George Monbiot

Dr Grumble has always maintained that if there were decent journalists out there he wouldn't need to blog. The problem has been that the journos just do not seem to know what is happening. Now he has found a decent journalist. His name: George Monbiot. Curiously, Mrs Grumble, who some may remember is an ecowarrior, is one of his great fans. Take a look at what Mrs Grumble's friend, George, has been telling the public about what is happening to our NHS:

The Great Consolidation
The Patient Stalkers
The Patient is Dying
The NHS is Being Privatised
The Fat Cats Protection League
An Easter Egg Hunt

When are the public going to wake up to all of this? Why is our government so misguided? Gordon Brown must be stark staring mad. Because when the public finally does wake up to this they are not going to like it one little bit. The government is in the process of digging its own grave. And, amazingly, they don't seem to realise. Mark the Grumble words.

Clostridium difficile

Above are the figures from death certificates (from England and Wales) which mention Clostridium difficile. That's the infection that's caused and spread by doctors. Certainly that's the bit the government would like the public to hear. Because, despite the government's best efforts, doctors are continuing to cause this infection to spread. What the government is less keen on telling you is that the problem is worse in England than in Wales. Below are the figures for 2004 (civil servants are a bit slow so these are the latest Dr G can find):

England

Certificates mentioning C. difficile
2,155

% change since 1999
135%


Wales

Certificates mentioning C. difficile
88

% change since 1999
57%

So there you have it. In England doctors are getting worse in spreading and causing infection. In Wales they are also getting worse but not nearly as quickly. Dr Monk, though, has another explanation.


This post was first published under the title England versus Wales on 11th November 2007. It has been republished now because tonight Panorama is going to address this topic.

Tooke for the Tower?

Is Tooke being listened to or is our government so entrenched in its ways that the only hope for the NHS is to throw it out and hope the others can see the light? Is Tooke seen as a heretic or a saviour? Dr Grumble fears he knows the answer.

Here are some quotes from Sir John who was interviewed on Radio 4 recently (with thanks to Sam who pointed the programme out).

Different professional roles require different educational foundations. If you pursue a medical practitioner type of role, then you need a profound foundation in science, you need a deep education to enable you to undertake the clinical reasoning which is absolutely key to diagnosis - finding out what’s wrong with people. If the pattern doesn’t fit, you need to be able to go back to base principles and work things out from a knowledge of the science

.

On substituting healthcare professionals for doctors:

The results of role substitution experiments are not particularly well publicised, but when they have been conducted they’ve tended to reveal that the role substitutor for the doctor is no more cost effective and indeed in some cases less cost effective than the doctor doing that role. And the real reason for that is that a role substitutor may be able to follow a protocol, but unfortunately human beings and human disease don’t conform very neatly to protocols and that gets forgotten.

Referring to the skills escalator

In combination with a hierarchical control system and loss of clinical engagement on the ground, then it’s not surprising that doctors have felt somewhat de-professionalised and undervalued.

These few paragraphs are packed with Grumble themes. Some of you may remember speculation that Sir John must be reading Dr Grumble. But he probably hasn't. Everybody is actually thinking this way but not everybody is prepared to admit it. So will it be Lord Tooke or Tooke for the Tower? We shall see.

Trades and professions

When man developed agriculture some 10,000 years ago it was a major advance. Farmers were able to build up food surpluses and, since they didn't need these, they could trade them for things they did need. This meant that some people didn't have to be farmers. They could specialise in other things. And with time this led to trades and professions. The great advantage of this was that jobs could be done better by people who did that sort of work all the time. And when harvests were good people had time to sit and think. Some of them would become religious professionals who as well as praying and keeping the gods onside would do a lot of sitting and thinking. And from these sprung universities and scholarship. Such advances must have seemed rather without purpose in those days but nobody would now deny the great advances and benefits that resulted from time for sitting and thinking. Dr Grumble certainly thinks that this must have been one of the benefits of societies having a strong religion. All sorts of advances must have come from intelligent people congregating together to think, to teach and to learn. Time to think is frowned upon by modern managers. They seem to think that Dr Grumble should spend more and more time face to face with patients. That sort of approach can be damaging. It's this sort of thing that prevented doctors from getting sufficiently organised to prevent the disaster of MMC. Not allowing people enough time to think is dangerous.

So agriculture gave time to groups of people to be experts. Some prayed and thought and others became more practical experts of one sort or another. All had their important roles in society and were valued. Eventually those that sat and thought came up with writing and maths and science. In the end it was these people that produced the greatest benefits of all. But nobody was to know that.

Dr Grumble had the builder round not so long ago. He needed a couple of walls knocked down. Having a wall knocked down is quite cheap. It's building it again that costs. It's amazing how many people you need to build a new wall. There's the labourer who, under supervision, wielded the hammer and moved the rubble. Then came the bricklayer and then the plasterer and then the electrician. In between a very old pipe was accidentally broken so the plumber came too. "Why so many?" thought Dr Grumble. Each job looks simple. It would be so much more efficient if each person in the building trade could do all of these tasks. So why haven't builders organised themselves like that? There must be a reason.

Of course, health care is similar. Many years ago Dr Grumble was looking after one of his boss's private patients. She looked lonely in her single room and Dr Grumble commented accordingly. As it happened she had been counting the number of people that came into her room every day. It was over 60. Each had their own role.

A couple of weeks ago Dr Grumble was responsible for a few very ill patients. One of them, a young man in his thirties, was worrying Dr Grumble. It looked as if he might die from an undiagnosed infection that was iatrogenic. The number of people involved in his case was too great to count. Dr Grumble can immediately think of at least five consultants some at other hospitals. We didn't get these people involved for fun. Each had a role. Dr Grumble's job was to put it all that expertise together and take overall responsibility.

If you work in an organisation that's full of doctors the role of doctors is generally recognised and used to be valued. But when Dr Grumble worked more than ten years ago in a part of the civil service that was being privatised he was told that the doctors didn't do anything that others couldn't do. And he was also told he was paid too much. The former was utter nonsense. The latter could be argued over. Dr Grumble just left. With people like that in charge it was the only sensible thing to do. His job was advertised. They couldn't recruit. Nobody wanted a full time job with an organisation like that. And the salary was much more than they had ever paid Dr Grumble.

So where is all this heading? It's to tell you that the NHS managers are becoming equally mad. They have long been saying that we don't need in the NHS all these professional groups with their own areas of interest. And, yes, they are saying that the worst amongst these are doctors that do not do anything that others cannot. And if they do it's only because they or society has set up systems that prevent others from doing their work. What, after all, does a doctor have that others don't? That's easy. It's a list of skills and competencies. It follows that if you can gain all the skills you can hop on the skills escalator and become, say, a cardiologist. And if you don't believe Dr Grumble that this is what they really think, try the career options tool. Dr Grumble hopes this is a spoof web site created by a disaffected doctor. He fears it is genuine and that you, the taxpayer, have paid for it.

This post was first published under a different title on 28th May 2007 along with some pictures which are now lost. It seemed to be a rather heretical view at the time. But since then quite a lot has happened and the government that has been responsible for all of this is now looking very weak. Perhaps there is now a chance to reclaim our profession - not for ourselves but for our patients.

Two quotes

The first quote is from Lord Darzi:

When a clinician sees a patient it can be something of a one way conversation, with the clinician simply talking about a diagnosis or treatment.

It's hard to believe that any competent doctor could write something like that.




The second quote is from a Department of Health spokesperson

We greatly value the key role of doctors...............

It's hard to believe that any competent health department needs to say something like that - about anything.

Polyclinic Policy

Dr Grumble is trying to hold off from blogging but the latest polyclinic rumours do make it difficult. Two patients per polyclinic per day! Can it be true?

New relevance to an old post

Dr Grumble does not read the newspapers that suggested that Mr Prescott was not as well endowed as his mistress might wish. He learnt about this story from Have I Got News For You and has subsequently discovered that the story had its roots in a blog. Perhaps alleging that the organ was the size of a cocktail sausage was a better story than suggesting it was the size of a knockwurst which if Allo Allo is to be believed is really quite big.

But the key question that interests Dr Grumble is whether or not this story has a possible medical basis. Well it does. Because Mr Prescott is somewhat portly and being portly can cause your penis to shrink or even vanish altogether.

The Prescott penis: a plausible tale.

Before any of Dr Grumble's fatter readers get too alarmed it should be pointed out that this phenomenon is potentially reversible. In fact the shrinking is really an illusion. It's not the penis itself that shrinks; it's still the same size but it gets lost in the fat. Go on a diet and the penis will magically get larger!

This post was first published on 6th May 2006 under the heading Cocktail Sausages and Mr Prescott. Today we learn the cause of the Prescott embonpoint.

Polytical Healthcare

In the interests of his own safety Dr Grumble was not planning to post anything new. But Mrs Grumble is so dismayed by the polyclinic developments that, despite the risks, she has encouraged a new post on the topic. So what is there new to post about? One thing is the views of the NHS Confederation who seem to have hurriedly brought out a publication on the topic. It's of great interest to Dr Grumble who wonders just what is driving this frenzied imposition of polyclinics. Of course, what the NHS Confederation say and what the real drivers are might be quite different. Curiously, the box at the very top of the Introduction to Ideas from Darzi: polyclinics reads:


This is odd. First, because the document is called 'Ideas from Darzi' and this box reveals that it is not Darzi's idea at all. (Not that anybody thought it was.) And second, because the fact that everybody else is doing this does not mean that it is the right thing for British patients who, until recently, had the best primary care service in the world. Certainly this box is no justification whatsoever for polyclinics. It is plainly not intended for the discerning reader.

But don't worry because, according to the Confederation, the design rules that underlie the idea of the polyclinic appear to be 'fairly uncontroversial'. What are these fairly uncontroversial design rules? And, if they are uncontroversial, why is there such an outcry about polyclinics and why are they being imposed in such a heavy handed manner? If these Darzified clinics are so very wonderful why are we not all clammering for them?

The first wonderful thing about these clinics is that they will produce larger groupings of primary care professionals. Note they say 'primary care professionals'. You need to read these documents carefully. You are probably intended to think they mean doctors. But that is not what the document says. Draw your own conclusion.

Second these clinics will exploit 'economies of scale'. The relevant paragraph is short but examples given include the 'highlights of improved telephone booking'. Come on! And better access for those with learning disabilities and the mentally ill. To Dr Grumble this doesn't even sound faintly plausible. If you put more GPs (sorry - primary care professionals) together then patients with disabilities are less likely to have a GP close to where they live. These claims are disingenuous.

Third we are told the need for patients to travel to hospital will be reduced by 'relocating high volume work'. We are not given examples. One would think that high volume work, being high volume, can already be done in a group practice. The care of asthmatics, diabetics and the like would seem to be examples. So what are the conditions that polyclinics can deal with that current GPs (sorry - primary care professionals) cannot? Probably they exist but we are not told. Instead, in a very short paragraph we learn from 'Bunny Hill Primary Care Centre' that patients prefer a 'non-hospital setting' - which makes one think that perhaps they might like their current GPs' surgery. After all polyclinics do sound rather polyclinical.


Fourth we learn that polyclinics will break down the 'traditional barrier' between primary and secondary care. An example is how in Sunderland a shared approach has reduced unnecessary dermatological surgery. Now that is interesting. How could that happen? Could it be that GPs were cutting too many harmless lesions off? That doesn't sound like a very good argument for encouraging GPs to do more. But there is no reference so perhaps this interpretation is wrong.

Fifth we learn that space will be made for other services:

• community health services
• other related health services
• social care services
  
• leisure services
  
• housing services
• benefits services

Then there is another box which is presumably to enhance some key point, some killer fact. Here it is:


Here we have the implied allegation that nobody cares about the time the patient has to spend and that polyclinics would be much better. But it's nonsense isn't it? The polyclinic is more likely to be further away from the patients home. How are the elderly and disabled supposed to get there? Why this apparent interest in the young commuter? Could it be that they have money to spend on additional services in the polyclinic? But what about the killer fact in this box which is of course all the money spent on travelling to the hospital and on hospital car parking (who imposed this by the way?) all apparently because GPs cannot take blood. Come on. Mrs Grumble retired from inner city general practice 15 years ago and she cannot remember a practice that did not have a service which sped blood samples to the local hospital.

Of course, there are many arguments (pdf) against the polyclinic idea. Here Dr Grumble was just trying to grasp from the NHS Confederation the points in favour. Sadly there don't really seem to be any. None convincing anyway.

Who are these people in the NHS Confederation with such a great misunderstanding of primary care? Do they really have the interests of our patients at heart?

Polydisaster

Lord Darzi, who seems to be rather rarely graced with his new title by doctors, wants a more personal NHS. When Mrs Grumble was a GP she shared the on call with her partner and one other GP. Patients could telephone at any time of the day or night for all of the 168 hours there are in a week and one of the three doctors (in the week one of two) would be available. And telephone they did. Often Mrs Grumble would go out into the heart of Brixton to deal with the multitude of problems that were thrown at her. With two young children and a husband doing alternate nights (plus of course all the days and half the weekends) in an ITU it was tough. It was too tough. When she could Mrs Grumble found a less demanding job. It's no wonder GPs don't want to go back to that sort of commitment. But at that time British general practice was the envy of the world. GPs took pride in knowing their patients and being available for them out of hours. But gradually the phone calls from the public at the dead of night saying "I want the doctor out" went up and up. It was never going to last. GPs with high ideals struggled to keep it going. The final death knell was the government's new contract which destroyed the last remnants of this highly personal service. Where else in the world could you have expected your very own doctor to get out of bed to deal to your every need for nothing - or even for money? Yes, it had to end. And now the noble lord wants a more personal service. Something that has already, albeit with some justification, been thrown away by, not doctors, but the government. And how is the new lord going to bring back a personal service? He's going to do this with polyclinics. What could be more impersonal than that? Is this another new initiative that just hasn't been properly thought through? Or is this, as many think, a back door to privatisation? Cock-up or conspiracy? In the NHS it's usually the former. Dr Grumble fears yet another ill-thought-out reform.

A patient for the polyclinic?

Here's a letter from the Guardian which is reproduced for convenience below:

Ara Darzi plans to deliver "the kind of personalised care we all expect". But his proposals to develop 150 polyclinics in London are completely at odds with this vision. Enormous, distant health centres with vast numbers of staff and doctors are the antithesis of personalised care. It is inevitable that these plans will increasingly remove the right for patients to consult their own GP at a local and convenient surgery. Recently, Warrington primary care trust's plans to replace all GP surgeries in the town with six polyclinics proved massively unpopular and were shelved as a result of patient protest. While there is a national need for further improvement and investment in practice premises, the surgeon-minister's plans are spectacularly misjudged. Dr Martin Breach

The government is surprised at the opposition to polyclinics. They should have read Dr Grumble as this post was first published on 6th October 2007. But this is not a government that listens to doctors.

Takotsubo

It's Dr Grumble's 12th day at work. He's been 'on take' which is not without its stresses. But the weather has been warm and the number of admissions very manageable. It's actually been enjoyable. And, of course, even at his great age Dr Grumble is still learning. Medicine is like that. You never know it all. There's always something new.

On today's ward round we had a lady who Dr Grumble thought had acute coronary syndrome. Nothing unusual about that. She had developed severe chest pain while getting upset about something. One of the joys of the take is that you are surrounded by bright, everchanging (shiftworking) young doctors. This week's were excellent. Today's were all were female. It's nothing to do with the Grumble attractiveness. It's everything to do with the feminisation of medicine. And some women in medicine are concerned about that. One of these ladies suggested an alternative diagnosis for the woman with the chest pain. Dr Grumble never minds helpful suggestions but it is a little awkward when the suggested diagnosis is not a condition he knows much about. And Dr Grumble does not know much about takotsubo syndrome. He did not even know what a takotsubo is. But he does now. It's an octopus trap. And here is one:

Now what do Japanese octopus traps have to do with Dr Grumble's patient? Does the picture below help?

Perhaps not. You can read all about takotsubo syndrome here.

And, in case you're wondering, the patient had acute coronary syndrome and is doing very well.

This was first posted on 4th May 2007. It has been republished now because Dr Grumble has just seen a more convincing case of takotsubo syndrome on his post take ward round and there seemed to be some ignorance about the condition amongst those accompanying him. And it's a harmless enough post. Nothing remotely political or critical here.