30 April 2009

The NHS market

Dr Grumble would argue that the market has failed. It seems he is in good company. The top man agrees.

19 April 2009

Operant conditioning

There are quite a few things about human behaviour that have always amazed Dr G. As a child, growing up not long after two world wars, it seemed quite likely that one day Dr Grumble might be called up and have to go to war. In America that happened. Young men were sent to Vietnam. Amazingly they acquiesced and went. Some died. Others were maimed. Dr Grumble has never been much of a one for history but it did always seem to the young Grumble that some wars didn't seem to have much of a point to them. To this day Dr Grumble cannot grasp what the First World War was about. And for that reason it baffles him that young men wanted to volunteer to be killed in their droves in the trenches. Many of them might not have known quite what they were letting themselves in for but war is war. It is not a picnic so really they should all have had some idea of what might happen to them. So many young men died in the Great War that as a young medical student Dr Grumble became very aware of the vast numbers of his elderly women patients who had never married. There had just not been enough men to go round. Sometimes these sad elderly ladies would tell heartbreaking stories about how their fianc├ęs had left to fight in France never to return. Occasionally Dr Grumble would be shown a last letter kept forever in a handbag. For each death at the front several lives were ruined at home. The scale of the misery was enormous.

It's a curious feature of wars that the young die and the old organise the deaths. It's about how human society is structured. Those with knowledge, intelligence and power control those without. Sometimes you hear young doctors bemoan how consultants have sold their training down the river. It is not really true. None of us was asked. But they are right in that the sorry saga was about those with power (not the consultants) controlling those with no power (doctors as a whole). Why they want to do this Dr Grumble will leave you to decide for yourself. It's part of the way societies work. Those with power control those without power. In general those with the power gain and those without lose. It is one of the reasons why some doctors are 'rather anxious' about the elitist charity Common Purpose.

How you control people is an interesting topic about which Dr Grumble has little expertise. But, of course, Dr Grumble does himself control people. He controls clinical staff who work for him. He rarely has any difficulty doing this. His decisions might be wrong but somehow those that work for him are conditioned into knowing that his decision is the one that will stand. This is not done in a climate of terror or fear. In fact if there is something that Dr Grumble has overlooked this will be pointed out to him. And Dr Grumble is quite prepared to change his mind if the evidence requires it. But if there are differing views Dr Grumble's is the one that carries. Everybody accepts this.

Dr Grumble is aware that he also controls his patients. Sometimes he tells them what to do. He may, for example, advise them to stop smoking. This is of limited effectiveness. Telling people directly what to do is not a good way to control them. Sometimes patients have to make a decision. It could be whether to be treated in one of several ways or perhaps not to have any treatment at all. The patient thinks they are making the decision. In reality Dr Grumble wants the patient to make the right decision. They almost always do because of the individualised way Dr Grumble advises them. They feel they have made the decisions themselves but Dr Grumble helped them quite a lot probably without them really knowing. Dr Grumble sees nothing wrong with this. If he goes to the garage with a broken car Dr Grumble is very happy to follow the advice he is given. The only problem at the garage is that they could want to sell the expensive option. That sort of thing can happen in medicine too - especially private medicine.

If you are out to sell things you can use techniques to get people to buy things they don't really want. Dr Grumble knows because he has been a salesman. Dr Grumble, you see, used to sell brushes door to door. He was given half a day's training. The training was very effective. Dr Grumble had the highest sales in the region. The interesting thing was that one day Dr Grumble would sell whisk brooms and the next day it would be carpet sweepers or fire extinguishers. By looking at the sales figures it was apparent that Dr G was selling what he wanted to sell and not what people particularly wanted to buy. He was controlling people. You can easily persuade people to pay for things they don't need or can easily get for nothing. Bottled water is one example.

You may be interested in knowing Grumble's sales tricks. If he was selling, say, a whisk broom he would give the customer a sample broom from his case. As he gave the customer the broom he would ask them to "feel how nice it is." He would point out all its wonderful features and let the customer try it out. Trying it for a short time was a key element. He would never ask the customer if they wanted to buy it. Instead he would ask what colour they would like. The decision to buy was never made. They just decided on the colour and that was that.

The technique for the fire extinguisher was different. Few people have a fire extinguisher because people don't have fires to put out very often if at all. They don't have a problem just as people who don't buy bottled water don't have a problem. The bottled water companies sell water people don't actually need by first sowing the seeds of fear into people by getting them to worry about what might happen if they don't drink their 8 glasses a day or whatever arbitrary figure they think they can persuade people to drink. You create the problem then sell the solution. It is the same sort of technique for fire extinguishers - though probably much more justifiable.

The long and the short of it is that there are all sorts of people out there trying to control others and they use various techniques that we scarcely notice. The relevance of all this to Dr Grumble is that we have entered a period when the medical profession is not in control of its own destiny. Others are setting the agenda and we have become puppets in our own theatre. We are, sadly, just like Skinner's pigeons.

18 April 2009

Measurement madness

In case you haven't noticed managers think patient care is about ticking boxes. Box ticking seems to be the way of modern management. The medical students fail to clerk patients as they should so somebody gives them a sheet to get signed off. You can see why. Patients develop pressure sore so the nurses are given boxes to tick. You can see why. The nurses are so busy ticking boxes that patients may have to lie for hours in a wet bed. Which, of course, may cause pressure sores. So somebody introduces another box to tick. You can see why. It's what Dr Grumble refers to as puppet-string management. All the staff are controlled by somebody in an office who pulls the strings. No thinking is required at the coalface. The idea is that the intelligent worker can be replaced by people who do not need to think but just have to tick boxes. All the thinking is done by the manager. The concept seems to have come from manufacturing. Building a car can be reduced to a set of simple tasks. You do the task, the conveyor belt moves on and you do it again. Dr Grumble has yet to visit a ward that is like that.

Qualify as a doctor and you will find that there are more boxes to tick. Not just about the patients but about you. The managers, you see, need to prove you can do all the things you need to do. So they get somebody (it could be a nurse) to tick boxes to say that you are competent. Naively the managers think your job can be reduced to a set of competencies. You can see why. They are thinking about factory workers. By now you will find the boxes are computerised. Whoever set the system up thought that would be convenient . You can see why. It's office-based people who decide these things. But you try and find a computer that's free on a busy ward. The managers think each box-ticking exercise should take a minimum of 15 minutes. You can see why. But they forget that's 15 minutes each or half an hour of medical time. And they don't seem to realise that consultants do not even have a 10 minute break in some places.

By the time you get to Dr Grumble's stage and you are fully trained you will find that you still need to get boxes ticked. Dr Grumble used to go to on courses he wanted to go on. About things he needed to learn. Now there is pressure to do courses the managers want him to go on. You can see why. There is pulling and pushing from the managers. Dr Grumble might want to go to a conference but the managers will prevent him because the work is building up. You can see why. So Dr Grumble waves the unticked CPD boxes and tells them he has to go. You can see why.

It never used to be like this and the system worked. But that was in the days when managers told Dr Grumble off for over performing. Now they want him to work all the time. Even at weekends. They even offer Grumble extra money. Before he did it for nothing. The system is changing: some of it is good and some of it is bad. The pulling and pushing has been designed so that when the system is fully on a private footing the managers cannot make doctors work to the exclusion of ongoing training. It is the way you have to do things because the imperative for all organisations is to earn money and it is doctors, and not managers, who bring the money in. Managers are just an overhead. It's as well to realise that.

Any GP reading this will know about ticking boxes. That's how GPs seem to be paid these days. Some managers somewhere have decided that general practice is rather like a car plant and can be reduced to some set tasks that the population needs done and that all you need to do is get those idle GPs to do the tasks, tick the boxes and Bob's your uncle. You can see why. But is it sensible? GPs are highly computerised and they are rather good at ticking boxes. Most of their patients come their way quite often so it's quite easy to tick the boxes. That's why GPs got paid more than the government intended. They said they would. Or the BMA did. But the managers thought they knew better.

Now if you reduce general practice to a box-ticking exercise you can see that general practice is not a difficult job. You just find out what boxes need to be ticked and get somebody to tick them. Since no thinking is involved you could delegate this task to somebody who is not actually trained to be a GP and is not paid as much. Perhaps even somebody who is not actually a doctor. GPs wouldn't want to do this because they realise that their job is very much more than ticking boxes. But Big Business, with eyes just on the money, would see that ticking boxes could be done more cheaply and wouldn't be at all interested in the many unmeasurable thinking things a GP does for which there is no fee.

Of course, all this has already gone way too far and whether we are talking about the competencies of young doctors or the hoops GPs have to jump through, frankly, it is all unstoppable. But like Iona Heath, Dr Grumble calls for restraint. Below is what Iona says in the current BMJ:


The quality and outcomes framework purports to measure clinical quality at the level of the individual, or rather at the level of a standardised individual of its own creation, and organisational quality at the level of the primary care practice. Take the case of a single patient with hypertension. However, she also has bronchiectasis after many years of smoking and has just had cancer of the oesophagus diagnosed. She has a child with severe learning difficulties and she is fearful, not only for herself but also about what will happen to her child. She is married and the relationship is difficult. Her sister has lung cancer and is already very ill. The sister’s children have problems and children of their own, and this is only the beginning of a story which becomes richer and richer the more that it is told. It is a story with multiple components, each of which interacts with the others unpredictably. Each of the components has a history that affects the interaction, and each has the capacity to affect the patient’s blood pressure and to support or undermine the treatment that is prescribed for her. To what extent does the achievement of a blood pressure of less than 150/90 mm Hg assess the quality of this patient’s care? Could it be that some of the apparently poor adherence to guidelines in primary health care is not a sign of poor quality but rather a sign that the indicators of quality are not yet adequate? There will surely come a point when we need to restrain our contemporary obsession with measurement. There will perhaps always be some essential components of care which verge on the ineffable and whose subtlety and effectiveness could be destroyed by the very attempt to measure them.


16 April 2009

How much do NHS managers cost?

If the NHS spends £7 billion on general practice how much do you think is spent on NHS administration? Would it be ten per cent of this figure? Twenty per cent perhaps? Half? No, that surely would be too much. On the other hand spending on NHS management has been going up recently. In fact it has doubled in the past 5 years of reform. So perhaps spending on NHS management may be a little more than you think. Just how much more you can find out here.

14 April 2009

The return of the doily

A strange thing happened the other day. Dr Grumble was seeing patients and a nurse offered him a cup of tea. This is not altogether unheard of but Dr Grumble generally declines. Sipping tea in front of patients doesn't come over too well. But, as it happens, Dr Grumble has started seeing the odd private patient and, because they have bigger slots, Dr Grumble often has time for tea. So, because he had time, Dr G accepted the nurse's offer of a cuppa. Now normally if you accept such offers you get a chipped and often somewhat grubby mug. But you are grateful nevertheless. On this occasion it was different. The tea was delivered by a smart waiter. There was a pot, a cup and saucer and a doily. And biscuits. Dr Grumble was amazed and then he thought a bit and wondered if he really should be amazed that somebody gives him a cup of tea - especially since he pays for the private rooms. And then he thought again and remembered that decades ago when he was a house physician in a large London teaching hospital everybody sat down to tea in the middle of the ward round. There was a big china teapot, cups and saucers and, yes, doilies.

Thinking a little more Dr Grumble remembers many times in the past when he used to have such breaks. The doilies disappeared but ward rounds as a junior doctor were often punctuated by coffee breaks. These occasions were immensely valuable because it enabled a different sort of information to flow between the consultant and the others. But now, as you will have guessed, Dr Grumble never has such a break - except on the rare occasion that he is in the private wing. Dr Grumble rarely passes the time of day with his juniors. We are all too busy with clinical information being passed hurriedly from one person to another following which Dr Grumble issues his orders staccato fashion. It's not good but there is little time for anything else.

So it made Dr Grumble laugh when the oldest Grumble child, a medical student at St Elsewhere's, came home for Easter and related what he had overheard a manager saying in the corridor. It went like this:


"What? The consultants don't have a break? Not even 10 minutes?

"That's dangerous!"


Yound Edward Grumble thought this was very funny. It's both funny and sad at the same time. Unfortunately NHS managers have no idea how things are at the coalface and they reveal their ignorance even to medical students. This one overheard remark will colour the young Grumble's view of NHS managers for some time to come. And worse, he's told everybody else.

11 April 2009

Dr Angry speaks out

Dr Grumble found the post reproduced below on dnuk. It refers to a recent Panorama programme, Britain's Homecare Scandal. The author has kindly given permission for it to be reproduced here. None of the views he expresses are in any way unreasonable. Dr Grumble considers them spot on but the author does not want his name to be revealed. Dr Grumble understands only too well why.

As you all know - because the government have told us frequently - the involvement of Private Companies in the NHS is a good thing because it will stimulate competition, put the rest of us on our toes, and raise standards.

Well last night there was a Panorama special which showed just how some private companies at least are working in the home care "industry".

Inadequately trained staff being given too much responsibility, lack of management back up, staff being driven on impossible time targets and being encouraged to falsify the amount of time they spent with each patient and absolutely appalling lack of record keeping plus piles of patient records residing in the boot of someone’s car.

Net result old people left in puddles of excrement not being cleaned, being injured by being hoisted by untrained staff not being fed etc etc. Does any of this sound familiar to any of you docs out there?

A good investment opportunity said the man in the City, downward auctions on price said a Health Board in Scotland, I refuse to answer that said the boss of the Scottish Care commission when asked if she would like her parents looked after by one of these outfits.

Now for the really scary bit: one of the companies shown up as delivering appalling standards was Care UK which delivered record profits last year and is also involved in providing private general practice. In particular they were awarded the contract to run a new practice and walk-in centre in East London.

Now I have no evidence that they are currently delivering anything other than good care in this operation. It would be pretty remarkable if they didn't as they are being paid sums way beyond that which ordinary GPs get for running a practice with hoards of staff looking after a list of less than 3000. But what will happen when the list expands and they have to face the daily reality of trying to deal with high demand and still make a profit?

A couple of years ago a young GP working for a private provider of general practice posted on DNUK about how they and particularly a nurse practitioner were left to run a practice with the nurse being forced to work way beyond her capabilities and lack of management back up.

Of course there are some examples of poor general practices run by GPs but I think the majority of GPs put their heart and soul into providing a good service for their patients mainly I think out of their own sense of professionalism but also reinforced by the thought that if we fall short we will be personally answerable to the GMC and the Health Care Commission to mention just two. And, dare I say, most of us still care about patients as individuals.

Already we have seen in Stafford, and lots of other hospitals not mentioned in the press, what happens when managers and targets take precedence over professionals. How long will it be I wonder before we see a Panorama programme on poor general practice being delivered by a private company.

How much longer will it be before everyone get wise to the fact that this government’s half-baked and non-evidence-based ideas about stimulating competition are not only not working and squandering resources but are just plain wrong? Wrong for the NHS, wrong for professionals but, most of all, wrong for patients.

Dr Angry


The Panorama programme seems to have disappeared from iPlayer curiously early but Dr Angry conveys the essence of the programme so very well that you do not need to watch it.

07 April 2009

Need or profitability?

Big Business has never succeeded in making a profit from the medical care of poor people. If you are looking for profitability in healthcare you need to contrive to make the wealthy worried well even more worried and in the process milk as much money as you can out of them. If you are a government looking for cost-effective healthcare this approach is, of course, a nonsense. Cost-effective healthcare needs to be provided on the basis of need. This is not rocket science. It is utterly obvious. Why do so many people argue otherwise? Dr Grumble will leave that for you to work out for yourself. Is there any hope that our government will start heading down the right road? Not if you believe the line Dr Grumble morosely took in his last post. But, in the depth of his despair, Dr Grumble thought he would reminisce about how the NHS started and he come across this video of a lecture by Dr Julian Tudor Hart which ends in a wonderful message of hope.

04 April 2009

Rape of the NHS or crafty seduction?

There is a certain sort of person who thinks that the problems of the health service can be put right by putting it all on a private footing. Dr Grumble can easily follow the logic. This sort of thinking is very seductive. Essentially you use the supermarket argument. If you don't like Asda then try Tesco. It works, it seems, for supermarkets so why not for healthcare? For this to work you need at least two supermarkets. If one turns out to be no good (as was the case in Grumbletown) it will wither on the vine. After a few visits Mrs Grumble refused ever to go to her local Safeway store because of the way she was treated. Perhaps others were treated badly because the store closed, was taken over by Waitrose and is now thriving. Market forces in action. It is, as Dr Grumble has said, very seductive.

What is the disadvantage to such a system? In Grumbletown we have at least three supermarkets. Perhaps it is more. It depends how you count them. Do we need three? Wouldn't it be more efficient to have just once enormous supermarket run by the Grumbletown council? Of course it would. The council could decide what people need and what the supermarket should stock and it should all be so cheap because of the economies of scale. And if the council was to run it they would choose a standard soap powder and a standard shampoo so that there would be no waste stocking whole ranges of items. Amazingly, some people used to think that way. Nobody does any more. Such thinking has become utterly discredited. The arguments for markets seem so clear that Dr Grumble could easily, as an exercise, write something for the Telegraph making the key points. Telegraph readers would eat out of the Grumble hands.

Seduction, though, is dangerous. There is a great risk of your being persuaded into doing something that you just might not do if you considered things a little more carefully.

For some time Dr Grumble has had major doubts about markets in healthcare though nobody was ever going to listen to him. Whys should healthcare be different from the supermarket or the shopping mall? Markets seem to work wherever you try them. And they seem to just run themselves. No effort is required. You just free things up or deregulate and human nature takes over.

For many long years there were no really good examples out there to demonstrate that markets are not necessarily a panacea for all ills. Books on the market were often (wrongly in the Grumble view) critical of healthcare in particular for not embracing the market. But that was before the banking crisis.

Memories are short but Dr Grumble remembers so well those so-called experts in finance who were on Radio 4 each morning patronisingly trying to educated the populace. They spoke about the need to compete globally. Competition and globalism were their watchwords. They repeatedly said that if we didn't deregulated others would and that we had to compete with the likes of Iceland. Even Dr Grumble's cosy building society manager came on to say that he needed to pay Dr Grumble for his share of the building society so that he could go out and borrow on the markets like a bank. And it would be win win. Dr Grumble would get a few grand and the manager would get a few hundred grand - maybe even millions. Money that seemingly came from nowhere - because it did come from nowhere. Dr Grumble was not seduced by these daily blandishments but his voice didn't count. Everybody else involved went for the quick buck. You can understand why. The consequences are now well known.

Money markets are not much like supermarkets but then neither is the NHS - though this doesn't stop similar arguments about globalism, competition and deregulation. The only point Grumble wishes to make here is that it is very easy to be seduced by arguments about markets that do not necessarily apply to the NHS any more than than they should have to banking. To those in the process of being seduced it is salutary to take some time out to think and escape the passion of the moment.

Unfortunately, when it comes to the seduction of the NHS by the envoys of Big Business it seems that all the clothes have been hurriedly flung off, the bed covers have been rolled back and the tantalising consummation has become exquisitely irresistible. Or is it rape? Perhaps it doesn't matter because either way it is looking unstoppable.

03 April 2009

Surgery poorer at treatment centre

The article is here. But will any of those in power take any notice?

Some may not be able to access the full article. You can find a summary here (scroll down a bit) and there's a news article here.