19 June 2011


@drgrumble are you going to 'come out' soon? :) I think you might!

So read the tweet from @amcunningham. Yes, Dr Grumble is on twitter. A waste of time? Not really. Teaches brevity you see. Only 140 characters. It's a good discipline. Could change the character of this blog.

Long ago Dr Grumble decided against posting anything about patients. It is a great shame. In his initial naivety, Grumble was hoping to post the odd clinical vignette based on real but anonymised cases. For a while he did. To preserve anonymity he changed the details of the cases he had seen to make them unrecognisable. Genders, ages, dates, places and ethnicity were all changed or randomly allocated. It didn't work. Sometimes the details were tweaked so much that comments would be made pointing out some inconsistency that didn't exist in real life but arose because of the disguise. Then there was always the possibility that while nobody could possibly recognise the patient, the GMC might think that the patient could be recognised from the information provided or, if the case was rare or had some unusual twist, the patient might recognise themselves. Dr Grumble's anonymity was a part of trying to keep his patients anonymous.

But there are other reasons for having a nom de plume. There are other people whose identity you might want to conceal: friends and acquaintances for example. Take yesterday. OK, it might not actually have been yesterday but let's say it was. Yesterday Dr Grumble had some friends around. One had not long ago had her 60th birthday and she regaled us with the tale of her pooh sample. For those of you without a 60-year-old in the family you may not have grasped what this is all about. Once you reach your sixtieth birthday, if you are lucky enough to live that long, you will receive a letter, not from the queen, but from the NHS. It will tell you that you are to be offered a pooh test to look for bowel cancer. Just as you have come to terms with this, a little pack will arrive in the post with the testing kit and instructions. The first challenge is to catch your pooh. You cannot let it plop into the loo. That's not allowed. Somehow you have to catch it. According to Grumble's friend an old ice cream container works well. Your poohs will turn out to be heavier than you expect. You crouch, do the business and catch your plops. Those of you familiar with German loos will know that this is a smelly experience. You then take the sticks, kindly supplied by the NHS, and spread your pooh in the appropriate cardboard window. Two spreads from different parts from each motion. And you do this three times. As Grumble's friend said, it makes a new meaning of the phrase Poohsticks. But the funniest thing of all, if any of this is funny, it that they give you an extra special envelope to send your sample back in and, just after you have sealed it up (no, you don't have to lick it), you will read on the outside "Business post".

After you have tested your pooh, you get an invitation to have some sort of a check-up at the GP's. It is done by a nurse. Just what the nurse does Grumble does not know. Probably she tells you to stop smoking and takes your blood pressure and things like that. In the case of Grumble's friend she discovered an irregular pulse. Good you might think. But it wasn't atrial fibrillation it was just the odd ectopic. This is something that Dr Grumble would have dutifully recorded and would not even have told the patient. But Grumble's friend was sent to the hospital where she had numerous tests paid for under payment by results and was then told there was nothing to worry about. Very costly one would think.

Since Dr Grumble has been tweeting he has had a few contacts with the great and the good, the powerful, the odd celebrity even. No less a person than Alan Maynard tweeted about how nurse practitioners could do some of the jobs of GPs. Mrs Grumble, who used to be a GP does not share this view. Clare Gerada concurs tweeting that there is no such thing as a trivial consultation - which, interestingly, was Mrs Grumble's exact point. It's annoying when management types claim to know more about a job than the people who do it. Many of us will know of some nurses doing doctors jobs who cost more than they save. The same has been shown of some GPs doing consultants' jobs. Dr Grumble generally avoids such anecdotes because he doesn't want to cause upset. In any case, Grumble is employed. He needs to keep his employer sweet. His employer wants more healthcare assistants to do nurses jobs, more nurses to do doctors jobs and more GPs doing consultant jobs. Pointing out that this is not always the right way forward is unwise. Nurses for nursing, doctors for doctoring, GPs for general practice, consultants for consulting and managers (not doctors) for managing is not the way you are allowed to think any more. But that is what Grumble thinks and that is just one reason why he is going to stick to his nom de plume.

11 June 2011

Radical policies for which no one has voted

If a government is pursuing radical policies for which no one has voted what can you do? Not much really. Writing to your MP is worth a try. It might be more worthwhile if your MP happens to be in the cabinet.

A friend, briefed by Dr Grumble, sent this letter to his MP, a well-known cabinet minister:

Dear Cabinet Minister,

Health and Social Care Bill 2011

I am writing to express my concern about the general direction of the proposed NHS reforms. We have been repeatedly told that the NHS has to change. The evidence for this assertion is lacking. We do have a problem: health-care spending is predicted to rise because of the increasing numbers of elderly and the ever-increasing costs of treatment. That is the problem, not the current structure of the NHS.

The Commonwealth Fund has found the NHS to be the most cost-efficient healthcare service in the world. The World Health Organisation recognises the French system as being the best in the world but the French spend 11.2% of GDP on health care compared with our 8.6%. Despite this, our figures are improving much more rapidly than those in France.

I am particularly concerned about the move towards privatisation and a more American-style system. In the United States spending on health care in the year 2005 was £3921 per person whereas the figure for the NHS was £1603. Are their results any better? No. The British have generally better health and live a year longer. And the cost of administration of the US system is three times that of the NHS.

Why can we not accept that rationing is a fact of life in all health care systems. We need to ration on the basis of need. The National Institute of Clinical Excellence has led the way on this, is admired throughout the world and has ensured that we provide the best treatments to the greatest number of people.

We all accept that there is a need to keep healthcare spending under control but allowing the NHS to fragment into a loose association of multiple providers all in competition with each other is hardly the route to cost-effective integrated health care. I do hope you will do what you can to ensure that the Bill is shelved.

Yours sincerely,

A Grumblefriend

The reply he received is as follows:

Dear Mr Grumblefriend,

Thank you for your letter. Our plans to modernise the NHS have a simple aim: to ensure everyone is provided with healthcare - free at the point of use - which is the best in the world. At the moment, and despite years of extra investment productivity has declined by 15 per cent over the previous 10 years. We have to modernise the NHS to ensure that it is ready to meet the twin pressures of an ageing population and rapid advances in medicine.

We have already made several changes in response to concerns voiced by healthcare professionals - this includes strengthening the provision that competition will be based on quality not price. I can also assure you that the Secretary of State will still have a duty to promote a comprehensive health service. Now that the Bill has passed through the Commons there is a natural pause before it is considered by the Lords. We will be using this break to listen to the concerns that people still have. Where those concerns are genuine we will engage with those who want the NHS to succeed and make amendments to improve the Bill.

Yours sincerely,

A Cabinet Minister

The cabinet minister signs off with just his first name. Grumble's friend moves in high circles. The letter is clearly a standard reply. It even mentions a major concern that Grumble's friend neglected to raise: the crucial change in the responsibility of the Secretary of State who now only has a duty 'to promote' a comprehensive health service. Plainly it is not just a few maverick medical bloggers who have spotted this fundamental change to the law.

This bland mollifying reply, sent doubtless to numerous constituents, actually reveals that they are not going to budge one iota on this crucial point. No longer will the law state that the Secretary of State
"must...provide or secure the provision of [National Health] services.."
The duty to provide comprehensive health care has gone. The requirement that previous benevolent governments took upon themselves at times of great hardship to provide healthcare for us all, rich and poor, has been taken away. It has gone forever.

‘The NHS will last as long as there are folk left with the faith to fight for it.’
Aneurin Bevan

Are there still enough folk out there with the faith to fight? Possibly not. Not in parliament anyway. People are afraid. Very afraid. And they are right to be.

06 June 2011

02 June 2011

Just how much can you get from a pint pot?

Never in the history of the NHS has a parliamentary Bill met with the level of opposition that has confronted the Lansley Health and Social Care Bill. What Lansley lacks in drafting skills he makes up for with tenacity and nobody would be surprised to learn that he is now fighting a rearguard action to drive through the changes he and his henchman have decided are necessary. Now you might think that Grumble is a bit antagonistic towards Mr Lansley. And you would be right. But Grumble is a fair man and he likes to look at the evidence and, if there is no evidence, the arguments. So it was with interest that Grumble read Lansley's recent article in the Telegraph. Unsurprisingly there is quite a lot wrong with it.

Now if Grumble were to write an article on the NHS he would start with a little homily about the wonders of the health service. It is the obvious way to start but we don't get this from the Secretary of State. Oh no. Quite the opposite. He sees the NHS not as something to be valued and cherished but a burdensome yoke. Keeping it going as it is will inevtiably lead to a 'crisis tomorrow'. What is his evidence? It is that there are 'enormous financial pressures looming on the horizon'. You have heard it all before. This is the 'something must be done' argument which politicians use to justify almost anything that they want to change - especially when they have no better argument for change.

Now nobody doubts that there is going to be a crisis ahead as far as funding the NHS is concerned. But this is not to do with the NHS itself. This is a problem which is going to face every modern healthcare system in the world. There are various reasons for this. Lansley enumerates them - one of the few things he has got right.

Another thing that Lansley probably has got right is the funding gap. He tells us that by 2015 the health service will need £130 billion per year and that this leaves a funding gap of £20 billion. OK. Dr Grumble believes him. Something does have to be done to deal with this. But what is his solution to this problem? The answer it seems is that the NHS is going to have to work smarter. Then, in the same breath, he trots out the already discredited but now standard political tale of the poor cancer performance of the NHS and the equally discredited heart disease figures. What has this to do with saving money? If he is right and we are doing so badly, this is going to need more money not less. This is not just about 'working smarter'. And, in any case, if you save people from these diseases they live longer to die of something else and that ends up costing the NHS more not less. It is actually the success of the NHS with rapidly increasing numbers of elderly that has caused the impending healthcare spending crisis. It is not the poor performance of the NHS that is responsible for the looming crisis, it is the opposite.

Then he trots out the oft repeated mantra of 'no decision about me without me' and 'patient empowerment'. Laudable though these may be, how can patient empowerment possibly fill the funding gap?

So now Grumble is really left wondering about what the Lansley Bill is really about because saving money through improved efficiency does not seem to be it. Empowering the patient and chopping up the NHS into multiple providers each competing with each other is hardly likely to save money. The reason why there are now so many managers in the NHS is because of the preparation for privatisation. Running a market inevitably wastes money. It requires managers to commission services and it requires regulation. What is even worse is that organisations which get paid per item of work will, surprise, surprise, do more work. That might be good for waiting lists but it is not good if you want to save money. Saving money is about minimising healthcare and, believe it or not, you probably can do that without necessarily damaging the quality of care. That is smarter working but you won't get that from a market that pays you more if you do more work.

What is this Bill really about? How is Lansley going to make up the £20 billion shortfall when the new NHS he is creating will be less and not more efficient? There can be only one answer. This is the beginning of the winding down of the NHS. Patients will somehow be persuaded that they need to pay for some of their healthcare themselves. That is where 'empowering the patient' comes in. What other explanation can there be?

Oh, one more thing Grumble nearly forgot. Messrs Lansley and Cameron like to compare healthcare in France with healthcare in the UK to demonstrate how rotten the NHS is. It's doubtful if the figures they give you are at all reliable but one thing they always fail to tell you is that in France they spend 29% more on their healthcare than we spend on the NHS. If we did the same we wouldn't have a funding shortfall. We would be in credit.

Mr Lansley is never going to get a quart out of a pint pot and he knows it. The real intent is in the title of the Lansley article: "Why the health service needs surgery". Notice the NHS doesn't need medicine, it needs surgery. And we all know what that means. Surgery involves cutting and Dr Grumble is suspicious that the Lansley Bill will ultimately lead to exactly that: cuts.