27 June 2008

Companies run by nurses to compete with GPs

That's the rumour anyway. We will have to wait for Lord Darzi's report on Monday to see if it's true. It sounds crackers to Dr Grumble but he will hold fire until he sees the detail. Apparently you will be able to see the report launched online here. But that will be no good to Dr Grumble. He will be in a busy clinic. It's a shame they don't release these things on a Friday. Perhaps then you could find time to read them. Maybe they don't want you to. Maybe there will be a press statement making it all sound wonderful before anybody has had a chance to read the detail. We shall see.

This government has never liked GPs. This government has failed to realise that GPs and not nurses are the key to delivering quality care. This government has failed to realise that, since the inception of the NHS, GPs have laid the NHS an enormous golden egg. Patients like GPs. This government will pay the price.

22 June 2008

Red pegs

Patient dignity is climbing up the hospital agenda. Dr Grumble has been concerned about it for a long time. But working on a busy ward without the right infrastructure makes delivering on dignity difficult.

Somebody must be doing a good line in red pegs because in Dr Grumble's hospital vast numbers have suddenly appeared on all the wards. They are a bit like those old fashioned wooden clothes pegs except they are made of bright red plastic. You put them on the curtains around the bed when the patient is not to be disturbed. It's a privacy and dignity thing. The odd thing about NHS curtains is that they never quite meet. There's always a gap of about a foot. Whoever orders them does not seem to realise that when you are ordering curtains they need to be a bit longer than the length of the rail.

But why are we even bothering with curtains? Why don't our patients have individual rooms? Why are the sexes still mixed on open wards - another government broken promise which the hapless Lord Darzi was forced to announce? Why do the staff forget their patients are people? And why do they call these people much older than themselves by their first name (when they never ever call Dr Grumble by his first name). On this last point, they will tell you that the patient has been asked how they would like to be addressed - but they don't ask Dr Grumble. Actually, Dr Grumble likes a bit of this sort of formality on the ward. Titles like 'Dr' and 'Sister' elevate people a little in the eyes of patients and it also says something about what the holders of the title do and what they are qualified to do. Does Dr Grumble need elevating? Perhaps. He can manage without but if staff treat the consultant with a bit of respect perhaps patients will trust him a little more. And that's important. But staff should also be showing the same respect to patients. And that's important. More important.

Incidentally, staff who work with Doc G away from the wards call him by his first name. There's some sense to this. It doesn't matter away from the patients. A few oddballs call Dr Grumble 'sir'. That's a bit over the top but it does no harm. But, in British English anyway, calling somebody 'sir' implies a bit of subservience. We need a word like the French 'monsieur' which doesn't seem to have such connotations. It's good to show respect regardless of rank. For patients it's vital. Left to his own devices Doc G would require patients to be called Mrs Bloggs until they asked otherwise. But Dr Grumble is a curmudgeonly old fart. Nobody is going to listen to him.

As for the red pegs, it's good to make staff think. But they are a cheap solution to an expensive problem: too few single rooms - though there is evidence that single rooms are cost effective. The Americans have figured it all out. They have found that single rooms:

  • Shorten length of stay
  • Shorten convalescence
  • Lessen nosocomial infection
  • Lower readmission rate
  • Reduce non-productive employee time
  • Reduce skilled nursing time/costs
  • Allow better bed management
That's what Lord Darzi should have told his masters.

Dr Grumble is fed up with the lack of dignity on the NHS wards. Dr Grumble is fed up with infections racing around the ward. Dr Grumble is fed up with seeing patients dying on the open ward surrounded by grieving relatives. It's not fair to the dying patient. It's not fair to the grieving relatives. It's not fair to the other patients. Each of these needs their privacy and dignity. Lord Darzi, please listen. This is not fair. It's not right. You need to get these basic things rectified before embarking on ill-thought-out initiatives with a political agenda.

This is not something we can solve with a bag of clothes pegs.

21 June 2008

Darzi's five pledges

In his reassuring way Lord Darzi made five pledges in his report Leading Local Change. Here they are:

  • Change will always be for patients’ benefit in terms of quality of care
  • Change will be clinically driven
  • All change will be locally led
  • People affected by proposed NHS changes will have a chance to comment, and
  • Existing services will not be withdrawn until new, better services are available.

The pledges are, indeed, reassuring. No need to worry then. No need to worry that things might be steamrollered through without being driven by clinical need. No need to worry that the changes might be detrimental to patient care. No need to worry that these changes might be forced through without anybody having a chance to comment. So everything is all right. Lord Darzi can be trusted. After all he's a doctor. Partly anyway.

But wait. What is this in the BMJ? It's a letter from a GP who seems to think Lord Darzi has reneged on his promises. Surely not? Not a dishonest doctor. It can't be. Or is he no longer really a doctor?

With apologies to those, like Dr Grumble himself, who cannot read the full BMJ article because they have resigned from the BMA over their inability to look after our profession.

NHS bed numbers slashed

This graph is remarkable. It shows quite clearly that as the population has been getting older and inevitably sicker, NHS hospital beds have plummeted. So who is looking after the patients who would have been occupying the missing beds? And where are these poor people? They must be somewhere out there in the community. And somebody in the community must be looking after them.

Let's hope so anyway.

Believe what you see, not what they say

We are told that the Darzi agenda is not about privatising general practice. Dr Grumble is not so sure. How else can you account for this?

One stop shopping and medicine

Dr Grumble runs a one stop shop. It's very successful. The patients like it. Dr Grumble likes it. It was Doc G's idea. Medicine these days has to be like shopping. And best of all in the managers' eyes is the one stop shop. Dr Grumble knows the way managers think. He knows the buzz words that set the management alight. But even Dr G was surprised by the alacrity with which his idea was adopted.

So, you see, Dr Grumble has nothing, in principle, against adopting some ideas from the world of shopping. It can work. But is this really sensible for, say, a cholecystectomy? Lord Darzi regularly gives this as an example. He catalogues the numerous trips a patient has to make to get her gall stones fixed. In Sainsbury's you wouldn't make several trips for your shopping. That, anyway, is the Darzi line. He really can be quite beguiling. But then in Sainsbury's they won't fix your gall stones. Not yet anyway. And you don't have your gall stones done every week.

Not only do you not have your gall stones done every week, you don't actually go to your GP with gall stones. You go to your GP with symptoms. Galls stones may present in different ways and the same symptom could have a number of different causes. Abdominal pain could be gall stones. It could be a heart attack. It could be nothing much at all. It could be numerous other things. It could even be cancer. That's why you need a GP. You can't just look up which expert to see on the internet. You really can't.

But if Lord Darzi had his way you would enter the one stop shop with tummy ache, have an ultrasound to confirm your gall stones and leave with your gall stones in a jar. And, of course, there would be no need for any follow up just to tell you that Lord Darzi has done a good job. This is brain stem thinking. A lot of people have tummy ache. A lot of people have gall stones. Quite a few people who have their gall stones removed still have the tummy ache. The gall stones, you see, were not the cause. It's just not that simple. But if you are a one stop surgeon you will never find that out.

Please, Lord Darzi, medicine is just not like this. Surely you know. Have your political masters bamboozled you with the results of their focus groups? If you ask people if they would like their gall stones done in a one stop shop instead of several visits, they will answer yes. But this does not mean they have thought it through. It doesn't make it sensible. Your job, Lord Darzi, is to put some sense into this madness. Please.

20 June 2008

Georgi Markov

The case of Georgi Markov has hit the headlines again. Here's an old post from Dr Grumble.

15 June 2008

The death of GP care

Dr Grumble has just read this stunning article. He was stunned because, for the first time, a journo appears to have got it right and understood exactly the problem with polyclinics. Well done the journalist, Keith Hopcroft, on excellent research producing a simply brilliant article deserving of the highest journalistic accolades. Just who is this journalist with something useful between his ears? But wait. Isn't Keith Hopcroft an expert on itchy bums? Strewth! He's not a journo at all. He's a GP moonlighting.

Dr Grumble has a message for Dr Hopcroft. Keith, you are wasted on itchy bums. Stick to getting out the message on the polyclinic problem.

14 June 2008

The two Steves, polyclinics and propaganda

Dr Grumble has been reading an interesting document. As he writes he is not sure whether or not to provide a link. Since he has been outed Doc G is wary of criticising people in powerful positions. In any case, it's not the individuals he wants to criticise - it's just the wrongness of their thinking that needs addressing. Already you probably have enough information to find the document if you want it. The miracle of Google means that entering 'Steve' and 'polyclinic' should lead you there if you are at all interested. Google never ceases to amaze Dr Grumble.

Anyway, one of the Steves is a GP and gives a beautiful account of what a GP is all about. And to support the status quo he points out that British general practice is widely acknowledged as being the best in the world. He's right. Well, he was until recently. But since the new GP contract the chances of your own GP dealing with you in the night is remoter than it was. Does that matter? Very much. Dr Grumble is saddened by the number of old people shunted unnecessarily to hospital because there was no GP who knew them to deal with them at home. No wonder admissions have been shooting up though that's another story. But it does show the folly of meddling with general practice. If it ain't broke the government shouldn't go fixing it. And Steve number 1 doesn't think it UK general practice is broke.

The other Steve is a top gynaecologist. He doesn't say that general practice is broke but you can read between the lines. Dr Grumble has heard him speak. He has even exchanged a few words with him in a semi-public setting. Steve number 2 is very persuasive. He concludes, apparently convincingly, that the status quo is 'not acceptable'. Plainly he must have some killer fact to support this view. And he has. It's there as an emotive introduction to the argument. Here it is:

I think the chances of dying from breast disease in this country should be roughly the same as the chance of dying from breast disease in France, Germany, Holland or Japan. Unfortunately it is far from the case.

So that is Steve number 2's killer fact. It's a wonderful statement to bring you around to his point of view. It's a wonderful statement because nobody could disagree with it. It's a motherhood and apple pie statement. But is it true? Why has he said 'breast disease'? What breast diseases do you die from other than breast cancer? Presumably he is trying to obfuscate. Otherwise surely he would say 'breast cancer'. Steve number 2 is not daft. As Dr Grumble says, he can be very persuasive.

Do the facts support the propaganda?

So what are the facts? How does the National Breast Cancer Screening Service in the UK compare with that in other countries? Mrs Grumble says it is amongst the best. She's probably right. It's something she really knows about. Yet Steve number 2 has chosen to put the boot in on its 20th anniversary - just as figures come out showing that, in the UK, 6 out of 10 women diagnosed by screening have the same survival rates as the general population. And, of those not given a good or excellent prognosis, 86% survived fifteen years. These figures are already out-of-date. Inevitably they refer back to 15 or more years ago when the NHS was grossly underfunded. Mrs Grumble says there is a continuous improvement. So Steve number 2's killer fact is not a killer fact at all. It's not, in fact, a fact. And it has nothing to do with polyclinics. Nothing whatsoever. In any case all this is very complicated. In the UK local breast cancer survival rates vary. The reasons for this are unclear. The one thing we do know is that your chances are better if you are referred to a big centre. That is nothing to do with GPs. Nor polyclinics. Nor integration of primary and secondary care. It's to do with hospitals. Steve number 2's barely veiled criticism of GPs is unjustified - at least on the evidence he gives. It's in the hospitals that patients live or die. He needs to look to his own organisation. And, to be fair, that is what he is also doing. As well as expanding into wonderful polyclinics in, would you believe it, Abu Dhabi.

Why are we looking at polyclinics to solve the problems of integration in the NHS when most of us in secondary care can't even email our GP colleagues? And surely involving private companies is only going to make integration worse? What a crazy world!

09 June 2008

GP closures 'far from the truth' says Johnson

Believe what you see happening and not what you are told. That is the advice from Dr Grumble. For a FactCheck see this from Channel 4.