31 October 2009

Granny Smith

There was a time when if you were a passenger on a train you were referred to as a passenger. Now, of course, you are a customer. Managers think this change is important. As a passenger Dr Grumble finds it irritating. It gives him the impression that the railway now just wants to profit from him and not look after him as he tries to get from A to B.

There are those in the hospital, not usually doctors, who insist on calling their patients clients. The implication is that there is something demeaning about being a patient. Dr Grumble is a patient like everyone else. He doesn't feel demeaned by being a patient. Dr Grumble happily refers to his GP as his doctor and Dr Grumble sees himself as one of his patients. He is certainly not a customer nor does he want to be.

In a heavily veiled sort of way this is all about money. Passengers are people who go from A to B. Customers are people from whom you extract money. The managers want the staff to focus on where the money comes from rather than getting people from A to B. Big Business is interested in the corporate customer. BA is interested in Dr Grumble the business traveller but not Dr Grumble the cheapskate tripper.

You can see the same changing focus in healthcare. The people who are sick are the poor and the elderly. They make needy patients but are not ideal customers. Yet NHS provision is moving more towards the needs of the city slicker and the worried well. These people are customers rather than patients. They are vocal. They have power. Their money speaks. Polyclinics for healthy patients with money are attractive for Big Business. They will be easy to privatise. And privatised they should be because the taxpayer should not be paying to meet the needs of the wealthy worried well. It's the impoverished chronic sick that need the NHS and the taxpayer's support.

Contrary to what the vocal worried well believe, the concerns of GPs about the change to Martini healthcare were nothing to do with restrictive practices. Their concern was for Granny Smith. It was to do with their realisation that in today's NHS Granny Smith doesn't seem to matter any more.

The Nutt case

If ever there was a politically bad decision it is the 'sacking' of Professor Nutt. Dr Grumble has met Alan Johnson. He has shaken his hand and heard him speak. He has even been photographed alongside this great man. This wily former postman is too shrewd to make an elementary political mistake. So who would have been behind this decision? Who is the politician intent on shooting himself in the foot? The answer is probably in the video.

Well said, Mike. But you know very well that your advice is unlikely to be followed because there are no good reasons.

24 October 2009

Terms of Reference for the Advisory Council on the Misuse of Drugs


It is the duty of the Advisory Council on the Misuse of Drugs to keep under review the situation in the United Kingdom with respect to drugs which are being or appear to them likely to be misused and of which the misuse is having or appears to them capable of having harmful effects sufficient to constitute a social problem, and to give to any one or more of the Ministers, where either Council consider it expedient to do so or they are consulted by the Minister or Ministers in question, advice on measures (whether or not involving alteration of the law) which in the opinion of the Council ought to be taken for preventing the misuse of such drugs or dealing with social problems connected with their misuse, and in particular on measures which in the opinion of the Council, ought to be taken.

A further duty is placed on the Advisory Council to consider any matter relating to drug dependence or the misuse of drugs which may be referred to it by any Government Minister (as defined in the Act).

Ministers - ordinarily the Home Secretary - are obliged to consult the Advisory Council before laying Orders before Parliament or before making Regulations (or any changes to the same) under the Act.

Quick facts from Canada

Dr Grumble is not a manager. He was once but he isn't now. He has decided to focus on his clinical work. One reason he is not a manager now is that his heart is not in management. He does not think the NHS is heading in the right direction.

Dr Grumble believes that we can still afford universal healthcare but that we do have to keep the lid on spending somehow and that privatisation will have the opposite effect.

Instead of thinking things through most of our politicians just follow the siren voices of those who stand to make money from privatisation. Proving to our masters that privatisation will cost more and not less is a challenge. Private is good. Private is efficient. That's the mantra. It is hard to gainsay.

But what is the evidence? Here from Canada are some bullet points that suggest that Grumble may just be right:

  • The British Medical Journal reported in 2004, that the public health system was charged 47% more for hip replacements performed in private surgical clinics than for the same procedures provided in public hospitals.

  • The for-profit cancer surgery clinic opened by the Conservatives was eventually closed down after the provincial auditor found that it cost $500 more per procedure than public hospitals.

  • Studies reported in the Canadian Medical Association Journal show that meta analyses of for-profit hospitals and clinics show that they not only cost more but they lead to higher death rates as the for-profits skimp on trained staff and quality.

  • The Alberta Branch of the Canadian Consumers Association studied wait lists and costs for cataract surgery in Alberta and found that wait times in Lethbridge with 100% public surgeries were less than half those in Calgary with the majority of the for-profit clinics, and costs were $400 less per eye for the same lenses.

22 October 2009

Dr Grumble's letters

Every week Dr Grumble writes scores of letters. The NHS cannot afford enough secretaries to do all Grumble's typing so the letters get typed in India. They used to get typed in Canada or New Zealand. Dr Grumble's New Zealand secretary was excellent. The one in India is not so good. The Indians speak English but it is their own sort of Indian English and this comes across in Grumble's letters. Dr Grumble checks his letters online. He can check them from anywhere in the world. He corrects the letters and then they get printed out. Letters to a GP are addressed automatically. Software does this magically from the hospital database. It all sounds very modern but the process has a very strange twist which only the NHS could manage.

The letter is printed out. Dr Grumble then checks it again because all sorts of errors creep in as a result of the computerised element of the process. The letter is then put in an envelope and it is delivered by the postal service to the patient and the patient's GP. The GP then has to read the letter. Quite often the letter goes to the wrong GP. The GPs find this annoying but the computer does not understand that it needs to send the letter to the right doctor. What happens then is very odd. The GP scans the letter, puts it on his computer and shreds the letter. A letter that began as computer code in the hospital is turned into something we can read on paper, taken to the GP's surgery and turned back into something a computer can deal with. It does not take a genius to be able to see that there is a better way. It is called email. But where Dr Grumble works we do not use this newfangled system. Which is odd. Very odd.

17 October 2009

The Grumble Credo

In its bricks and mortar, people and services, the NHS embodies something which is truly great about Britain. That something is equity: the spirit of fairness for all and the equal right of everyone regardless of age, background or circumstance to get the healthcare they need.

Those words are a bit cloying but it is what Dr Grumble believes. After all Dr Grumble has been described by overseas commentators as a socialist blogger. Praise for the NHS is what the Grumble readers expect as a general election draws closer. So let Grumble continue:

The NHS really is one of the most precious gifts we enjoy as British citizens.

Perhaps by now you have realised. These words are too sugary to be Dr Grumble's. Can you guess who wrote them? The writer believes them. He has good reason to write these words. Personal reasons and political reasons. The writer is, believe it or not, David Cameron.

Unfortunately people close to David Cameron probably do not think of the NHS in quite the same way.

Here is a clue to the way the Cameron henchmen are thinking:

Despite believing that market mechanisms work, [Labour] have failed to open up the market for the provision of NHS care so as to drive up standards.

You can find all this in the Conservative's NHS Improvement Plan (pdf). Here they laud Labour for privatising parts of the health service, recognise that this policy has failed and imply that the solution is to throw even more NHS services out to the market wolves. The failure of the market is recognised yet the response is to propose more of the same. There is no recognition of the vast sums now being spent on running the costly market processes. There is no mention of how the well heeled bureaucrats employed to commission the services are sucking up the billions that we all know are no longer reaching the front line. Despite all that has happened in finance as a result of the present government leaving things to a market free-for-all (encouraged it would seem by the opposition) there is still the widespread blinkered view that markets will somehow solve the problems of the NHS. It is just not true. Markets are causing the problems.

There are those elsewhere who think even more misguidedly. Take this quote which begins with a wonderful pun:

Focused eye surgery centres, heart health and orthopaedic hospitals, for example, can streamline processes and deliver far higher output and quality than the hotchpotch of services provided in general hospitals.

This fails to recognise that operating on elderly people with multiple pathologies in a streamlined highly efficient centre is not a good idea. General hospitals are not places where you have general doctors who have a stab at anything and do nothing well. They are places where there are teams of experts so that individuals can get the full range of expertise they need. When you fracture your hip and go into heart failure it is really not a good idea to have the heart doctors in their own streamlined centre across town. We need bigger hospitals not smaller. NHS patients have suffered too much already being transferred from one hospital to another because of failures to provide the full range of what patients may need all under the same roof.

Here is another nonsense:

At present, the NHS locks in inefficiencies due to two antiquated models: the general hospital and the general practice – both designed a century ago when medicine lacked evidence-base and was largely intuitive. Far more productive, now that we can make definitive diagnoses in many cases, would be to integrate the diagnostic work across the two, and hive off many procedures that occur after a definitive diagnosis to specialist centres.

This makes little sense to Dr Grumble. Whatever does the author think happens now? If you need your stitches taken out it makes sense for your GP's nurse to do it. If you need your appendix removed this is no longer done on the kitchen table. You go to the hospital. And what about today's news on the increase in children's admissions? What's the betting that that is the consequence of the loss of the antiquated 24/7 care that used to be the responsibility of individual GPs?

Here's more:

Real reform should thus look at the demand side too; at breaking PCTs up into groups of competing social insurers, as already exists to great effect in many European states such as France, Germany, the Netherlands and Switzerland. This is not a threat to universal and comprehensive ideals. With the state paying for, or topping up, premiums for those that cannot afford health insurance or with chronic conditions, these ideals are preserved – just as Europe. The difference is that healthcare premiums are paid direct to insurers, rather than to the state through taxation, and people are able to choose between them on the basis of quality and price. If service is poor, or insurers fail to back innovative providers, declining custom gives a powerful incentive to improve.

Anybody who thinks this will make healthcare more cost effective than the NHS used to be before the recent meddling is clearly living in cloud cuckoo land. But then a lot of people do, it seems, live in cloud cuckoo land.

Dr Grumble agrees that large improvements in funding in the NHS over the past ten years have not brought matching improvements in services. There are all sorts of reasons for this. One major factor has been the cost of running a failed NHS market.

10 October 2009

The law is no ass

Ignorance of the law is no defence. It would take you over 400 years to read all of the law that applies today in the UK. None of us can do this. Doctors cannot even read the parts of the law that most affect their practice. Instead we just do what we believe to be right and, generally, if you do this the law will protect you.

If you keep somebody alive because you believe that is the right thing to do the law will protect you. If you allow somebody to die because you believe that is the right thing to do the law will protect you. If you do what you would not naturally believe in your heart of hearts to be right it is likely that there will be a law that will condemn you. When it comes to the practice of medicine our laws are not that bad.

So if a patient with mental health problems arrives in your hospital having taken an overdose with a note pinned to her chest asking you not to treat her you might feel that she should be treated. You wouldn't worry about the Mental Capacity Act because that is there to protect people who are unable to make decisions for themselves not to condemn them. You remember reading that somewhere. In any case you feel sure that saving the patient's life must be the right thing to do.


Time is of the essence so you really should get on with treating your patient. Trawling around the niceties of the law is not an option. Treat and trust that the law will back you is the only sensible way forward.

But just suppose that for some misguided reason somebody in your team decided to check with the hospital's solicitors that it was alright to treat such a patient. What advice would you expect? How do you think they would deal with the apparent conflict between the Mental Capacity Act which requires you to do what the patient wants which is to die with the Suicide Act 1961 which prevents you from aiding and abetting the suicide of another?

The lawyers would, of course, reassure you that there is no conflict between the Mental Capacity Act and the Suicide Act 1961. Nothing in the Mental Capacity Act affects section 2 of the Suicide Act 1961. That should be obvious but to avoid any possible doubt the scope of the Mental Capacity Act was clearly stated in the Act itself:

Scope of the Act

For the avoidance of doubt, it is hereby declared that nothing in this Act is to be taken to affect the law relating to murder or manslaughter or the operation of section 2 of the Suicide Act 1961 (c. 60) (assisting suicide).

Which means that section 2 of the Suicide Act 1961 applies the key part of which reads:
A person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be liable on conviction on indictment to imprisonment for a term not exceeding fourteen years.

Which rather means that the doctors who allowed Kerrie Wooltorton to die were rather poorly advised. One thing is for sure. Nobody is going to go to jail over this. Certainly not the solicitors who gave the rotten advice. And the coroner doesn't seem to have got the law right either. Or is Dr Grumble completely wrong? After all he knows nothing about the law.

07 October 2009

A Myth and a Fact

04 October 2009

Alan Milburn attacks Andy Burnham

So Alan Milburn has attacked Andy Burnham for making the NHS the preferred provider. Now why can that be? Does this hold a clue:

Interestingly, former health ministers have done particularly well. The ex-health secretary Patricia Hewitt earns more than £100,000 as a consultant for Alliance Boots and Cinven, a private equity group that bought 25 private hospitals from Bupa. After leaving the department, her predecessor, Alan Milburn, worked for Bridgepoint Capital, which successfully bid for NHS contracts, and now boasts a striking portfolio of jobs with private health companies.

When I rang Milburn yesterday to ask whether he saw any conflict of interest in his directorships, he swore and hung up........

It is a peculiar change of policy. Dr Grumble has witnessed how the private sector has been wooed under ludicrously favourable terms. When it comes to private providers the term "level playing field" is not in the government's lexicon. As a result the private companies have been on a runaway gravy train rife with nonsenses - such as being paid for operations they haven't even done. And all this has been carefully but surreptitiously crafted by Burnham and his henchmen.

So why the change of heart? Has Andy Burnham really seen the error of his ways? Or has he realised that the great British public is beginning to rumble what is going on? Or is there another explanation?

Whatever the real reason, mark the Grumble words. The policy will drift back after the election. Probably more quickly under a Labour government than a Conservative government. The Conservatives are distrusted when it comes to the NHS so have to tread more carefully. Unfortunately the same malign interests lean heavily on both parties. All three parties actually. What the British public want does not really enter into it - except just before an election. For we are now entering the period known euphemistically as the post-democratic era. Those in charge know what is best for us and just get on and do it. But they don't expect doctors to behave like that. Rightly or wrongly. Odd that.

01 October 2009

A flawed Act

Dr Grumble has never been entirely comfortable with the Mental Capacity Act. He preferred the law when it was vaguer. He always felt that if he acted in good faith and documented carefully the reasons for the decisions he had made the courts would protect him.

When the Mental Capacity Act was introduced Dr Grumble was specially trained by a barrister on what it would all mean. She made it quite clear that if Dr Grumble ever treated a patient against their wishes he would be guilty of assault. That's fine. Dr Grumble has never had any difficulty allowing patients to reject treatments they do not want even if it causes their death. Not usually anyway.

But there is one situation when Dr Grumble would be very uncomfortable about following the law and he put this to the barrister. He asked what would happen if a silly girl came to the Emergency Department having taking a potentially fatal overdose and declined treatment. Silly girls do this. They do it quite often. The next day they can feel different. So Dr Grumble has treated them against their will on many occasions and they have never in the past taken any action against him. But that was in the past when the vagueness of the law offered more protection and acting in good faith was always looked upon favourably.

Dr Grumble asked the barrister to clarify what the position would be following the introduction of the Mental Capacity Act if he decided to prevent the death of a young girl who refused to be treated having taking an overdose. The answer, insofar as lawyers will ever answer a question, was not reassuring. It seemed that even if the patient was depressed Dr Grumble would be required to let them die.

To allow a patient to die in such circumstances is so obviously wrong that Dr Grumble has decided to ignore the law in such a situation, save the patient's life and accept the consequences. If the patient dies they won't complain and if they live they are quite likely to be grudgingly grateful. And if Dr Grumble got it wrong they can always have another go at killing themselves. After all killing yourself is not that difficult if you really want to do it. The strange thing is that many people who try to kill themselves turn up in the Emergency Department where treatment can be offered. There is a reason for that.

Not all doctors are as brave as Dr Grumble. This was predictable

Some of Nutty's comments have been removed at her request.