28 March 2009

The NHS and supermarket mentality

What you do not appreciate is not valued, and that which you do not value is soon lost.

Not the words of old Dr Grumble but the words of a junior doctor. But it is a point that worries Dr Grumble. Our government seems intent on undermining the NHS in the eyes of the public. Public expectations are being driven ever higher and nobody seems to realise, certainly not the government, that these are expectations that can never ever be met. Despite bankers demonstrating the catastrophic problems that can result from unfettered markets the government continues to see markets as the solution to the NHS. This can never be. Why the management gurus cannot grasp this escapes Dr Grumble. For them there will follow at the end of this post a little allegory which was stimulated by these words from a junior doctor which set Dr Grumble thinking:

The harridan with the woman then proceeded to say - really nastily - "I think we'll change the whole hospital next time. We won't come here again."

What do these people think the alternative is? Is there a Special Hospital around the corner where their trivial tax payments are magically converted into their own private physician, caterer, and a master of ceremonies who ensures things happen at the moment they snap their fingers?

The alternative hospital down the road is, of course, the model our government favours though, as the junior doctor plainly realises, it is not a realistic or sensible one. Shopping around for healthcare seems to be the government's panacea for each and every problem of the NHS. But shopping around is not what you do when you are ill. Shopping around is what you do when you go, say, food shopping with your own money. You can chose Waitrose or you can go for Asda. If someone else is paying it will be Waitrose. If you are paying it could be Asda but it might be Waitrose depending on how much you are prepared to spend. If somebody else is paying you will moan if they make you go to Asda.

It is a not such a strange thing that if you open the doors of either Waitrose or Asda and tell the customers that everything is going to be free there will be queues at the door and the shelves will soon be empty. Just imagine what happens in this idyllic world of the free supermarket. Inside the shop the underpaid shelfstackers work in a mad frenzy trying to keep the shelves full. But however hard the stackers work to ensure the shoppers have everything they need, the customers keep emptying the shelves. The shop is always thronging with people. It's difficult getting from one aisle to another. The shopping process is inefficient. Cleaners can't clean because the place is so full. This needs a management solution. So the managers limit the number of people allowed to come into the shop. Queues build up outside but people are prepared to wait for over six hours for something that is free. But that is the only way you can control demand. In any other shop you control demand but putting up the prices. But that can't be done in the mad world of the free supermarket.

But limiting demand by controlling the numbers allowed into the shop also has its problems. The queue outside the shop grows and grows. People start travelling from abroad to take advantage of the free food. Soon the queue is blocking the whole high street. This needs a management solution. So the managers introduce targets. People must not wait outside the shop for more than, say, four hours. So they double the size of the shop and employ more stackers. They even open another shop to compete with yet more free food. The stackers find there is more work than ever because as the queue time shortens to four hours all those people who couldn't be bothered to wait six hours decide to go shopping for free food. For the queue to grow despite the management's efforts the managers are convinced that the stackers must have been slacking. The managers whose pay depends on keeping the queue short, unusually, take to the shop floor and goad the stackers who are already working as fast as they can. Shortcuts are forced onto the supermarket workers. At the meat counter somebody starts using the knife used for raw meat on the cooked meat. And for a while everything is OK. But then one day there is an outbreak of illness caused by E coli 0157 and a lot of people die. And very curiously everybody is surprised and wonders how this could possible happen.

25 March 2009

It's a funny world

Here's what Mr Obama says about the idea to roll out something like Medicare to all :

“It gives consumers more choices, and it helps keep the private sector honest, because there’s some competition out there.”

How very odd. Our government wants to introduce private providers to increase choice and provide competition. The US government wants to introduce a public system to increase choice and provide competition and keep the private system honest. The US government seems convinced that their private system has its problems (honesty apparently) and our government seems convinced that our public system has its problems. Those connected with private healthcare in the US seem worried about the US proposals. Dr Grumble is worried about the UK proposals.

What is the common purpose here? It is that on both sides of the Atlantic this has been driven by managers with a common mantra whose chant goes:



Contestability (which is, of course, newspeak for competition)

But the real aim in the UK is for the government to divest itself of all healthcare organisations. What our government really wants is a multiplicity of providers and it wants to be directly responsible for none of them.

Bizarrely, given our recent economic woes, freeing organisations to do as they please is still seen as a success. Yet we know that as the reins were eased in Stafford the management focus was instantly transferred from patient care to matters of money. It may seem odd but it is a sad truth that organisations generally value money more than lives.

Just as bankers were freed from tight constraints we now have the formerly highly regulated healthcare professionals being freed from their traditional boundaries. Nurses and pharmacists are missing from Dr Grumble's ward because they are on prescribing courses though how they can they prescribe when they are not trained to diagnose is not clear. And who is to look after the ward or the pharmacy if they are doing the doctor's job? Blurring is of course the management aim. It's about plurality and contestability - words whose meaning is vague except to those who coined them. There's a name for this. It's semantic deception. The nurse and the pharmacist will bit by bit compete with the doctor. There's a name for this too: gradualism. The patients won't know any different because you cannot recognise who is who any more. The doctor's white coat, a relic of the days when hospitals were scrupulously clean, has been banished - paradoxically on grounds of cleanliness. Nurses and healthcare assistants are already indistinguisable to the average punter. There is a theme to all of this. It's the same deregulatory theme that was used on the bankers. But government never learns from its mistakes.

23 March 2009

A great idea

Between patients in his clinic, a wonderful money-making idea has dawned on Dr Grumble. He is going to set up a web site that will transform the NHS. It is going to be called ratemyNHSmanager.com. Doctors will be able to log in at any time and give frank accounts of occasions when managers have put patients at risk or damaged clinical care in some way.

Please understand that Dr Grumble is not saying that bad management ever happens in his Trust. Oh no. But there may be other hospitals in the land where managers focus on targets instead of patients . The site is for those bad places and for those bad managers but those that work in Dr Grumble's hospital will be pleased to know that you will be able to praise your manager too. Using the wonders of web technology this initiative will be bound to transform the NHS because it will make sure that managers perform in their main duty which is to facilitate great patient care. Dr Grumble feels sure that the government will soon be on the 'phone asking where to send the big cheque to support this great idea. Or they would be. But for the fact that Dr Grumble is not a Common Purpose graduate.

22 March 2009

Democracy RIP

We used to have something of a democratic process in the United Kingdom. There were left wingers and right wingers. There was the Tory party which was a bit to the left of New Labour and the there was the Labour party which was to left of anything you can now dream of. Each party had their mavericks who expressed views that were two standard deviations more extreme than their party's mean. There was genuine debate in parliament. A full range of views was aired. We had a vibrant press. You could easily find newspapers with a very left wing perspective and newspapers with a very right wing perspective. But many of those differences are now much more blurred. The main political parties no longer look to separate themselves with clear blue water. Instead, like the coxes in the boat race, they fight for the middle way. Mavericks are no longer admitted to the exclusive club at Westminster. To become a parliamentary candidate for a major party the first prerequisite is to be prepared to toe the party line. If you have the misfortune to meet any of these colourless people you will find it hard even to know which foot they kick with.

All this is bad. Consensus may sound good but it's dangerous if it is just a consequence of being given the same hymn sheet to sing from. For too long fundamental wrongs about the way we
have been heading have gone unquestioned. The banking catastrophe is just one example. Why were no questions asked about that? Was it really that people were unable see the evils of what was going on? Or was it that they had no way to blow the whistle?

If there is one group that is mostly to blame it is the journalists. What, for example, have they really done to flag up the problems of the misdirection of the health service? How often have they picked up stories spoon fed to them by the bloggers? The word 'never' springs to mind.

The journalists do have some insight. Here's Nick Cohen:

... those who ought to have shouted from the rooftops about patients begging for help from excrement-stained beds bit their tongues. Their dereliction of duty is all the stranger because, while Labour did not regulate the City, it sent an army of quangocrats to monitor the NHS and helped staff raise urgent concerns by providing statutory protection for whistleblowers.

For all that apparent encouragement, whistles were not blown by doctors or nurses in Stafford. Instead of independent professionals with the confidence to defend the public interest, the Healthcare Commission described sullen staff, bullied by managers and neglectful of patients. Doctors told its investigators that they had been "proletarianised": turned from professionals with their own codes and standards into employees who must obey.

And here is a telling paragraph:

Suppose whistleblowers were to turn to the press. They would find a cowed Fourth Estate, which is being battered by the recession, and a judiciary which does not believe in freedom of publication. (Source)

Of course this does not make sense. The recession is no reason not to publish a good story. And it can't really be the judiciary blocking the truth. So why has the press repeatedly failed to relay what the workplace bloggers have been saying for 4-5 years until, that is, the cat is already out of the bag?

21 March 2009

Curing with the knife

According to Dr Crippen, and he is right, there are three medical procedures that can be dramatically live-saving.

The three procedures are:

1. Relieving a tension pneumothorax
2. Performing a tracheotomy
3. Drilling burr holes into a skull

Dr Grumble has done numbers 1 and 3 as emergencies. He has lost count of the number of times he has done number one. He has never done number 2 as a lifesaving procedure. The reason for this is that by the time patients get to see Dr Grumble with their airway in difficulty they are usually either dead, better or can manage without the Grumble knife for long enough for somebody more expert than Grumble to deal with the problem. There are also sometimes other tricks you can do to buy time.

But Dr Grumble did once get to sharpen his knife. It was so long ago confidentiality is really not an issue so Dr G is going to tell you the story.

At the time Dr Grumble was working as a Senior House Officer in the intensive care unit of a large teaching hospital. These days such units have vast numbers of junior and senior doctors supporting them but when Grumble was a lad it was different. Out of hours Grumble was it. Any problem and he had to deal with it. The ITU had an excellent reputation. It was almost certainly the best in the land. Any major problem in the rest of the hospital and the patient would be propelled to the ITU. As the patient entered the safe haven of the ITU the accompanying doctors would heave a sigh of relief and vanish.

One evening when Dr Grumble was the only doctor in the ITU there was a phone call from one of the wards. A young boy admitted for a routine operation had suddenly taken a totally unexpected turn for the worse. The attending doctors wanted to wheel the patient straight to the ITU where the young Dr Grumble was it. Sometimes moving emergency cases seems to take an eternity but the young boy arrived in double quick time. True to the usual form, as the bed entered the portal of the ITU the doctors in attendance vanished as quickly as they had appeared and poor Dr Grumble was left with a young boy that looked to be breathing his last, a boy who moments earlier had been completely fit and well.

The history in medicine is all important (Dr Grumble only heard that later) but the young boy could not speak and his doctors had left no clues as to what might have happened that fateful supper time. Dr Grumble had certainly never seen a problem like it before but it was clear that this poor boy's upper airway was obstructed and he could hardly move any air in of out of his chest. Perhaps now, with experience, Dr Grumble would have been able to work out what must have happened but these things are very difficult and very frightening if you are the only doctor there, the urgency of the situation is not in doubt and you have no mileage.

The young doctor's most helpful bit of equipment is the telephone. You use it to summon others to help you out of a difficult situation. Dr Grumble still tells this to his most junior staff but they now only work in the day so for them it is never so frightening. In those days surgeons of all sorts were available in the hospital day and night. It's no longer the case as working hours have been slashed but then Dr Grumble could be sure that somewhere in the hospital there would be an ENT surgeon. So he phoned them and explained as graphically as he could the gravity of the situation and how he needed their urgent help. And then he waited and waited and waited. As the patient's condition deteriorated Grumble began to realise that the patient might need a tracheotomy there and then. It was a well equipped ITU. We had all the kit. Dr Grumble got it out ready and started to sharpen the knife. The boy began getting even worse. He was turning bluer and bluer (no pulse oximeters in those days). There was no more time. Eventually Dr Grumble realised that he was going to have to do something himself. The boy was not yet unconscious. Dr Grumble picked up the knife. A look of horror crossed the boy's face. He sat bolt upright and vomited. And out came a large chunk of fish and a fish bone. And from that moment on the young boy was fine. And then the ENT surgeons arrived and wondered what all the fuss was about.

17 March 2009

Mid Staffs Investigation

The report entitled Investigation into Mid Staffordshire NHS Foundation Trust (pdf) comes to over 150 pages. Dr Grumble has not read it all yet but he decided to do a search for the word 'target'. Unsurprisingly it appears over 50 times. Dr Grumble thinks that the management of this hospital focussed on the things that would make the management appear good and lost touch with the real purpose of a hospital which is to look after patients safely and effectively.

As happens in many hospitals clinicians were pressurised. Here is an example:

The junior doctors...........were often put under pressure to make decisions quickly in order to avoid breaches of the target......

.......patients were sometimes rushed from A&E to the EAU without proper assessment and diagnosis.........[to meet the target]
Dr Grumble has witnessed junior doctors being pressurised. It is so endemic that the pressure continues even when Dr Grumble is present. There is no insight into the fact that hassling a junior doctor into making a decision when he is not ready to do so is plain dangerous. Does this sort of thing happen in your hospital?

15 March 2009

The war on experiential learning and professionalism

Dr Grumble is responsible for a large number of doctors in training. Not as many as 100 but close to 100. There has been a great deal of focus on the training of junior doctors in recent years. Who advised on this Dr Grumble has no idea but he does wonder. Whether any practising doctors were involved Dr Grumble has no idea. He wonders about that too. Because, as we all know, what our junior doctors have ended up with is lots of boxes to get ticked. It seems that the process is more to do with covering the backs of managers than training doctors to a high standard. After all if a doctor has lots of competency boxes ticked there can't be a problem, can there? But, in reality, we all know that these boxes only score adequacy at a very basic level. They are not about excellence. The competencies are not the same as understanding. They do not measure the higher level functioning of a professional. Come to think of it, they do not seem to measure anything useful at all. So it does not surprise Dr Grumble to learn that there is actually no evidence to support their use. So, if there is no evidence, why was this rolled out the way it was across the nation in every specialty? That's something else Dr Grumble does not know the answer to.

Wind back now to when Dr Grumble was a junior doctor. The NHS then was thronging with junior doctors. There were few consultants. The junior doctors spent long hours in a learning environment called a hospital where they worked at being doctors. They learned a lot. They became enormously experienced. Many worked more hours as junior doctors than some people work in a whole lifetime. It was a training that worked and worked well. Doctors came from around the globe to train in the UK. Not just from deprived parts of the world, Australians and the like used to come too. But now it's the other way around, our doctors are leaving to train in the Antipodes. Now why do you think that is?

So where did the competency model that we had no need for come from? It was actually from industry. The idea is that you have a task in, say, a factory and you break it down into its component parts. You then assess the trainee on each of the stages involved. Perhaps it is appropriate to the production line. Dr Grumble has no idea. But is it appropriate to the practice of medicine? Meeting competency criteria are certainly not the same as being professionally competent but our masters seem to make out that it is. Being able to give an anaesthetic might seem to an outsider to be a straightforward competence that you can tick a box on but even an ordinary doctor like Grumble knows that anaesthesia is much more than that. And so, of course, is the rest of medicine. It is about professionalism. It is about high level complex decision making based on experiential learning. True professionals don't just follow rules. That's not what they are there for. They are there to think on their feet at a high level. They are there to deal with uncertainty. They work in areas of greyness. The practice of medicine is not about simple competencies. It is about multifaceted high-level professional competence. These are not things that can be simply measured. They are too complex for that though they can be recognised when you see them. Sadly, appraisal, grading and league tables seem to be the order of the day for our political masters. There is no getting away from them. And now it is reaching really absurd levels.

Can we do better in our assessment of junior doctors? Dr Grumble does not think we easily can. We do not yet even understand the heuristic processes by which a doctor makes a diagnosis. If we don't even understand how good doctors do these basic things how can we easily appraise learners?

And, to make matters potentially worse, we are now going to have to reduce the hours our doctors work whether we or they like it or not. There are 168 hours of the week when care needs to be given. If hours are too short consultants and juniors will only meet like ships in the night.

Whatever happened to Tooke? Sometimes there seems to be no progress at all and that our masters keep blundering on.

14 March 2009

An expensive dog's dinner?

Do you remember when Dr Grumble introduced you to the words 'contestability' and 'plurality'? He puzzled over these strange words and what they might mean. He came to the conclusion that they were veiled references to privatisation of large chunks of the NHS.

The trouble with privatising the NHS or with putting it on a private footing is that you lose two of the greatest strengths of the NHS. The first great strength was that it needed few administrators to run it. Of course that is no longer true. The number of managers is shooting up. The reason is that if you are working like a private organisation you need to look after the processes like billing and, yes, even advertising like a private organisation. The NHS never used to need to send out bills and advertise. How does this affect us at the coalface? To give just one example, Dr Grumble's hospital now has a very large press office and, from time to time, a large car is sent to whisk him to the heart of London to talk on the telly, or God forbid, even on LBC. All this is new. It all takes time. It all costs money. And none of it makes sense unless you have competition and choice - more favourite government words. And to have choice you need Choose and Book - which is also expensive. And to have competition you need to duplicate services. Which also costs more because you have at least two of everything. And you need to know what you are buying so it is claimed you need the execrable iwantgreatcare.org. And the end result is that you have a gleaming new polyclinic with lots of investment and advertising versus traditional GPs with good quality family doctoring. Which will win out do you think? Dr Grumble knows. If you can persuade people to pay for water they do not need the answer is clear. But people will not be getting what they really need for genuine quality care. They will be getting what they have been persuaded they need but really just want. Because of the power of advertising. Which will be another very expensive part of the process.

Those that didn't believe Dr Grumble (and there were many) when he said the health service was essentially being privatised should surely believe him now. A few short years and all has become clear. Of course for this to work you need multiple providers. You need world class commissioning. You need supermarket-type competition. And all this means that you lose the other great strength of the NHS - cooperation and collaboration. So, to deal with this you, have the Orwellian Cooperation and Competition Panel which doubtless will also waste yet more of your money. Nobody knows how this will work. Nobody knows if any of this will work. Nobody knows if all these things will cost more than they save. But you could have a good guess.

Here is some newspeak for you:

"a community in which power, wealth and opportunity are in the hands of the many not the few, where the rights we enjoy reflect the duties we owe...in which the enterprise of the market and the rigour of competition are joined with the forces of partnership and co-operation."

Where do you think that comes from? Yes. It's Nulabour-speak. Their new Clause 4. Would you believe it?

With thanks to Richard Taylor who was the inspiration for this post.

10 March 2009

The workhouse mentality

Dr Grumble has lost count of the number of hospitals he has worked in that used to be the local workhouse. People used to be terrified of the workhouse. Men were put one side, women the other. Husbands and wives were separated: children were separated from their parents. As a student Dr Grumble used to wonder why patients were terrified of going to particular hospitals. It wasn't MRSA. It wasn't that the hospitals were dirty. It was because the hospital had been the workhouse and the terror which the workhouse had held had carried over to the time when the workhouse had become a hospital.

In the Grumble hospital we have a new young consultant. She is very good and very enthusiastic. She is an integrated consultant or something like that. Dr Grumble is a hospital consultant but if you want money for a new consultant these days you need to go into integration mode. It's all to do with the government mantra that patients do not like hospitals and want and should be treated close to their homes. Perhaps this is right. Perhaps it is wrong. It really doesn't matter because that is what we are required to do. Dr Grumble has a patient who is chronically ill. Mr Coulthard is a nice man but he is struggling to manage at home. The nice young integrated consultant has been to see him. She has persuaded him to go into a home. Or she thinks she has. The idea is that he will go into a home. His wife will be elsewhere. It's like the workhouse. But Mr Coulthard is has changed his mind. The integrated consultant is said to be baffled. "I've been with my wife for 60 years," he told Dr G today. "I don't want to be apart from her". Nor should he be. We still have a workhouse mentality.

We treat people like this because they are old and don't matter. Or so you might think. But it's worse than that. The truth is that it is nothing to do with age. It is just that our systems do not begin to understand what matters to people.

What is the worst the Grumble hospital can through at you? Whether you like it or not Dr G is going to tell you. If you are a young lady and you have a baby that you are breast feeding and you have the misfortune to, say, have bad pneumonia you might think that the Grumble hospital would allow you to bring your baby into hospital with you. But no. That is not allowed in the Grumble hospital. The managers keep hectoring the staff about putting the patient first and patient dignity but you are not allowed to have your newborn baby in the Grumble hospital with you. It is workhouse mentality. It is an outrage. But it is not something Dr Grumble can do anything about. Which is one of the reasons why he has a blog.

07 March 2009

Nice one, Cyril

The picture that was here has been removed because, according to Dr Grumble's legal advisor, it was a violation of copyright. Daft these laws because presumably you could look at the picture if Dr Grumble told you where to look.

Sometimes Dr Grumble has the sensation that there is a hidden force out there that is driving the course of healthcare in completely the wrong direction. Sometimes things just do not make sense to Dr Grumble. Why should apparently highly sensible people at the top of their professions veer the wrong way? Is there some Orwellian force at play?

What does the word 'Orwellian' mean? Mrs Grumble says it refers to a world where everything is controlled, you have to follow the party line and sometimes you have to agree that two and two make five. Here is an Orwellian letter from the Times that Dr Grumble stumbled upon in the comments on Jobbing Doctor's blog.

Sir, As clinicians and partners working in the capital we find it sad that your story on Professor Darzi’s excellent report Healthcare in London (“Local hospitals face axe”, July 11) concentrates on hospital closures and not on the main theme, that patients need the best quality care in the right place.

The care provided to stroke patients in the capital is just not good enough. There are many small GP practices without the facilities to offer even blood tests and ultrasound to their patients, while the hospital may not be the right place to go for a wide range of relatively minor complaints. That is why the polyclinic is proposed. We agree with Professor Darzi that better specialised care in major acute hospitals, treating in particular stroke and heart attack patients, will significantly improve the outcomes for a large number of people.

CATHY WARWICK, Visiting Professor of Midwifery, King’s College Hospital NHS Foundation Trust




DR MAGGIE BARKER, Deputy Regional Director of Public Health, London

SIMON CRAWFORD, Chief Executive, West London Mental Health NHS Trust

This is a two and two make five letter which, according to Mrs Grumble's definition, makes it Orwellian. What can be behind this? Does Dr Grumble's friend or her Black Cat have the answer?

01 March 2009

I have the time

Perhaps there are important people out there reading the Grumble blog. Not long ago Dr G was complaining about how patients were left to starve on the ward. Food was given to the patients but nobody was helping the patient eat it. Things were so bad that the junior doctors became so fed up having to give patients intravenous fluids that they began doing rounds helping patients to drink. Watering rounds they called them. That is what was happening but Dr G might just have thought it unwise to mention that particular one at the time. Does anybody listen to Dr Grumble? Perhaps. Since Grumble first raised the feeding issue we now have 'protected meal times' when all other work ceases so that patients can get fed. Superficially it seems like a good idea but it does not actually address the fundamental problem which is lack of nursing time on medical wards in particular. It frustrates Dr Grumble that in today's hospitals for every major problem there is some knee jerk management solution. But the solution never involves more resources. It never addresses the fundamentals.

So how do you address the fundamental problem of lack of nursing time. They have the answer in the United States. It is another quick fix management solution. It is called scripting. It is really very simple. All the nurse has to do is say to each patient, "Is there anything else I can do for you? I have the time." The reason this has been introduced is that surveys (conducted, of course, by some outside company) have shown that patients do not think the nurses have enough time to deal with their needs. So the idiotic knee jerk management response is to get the nurses to say they have the time. Mark the Grumble words. This will be seen in the UK as being such a good idea it will soon be rolled out across the NHS. But, like all the other similar initiatives, it completely and utterly fails to address the underlying problem and hacks off the staff no end.

Unfortunately hospitals, both in the US and the UK, are now focussed on superficial images rather patient care. Shopping for medical care and competition by flat screens has now come to the UK with the focus moving towards thick-pile carpets which cost relatively little and bolster images and away from more nurses which cost a lot and are less visible.

If anybody was wondering how Dr Grumble's patients heard the news about Ivan Cameron's sad death so quickly, it was from the large flat TVs recently installed in the Grumble waiting room. This is really not what hospitals should be about. Shop floors workers know that. Even in the US. Money really needs to be directed towards patient care and not towards creating marketing images.

With thanks to Nurse Anne who triggered this post.