31 May 2009

Just a dollar a week

It would be interesting to know what Karol Sikora's views are on all those in the United States without healthcare insurance. The NHS may have its problems but at least we ensure that our children's healthcare needs are looked after.

Was Tony Blair a Tory?

In the current climate of despondence over the probity of our parliamentary representatives Dr Grumble's view that all politicians have now become essentially the same may strike a chord with some of his readers. It not so much their pay and allowances that worries Dr Grumble. It is the sameness of their policies which is the focus of Grumble's concern. For democracy to thrive you need to have a variety of policies to choose from. When major policies are up for discussion in parliament you need an opposing view, a devil's advocate. If you do not have proper debate you will make wrong decisions. Far from cautioning the New Labour government when it has been heading in the wrong direction, the Tories have egged the government on. Deregulation of banking or independent treatment centres for NHS patients are examples that spring to mind. If you want something even more serious, what about the Iraq war?

Consensus might sound a nice word but in politics it is just not healthy. Politicians tutored by management consultants now have their political thinking dominated by what they believe to be inalienable truths about our world. How often do you hear politicians talk about globalisation? The world has always been a globe. A century ago a quarter of the world's population was administered from our own small island. You can't get much more global than that. Globalisation is not something that must dominate our policies any more now that it did when we ran the world. Especially when it comes to healthcare. This is just manager speak. Nonsenses follow from this thinking. You hear stories about manufacturing in the UK being a thing of the past. Finance is more important for us, they say. People in China will make things more cheaply than we can. We can never compete. But they don't tell you that they will be able to do finance in China too. Or that we have been earning more in the UK from manufacturing than from finance. Or that manufacturing provides 60% of our exports. Or that even the Japanese may base their Formula 1 team in the UK because we are actually quite good at making things. And politicians seem to forget that we have people in this country who do not actually have the intellect to work in finance but could manage to work on a production line. Tell that to the manager types and they will tell you that these people just need to go to university to become bankers. It's madness. In any case, what is wrong with giving people apprenticeships so that they can learn to do honourable and valuable work with a spanner? This blinkered management thinking really is nonsense. They have done the same to doctors and nurses. Somebody somewhere seems to think that training just needs lectures and simulations. The apprenticeship element of medicine is rapidly being eroded. More nonsense from those that just do not know.

You might think that our politicians would be free thinkers who could generate new ideas but there is not much evidence of that. The love affair between Tony Bair and Margaret Thatcher is well known and it seems that even his successor wanted some of her reflected glory. Gordon Brown's admiration for her as a conviction politician is fair enough but Grumble has belatedly realised that Blair and Brown not only admired her for her convictions they actually shared those convictions. It must now be clear to all that Blair was the first Tory to lead New Labour and Brown was more of a soulmate than we once believed.

OK. Where is this all going, I hear you ask. Grumble is not often quite so engaged in the nuances of party politics. But the house of cards is collapsing for Brown. Everybody now believes that we are rapidly heading for a Blair look-alike in Number 10. So what does this mean for healthcare? Can we hope for some really innovative policies from the opposition or are they going to be constrained by what the management types tell them is the way forward? The answer is clear and it is not at all surprising. It is going to be yet more of the same. It is all here in this attack on nice Alan Johnson from Andrew Lansley. It's great to have an attack from the opposition but for God's sake can't we have some original policies. To say that the present incumbent it heading the right way but just hasn't yet implemented enough of the policies is not exactly impressive and plainly shows no understanding of the rapid and often damaging pace of reform that has been taking place in the NHS. If some of this had been done more slowly perhaps all the mistakes GP (out-of-hours care springs to mind) that the government partially recognises might not have been made. And, as for wastage, Dr Grumble would love to know how much has been spent on new quangos and all the mechanisms for implementing change and running a market within the NHS. How can anybody be enthused with more of the same from Andrew Lansley?

Here's some of Dr Grumble's thinking on the Lansley speech in crude bullet points:

  • More choice of GP and abolishing practice boundaries is nonsensical and an exacerbation of the current government's wrong thinking. The whole point of a GP is that they are close and there's continuity.

  • More choice of hospital is rather an irritating thing to hear because in the old days GPs could send patients absolutely anywhere. Which government stopped that, Mr Lansley? In any case most patients are quite content to go to the nearest hospital. Even Dr Grumble does not know who is the best doctor to see and, no, you really are not going to be able to find out from masses of spreadsheets.

  • Criticism of the pace of introduction of Foundation Trusts is a little worrying because some of us believe that clinical disasters have resulted from too fast a pace. It is better to get things right rather than get them done too quickly.

  • Criticism of the rolling back of the independent treatment centres seems odd to Dr Grumble as there seems to be ample evidence of these places wasting taxpayers money and not always being up to NHS standards. Which, frankly, was quite predictable.

  • And then the final ludicrous canard. That it's all the fault of patients who need to pull themselves together eat less, exercise more and drink less alcohol. This are laudable aims but government policy and not lectures is more likely to affect these behaviours and, sorry Mr Lansley, if people live longer it actually ends up costing you more. Eventually we all die and quite a few of us get ill on the way.

  • Oh, there's one more thing. It's going to be tough and £20 billion is going to have to be saved. Another policy that would be the same whoever wins the election.

Mr Lansley deserves a more in-depth critique but Dr Grumble has to mow the lawn.

24 May 2009

Ten lords a-blogging

Dr Grumble is a strong supporter of the House of Lords. There was a time when the House of Commons may have done its job properly but that is no longer the case. Like many others, Dr Grumble is thoroughly disenchanted with the career politicians who just do what they are told by the party whips. We need people in parliament who have had a life outside politics, who have some sort of expertise and who can think for themselves. The odd honourable independent does slip in to the Commons but they are few and far between. Dr Richard Taylor, a physician, is an example. How do you think he voted on the Iraq war? How much do you think he claimed in allowances compared with the others? You can find out here if you can't guess.

There are a good few blogging lords. Lord Darzi has a blog but it is rather lacklustre and best known for being something of a damp squib. In desperation Lord Darzi's blog has undergone a face lift and his fan even got a mention. Perhaps Dr Grumble is being unkind. Quite honestly he no longer reads the Darzi blog. Of nobles' blogs Dr Grumble prefers Lords of the Blog which has many more readers and some decent writers. Lords of the Blog is a genuine blog with contributors from all parties. Their lordships do not hesitate to put you right if you have got something wrong. That, of course, is the strength of blogging. Here is Baroness Murphy putting Dr Grumble right when he asked to be elevated to the House of Lords to increase the number of doctors in the second chamber:

But Dr Grumble, we have lots of medics in the Lords of whom I am one of course. We have Murphy, Walton of Detchant, Turnberg, Finlay of Llandaff, Alderdice, Patel, Rea, Winston…and Darzi of course, plus at least 2 dentists, Colwyn and Gardner of Parkes, several trained nurses including Emerton. There are no doubt more that have slipped my mind for the moment. The health professions aren’t badly represented and of course on health policy we hold widely differing views, so that’s quite a bit reassuring.

It's sad that Dr Grumble who was angling to to become Lord Grumble of Blogspot was rebuffed but it's a great honour to be put right by a baroness. It's not actually the first time Dr Grumble has been put right by a baroness but that's not the point. Dr Grumble could be anybody. Baroness Murphy has no idea who Dr Grumble is but she still interacted as bloggers around the world do. It makes Dr Grumble feel that the democratic process is working. It's just rather unfortunate that it's the democracy bit that is completely missing from the Lords. Not that Dr Grumble wants an elected second chamber. Not at all. There is not much wrong with the House of Lords as it is. Quite often they come to what the public would consider to be the right decision when the Commons has got things very wrong. They do a lot of the donkey work on details that the Commons just cannot be bothered with. And, as for democracy, the elected chamber has the final say anyway. So what could be better than that?

Hazardous waste

There is one thing that is vital if quality healthcare is to continue to be made available to all and that is keeping a lid on the costs. This is a challenge that in the UK we have tried to address with organisations like NICE. Some drugs are just so ridiculously expensive they cannot be cost-effective. But put that in a tabloid headline or listen to the likes of Karol Sikora and it can be a difficult line to defend. If you are a doctor out just to make as much money as you possibly can, it would not be a line you would want to defend.

Despite the innovation of NICE, in its headlong rush to a more US style of medicine, our government, with its penchant for Walk-in Centres, Darzi polyclinics and the like has repeatedly failed to grasp that more care is not necessarily better care. There is another side to this story and it is being told in a film:

Money-Driven Medicine explores how a profit-driven health care system squanders billions of health care dollars, while exposing millions of patients to unnecessary or redundant tests, unproven, sometimes unwanted procedures, and over-priced drugs and devices that, too often, are no better than the less expensive products they have replaced.

It’s ‘hazardous waste’—waste that is hazardous to our health.

‘We want someone to know what is going on,’ explained one prominent physician in Manhattan. ‘But please don’t use my name. You have to promise me that. In this business, the politics are so rough—it would be the end of my career.’

The New York premiere of Money-Driven Medicine is on June 11th. Dr Grumble will be 2400 miles away from New York so he is not going to be able to make it but there is a DVD on its way.

21 May 2009

Richard Granger

Quite a few people would be interested in knowing what Richard Granger is up to now. It seems Private Eye might like to tell us but according to this evidence it seems somebody has put the frighteners on them. Here's what Mr Hislop had to say:

Last week I received this letter from Schillings, a firm who do a great deal of threatening newspapers and other publications in terms of privacy. Now, Schillings have sent me a letter saying they act for a man called Richard Granger. He will be familiar to you. Mr Granger was in charge of the NHS IT project, which is responsible possibly for losing the country maybe £12 billion of money. That is everything in the present round of cuts times about four. Now, Mr Granger is not involved in a sex scandal; Mr Granger is not involved in a legover case with the News of the World. He is a legitimate target of inquiry for journalists. I have a letter from Schillings here saying, "We understand that your journalist has been approaching various parties to make inquiries". That is it, a lawyer's letter straight in. It quotes Reynolds immediately, "We remind you of the recent judgment ... defamatory allegations ... confidentiality" ‑ it is confidential and private, what we are asking about, his business life. He wants to know all the allegations, everything in advance, he wants to know when we are going to publish, and we end up with a threat. That is a "chill" wind.

Does Dr Grumble know what all this is about? He might have quite a good idea but he is just guessing. It would be nice to know for sure. We have a right to know. But will we?

17 May 2009

Diagnosis is the key

There are not many articles in the Health Services Journal that set Dr Grumble alight. Management is pretty boring. But management is important which is why Dr Grumble keeps an eye on the HSJ just as they keep an eye on him. Managers often seem to get hold of the wrong end of the stick. Putting them right is a challenge. They come from a culture of suspicion - especially about doctors - so sometimes they just won't listen. Doctors who go into management are not always a solution to this problem. Doctors who choose to head for management are not necessarily the best individuals we have on offer and they tend to go native. Patients and quality of care quickly get forgotten. Spreadsheets and targets rule their day. And thinking goes out of the window. Too many managers, medical or otherwise, are like puppets on strings.

Perhaps that is why managers, medical and otherwise, want to turn clinical care into puppetry. Issue doctors with protocols and patient pathways, give them a few boxes to tick and problems will just disappear. That anyway is how managers think it should be done. But it is not as easy as that. Protocols may require, say, the correct interpretation of an X-ray and junior doctors required to follow the protocol may not be able to read the relevant radiograph accurately. Managers fail to grasp this. To them a broken bone is a broken bone. If a doctor can't see a fracture managers see that as odd. They will rectify the problem by sending the relevant staff on a half-day course to put right what is really a lack of experiential learning. But you cannot make up for lack of experience by going on a course. You can't tell a manager that. A broken bone is a broken bone. You can see it on an X-ray. They know that. The concept that it might actually be quite difficult and need a lot of practice escapes managers. They will tell you that practising medicine is like flying a plane. All you need is the right simulator.

Dr Grumble has often seen the wrong pathway followed because the diagnosis was wrong in the first place. This happens because diagnosis is not easy. If you have, say, a pain in the knee and the X-ray shows something wrong in the knee it may seem as if you are home and dry but it could be that the pain is actually a result of pathology in the hip. Even orthopaedics may not be straightforward. You don't want your knee replaced if the problem is in your hip.

On more that one occasion Dr Grumble has been asked by publishers to write a book - not on particular diseases but on symptoms. Instead of there being chapters on heart attacks or pulmonary embolism, there would be chapters on chest pain and breathlessness. Even publishers seem to understand that patients do not arrive at the GPs' surgery with pulmonary emboli - they come with breathlessness or some other symptom. Yet, if you look at standard textbooks, you will find plenty of good articles on pulmonary embolism or myocardial infarction and rather few on how to diagnose chest pain or breathlessness.

Goaded by his would-be publishers, Dr G has learned that surprisingly little is known about how doctors make diagnoses. Many of Dr Grumble's colleagues think that today's junior doctors are not as good as they were. Even the juniors themselves, worn down by MTAS and MMC, are beginning to believe this. It is nonsense. It is very difficult to recall what you once did not know. Experiential learning sinks in slowly. You carry it with you for ever and it is the key to diagnosis. Unlike some of his more arrogant colleagues, Dr Grumble can remember when as a junior doctor he would struggle to get to the nub of a patient's problem when the consultant seemed to be able to score a hole in one without even trying. Dr Grumble did this himself the other day with a case of mitral stenosis. A few seconds auscultation and, despite the near-by vacuum cleaner, Dr G was able to describe the tell-tale murmur and even made a few comments about the pre-systolic accentuation. You can't do this unless you have had experience. Few of Dr Grumble's junior doctors have heard such a murmur before. Often diagnosis is more subtle than a single physical sign but Dr Grumble can still, sometimes, find it easy to get there despite red herrings fed his way. Surprisingly, it seems that rather little is known about how experienced doctors are able to do this. The books say it is something to do with heuristics which seems to Dr Grumble to be a way of saying we don't know quite how it is done.

Given the importance of diagnosis, it is odd that there has not been more research on how it is we reach or fail to reach this crucial bottom line. Dr Grumble thinks it is for the same reason that Dr Grumble has, mostly, avoided writing book chapters focussing on symptoms rather than disease. He has done it and some lectures too but it is not easy if your audience is senior. Like most, Dr Grumble has tended put the topic of diagnosis into the too-difficult basket. The relative lack of research in this area probably has the same cause. It's just too difficult.

On the other hand Dr Grumble spends a long time with medical students trying to teach them how to reach a diagnosis or, better, a differential diagnosis. Diagnosis is what most of Dr Grumble's bedside teaching is about. An old lady falls over. The notes read 'impression: mechanical fall' because she tripped over a rug. There is no thinking here. No differential diagnosis. Dr Grumble has rugs at home. He has never fallen as a result. So when an old lady falls what could it be that has caused it? How do we find out? What things should we consider? Students don't always appreciate such teaching because you have to make them work. You have to get them to think on their feet. Any thinking will do. There are no right or wrong answers - though the students tend to think there are. The old lady could have fallen because she lost her glasses or because of postural hypotension or very many other things. The problem is considering all these possibilities and working out which it is.

So what is all this to do with the HSJ? It is that the HSJ has actually got a rather good article addressing the issue of diagnosis. The managers have at last realised how crucial this is. They have discovered that:

...... of 840 emergency admissions, revealed five (0.6 per cent) had been diagnosed incorrectly - all by junior doctors.

Dr Grumble would like to know more about this study because he doesn't think he performs anything like as well that. And it seems particularly surprising given that even in intensive care we are told:

.....one study found major diagnostic discrepancies at post-mortem in one in five patients who died on an intensive care unit.

Probably what this discrepancy shows is just how little we know about this topic. Dr Grumble has some awareness of his own deficiencies but he comes from an era when we did many more post mortems. Our bosses insisted on it because they knew that their diagnoses were often wrong and that they needed to know when they were wrong. These days we never find out just how wrong we were.

Anyway, the HSJ article is a good one and well worth a read.

15 May 2009

Systems at fault

When things go wrong it is often the individual that takes the blame. Quite often there are additional factors. A nurse who gives a patient the wrong drug or drug dose will have to take responsibility for the mistake but it could be that the system was rushing her or that the system allowed her to be interrupted. Quite often the nurse will pay the price and the system carries on as before.

If a doctor is jetted in from abroad and gives the wrong dose of a drug he must take responsibility. If he gives ten times the dose it seems totally unacceptable. But if it is the first time he has worked in the UK and he is not familiar with the drugs he is given there are also problems with the system. No doctor should be permitted to work out-of-hours unsupervised in such circumstances. But how can you possibly give ten times the right dose? Surely common sense would dictate that there must be something wrong if you had to open ampoule after ampoule to make up such a large dose? After all most drug ampoules contain about one standard dose. You can be fairly sure of that wherever you work. Or could there possibly be yet another problem with the system that needs addressing?

14 May 2009

Agenda item

OK. The NHS is not perfect but Dr Grumble thinks this man has lost the plot. By a strange turn of fate, Dr Grumble has actually met Dr Sikora while treating a relative of his. Do think that would have been private treatment or NHS? Dr Grumble is not going to say. There are some confidences you must keep. If it was NHS then Dr Sikora cannot really believe that NHS treatment is that bad. If it was private Dr Grumble should be flattered because choice was being exercised.

Why are MPs different?

Yesterday Dr Grumble sat on a committee that advises the government. Clearly he can say no more about the detail. The committee has a few doctors on it but not many. Dr Grumble is the only one that a patient would consider to be a real doctor. The others don't really look after patients. Not directly anyway. Some of those who sit on the committee, in their day jobs, would not be paid that well. One is a teacher. We can claim our expenses and we can claim our time for reading the papers. Dr Grumble under claims. The civil servant in charge of the claims tells him that most of the committee members clearly under claim for their time. It worries her. If we under claim, the budget for next year will be cut. Hospital doctors are well known for under claiming. They used to be anyway. Their thinking was that any money that they claimed was then not available to patient care. The way things are going with private businesses ripping off the NHS it is no wonder that such attitudes are changing. But it is clear, nevertheless, that many of the other committee members who are not doctors do not feel that it is right to take all of what they are entitled to from the taxpayer. So why do MPs take a different line?

13 May 2009

Post pulled

A reader has suggested it would be better to pull the post entitled 'Bloody Solicitors'. He's right. Dr G was angry and posted very unwisely.

There is quite a lot more that Dr G does not publish. Sometimes it is very clear where to draw the line. Sometimes things are a bit grey. Sometimes what Dr G says is heavily disguised. Sometimes Dr G gets it wrong for emotional reasons. He's grateful to his readers for pointing out when he oversteps the mark.

12 May 2009

Who would you immunise?

Here's a good one. A hospital not far from the Grumble hospital is holding daily meetings to deal with the 'flu crisis. Not that they have seen a case yet but that does not stop them worrying. The Trust board is worried about how the 'flu might affect them. One of the questions they have been asking is whether or not the current 'flu vaccine will give any protection against swine 'flu. Nobody actually knows the answer to this question. The hospital concerned has 18 doses of the vaccine left. It expires soon so it has to be used. Who should get it? That is the dilemma. If you were to ask Dr Grumble he would say the infectious diseases staff should get it. Or maybe the intensive care staff. Or perhaps they could do the decent thing and offer it to local GPs who are the ones that have to go into people's homes and take the swabs. Any of these would be a reasonable choice. Guess who they decided should be offered the vaccine. Can you believe that they decided that the members of the Trust board should be immunised?

09 May 2009


Dr Grumble has signed the Official Secrets Act. More than once. It doesn't actually make any difference whether you sign it or not. In one government department they don't bother. In another they do. Dr Grumble is holding back here. Even that is a secret. Almost anything can be seen as an official secret. You can see the reasons for secrecy - sometimes. But quite often it seems that secrecy is being used to protect somebody. Secrecy over MPs' expense claims could be seen as an example. The taxpayer pays. Why shouldn't the taxpayer know where his money is going?

Another form of secrecy is commercial secrecy. Data submitted for medicines licensing is an example. The results of drug trials are not always in the public domain and the licensing authority cannot release them because of commercial confidentiality. Yet for many of these drugs the taxpayer foots the bulk of the bill. So why shouldn't the taxpayer have access to the data which led to the granting of a product licence? Why shouldn't patients taking medicines have access to all the data upon which the safety and efficacy of the product was judged? They have to take the medicine. They have to suffer the adverse events. They are the ones for whom efficacy matters most. Surely they have a right to see the data? And, of course, the same goes for their doctors. This could be a condition of the licence approval. It would be unlikely to cause commercial damage.

But what has really goaded Grumble into this tirade on secrecy? It wasn't the MPs' expenses. It wasn't even the drug licensing issue. It was frustration that we do not know how much the parts of the NHS that have been privatised are costing. Except that is for one ISTC. You can read about that in an article written by Allyson Pollock.

It's long article. Here's a key bullet point:

  • The Scottish Regional Treatment Centre treated only 32% of annual contract referrals in the first 13 months of operation at 18% of the annual contract value. If the same patterns apply in England, up to £927m of the £1.5bn may have been paid to ISTCs for patients who did not receive treatment under the wave one ISTC contracts.

Allyson tells it as it is. She can't be much loved in some quarters. She will never be Dame Allyson. Probably she doesn't want to be a dame.

She must have difficulty getting funded - except, that is, for one-way trips to Outer Mongolia.

03 May 2009

Atrial fibrillation

You can read about atrial fibrillation here. You will see there is a 'new' test to diagnose it. The new test takes 21 working days to give you the answer which is not exactly quick. But it might be worth knowing if you have atrial fibrillation. You might be more likely to have a stroke and you might be somebody who would benefit from anticoagulation. Dr Grumble is in the at risk age group but he has not had the new test for 'Afib' as they call it. Is that foolhardy? No. Dr Grumble can feel his pulse. It is regular. He hasn't got atrial fibrillation. A GP could do this and give you the answer straight away. It an old test but, if necessary, he could do a newer test, a twelve-lead ECG. But wait. An ECG could miss atrial fibrillation because it can be intermittent which is one of the reasons listed for having the new test. But look further down the page and you will see that the 'new' test will only diagnose atrial fibrillation if you have it while you have the test done. It doesn't sound as if the 'new' test is any better than a twelve-lead ECG. In fact it sounds rather worse. Are the public being conned?

Wait a minute. The new test is an ECG. Does any of this make sense?

Nellie's reward

Last week Dr Grumble was within metres of the great Lord Darzi. The real ermined man, not his robotic look-alike. Dr Grumble heard him speak and for the first time Grumble thought that the noble lord might just be on our side. But Lord Darzi is a consummate politician. He knew his audience was full of doctors and he knew just how to woo them with his soft Irish brogue. One of the things he went on about was quality. He pointed out that doctors want quality. He pointed out that doctors like competing with each other on quality and that this was ingrained into us. It is true.

Essentially Lord Darzi said that we like to do a good job. He is right. We do. And so do nurses. We don't need special bonuses to do the best job we can. Nor do nurses. Doctors are very good at doing the best job they can within limited resources. So are nurses.

In medicine you rarely have everything you need instantly. The diagnosis would be nice but cases are more often grey than black and white. There is always a differential diagnosis.  Patients and relatives do not like uncertainty. Nor do doctors. Uncertainty needs to be managed. But we learn to work in our imperfect world. Amongst the imperfections are resource limitations. Even our friends across the pond recognise the problems involved in getting sophisticated investigations out of the radiology department late on a Friday. 

Perhaps it is our collective readiness to paper over the cracks in our service, some of which are inevitable, which has led to our unwillingness to raise the roof when things really go wrong. But some of what we see in the way of limited resources is endemic, planned even. It is a systematic collusion with inadequacy. Why, for example, can more and more work be piled onto nurses apparently without limit? Below is what Nurse Anne has to say on the topic:

It was chaos. Thank god Nellie came in. A childminder may be able to set a limit on the number of people she looks after but a nurse cannot. A childminder cannot have additional children dumped on her with no warning, on top of her other charges. But we do this to nurses and expect them to function every day. Otherwise, they would have to close much needed beds.

Dr Grumble has witnessed some of this sort of thing for himself. He felt that acutely ill patients were not getting the attention they needed. He pointed this out. Not once but on every occasion he could. Eventually things did change. What changed them? Was it the Grumble concern about quality? No. Not in those days anyway. Probably it was the belated realisation that, in the acute setting, employing sufficient nurses might just enable us to discharge patients more quickly. Did it work? Yes. Did Dr Grumble get any credit? No. Does he mind? No. It's much better now and that is all that matters.

But look at what happened to poor Nellie who was just trying to help out and do her best for her patients despite limited resources.