29 May 2008

Save your surgery

Every time Dr Grumble tries to stop blogging there is some new crisis which is of such enormity and great concern that he feels that he just has to do something. The crisis facing every UK citizen at present is the threat facing UK general practice, the jewel in the crown of the NHS.

It may be that if you are young and fit this has passed you by. Quite probably if you are old or disabled or have a chronic medical condition you will know what this is all about. If you don't know read what Russell Brown said in response to a request for clarification to the lawyer brother of a colleague:

When he is elderly and has multiple diseases which need an holistic overview to ensure he receives the best care for him personally, he won't get it if these plans come to fruition. What he will get is a series of "Health care professionals" who will on the whole not be medically trained or, if they are medically trained, will not necessarily be a primary care physician. Consequently he is likely to end up seeing a different person every time he has to visit with no-one taking overall responsibility for the care he is receiving.

If you want to do something to try and prevent these changes sign the petition. If everybody who reads this signs it will be enough to make a difference. And please tell your friends.

The worm is turning

When it comes to things that matter to them our patients are remarkably politically astute. There are people who believe propaganda but many don't. The widespread criticisms of doctors that the government has managed to spin onto the front pages of our newspapers cuts no ice with the public. The public has a lot of contact with doctors - mostly face to face. People believe what they see for themselves and not what they are told. GPs are seeing this daily in their surgeries. Dr Grumble has seen it in his hospital.

Here is a quote pasted in from dnuk, a forum just for doctors. It's pasted in exactly as it was posted:

i have had 4 patients ask me this morning where i will be going if the new private clinics make this practice unviable.I (whilst as per GMC) cannot comment on politics during a consultation I have advised them of my back up plans of working broad.The patients are scared. the most vulnerable are the most scared.they know HMG is untruthful when they say local clinicians are involed in the polyclinic plans. we are not.the NHS is failing as a result of new labour, ready to be privatised and dumbed down.the long term ill, the elderly and the poor will fare worst and their right to a doctor (not a nurse) and continuity will be diminished.a sad dogma from a failing prime minister

Of course Dr Grumble and many others have been saying all this for some time. But it seemed that nobody was listening. But the patients obviously don't need to be told. They can see what is happening. This could be very damaging for the government. Some people are very dependent on their health care. It's hard to understand how the powers-that-be could have got things so very wrong. Perhaps listening would have helped.

25 May 2008

Privatising the NHS

Dr Grumble has told you about his friend, Philip, who just does not believe that the NHS is being privatised. Dr Grumble has another friend, Sarah, who realises what is happening (her own work is going out to tender) but doesn't seem to think it matters. So, working in the NHS, we have a group of doctors who cannot open their eyes and a group of doctors whose eyes are looking through rose-tinted spectacles. And, presumably, there is a third group which thinks that privatisation is heading our way and may not be such a good thing.

Probably, if regular readers have not given up on the cautious Dr Grumble, you will think that he takes the view that privatisation is happening and is bad, bad, bad. But Dr Grumble is a physician and brought up on the grey case. Nothing is black and white. He happens to think that in Sarah's area of work (sorry to have to avoid just what this is) it might not be too damaging to privatise the service. One thing is certain: Sarah, as a highly skilled consultant, will get more money if the service is thrown into private hands. Less skilled people are likely to get less. That's the way markets work. Those in short supply cost a lot and those that are plentiful are cheap. Dr Grumble already does a small amount of work for a private company. If he worked for them full time he would be on a top barrister's salary not a doctor's. Are such changes bad? You can decide. Dr Grumble's point is only that he wants you to know that, if he is opposed to some of what is happening, it is not because of the consequences to his personal finances. What does worry Dr Grumble is the potential cost to the taxpayer. Because, if one thing is important in the world of ever-more-costly medical care, it is keeping the lid on expenditure without damaging the patient.

So the key question is: will privatising the health service cost us more? The arguments about this are there in the Grumble head waiting to get out. One day Dr G may enumerate them. To cut to the bottom line, some of what is proposed is so obviously a bad deal for the taxpayer that he cannot believe that government does not realise the folly of its ways. But governments do not necessarily do what is sensible. And they do not necessarily see what is obvious. Here's an example from Andrew Marr's excellent History of Modern Britain:

The problems with selling off an elderly, loss-making railway system on which millions of people depend, are obvious. If your first aim is to raise money, then you have to accept that fares will rise briskly, and services may be cut, as the new owners try to make a profit. This will make you less popular. If, however, your aim is to increase competition, just how do you do that? Different train companies can hardly compete directly, racing each other up and down the same track.

Very similar arguments apply to the health service. But this will not stop the government privatising the NHS. There are powerful forces at work driving this. Some think they are unstoppable. Dr Grumble does not agree.

And for Philip, who does not think the NHS is being privatised, here (pdf) is some recommended reading.

23 May 2008

The myth of patient choice

To avoid trouble Dr Grumble is trying not to blog. But it's hard. It's ten past eight. There's a busy day ahead but sometimes something happens that makes you so angry your wrath has to be vented. Dr Grumble has just finished his work in the Call Centre. He has to prioritise referrals and allocate them to the right clinics. While he was there the phone rang. Although it was before 8 o'clock there was a charming girl there to answer it. She was full of how can I help yous and no problems. But there was a problem. As dates were being discussed for the patient's appointment the clerk explained to the patient that the appointment she wanted would not be possible. It was too far ahead. We have targets to meet. Patients have to be seen within a certain time whether they like it or not. There is no patient choice in this whatsoever. Now isn't that just mad?

17 May 2008

The virtual polyclinic

Just what is a polyclinic? Is it just a bunch of GPs forced to abandon traditional surgeries around the corner from patients' homes? Or is it a small hospital with some GPs thrown in? Might it even be part of a large hospital? Could it have a medical admissions unit or a high dependency unit? Might there be a CT or MRI scanner? Or could it be a base for community nurses? Or perhaps it could be a place where people are advised how to stay well? Or maybe they could get alternative therapies there? Or could there be a swimming pool or even a gym? And maybe a health food shop? Does Lord Darzi have it clear in his own mind? Find out in the video.

Hopes LIFTed for the NHS?

Dr Grumble bumped into an old friend the other day. We will call him Philip. Philip is a bumbling academic type. He is highly intelligent with many scientific papers to his name but somehow he never quite catches up with the reality of what is going on around him. Philip is a strong supporter of the NHS so it was natural for Dr Grumble to mention his concerns about imminent NHS privatisation. Philip looked utterly bewildered. He thought that Dr Grumble's interpretation of the goings on in the NHS was quite wrong and said so unequivocally. Which just goes to show that many people must believe what they are intended to believe.

But what we are told really does not bear scrutiny. Ben Bradshaw claims that he is going to improve access to GPs by moving them away from the homes of the elderly and disabled into polyclinics. The claim is a non sequitur plain and simple. But Philip seems to believe what he is intended to believe.

Of course it could be poor old Dr Grumble that has this wrong. Perhaps he is deluded. He feels so sure of the government's intent that he has scarcely thought it necessary to argue his case. But if others don't see things the same way perhaps he needs to look for evidence. The trouble is that the government's intent has been deliberately obfuscated. Oh dear. Dr Grumble's thoughts are looking more and more like a pathological delusion. Perhaps Dr Grumble is plain wrong. Or mad. There are after all reassuring pieces from the Department of Health FAQs:

So it seems that poor Dr Grumble has lost the plot. Philip, the batty academic, must have it right. But wait. If you really want to know what is planned for your NHS, you must read the relevant Department of Health documents in toto. Now that is heavy going. But here is a taster - a few snippets to whet your appetite:

….the private sector has found the primary care market a difficult one in which to operate and develop….

The Department of Health has entered a national joint venture with Partnerships UK to develop and encourage a new market for investment in primary care……

This limited company - the LIFTco - owns and maintains the building and leases the premises to PCTs, GPs, Local Authority Social Services, dentists, pharmacists, etc.

A private sector partner is identified through a competitive procurement…..

The new LIFT company has a board of directors which reflects the shareholding split within the company.

LIFT represents a sizeable new market and the first tranche of schemes across all 42 sites - now supplemented by eight fourth wave projects (there are 50 NHS LIFT schemes) - represents investment of around £1 billion.

A company is [a] relatively simple and efficient way to structure a Public Private Partnership

...we can sell our shares. This is not a long-term investment - it is a catalyst for change

Of course, these snippets have been highly selected to support the Grumble delusion. Patients' groups have studied the full documentation. And they are content.

'We fully support the introduction of 'super surgeries' which we regard as good for patients.'

'A one-stop centre for total health care will be more convenient for patients, particularly patients and those with long term medical conditions

'We are extremely pleased that these centres are being set up in some of the most deprived areas in England.'

Michael Summers, Chairman, The Patients Association

The patients seem happy enough. And this is all about patients. The end result is what matters not the route to get there. So that's OK. The patients are happy. Dr Grumble doesn't need to be worried. Philip the academic must be right after all. There is nothing to be worried about. Nothing at all. But it is privatisation.

14 May 2008

Improving not privatising the NHS

Ben Bradshaw claims the government's proposals are about improving rather than privatising the NHS. He claims that polyclinics are for London where there are special problems and not necessarily for other parts of the kingdom. 

Dr Grumble once worked for a part of the civil service that he thought was being prepared for privatisation. He asked many times if this was the case. Every time the answer was the same. There were 'no plans' for privatisation. But everything that Doc G saw with his own eyes suggested otherwise. The organisation is now a private company.

So Dr Grumble's advice is to read Ben Bradshaw's article very carefully. Look out for what he has not said. And then open your eyes and watch what is happening. Are polyclinics being rolled out as rapidly as possible across the land? Are private contractors being given a head start over existing suppliers? Is Big Business getting its nose in the trough? And are GPs' surgeries close to the homes of the elderly and disabled being moved to large polyclinics, sorry, health centres? Believe what you see with your own eyes and draw your own conclusions.

12 May 2008

Healthcare in the UK

The Royal Society of Medicine holds Medicine and Me meetings which are intended to give patients the opportunity to interact with healthcare professionals. At a recent meeting the audience was asked to vote on one of the following:

A patient asked Dr Grumble to publicise the result. Apparently some of the things that the government is trying to do with the health service are not at all popular with patients. The public may be more aware of the Darzi agenda than some doctors think.

11 May 2008

Darzi's heart attack management

According to Lord Darzi this is how the NHS should change its practice to manage heart attacks. Or so it seems from his latest report.

Dr Grumble is utterly gob smacked. If this is Lord Darzi's idea of an improvement then there's trouble ahead. We can do better. Much better.

09 May 2008


If Dr Grumble was in charge and he wanted to get the best value for money out of the NHS, he would pour cash into the traditional general practice. It is utterly obvious that this is the sensible way forward. What you do not want is loads of dumbed down staff with access to a mottley collection of special tests in a polyclinic. That is never going to be cost effective. What patients need is a good doctor who knows them with common sense not an itinerant sub-doctor with access to investigations. Medicine is about taking a history, examining the patient, knowing the patient and thinking. It's not about protocols and liberal tests. It really isn't. Patients might want tests but that is not always what they need. So why is our government doing this? If these polyclinics are about money, it just does not make sense. Or does it? The answer is hidden here.

04 May 2008

SPRATs to catch us

Many Grumble readers will have come across the mini-PAT. For any that have not, it is a peer assessment tool . There is a big industry now in these things. They go by various names: multi-source assessment, 360 degree feedback, peer review and peer rating are all examples of the same sort of appraisal technique. And, in case you're wondering, SPRAT is the Sheffield Peer Review Assessment Tool. In Sheffield they gave up making knives some decades ago. They now have a big computer, loads of staff and do mini-ePATs. And they are thriving. This is big business. Sheffield is now the premier provider of workplace assessment across the UK. So they must be doing a good job. Or so you would think.

If you ask those that should know about the evidence base for these mini-PATs you will get a blunt reply. They will look down their noses at you and there will be the implication that you must be pretty ignorant on the topic to have needed to ask the question. The curt put-down will mention validity, reliability and the like. You will have to wait until a Bank Holiday weekend to find out what the evidence really is. And then you will get a shock. Because if you look up the rather sparse number of publications on the topic you will find statements such as this:

It is no secret that mini-PAT lacks sufficient field evaluation and has not gone through any stringent criteria that are required for the validation of an assessment tool.

And further:
No evidence of reliability has been published to date.........

Furthermore, more generally:
Non specific feedback does little to effect a change in performance.

In a third of cases feedback results in decreased performance.

An improved outcome is by no means the rule.

It is then that you will understand why Dr Grumble has been given such short shrift when he has queried these dubious newfangled initiatives. There is no firm evidence to support the mini-PAT. The emperor really has no clothes. Yet every new doctor in the land is being subjected to trial by mini-ePAT. And the results will be stored on a Big Brother computer for the rest of time. A whole industry in Sheffield is dedicated to this stuff. All based on smoke and mirrors. Does anybody know where Dr Grumble can buy a decent knife?


Aza Abdulla A critical analysis of mini peer assessment tool (mini-PAT)

03 May 2008

Value for money