27 February 2010

Foundation Training

An inordinate amount of effort has been put into the reorganisation of the training of junior doctors. The Foundation Training programme was the trail blazer. Dr Grumble has no idea how much it has cost. There have been direct costs and there have been hidden costs. Both are likely to be have been substantial and, in the current climate, no longer affordable. Ensuring better training is laudable, essential even. But how much has this all-singing, all-dancing Foundation Training delivered on its objectives?

Dr Grumble sometimes looks at his Foundation doctors and asks himself how much their jobs and their training differ from the training he had. The truth is that surprisingly little is different. Some things are a bit better. Some things are a lot worse. Quite a lot is much the same.

Dr Grumble felt as a house physician that he belonged to a well defined team or firm as we called it. In the teaching hospitals we were overflowing with staff. The great man (and it almost always was a man) was accompanied by an enormous entourage. Doctors came from around the globe to learn. Everywhere there was a great hunger for learning. There was a wonderful esprit de corps. Much of this has gone. Staffing has been pared down to the bone. Doctors no longer come from abroad. Shift work is the norm and with that the feeling of belonging has evaporated. Esprit de corps is no more. Foundation doctors are with us for too short a time to settle in and thrive. It's not the learning environment it once was.

Meanwhile the documentation of the Foundation doctor's learning has grown beyond belief. There is an array of supervisors and assessors who have pages and pages of online boxes to tick. The documentation makes it look as as if a lot has gone on. In reality it is a shallow charade. Hours are spent struggling with eportfolios. The boxes to tick are overwhelming and get in the way of a quality educational relationship.

But don't listen to Dr Grumble. Nobody else does. Certainly not in the Foundation School. Listen to a junior doctor. This is what Nick says:

Training is now a mess. It is virtually impossible, thanks to the shift patterns worked by all doctors, to find time to spend with patients in the company of a senior doctor who can teach you. The workplace assessments hinder this because they are badly thought out, have no appreciable evidence base, and cast spending time with trainees as a box-ticking exercise for senior doctors who find that process as loathsome as most trainees do. You cannot make up for that deficiency in clinical time with your seniors with any amount of well-intentioned “modern adult education”; helpful though things like ALS and simulation training are, they must be adjuncts to and not substitutes for training on the job. Education is haphazard at best, with trusts given the impossible job of delivering the entire Foundation curriculum to a group of shift-workers in disparate geographical locations. Foundation education sessions are therefore variable in quality to say the least, particularly at F2 level where nights and A&E rotas are commoner. Outside education courses, although they are the single most useful things you can do to further your career, are almost never funded and rarely allowed as study leave during the Foundation Programme.

Nick has a degree in English. You need a degree in English to get a good job these days. And to write a decent blog.

25 February 2010

Foundation, finance and *uck-ups

The alliteration was too good to miss. It's a shame about the asterisk but Dr Grumble does not want to attract inappropriate traffic. So why these three F-words? It is because Dr Grumble thinks they might just be connected.

If you are in charge of a hospital your main focus should be on providing a high quality, safe service. Everything else should be secondary. If you have to overspend to obviate a disaster you should do it. It actually used to be like that. Everybody understood that safe care was paramount and sometimes the balance sheet but not the patients would have to suffer.

Where do you think this paragraph comes from?

The minutes of the executive team suggested that the main focus of the executives was also on finance, the PFI, service reconfiguration, service level agreements and, latterly, foundation trust status. (pdf)

Could it be from some inquiry into the Mid Staffordshire Foundation Trust? Perhaps it could. But it isn't. This is from the Mid Stafforshire Inquiry:

If there is one lesson to be learnt, I suggest it is that people must always come before numbers.

The very interesting thing is that Dr Grumble had not read the Mid Stafforshire report as he started this post. He just somehow knew what it was going to say. And amazingly on the second page in the covering letter there it was. People must come before numbers. Which is a pithier way of saying what Dr Grumble has always known.

But the question Dr Grumble would really like to ask is whether the creation of Foundation trusts has created this problem. It seems it has. Which means that the problem has been of the government's own making. Yet it seems they are powerless to undo it. Worse still, the opposition want to speed up this flawed process. Is there no hope of some sanity?

24 February 2010

Halfway houses

Dr Grumble has been planning for some time to do a post on how to save money in the NHS. But the post would be too long for anybody to read. This does not mean that Dr Grumble thinks that the NHS is inefficient or that if it were privatised everything would be put right. In fact Dr Grumble takes the opposite view. But there are quite a lot of things that could be done to save money.

When Dr Grumble first started on the wards as a medical student there was something that immediately surprised him. What surprised him was that few of the patients on the wards looked ill. In those days we had many more hospital beds so perhaps that was not altogether surprising. With fewer beds and ever increasing numbers of elderly patients, has that changed? Not a bit. Walk around the average medical ward and the patients will mostly look reasonably well. So why are these patients in hospital? The answer is simple. They cannot go home.

It is a curious thing that managers think the patients are in hospital because they are ill. But many medical patients are in hospital because they cannot go home. It is important to understand the difference. There is no point in getting Dr Grumble to see his patients at weekends to try and discharge them as soon as they are well enough if they are not in hospital because they are ill. All this talk of care in the community and we cannot even return patients to the community early. Why is this?

There are all sorts of reasons why patients cannot go home. They may not have a home to go to. Relatives may be unable to take them back. And it is not uncommon for patients to lose their lodgings while they are in hospital. Surprisingly often patients lose their front door keys. Sorting out problems like this takes time. Meanwhile, every day that goes by a hospital bed day is lost. We do kick some out onto the streets if it looks as if they can manage. Dr Grumble does not like to do this but those are the rules. And there is little alternative. But most patients cannot go home because they cannot manage. They are not acutely ill but chronic problems and the ravages of time render them unable to look after themselves. They can be looked after at home but that is in the realm of social care. Over this Dr Grumble has scant if any control. The money comes from somewhere else. The prime concern of social workers are their clients in the community who are at risk. They never give priority to patients in hospital who are safe. The incentives to move them home are not strong.

When Dr Grumble was a young house surgeon he had access to halfway houses. The surgeons took well patients but after cutting them open they became unwell. They needed time to pick themselves up but not necessarily medical care. For these people we had houses in the country they could go to to recuperate. Over the years, one by one, all these places seem to have disappeared. In any case Dr Grumble's patients are not likely to get much better. But they don't need to be in hospital. What they need is a halfway house why they wait for a nursing home or other appropriate placement. And the bill needs to go the social services.

23 February 2010


Lifeblood is a good name for a charity. Especially a charity which aims to increase awareness of thrombosis.

This is what Lifeblood says:

In the UK, the Government has estimated that more than 25,000 deaths occur each year because of VTE, acknowledging that this accounts for more than the combined deaths attributable to breast cancer, HIV, and road traffic accidents. Source.

It sounds OK. If it is true. But is it true? Where did the House of Commons Health Committee get its figures from? Could it have been from Lifeblood by any chance? Perhaps not. This is what Lifeblood stated in their evidence to the Health Committee:

In the UK VTE causes around 32,000 deaths each year.

So what is the real figure. Is it 32,000 or 25,000? Or could it quite possibly be very substantially less? It would be interesting to know what the Office for National Statistics says. Does anybody out there know?

21 February 2010

Private finance or public swindle?

When the general election comes we need to vote for a party that can unpick all of this. Now which one would that be?

20 February 2010

What can you see?

Here's a picture from one of those new fancy scanners they have at airports. They work like those James Bond glasses that can see through clothes. They use X-rays. Dr Grumble heard on the radio that the radiation did not penetrate the skin which surprised him.

Have a look at the scan above? Can you see the lungs? Can you see the tibiae? That's odd if the radiation doesn't penetrate the skin.

Do we need to worry? It depends on the dose of radiation we can expect to receive from these scans. We are all exposed to radiation - especially Dr Grumble's Cornish readers - and flying itself exposes you to cosmic rays. Nobody seems to worry about getting irradiated on a transatlantic flight. A few people worry about chest radiographs. Yet a transatlantic flight is roughly three times the radiation dose from a standard chest X-ray. Have you ever worried about eating Brazil nuts?

14 February 2010

What do our managers read?

As far as Grumble knows the only journal our managers read is the Health Services Journal. Dr Grumble cannot read this rag. It is not something he subscribes to. But the little snippets he reads from their blog make it seem like the Daily Mail. It seems to be one of those 'journals' that reinforces the mistaken models of the world that some people stubbornly carry in their heads. It might even be responsible for creating these falsehoods.

There are general themes which run through the HSJ output. Doctors are bad is one. GPs are idle money-grubbers is another. And the canard that markets are always good persists despite all the recent overwhelming evidence to the contrary. Doctors are just out for themselves and not interested in the welfare of their patients is another brutal allegation that really hurts. Dr Grumble has decided that he can no longer stand by and ignore the garbage that forms the output from the HSJ. Managers and doctors need to work together. Managers need to support doctors. How can we expect this when the HSJ publishes such falsehoods about us?

Doctors more than management want good care for patients. It's our raison d'etre. It's the overarching focus of our daily work. We, unlike managers, see the consequences of poor care. We more than managers have to communicate the consequences of poor care to our patients or their relatives. How can these people have the effrontery to educate us that patient care is paramount and accuse us of just being out for ourselves? They are the ones who sometimes fail to grasp the primacy of patient care. Not doctors. Unbeknown to our managers concern about patient care is a cardinal reason for the divide between us. We want to provide good care regardless of the cost. Managers always want to keep the lid on spending. That is a constant cause of friction. Doctors are bound to lobby for their patients to see that they get what they need. We are always battling for our patients. But we do live in the real world. We do see that costs must be contained. But what chance is there of our working together when we are constantly being undermined by HSJ blather?

It's a strange irony that it is managers who seem intent on trying to turn us from public servants with a genuine interest in patient care into the money grubbing people the HSJ likes to portray us as. Managers were the ones who essentially forced new contracts onto consultants resulting in our being paid for the very first time (on paper anyway) for all the work that we do. Doctors who were reluctant to move from a professional and vocational contract are now being paid more. Did our masters expect us to be paid less? Perhaps they really did. Perhaps managers just cannot grasp that doctors do whatever is necessary to meet the vital needs of our patients whether we are paid or not. And the same people made similar mistakes with GPs. For it was managers who forced GPs to jump through ever more hoops to be paid - which they promptly did. The BMA dutifully told the government that it would result in their being paid more. But the BMA was not believed. Yet the HSJ continues to distrust them.

The problem is that the HSJ has repeatedly fed a very wrong model of the world into our masters' minds. It has come from a number of inaccurate sources. Sometimes these have been blatant perversions of the truth. Below is just one small example of how the HSJ twists the truth. It is a quote from the editor's blog from a post entitled Public services failing to satisfy customers:

Figures from the UK Customer Satisfaction Index revealed that national public services, including the NHS, achieved the second lowest score among the 13 sectors measured.

The picture was repeated for local public services such as GP surgeries, which were also in the bottom half of the customer satisfaction service league table.

Now from that you would get the impression that GPs are a pretty bad lot, wouldn't you? Like the Daily Mail HSJ reader you might think that something must be done. But if you take the trouble to look at the facts, you would be surprised to learn that GPs were in the top ten of local services just behind the ambulance service:

  1. Your local Ambulance Service — 81.6
  2. GP surgery / health centre — 77.5

They were not only in the top ten. They were second! And, if you want to compare them with other categories, they scored more than Starbucks, VW and Virgin Media. But the HSJ won't tell you that. Now why do you think that could be?

The Jobbing Doctor describes another unwarranted attack on doctors in the HSJ. And like a sheep a manager weighs in and puts his misguided boot in only to have to back down when the redoubtable Clive Peedell puts him right. Read JD's post and put your blood pressure up.

13 February 2010

Matron Healthcare

Grumble's first movie

Dr Grumble has just had a go at making his first movie. It hasn't been a 100% success but it is a start. For a first movie it is not that bad. The one thing Grumble has not succeeded in doing is embedding it here. It works well in the blogger preview but when it is published you can only see half the image. So if you want to see the Grumble movie you will have to visit Xtranormal. The movie is called Matron Healthcare.

10 February 2010

Two characters

Where do your sympathies lie?

07 February 2010

Did Blair mislead parliament?

Is the answer here?

A very French proposal

From time to time comments appear on this blog saying how much better healthcare is in other countries. France is often claimed to be the best country. How people know is unclear. Most of us do not have that much experience as patients in other countries. Dr Grumble does occasionally interact with French doctors. He has visited parts of France which excel in his particular specialty. Are they better than us? The honest answer is that they are. It's not a marginal thing. They are head and shoulders above us.

As it happens Dr Grumble has recently been working alongside a French consultant. Getting locums with the right expertise can be difficult so the Grumble hospital recruited one from France. What would he think of the NHS? Dr Grumble tentatively asked. He shrugged in a typically French way. "It's the same," was all that he would say. The French doctor was a good one. The decisions he made were much the same as Dr Grumble would have made. From a distance French medicine can seem rather different from English medicine but the similarities are greater than the differences.

French doctors, junior and senior, are unusual in the UK. Dr Grumble has had the occasional medical student from Paris. He remembers one particularly well. Towards the end of her stay she beckoned Dr Grumble and told him she had a good idea for an improvement. Dr Grumble was all ears. What was this innovation going to be? If you know anything at all about France, what she had to say will not be a great surprise. But like all simple improvements that those from outside the NHS think would be easy to implement, the French student's proposal was a complete non-starter. Dr Grumble just laughed. He didn't mean to. But her proposal was so very French.

So what was the proposal from Grumble's Parisian student? Dr Grumble sat down to listen. She began by saying that we were leading unhealthy lives. All we had for lunch was a rushed sandwich. And that was on a good day. She was shocked that we did not do what they did in the French hospitals where they took an hour or so's break for lunch. They had a proper sit-down meal and the hospital paid for the wine! Dr Grumble didn't really laugh. He did inside but it is not good to laugh at serious suggestions made by students and she was serious. She was unable to grasp that nothing like that was ever going to happen in today's NHS and she looked visibly disappointed that Grumble was not going to make an immediate appointment with his masters to sort out the wine supply.

Believe it or not, this is an absolutely true story and while the student's suggestion does seem today to be absurd, Dr Grumble can remember times when we did sit down to lunch. And it was a healthy thing to do. It was healthy for the well being of the hospital and our patients. We met our colleagues. We learnt what was going on by chatting instead of by reading propaganda news sheets from the management. We learnt who to refer to. We discussed cases with colleagues that would otherwise not have been discussed. A lot of work was done in a painless way. But the world moves on - not always in the right direction.

03 February 2010

Push-you-pull-you management

There was a time when a consultant in the NHS was a professional. He didn't really do what he was told to do because he wasn't actually told to do anything. He decided what needed to be done and did it. He decided how much training he needed and did it. He decided how much time he had to teach and he gave that amount of time. He decided what treatment his patients needed and he gave it. Perhaps some abused it. Most did not. Dr Grumble well remembers waiting in the car outside the NHS hospital while his father did a quick Sunday morning ward round. Nobody paid him. He just wanted to check that the patients he had operated on were all right. That was professionalism.

But that was yesterday. Now you are required to do set amounts of everything. A set amount of Sundays, a set amount of training and a set amount of teaching. These things are logged and measured. Some things are measured thoroughly, others are measured less thoroughly. You do exactly what the management require. It is like being a puppet on a string.

Being told what to do to at this level of detail does not make people happy. But there's no need to worry because happiness is another thing they measure. Dr Grumble will not give you the results of the happiness measures in his neck of the woods. That would not do. Suffice it to say that a lengthy document has now come out from the top management on how to improve staff morale. This is what Grumble calls push-you-pull-you management. They make the staff unhappy so the management alter course and try to make the staff more happy. It sort of oscillates.

This level of tight management control has now extended into clinical matters. Woe betide if you don't follow the latest treatment guidelines. Your performance is scored. It is put on a graph. It is compared with the performance of others. It seems reasonable in a way but the truth is that the guidelines are often decided on a show of hands at a meeting. Some change so rapidly that they just cannot be based on scientific advances. And finding the latest documents is time consuming. The whole thing is oppressive.

Last week Grumble had an email telling him to discharge patients as early as possible. Actually this is not quite what it said but that was the message. They don't like to actually tell you to discharge patients. Not yet anyway. This week Dr Grumble had an email saying that they were concerned about the number of readmissions. Patients are being sent home too early. Now isn't that a surprise? That's what happens with this sort of management. They push you one way and then pull you another. Sometimes you think that things would be OK if only they would leave you alone.