30 July 2008

Starving to death in hospital

Dr Grumble was at a meeting the other day at which he was urged to recognise the problem of malnutrition in his patients. The allegation was that doctors often fail to spot the problem. The recommended solution was loads of supplements and, if necessary, feeding the patients with tubes either poked through their noses into their stomachs or plunged more directly into their stomachs through their abdominal walls. For some reason, like so many things these days, it's doctors that are to blame.

But Dr Grumble has another explanation. He thinks it's the nurses that are to blame. Nurses have become very good at paperwork and very good at doing work (though not the chores) that used to be done by doctors but they have become very bad at basic nursing care. And what could be more important than getting patients to eat and drink? From their voluminous paperwork nurses frequently tell Dr Grumble that patients are not eating enough. Dr Grumble asks why. Often the explanation is that the patient just won't eat. Around the bed of such patients invariably you will find a wonderful collection of expensive nutritional supplements of one sort or another. They cost more than a decent meal. Yet often they are untouched by the patient and more often than not they are just out of the patient's reach. After Dr Grumble has been told this, he will select the most appetizing supplement, usually a pot of yogurt, and pass it to the patient. Not infrequently the patient will snatch the pot from Dr Grumble and consume the contents ravenously. These patients are indeed starving. They are starving not because the hospital food is bad (ours is quite good). They are starving because the nurses don't even ensure the food is within reach of the patient. They certainly don't spend enough time feeding patients unable to feed themseves. Some patients need to be fed like a baby needs to be fed. It needs time. It needs patience. It needs kindness. It needs attention to basic needs. It needs nurses - good old-fashioned nurses. These nurses need to be supervised by senior nurses, proper ward sisters, not managers, who need to have pride in their work and be rewarded. These nurses need to be rewarded for nursing not for becoming quasi doctors. Running a busy ward is a great responsibility. It's not easy. Why is that never recognised?

The solution to hospital starvation lies not in criticising doctors for not appreciating the problem of malnutrition and being reluctant to assault their patients with tubes. Nor are the nurses themselves to blame. We should criticise the rotten systems we have created for training nurses. We used to have vocational nurses, people who had a calling to nurse, who trained in an apprenticeship based around caring for patient. But now we have too-posh-to-wash nurses with degrees who think that basic nursing care is beneath them. We should be spending money on nurses not to become pseudo-doctors or managers but to do, yes, nursing - basic nursing. And instead of those expensive but not always appetising supplements we should spend money on better hospital food and round the clock availability. There was a time when a nurse could rustle up an omelette in the ward kitchen. If this is no longer allowed we need decent alternatives. Who knows? It might even be cost effective.

Far too little attention has been paid to these issues. It was some years ago now that Dr Grumble noticed that those plastic teacher beakers with a spout that were used to water patients had disappeared from the wards. Young doctors have never even seen them. Before then nurses used to feed patients from enamel containers with a spout. All these things have gone and the only substitutes have been the doctors' tubes. Reluctant to resort to these, doctors are now having to do the watering rounds.

British nursing used to be the envy of the world. It's very sad to see the way it has gone.

This post was first published on 20th October 2007. It has been republished now in response to this.

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.

26 July 2008

How the advent of the NHS caused blindness

Patients like oxygen. They think it is good for you. Nurses like oxygen. They think the same way. Ambulance staff certainly like oxygen. But is it always good for you? The answer is a definite no but it's well nigh impossible to get some of these groups to listen. You are onto a loser if you try telling people - even those that really should know better - that oxygen might actually be causing trouble.

Imagine if you had a tiny premature baby to look after and somebody told you to restrict its oxygen supplementation. What would you do? Supposing some eccentric told you that he thought that oxygen might actually be harming premature babies and that he was going to do a trial to test this hypothesis. Would you be tempted to turn up the oxygen at night when the eccentric was not around? You would not be alone. This is what the nurses did in some of the trials designed to investigate the cause of retrolental fibroplasia, a cause of blindness. This disease started in England just as the NHS started. That was the key clue that led to the cause of the disease being found. You can read the story here and here. But if you're not interested, how about watching the video below?

This post was first published on 23rd June 2007. Dr Grumble has republished it in response to this post from Nice Lady Doctor.

16 July 2008

How things change

It is rumoured that the GMC is supporting web sites which make recommendations on the quality of particular doctors. This is what the GMC used to say:

Doctors should not ....... cause, sanction or acquiesce in the publication of their names or practice details in any professional directory or book which purports to make recommendations as to the quality of particular doctors or their services.

Advertising - Guidance from the General Medical Council
Published 1995
Withdrawn 1997

How it be so wrong to do this in 1997 and so right in 2008? Is this about the death of professionalism?

The reason we don't advertise is that, contrary to what many are now trying to tell us, medicine is more than a commercial activity. The GMC itself used to agree with Dr Grumble:

The promotion of doctors' medical services as if the provision of medical care were no more than a commercial activity is likely both to undermine public trust in the medical profession and , over time, diminish the standards of medical care which patients have a right to expect.

Withdrawn 1997

What has caused the GMC to change its view? Why is it now all right for a doctor to set up practice in, say, some heavily advertised Virgin polyclinic and get a cut when he refers a patient for some doubtfully efficacious Virgin add-on therapy? If patients want alternative treatment that is fine. But they must go into it with their eyes open and we as a profession must not collude and make commercial profits from our collusion. This is about trust, the trust the GMC mentioned in the quote above but now seems to have forgotten. When a patient sees a doctor they should feel confident that they are getting advice that is not tainted by the needs of commerce. That doesn't always happen. But that should be the aim. The fact that mostly it does happen, especially in general practice, may well be why the public trust doctors so much. Patients need to be able to trust their doctor. We must preserve this trust at all costs.

Professional self-regulation emerged in the 19th century. It was not just doctors. Lawyers, auditors, architects and engineers did the same. They did it to set standards, maintain public trust and to prevent the public being exploited by unscrupulous charlatans.

This need has not gone away. Far from it.

14 July 2008

MRSA: How we lost control

Dr Grumble can remember when doctors (but not managers) had a real concern about MRSA. He can remember having his orifices swabbed to make sure he was not a carrier. Microbiologists of that era felt that MRSA was something that we could and should control. Dr Grumble can remember how seriously the problem was taken. There was concern in the lab and concern on the wards.

Swabbing of the Grumble orifices has not happened for decades. In fact it didn't happen for long because doctors found to be carriers were not allowed to work and pretty soon so many were sent off work that the managers felt that we were making too much fuss. At that time Dr G used to work up to 168 hours a week so losing a doctor was equivalent to losing 4 staff working normal hours.

How they used to screen NHS staff.

So how many of the staff are carriers now? Dr Grumble cannot tell you what the figure is for his hospital because, as far as he is aware, nobody knows. Nobody looks any more. We can't keep MRSA out of our hospital. The patients arrive with it and they have to be treated. Probably the staff have it and probably they spread it to their households. And probably they spread it from hospital to hospital. An Australian healthcare worker was believed to have brought an epidemic MRSA strain from Victoria to London to cause the 1982 outbreaks.

Dr Grumble, as some will know, left clinical work for 6 years. Over twelve years ago he returned to do a locum in a deprived district general hospital. When you leave and return changes hit you. And he can remember noticing, not without some horror, that the authorities had in the intervening 6 years given up the battle against MRSA. Patients with MRSA were being nursed in open wards and lip service only was being paid to barrier nursing. The hospital was a mad frenzy of busyness. MRSA was low on the list of priorities. There were not the resources to do things properly. Given the lack of resources the loss of control of MRSA was not really the fault of those at the coalface. They had not been given the tools they needed to tackle the problem.

Could things have been any different? The answer is yes.

A costly consequence of failure to deal with MRSA.

The figures below show the proportion of isolates of Staphylococcus aureus which are methicillin resistant in selected European countries (1999-2002 figures):
United Kingdom 44.5%
Netherlands 1%
Sweden 0.7%
Norway 0.2%
Quite a difference. Now why should that be?

Dr Grumble once tried to transfer a Dutch patient to a hospital in the Netherlands. When he tried to negotiate this he could detect the shock at the other end of the telephone when the Dutch staff realised they might have to take an inpatient from the UK. They would not even begin to consider this until he had been screened for MRSA - which is not part of our routine. In the Netherlands and parts of Scandinavia in most hospitals they have an aggressive MRSA search and destroy policy. They even screen exposed healthcare workers. It can be done. It works. It should have been done in the UK. Dr Grumble can remember those that understand these things shouting their concern from the roof tops. Nobody took any notice. And, unsurprisingly, these same people then seemed to just give up. You do. You get worn down if the management ignores you. And when the cat is out of the bag is there any point any more? It's odd that the management are now running around like beheaded chickens telling us off about this problem.

Can the management be blamed? After all, controlling MRSA would be costly. Of course they can and should be blamed because almost every analysis that has ever been done has shown that it is cheaper to control MRSA than to let it run wild. The cost of caring for patients infected with MRSA is so great that it makes screening look cheap.

A management failure to search and destroy.

Doctors are not much to blame for this. Those that knew lobbied hard. But loan voices can do nothing. The fault was with managers, managers who failed to heed the warnings of doctors, experts who knew what they were talking about. And now these same people are blaming the doctors for this. It makes Dr Grumble angry, very angry indeed. The ignorance of these people about the history of all this is breathtaking.

By the way there are more practising doctors in the Netherlands than in the UK - 57% more (2004 figures). Do you think that might help? Not from the viewpoint of managers. After all it's doctors that are to blame.

This post was first published on 3rd November 2007. It attracted some interest from Chris Vallance at the BBC who asked Dr Grumble if he would be interviewed on the radio. Dr Grumble declined. Others then expressed doubts about the truth of Dr Grumble's story. Anybody in medicine who is as old as Dr Grumble will know that the story is essentially an accurate account of how the battle against MRSA was lost in the UK a very long time ago. At that time no member of the public had ever heard of MRSA. Nor, probably, had any NHS managers. They weren't interested. They weren't listening to the concerns of doctors. By the time they were forced to listen it was too late.

Dr Grumble's story has to be true. Otherwise how can anybody account for the different prevalence of MRSA in the cleaner countries of Europe?

Never events

Operating on the wrong side is pretty disastrous. Perhaps to those outside medicine it may be inconceivable that this could ever happen. It doesn’t surprise Dr Grumble. Actually it surprises him that these things do not happen more often.

Proper procedures can bring about improvements. Just occasionally Dr Grumble finds an inpatient who has escaped being labelled. It worries him. That’s a mistake waiting to happen. But we haven’t always labelled patients. And we haven’t always labelled newborn babies. Many years ago Dr Grumble’s father introduced this innovation in the maternity hospital where he worked. Now it’s universal. Mothers no longer go home with somebody else's baby. But it’s difficult to make innovative changes at the coal face. Consultants certainly no longer have the power to do something so radical.

The Chief Medical Officer likes to make comparisons with the airline industry with its strong focus on safety and check lists. Check lists are thought to be one way to try and avoid errors in operating theatres. Probably they will help. But it may be easier to write check lists relating to the operation of an aircraft than for the ever-changing goings-on in an operating theatre.

In praise of check lists one often reads of the surprising finding that introducing a check list for the insertion of CVP lines saved 1,500 lives in the first month. Dr Grumble was stunned by this. For such a result it must have been that doctors were simply not doing what they should have been doing to insert a CVP line. Otherwise how would a check list have helped? How could doctors be so sloppy? Has Dr Grumble ever inserted a CVP line under less than optimal circumstances? Yes. Quite often. He has often not had the equipment he needed. He has often not had the assistance he needed. He has often not had the time that he needed. And, in days gone by, he was often exhausted. Check lists and a requirement that they be followed could well help. It is not necessarily the individual that is at fault. It is often an unsupportive system. And in which part of the NHS were the doctors’ efforts on CVP lines so sloppy that a check list was able to transform the outocme? Actually in was not in the NHS at all. It was in the US. Even Americans apparently take short cuts with their lines. It may even be that errors are worse over there than in the NHS.

But there's an ironic twist to this. Those smart US doctors who found an innovative way to deal with the sloppiness of those inserting CVP lines were sloppy themselves. They are now in trouble over the ethics of their study. It's a funny world.

13 July 2008

Profits or patient needs?

In this country we have a much better system. Who says this? Not humble Grumble but a Nobel Prize-winning scientist. You can listen to Sir John Sulston here. But will anybody listen.? Sir John may have the mental wherewithal but has he got the financial resources to bribe bend the ear of government?

Sir John is setting up the Institute for Science, Ethics and Innovation. If you want any help, Sir John, Dr Grumble is a willing volunteer. Good luck to you. You may well need it.

And let's not forget:

In this country we have a much better system.

That's what Sir John says. He's right. So why do so many want to change it?

12 July 2008

Did not attend

At Dr Grumble's hospital if a patient misses an outpatient appointment a standard letter is sent to the 'culprit'. The letter has been written by a manager or more likely a committee of managers. It is signed by the consultant. It is curt. It is somewhat accusatory. It is dismissive. And it takes no account of the many things that can go wrong to prevent a patient getting to their appointment. There is the assumption that it is never the fault of the hospital. Often it is. Whoever composed the letter can never have worked in an outpatient clinic.

Where Dr Grumble works patients frequently change address. Frequently letters arrive from GPs drawing attention to a patient's change of address. Dr Grumble reads these letters. He then puts an enormous arrow next to the sentence referring to the address change. If he has the right coloured pen to hand he does this in red. The appointment then gets sent to the old address. It is exasperating.

Some years back failed attendees at Dr Grumble's clinic were so high that he suspected something was wrong. There was. Somebody somewhere in the bowels of the hospital was pressing a button to send out appointment letters but nothing was happening. The button was being pressed but sometimes no letter came out. It took them a year to realise. It really is exasperating.

Of course things will go wrong. The odd computer glitch will happen. But some of our problems are created at the highest level and are completely beyond the Grumble control. When things go wrong, patients write to the consultant. Naively they think the consultant is in charge and can actually do something. Sadly they are not in charge. And quite often they can't so anything.

Last week Dr Grumble had the following letter. Dr Grumble has the original letter scanned in. But he's not going to let you see it. A breach of confidentiality could ruin Dr Grumble. So the letter pasted in below is paraphrased and typed.

Dear Mr (sic) Grumble

........I wish to inform you that I would not just miss an appointment. I telephoned to cancel my appointment 11 days before and asked to rebook it for September. I was told that I must rebook nearer the time..........

Mr A Grieve

Some time ago when we had all these targets introduced Dr Grumble pointed out to a senior manager that some patients might not want to be treated as quickly as possible. The manager seemed incredulous. Dr Grumble was also incredulous. He was incredulous at the manager's difficulty with this concept. The manager seemed to think that we all deal with life and death issues. Dr Grumble does deal with life and death issues. But not always. Some things can wait. These things have often been there for some time already. What matters to the patient is getting them fixed at a convenient time which is not necessarily instantly.

Where is patient choice in all of this? Where is, to use the words of our prime minister, 'putting the patient at the centre'?

08 July 2008

A gamble too far

Like the Jobbing Doctor Dr Grumble sometimes wonders if what he thinks he sees happening to the NHS is a delusion. Dr Grumble thinks that the NHS is sleep walking into a future that hasn't fully been thought through and that we are in danger of losing our universal healthcare. Dr Grumble is not going mad. Others think the same way. You can listen to them here. Please do. It's important.

06 July 2008

Tethered goat, honest broker or government stooge?

Many have dismissed Darzi as a government stooge. Even Alan Johnson referred to him disparagingly as a tethered goat. But when Lord Darzi became a GOAT, Dr Grumble was quite delighted - though he was not at all sure he was the right person for the job. A government of all the talents seemed a good idea. If there had been a snap general election he would have optimistically considered voting Labour. As things have turned out, that general optimism might have been misplaced. But the key question now is whether or not the noble lord has done a good job in his final report on the NHS.

So what is in this long-awaited report? Is it all motherhood and apple pie? Are there any horrors signalling more backdoor privatisation? Is it farewell to a free NHS?

Dr Grumble was actually heartened by a lot of what he read. But he does know that you really do have to read carefully between the lines of these reports. There is plenty of evidence out there that this government wants to privatise as much of the NHS as it can. But is Allyson Pollock right that Darzi's report signals that we are on the way to a US system with two tier care and charges? Perhaps Dr Grumble is losing his touch but it is not the message he got from a first reading. But reading between the lines of a lengthy document is a challenge and, on reflection, Dr Grumble is worried about strange experiments such as personal budgets. As Allyson points out this passes risk down to the patient. And what could be the point if privatisation is not the aim?

There are certainly some wonderful things in the report that will enthuse any clinician. There's talk about how we go to work to deliver health care, how we all want to do a good job and how we strive to improve. There's the implication that clinicians should be in the driving seat and that all that holds us back is lack of empowerment. There's talk of quality, measuring quality and making things better. Who could object to that? It's what we all want, patients and staff alike. There's no argument. But some of the detail such as the lack of payment for never events makes no sense unless Allyson is right.

So read what Allyson Pollock says carefully. And read carefully between the lines of the Darzi report. And then decide. Honest broker? Tethered GOAT? Or government stooge? Is the NHS as we know it safe? Or is this a preamble to US style care?

You decide.


As a final postscript Dr Grumble does want to point out that Darzi does say in quite a few places how bad things are now in the NHS. This is a common theme from the government. And they repeatedly knock doctors - especially GPs. Quite often it does not seem to be justified. Quite often if you look for the evidence it is just not there. Quite often you find the truth is quite the opposite. Here is an example:

On page 28 of his report, after slagging off GPs for not giving their patients advice on diet and exercise and referring to a claim from patients that GPs do not ask about emotional issues Lord Darzi states: "We lag behind our peers internationally" and gives a reference to the 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Now it just happens that Dr Grumble has read this report and is well aware of its conclusions. How the noble lord can possibly conclude that we lag behind is baffling. So why is that? It could be just a mistake. Or it could be deliberate. It could be that Allyson Pollock is right.

Lest you do not believe Dr Grumble's interpretation of the 2006 Commonwealth Report, below are unselected graphs from the relevant Commonwealth Fund press release (pdf). Do we really lag behind?

Decide for yourself.

05 July 2008

The patient right at the centre of care

In the video in the previous post Gordon Brown says that he wants the 'patient right at the centre of care'. Dr Grumble has no difficulty with this mantra. No difficulty whatsoever. The patient is at the centre of care. It's obvious. Very obvious. It's what Dr Grumble was taught repeatedly from his first day as a clinical medical student. But Dr Grumble feels aggrieved. He is aggrieved because it's an affront that the prime minister feels the need to tell doctors this. It's an insult that Mr Brown seems to think that doctors do not put their patients at the centre of care.

On the other hand Dr Grumble has never really thought that those other than the healthcare professionals in the NHS thought the same way about patients. Doctors never wanted those sick A&E cases piled up on trolleys in the corridor. Doctors never wanted long waiting lists with patients or their relatives phoning daily to check they had not been forgotten. It's easier and nicer for all to run a quality service with patients' needs the focus. But the managers never cared. They never saw the problem. They were never there at night. Never there at the weekend. Never there dealing with distressed relatives. Never there when the trolleys were piling up. It's the managers who failed to put the patient first. Not the doctors. Not the nurses. And not any of the other NHS professionals. And it's the managers who are still failing our patients. Not that it's their fault as individuals. Quite often their hands are tied by government edicts.

Last week one of Dr Grumble's clinics was uncontrollably disorganised. It's a medical clinic. The slots allocated for a new patient are just 20 minutes long. That's OK. Dr Grumble puts in patients that are clearly the simpler cases - cases he knows he can deal with speedily. For the more difficult cases he has other clinics with bigger slots. Enter the Wicked Witch - Choose and Book. Sounds wonderful. Works dreadfully. Unfortunately patients now have control of which slots they go into. Sounds good. Patient choice. But patients do not know how long Dr Grumble needs to deal with their particular problem. Patient choice is not at all the same as focussing on patients' needs. In the old days it was so easy. The GP wrote a thing called a letter. Dr Grumble read it and, putting the patient at the centre of his decision making, allocated the patient to the best clinic for their needs. If it wasn't convenient the patient could use a thing called a telephone and change it. But now, the government's C&B edict, the patients turn up in a Martini style - any place, anywhere, any time. Others have similar problems. It's not putting the patient at the centre. It's putting government initiatives at the centre. Mr Brown needs to learn from his own mantra.

Another example from last week shows the inflexibility of Choose and Book. What happened was this. A lady chose and booked into one of Dr Grumble's clinics. Whether it was the best clinic for her or not is immaterial because the patient had a domestic crisis and she couldn't come. So, helpfully, she phoned the receptionist to rearrange her appointment. Sensible you might think. But no. The patient had chosen and booked. Only she has the password to Choose and Book. The hospital cannot, apparently, change the appointment. That, anyway, is what Dr Grumble has been told.

Dr Grumble thinks that this poor patient who had a domestic crisis and in the midst of it all made the effort to phone the hospital is stuffed. She will probably have to start the whole process again. Dr Grumble doesn't actually know. He has, though, written a letter to her GP suggesting (and one hopes this isn't NHS sacrilege) that, yes, a referral letter is sent so that Dr Grumble can rectify this. Dr Grumble you see is no longer empowered to send her another appointment. That is just not allowed. Another edict. How's that for patient centred care? The patient is hardly likely to see this as putting her at the centre. And the poor GP will have to produce a letter. The GP will understand that Dr Grumble is not just being difficult. The hapless patient may well not.

Whoever dreamed up Choose and Book failed to realise that a hospital appointment is not quite like booking a flight. That's because the government takes advice not from health service professionals who know but from convincing management consultants who don't know but have a degree in, well, anything at all. Or maybe even nothing.

Of course, in case you don't know, Choose and Book is not much to do with giving patients what they need. It's about giving the government what it needs. And the government needs some way of getting patients to go to providers outside the NHS. It's all about back door privatisation. And the mechanism is patient choice and Choose and Book. It's not about patients. It's about government.

What have a cottage hospital and John Lewis in common?

Dr Grumble has worked for the NHS every day for the last 12 days. It's a quiet time of year for his specialty so it hasn't been too bad but the latest Darzi report has had to go on the back burner. He's heard the hype on the news but the nitty-gritty will have to wait. Dr Grumble is not yet sure whether the report is a bombshell or a damp squib.

Another thing that has been on the news is the John Lewis list. Readers of Dr Grumble are overwhelmingly from the UK. Most of you will know about the John Lewis list. But it may just be that some of you in the rest of the world, intrigued by the stories of our robotic lord , are still reading this so, especially for you, here is a link to the John Lewis list. Sometimes Dr Grumble wonders what our friends from across the pond think of a country that pays its Members of Parliament in goodies from a department store and gets a robotic lord to decide on the future of its greatest national asset. But that is today's UK. Even our prime minister, it seems, has realised that one of these eccentricities needs fixing. It's a shame he doesn't seem to know which one.

Anyway the news of the John Lewis list set Dr and Mrs Grumble talking about John Lewis. The John Lewis organisation is different - very different. Now Dr and Mrs Grumble know nothing about business and nothing about finance. Few doctors do. But one thing the Grumbles are aware of is that John Lewis is a partnership. There are no shareholders there creaming off as much as they reasonably can. They are partners. If you work there you are part of it. That's how it works. And it seems to be successful. So if it's so successful why are there not more of these sorts of enterprises? Knowing as little as he does about business that's not for Dr G to comment upon. But he does have some ideas.

Dr Grumble has always liked the idea of a partnership. When the water suppliers were sold off he wondered why ownership couldn't pass from the public to the water customers. If the pipes went to your house, you would be a partner. Of course, this would never have happened because the object of the exercise was to raise much needed cash for the government. It's always matters related to the flow of money that governs these things. Is that why there are not more partnerships? Potentilla would have known.

If you have got this far, you will be wondering why Dr Grumble is heading off into the realm of things that he just does not understand. The answer stems from this video of Mr Brown visiting a cottage community hospital.

Dr Grumble was a little worried that this was a venture involving Virgin, an organisation whose raison d'ĂȘtre is to make money. If you set out to just make money in healthcare you focus on the young worried well who don't need you but take whatever resources you are prepared to throw at them. These are the people prepared to spend billions on useless remedies for conditions they do not have. These are the people prepared to pay for water that comes equally or more wholesomely out of taps. The companies manipulating these gullible punters create anxieties and then deliver solutions for a problem that was never there in the first place. These are the avaricious healthcare organisations that advertise on the bottom of swimming pools to make sure they don't have to spend money treating the genuinely sick.

So you can see why Dr Grumble was worried about Gordon Brown's latest venture. After all, there was surely a reason why Mr Brown went to this particular cottage hospital. You can be certain of that.

But this can't have been a Branson venture or he would surely have parachuted in dressed in some ridiculous eye-catching garb designed to fill a front page. The truth worries Dr Grumble much less. It's clearly an experiment. But it's not one that Dr Grumble minds too much. Because it seems that the cottage hospital being visited by our esteemed leader is part of a partnership.

With thanks to the Witch Doctor who drew Dr Grumble's attention to this latest NHS venture. And with some reservations as quite a lot of these non-profit organisations turn out to be fronts for big business hiding in the wings. We shall see.