell the Department of Health. You have until 5th January.

The document this case study comes from is called Direction of Travel for Urgent Care. Dr Grumble suggests a U turn.

This post was originally published on 31st December 2006. Unfortunately nobody took any notice and it is now being made public that general practice as we know it is coming to an end. Click the headline below for more details.

I'm on Benefit, Doctor

Grumble likes to take a decent history when he sees a patient that's new to him. It's not always possible in today's busy NHS but he does his best. What he tries never to skimp on is finding out what it is that the patient has noticed wrong. And he tries too to find out everything medical (and maybe even not medical) that's troubling the patient. He likes to think he does this job well and that he gives the patient plenty of opportunity to mention anything of real concern. Sometimes the patient clearly has one major complaint and mentions nothing else. Often this is not something that would prevent the patient working. After going through the major complaints Dr Grumble asks the patient about their employment and he still has not stopped being surprised when, having listened carefully to all the complaints, the patient tells Dr Grumble they are 'on benefit'. Dr Grumble tries not to look surprised but he does think that anything bad enough to prevent the patient from working might at least have merited a mention by then. But no. Whatever it is, it was not important enough to tell Dr Grumble about. But Dr Grumble does not let his patients get away with just saying that they are 'on benefit'. It is after all his job to know why they are on benefit. Of course he gets a variety of answers. Quite often it is a 'bad back'. Fair enough. It can't be easy to work as a labourer with a bad back. But usually they aren't labourers. And aren't there other jobs that labourers could do? Working with a bad back can't be nice - but sitting at home with it without any work to take your mind off it could just be worse. Who doles out these benefits? Dr Grumble doesn't know. Well-meaning doctors may have a role.

This reminds Dr Grumble of the time when he pulled up at a petrol station to fill his tank. The car in front was plastered in disabled stickers enabling the driver to park almost anywhere without fear of a penalty. Poor man thought Dr Grumble. Obviously wheelchair bound. But no. Out of the car leapt a sprightly man and dashed into the shop to pay coming out laden with heavy goodies from the shop. "Whoever can have given that man all those disablement stickers?" he said angrily to Mrs Grumble. Mrs Grumble looked rather sheepish. "I did," she said. You see at the time Mrs Grumble was the man's GP and she had felt sorry for him. Angina or something. Doctors have a duty to do their best for their patients. But is making people arbitrarily disabled and moving them away from work and onto benefit doing patients favours? Dr Grumble has never thought so. And surely the system should prevent the obvious conflict of interest that results from a patient's own GP becoming involved in such decisions.

Dr Grumble might seem rather harsh over this but he's not you know. He's thinking of the best interests of these people. Dr Grumble takes the view that a slightly chronically ill patient would be better off in work rather than being tied to benefit. But how could you ever prove it? Perhaps you can't but apparently there is some evidence that Dr Grumble may just be right.

Dr Grumble is astonished.

This post was first published on 24th August 2006 but the subject remains topical.

Dr Grumble's archives

Dr Grumble is going to occasionally re-release past harmless posts which may still be of relevance and worth reading. He has been prompted into doing this by PhD Scientist's request for the Grumble greatest hits to be published as a book. It's a great compliment to be regarded as worthy of a book but Dr G quite honestly hasn't got time for that.

Dr Grumble pondering. With thanks to the Witch Doctor.

Anyway starting today there will be the occasional re-release of items of interest from the Grumble archives- especially if the post is still of some interest or is relevant to something topical.