Dedication

If as an experiment you put people in a room, give them an exam to do and then set the fire alarm off, the first thing they do is try to get more information. If there is no more information it is only those who have been trained what to do who take action. Nurses are particularly good. They are taught what to do when the fire alarms go off. They close doors and do all the things one should do in a fire.

Dr Grumble has spent much of his life in hospitals and but it was many years before he had any fire training. Inevitably he has encountered quite a few hospital fires. Many hospitals he has worked in have been old and poorly designed from the fire protection point of view. In some ways some of the newer hospitals have been worse. The hospital where Dr Grumble currently works has had some problems meeting the latest fire regulations. Dr Grumble has never thought that it would be possible to evacuate patients safely in the event of a major fire. The fire officer agrees.

Many years ago Dr Grumble worked in a hospital on the South Coast. It was old. From the fire point of view it was quite hazardous. To be fair the hospital authorities realised this and decided to have smoke detectors installed. They put one in the doctors' mess. Unfortunately the obstetrics SHO, a rather comely girl, smoked . Every night she would have a bedtime smoke and in response a horrible klaxon would sound.

In those days Dr Grumble worked a one in three rota. That meant that he worked ordinary working hours from about 8am to 7pm and he would also work every third night and every third weekend (day and night). It was tiring and you didn't get much sleep. So when Dr Grumble went to bed usually in the early hours of the morning he was often desperate for sleep.

One night at about 2am, just as he was trying to get some shut-eye, that wretched klaxon sounded. Even though he had the hots for her, Dr Grumble cursed the obstetrics SHO. He took two pillows and placed one over each ear. Then he bound the two tightly against his head with dressing gown cord. He didn't worry about how he would hear his bleep for emergencies. He was simply too exhausted. He lay on his bed with the penetrating noise of the klaxon somewhat dulled and tried to get some sleep. But it was never really going to work. And then through the muffled sound of the klaxon he heard somebody thumping on his door. Wearily he staggered to the door and opened it to find himself engulfed in acrid smoke. There was a real fire. He needed to escape. How would he get out? Dr Grumble was upstairs, the smoke was thick and downstairs it seemed even thicker. Then the lights went out.

Complete power failure in a hospital is rare. Dr Grumble can remember sewing up abdominal incisions by torch light but modern hospitals have generators that kick in very quickly in the event of a power failure. And then a worrying thought struck Dr Grumble. If he had no power quite possibly the intensive care unit had no power. And in the ITU there were several patients whose lives depended on there being power. Dr Grumble was the most senior person in the hospital. He needed to get to the ITU and see if they were in trouble. But how was he going to get down the stairs in the pitch dark and with all that thick acrid smoke? He took out a towel, quickly wet it, wrapped it around his head leaving a gap for his eyes and using his pen torch for light made his way down the narrow staircase keeping as low as he could to avoid the smoke. Fortunately he made it to the main corridor of the hospital. There there was more room for the smoke to rise and things were easier.

Already patients in beds were being rushed outside into the fresh night air. But Dr Grumble couldn't stop to help. He needed to get to the ITU at the other end of the hospital. He dashed there as fast as he could using all the little short cuts he knew from frequent cardiac arrest calls. When he got to the ITU gasping from a mix of exertion and smoke inhalation his fears were confirmed. The place was in pitch darkness apart from some torch light. The ventilators had stopped, syringe drivers were frozen and the nurses were bagging the patients. This did not look good. And then a wonderful thing happened. The fire brigade arrived. They were calm and professional. Just as Dr Grumble likes to appear in a crisis (even if he does not feel at all like that inside). But what could they do? There was no fire at this end of the hospital. The problem was just lack of power. But the fire brigade know about these things and they knew what we needed most. Light. And suddenly there was light. Almost immediately they erected bright lamps which enabled us to see what we were doing. Now it was just a matter of bagging the patients and somehow getting their drugs delivered. And then another miracle. Quick as lightning the fire brigade brought in a generator and somehow rigged it up to bring the power back to the sockets. Clever that. Dr Grumble was very impressed and very grateful. He was too busy ever to thank them. He thanks them now.

You may think Dr Grumble showed some dedication as did all those involved that night but he was not as dedicated as the radio presenter in the video below.

Why?

In the past 4 years according to Anna Walker of the Health Commission there has been a 20% increase in attendances at Accident and Emergency Departments. How odd. How very odd. Are people getting ill more often? Surely not. Perhaps there are fewer alternatives than there were. No. It can't be that. We now have NHS Direct and NHS Walk-in Centres. We never had those before. Or could it be that these new government initiatives make more work for A & E departments? Or could it be something to do with the new GP contract? Which is it Mr Brown? This is not something medical. There are no diseases that increase by 20% in 4 years. It must be something the government has done. So tell us, Gordon, what is it that your government has done that has made things so much worse? Dr Grumble would like to know. And could you undo what you have done please?

Leading from the front

Government should lead. Our government does not lead. It follows. It follows public opinion. You might think that is good. It is not. If you ask the public what it wants you will get different answers. The answers will depend on how you ask the question, when you ask it, which members of the public you ask and sundry other variables. The people you ask may not have thought much about the question so you may not get an informed answer. But that has never stopped this government consulting silly focus groups. People, who have never had a day's illness in their lives, are asked how health care should be organised. They simply don't know. They cannot be expected to know. It is not a criticism of them. It is a criticism of our government which seems to think that this technique is the way to win favour at the ballot box. It is not. And that is becoming patently obvious.

The principle applies to other aspects of government policy. For example, if you ask the public whether suspected terrorists should be locked up for 42 days you will get a yes answer. If you ask the public whether it is acceptable that somebody who might be innocent should be locked up for 42 days you will get a no answer. That anyway is what Dr Grumble suspects. It is not a way to formulate a sensible policy. And that is why we have this terrible law wending its way to the statute books. Dr Grumble thinks it is bad, his ennobled blogging colleagues think it is bad, even Stella Rimmington thinks it is bad. But the government goes blundering on.

Meanwhile intrepid Dr Grumble faces the threat of regulation of his blog by EU bureaucrats. One blog has gone already. What have they to fear from bloggers? On reflection maybe quite a lot.

Instant feedback

Have you heard about the latest plan to give patients a PDA so that if they are not satisfied they can press a few buttons to record their problem in real time. The idea seems superficially very attractive. In the area of the hospital over which he has most control Dr Grumble sees that all the patients are given a questionnaire about their treatment. It doesn't actually help Dr Grumble that much. He knows what is wrong. It's getting it put right that is the problem. Data can help with that. If doctors complain the room is too hot or too noisy, managers take no notice. If you collect lots of data from patients and then tell them, there is a chance that something may be done.

The problem with all of this is the time it takes. The other day Dr Grumble asked his staff if his patients were happy. The answer: "We don't know."

"But what about the questionnaires?"

"We don't have time to look at them."

Dr Grumble knows though that his patients are happy with his service. Yesterday a private patient told him how good it was. Unknown to the private patient the NHS patients get identical care - except their breakfast does not come delivered by a smart flunky with paper doilies. Whether the breakfast is any better or not Dr Grumble has no idea but the NHS patients have occasionally made compliments about the breakfast so it can't be that bad.

One of the Grumble children has recently been an inpatient in an NHS hospital. He is a medical student so he has a little knowledge about how things should be. He was spontaneously complimentary about the nursing. Dr Grumble is quite critical about the nursing in his hospital. It's his job to be critical. So what hospital was the Grumble offspring in? Dr Grumble's very own. And what do you think the food was like? For the first time Dr Grumble can tell you. Dr Grumble sat his boy up to help him eat but immediately he became rather pale and sweaty. There were technical reasons for this which are irrelevant but it gave Dr Grumble a chance to taste the soup. It was not bad. By then the Grumble boy had recovered and the rest of the courses including a delicious pudding quickly disappeared apart from some potatoes and veg which Dr Grumble tasted. They were excellent. How they survived the system which brings the food to the wards Dr Grumble has no idea but they did.

Since then Dr Grumble has told this story to some of his patients and their relatives. Some of the relatives have also tasted the food just as Dr Grumble did. They are agreed. The food at the Grumble hospital is excellent. The average cost for inpatient food is less than £3 per patient per day. The catering staff deserve some praise. They work miracles. It's a shame Dr Grumble cannot name them.

Just as when Dr Grumble does his ward rounds, he has become distracted and gone off into a little anecdote when the purpose of this post was to address the concept of instant feedback. But the anecdote does show that workers at the coal face have constant instant feedback. Doubtless those that prepare the food taste it just as Dr Grumble has. You don't really need PDAs to know how good a job you are doing. Unless you sit in an office. Dr Grumble wonders how many times the Chief Executive has eaten food intended for the patients. Perhaps he has. Perhaps he should eat it every day.

Some time ago in the early days of the internet Dr Grumble was warned semi-formally that the hospital was scrutinising his use of the web. Everything he did was logged somewhere. That's a worry if you are a blogger. But the reality is that there is so much data being collected that it is difficult to really know what people are up to. There are ways of dealing with this but these days the miracle of computing means we all suffer from data overload.

The same is true of data related to patient care. While the Grumble staff are currently too busy to deal with all the data they collect on patient satisfaction, Dr Grumble gets weekly reports on certain areas of his clinical performance - in other words how well he performs against a certain standard. Graphs are provided showing in some detail the yawning gap between what he is doing and what he should be doing. This is just in one very tiny area of Dr Grumble's practice. Of course it something of particular concern to managers. It's just about possible to deal with but if they monitored everything Dr Grumble did to the same extent it would be wholly unmanageable. Nobody would have the time. Needless to say it's to do with a target.

So while this instant feedback from patients seems at first sight to be a good idea you need to remember that doctors and nurses are always getting instant feedback from their patients. It might have some purpose for managers who spend most of their looking at data on their computers or sitting through torpid meetings but for those of us bustling about the shop floor it is unlikely to tell us much that we do not already know. And even when Dr Grumble tells the pwoeres-that-be that something is very wrong it takes a long time for anybody to do anything about it. Sometimes even when you give them the data they just don't want to know. They have a poor sense of right and wrong. What is clinically important and what is clinically not so important escapes them. But they do know what a target is.

Fumdamentalist marketeers

Dr Grumble knows a bit about markets. We all do. We use them practically every day. Dr Grumble has read books on markets. He has even read the Best Book on the Market. All the books Dr Grumble has read on the topic extol the virtues of markets. The authors of these books have a blind faith in markets. Their fervour for markets is almost religious. And when you have a religious fervour you tend to stop thinking. Unless, of course, your religion is Church of England in which case your fervour may be so damped down that some thinking is preserved. Today's Anglican leaders do think. They even tell jokes. Here's one. It's not particularly funny but it says something important. It's a joke with a message.

Q. How many economists does it take to change a light bulb?
A. None. The market will sort it out.

The Best Book on the Market is well written. It's good read. And it's short. So if you want to reinforce your faith in markets give it a read. But Dr Grumble suggests that you make it an Anglican-style faith; remain critical and remember the light bulb joke and it's message.

It's couple of months since Dr Grumble read the Best Book on the Market but as far as he recalls it is full of rather good anecdotes about markets. The underlying message is that markets have been around for ever, are everywhere and work. It's all very convincing. It's convincing because it is essentially true. Just as the essential truth of a religion can spawn religious fundamentalism, the essential truth of the value of markets has spawned a market fundamentalism. Governments in the hands of religious fundamentalists are not good. Nor are governments in the hands of market fundamentalists.

So what is wrong with markets? Are they all wonderful? Are they they only way? If you are are marketeer don't at this point get too worried. Dr Grumble is not a communist. Communism might be a nice idea but plainly it does not work. Markets are a nice idea. They may work and they may not. Where they work we need to capitalise on them. Where they don't we need to recognise that and find some other way. But we must not take a mindless fundamentalist approach.

Dr Grumble does not want particularly to point out the weaknesses of markets. He has no wish to knock a man when he is down. But there is no doubt that the human greed that brings so much good from the market can also bring a lot of bad. Long before our latest economic woes Dr Grumble used to ponder over the wisdom that enabled some of his patients to earn really enormous city bonuses but apparently to be protected from losing anything. It was bonus versus no bonus. Not bonus versus annihilation. So it is hardly surprising that with everybody being paid in a way which might enable them to make a small fortune but would allow them to lose nothing risk taking was the norm. And this money was all made from other people. It cannot have come from nowhere. It was not victimless. Yet much of the work was essentially unproductive. It was no more productive than a visit to the betting shop. And on this background of greed and bonuses when those in charge could win but not lose banks keen to get on the back of the housing boom lent money to those who could not afford to pay it back. All the traditional safeguards to prevent this were thrown out of the window for the sake of personal greed. And the banks that led the way were the first to fall. The bank depositors' money was at risk but was the bank manager going to lose the shirt from his back? Of course not. The one person who would not lose his home would be the manager of the bank which caused all the misery. The borrowers might lose their homes but not the lenders. But who was culpable? That's enough to make the Grumble point.

So if, dear reader, you now agree with Dr Grumble that markets don't necessarily work in places like banks and the City where capitalists thrive will you please just consider that markets may not work too well in healthcare either?

So from Archbishop Sentamu's joke about the light bulb here's a serious question:

Q. Which of the following patients can the market deal with well: Mr Smith with a sudden severe heart attack, elderly immobile Mrs Jones confined to her house with varicose ulcers, blind Mr Patel (who doesn't speak English) and has diabetes complicated by endstage renal failure and Mr Worried-Well City Slicker who is just worried?

A. Mr Worried-Well City Slicker.

So how has the market performed in the health service when it was asked to change a light bulb. That's a difficult one. Dr Grumble has no data. But the market was asked to put in some new sockets. You can see how well the market operated here. New sockets are the least of our problems in providing health care. If we can't get that right what hope is there for Mr Smith, Mrs Jones and Mr Patel?

This post is far too serious. We are in serious times. To cheer ourselves up let's finish with an apposite joke from none less than the Archbishop of York:

You will well know the story of the surgeon, the vet and the economist who were arguing that theirs was the world's oldest profession.

"Just look at the first chapter of Genesis," said the Surgeon.

"God created male and female in his image, there is no doubt that anyone who could put the human body together like that must be surgeon !"

"Not so fast," said the Vet. "Before he got round to making humans, God made the animals, everything that flies in the air and swims in the sea. So it stands to reason that God was a Vet."

"Nonsense" said the economist. "before he made man or the animals, God made the world out of chaos."

"So what ?" asked the surgeon and the vet.

"Well, who do you think made the Chaos ?" replied the economist.

Many thanks to Archbishop Sentamu for the jokes. He has a few more here hidden in amongst some important messages.

A question

Suppose you were a young doctor about to complete your pre-registration year. You would be looking forward to the certificate that you need to be able to practise. And suppose on your very last day as a pre-registration doctor a patient's relative complained to the General Medical Council about you. You need your certificate to get your next post. What do you think the GMC would do? Would they say there is as yet no evidence against you so we will issue your registration certificate pending an investigation or would they say a complaint has been received so you cannot be registered? Which do you think would be fair given that anybody can loose off a complaint at any time about any doctor? Would it be fair for a doctor's career to go on hold or for their livelihood to be taken away on the basis of an uninvestigated complaint? How long do you think investigating the complaint would take?

That wasn't a question. It was several questions. Dr Grumble intends no criticism. He just wonders what would happen in such a scenario. Does anybody know?

The worst is yet to come

Politicians are puzzled at why staff and patients are so critical of what they are doing to the NHS. They really cannot understand it. Yet some rational people within the NHS cannot understand what the goverment is trying to achieve. Here's what Gill George has to say on the topic.

The power of the medical blog

Dr Grumble used to criticise the GMC on his blog. But he decided that was unwise. The criticisms have been removed - mostly. More recently, Dr Grumble was too wary to criticise a web site supported by the GMC. But other bloggers were not so reticent. And it appears they have been listened to. By the GMC!

Dr Shirine Boardman

Not long ago Dr Shirine Boardman was calling for better diabetes services. But she doesn't seem to be at at work any more. How odd. How very odd.

Stark staring bonkers

Thanks to Jobbing Doctor for this one. Pharmaceutical companies are to be allowed to pedal their wares directly to patients. Just how mad can you get? They already pedal drugs to doctors who, without really being aware of it, get completely taken in by their blandishments. If doctors are taken in what hope is there for patients? After all the general public, some doctors included, can even be persuaded to buy bottled water when tap water would be just as wholesome - perhaps even better. And all this is happening at a time when we must keep the lid on unnecessary health spending. So Dr Grumble has a proposal. Let's not advertise drugs directly to patients and let's go one step further and ban drug advertising to doctors. That should sort it.

NHS247

Have you heard of NHS247? Perhaps. You might even be reading this on the NHS247 web site. Dr Grumble, you see, is one of a select group of NHS247 bloggers. The web site claims that the prime minister uses NHS247 as the principal source to "listen and lead" on healthcare. Dr Grumble does not really believe this but that is what it says on the web site. Of course the idea that Gordon Brown might be reading this does give Dr Grumble a little frisson of excitement. But, of course, he doesn't. Perhaps his civil servants give him a little précis. There are certainly civil servants whose task it is to read the blogs and tell those in power roughly how the populace are feeling.




As regular readers will know Mrs Grumble does not read the blog. She never has so presumably she never will. Dr Grumble doesn't mind. The blog is not for her. But on Sunday morning Dr Grumble may blog in bed and today Mrs Grumble's attention was drawn to some cloying musak eminating from the Grumble laptop. Dr Grumble had been checking over the NHS247 web site. Mrs Grumble took a look and immediately thought that NHS247 had all the hallmarks of a government site - especially the dreadful music.

Many readers will guess that a large pay cheque comes from NHS247 to the Grumble account for his scintillating input into NHS247. It might be unwise for Dr Grumble to bite the hand that feeds him. But fortunately Dr Grumble does not get paid so the issue does not arise. Not that it would have stopped Dr Grumble taking a swipe at NHS247 if he thought that was appropriate.

So who are NHS247? Dr Grumble really has no idea. There is a strong implication that they are paid for by government and that they have "insisted on independence" presumably to reassure the likes of Dr Grumble. Nevertheless Dr Grumble is a little uneasy. He has been keeping a wary eye on NHS247.

And that brings Dr Grumble to a comment on NHS247 which read as follows:

Reading around some medical blogs I came across the story of ***** ******.
There was not much detail about what happened, but from what I can gather he has been suspended for something he said in a doctor’s forum. Is this true? Does anyone know any details about what he said or why he’s been suspended?

If this is true, what on earth happened to freedom of speech? It’s absolutely ridiculous that somebody who has worked so hard to become a doctor to help save people’s lives is being suspended for having a bit of a rant out of work hours in an private forum, which has nothing to do with how he does his job!

Does anyone know more about what happened?

Dr Grumble knows quite a lot about what happened. And anybody who has been "reading some medical blogs" and clearly has an interest in the story should know quite a bit. (For those that don't know the story here's a summary.) But the one thing they shouldn't know is Dr Scott's real name. There have been some vague clues as to the young doctor's name but nobody has spelt it out. The medical bloggers and the press have been very responsible in this regard. Fortunately the name on the NHS247 web site is not accurate. But there was never a need to put anything other than a pseudonym.

Dr Grumble has conducted a google blog search with the real name of the suspended junior surgeon and has found not a single mention. He has also tried every permutation and variation on the name. So who has posted this comment? What enabled him to have a stab at the doctor's name? Can we trust NHS247? Just who are they?

Somebody from NHS247 kindly copies the Grumble blog across onto their web site. Dr G can't be bothered to do it himself. Probably she will read this post. They wouldn't want anything too subversive on NHS247. That's why they invited Grumble rather than Rant. So let's see if this provokes a comment. Those of us who work in the NHS would like answers to the following:

• Who are you?
• Are you are private company?
• Who owns you?
• What is your real purpose?
• How are you funded?
• Is this an attempt by government to wheedle its way into our private thoughts?
  
• How do you feed back what you uncover to government?
• Why is there a lack of openness about who you are and where you are coming from?
• Can we trust you?

Why do managers ignore patient safety?

Last week Dr Grumble saw a patient whom he thought he recognised. She seemed familiar. He thought he must have seen her before. So he checked the records to be sure. But there was nothing. Dr Grumble is getting on. From time to time he is mistaken. But then he asked the patient what her occupation was. She described herself as a Bought Ledger Clerk. Dr Grumble then remembered that the patient that he recalled also described herself as a Bought Ledger Clerk. What a coincidence. But it was not, of course, a coincidence. The patient had been registered twice, had two sets of records and had been referred twice to Dr Grumble for the same problem and had managed to get two new patient appointments within a week of each other. It happens all the time. It's embarrassing. Worse - it's dangerous. Dr Grumble apologised for his confusion and the patient told him that she had repeatedly been telling hospital staff that she had been double registered. Not one of the hospital staff she told took any action. This makes Dr Grumble angry. He arranged to have the problem put right. It is such an important problem that Dr G would do this task himself. But he is not allowed to.

This problem has been making Dr G angry for years. Two years ago he decided to have a blitz on the problem with the newly introduced online clinical incident reporting system. On average twice a week for several months Dr Grumble dutifully sent in reports on patient identification problems. Nobody took much notice. Eventually, after an exchange of emails Dr Grumble asked if he was wasting his time reporting these problems. Was there any point? And eventually he was told that he might as well not bother because they were doing all they could. That made Dr Grumble even more angry.

But Dr Grumble has an acquaintance in high places. And this is what he says on the topic:

We should no longer accept the level of misallocated records and the misidentification of patients as inevitable or normal.

Thanks for listening Bruce. And thanks for dealing with a longstanding problem that could have been solved long ago.





Dr Grumble's hospital now has a doctor as a Chief Executive. He is much better than the previous incumbent. So perhaps he will do something about this problem. We shall see.

Virgin on the ridiculous

The magnates at Virgin Healthcare blow hot and then blow cold. The truth is that they are not really interested in healthcare. Not genuine healthcare. They cannot be. If they were they would not be pulling out of their offer to sort out UK general practice. They would have a sense of duty and would see the job through. What can the 'dire economic climate' have to do with their decision? Surely that is just a lame excuse. Healthcare must be provided through thick and thin. In the UK government pays for most of our healthcare which is therefore relatively protected from the vagaries of the economy. So you might think that healthcare would be a good thing to go into at the moment. Unless your intention never was to provide basic healthcare to the elderly and the needy but instead to milk the wealthy worried well and the city slickers. Why else could there be this sudden lack of enthusiasm from Virgin?

Could it be that the real reason is that the government have at last rumbled Branson? They certainly seemed to think it was unwise to put Northern Rock into his hands. And what was Branson's reaction to that? He went out to get drunk. Not an unfounded allegation from Dr Grumble but a direct quote from Branson himself . Not a very responsible thing for somebody in charge of healthcare to do. But is he responsible? How many of you remember that in 1971 Branson was arrrested and charged for tax evasion? That's OK though because he didn't realise that evading tax was illegal. Now he avoids taxes. That's certainly OK. And his purpose is a good one. He avoids taxes so that he can give his money to good causes. He has a 'responsibility as a wealthy person to help the world'. Nice that. But is he really a lovable Father Christmas type? What sort of Father Christmas would admit to taking [recreational] drugs? If Dr Grumble did that he would be struck off. You can be suspended for just typing a four letter word if you are a doctor. Yet this man who was arrested and charged for a crime, who admits to having taken drugs and who gets drunk when he is upset was once seen as the way forward for UK general practice.

Perhaps it's time that Branson's associate Peter Emerson, (CV) an even wiser physician than Dr Grumble himself, should put an arm around Sir Richard and try and persuade him to do something less damaging than meddling with our GPs. Go on Peter. Do your duty. Get him to buy Alitalia or something. Be sure he leaves general practice alone. And if Holly now needs her real job back tell her not to worry. Dr Grumble will find something for her.

Dr Grumble's guilt

Dr Grumble feels an element of responsibility for Dr Scott. You see Doc G happened to see the original dnuk forum post which caused young Dr Scott to be suspended. When Dr Grumble saw what he had written he winced. He was gobsmacked. How could anybody be so foolish as to do such a thing? Did Dr Scott not realise that dnuk is festooned with elderly lurkers? Or did he just not care? Or had he had a drink or two before the scatological post?

With years come wisdom and responsibility. Dr Grumble's wisdom prevents him posting on dnuk. He knows how dangerous it is to reveal your views. There was a time when Dr Grumble suggested on his blog that some key figures involved in MMC and MTAS should consider their positions. Some of these have now resigned. Some have not. When Dr G realised that his identity was becoming known he decided to remove these old posts. Some may have thought that was an overreaction. Now though it is clear how wise that was. But Dr Grumble could have been wiser. When he saw Dr Scott's fateful post he should have acted. All that was needed was to press the forum abuse button and with luck the ferreting lurker out to stifle dissent would have been thwarted. But Dr G did nothing. Apologies Dr Scott. Dr Grumble is sorry. He too should have known better. So should the ferreting lurker.

Stop press

Dr Scott has been reinstated!

Patients, public and punters

As Jobbing Doctor has pointed out in his comment to the previous post, nobody listens to doctors any more. Not when it comes to the management of the health service. Not, anyway, real doctors. Doctors know the coalface. They work at it every day. Some patients also know the coalface. Different patients want different things. Doctors are not too interested in the worried essentially well. The commuter who wants something for his cold but can't get to his GP might be quite important to politicians and policy wonks but on the scale of life and death there are more important things in medicine. Much more important.

It worried Dr Grumble a bit when he started this blog and found some interest from patients. He didn't want to be dragged into dealing with their various woes. It would be unprofessional. But the patients who have been reading Dr Grumble have in no way abused the relationship and seem to share his views. They tend to be professional patients. Dr Grumble means that in the nicest way. They are people who, because of their affliction, have seen a lot of the health service. That's why their views are so meaningful. They understand. They understand much more than the politicians.

What Dr Grumble is coming round to saying is that it is quite clear (despite the NHS247 claims that the PM reads this blog) that politicians are just not going to listen to grass roots doctors and that the only hope for the NHS as we know it is via the punters. The public, properly marshalled, have the power. Potentially anyway.

Collectively the public, patients and punters do know what is going on in their health service. And they are beginning to make their voices heard. Probably they will be the downfall of this government. Probably this government will deserve its fate. And probably the next lot will go on making the same mistakes. But we must try and get things righted. Collectively. Patients and doctors. It's no good just wringing our hands. One day the self-appointed experts and misguided policy wonks will be rumbled. The days of the smart-suited management consultant with spurious expertise in, well, absolutely everything will one day be over. Surely. This madness just cannot go on.

Out of hours care

How can you spend much more on general practice and end up providing a very much worse out-of-hours service? Only this government could have done it.

Dr Grumble once spoke to a senior personage at the Department of Health. Let's call him Bill McCarthy. Bill told Dr Grumble that ministers are really puzzled as to why Dr G is so dissatisfied with their management of the NHS. After all much more money has been put in. Very much more. The trouble is, of course, that they have blown it. The government holds the NHS in trust for future generations. They have abused that trust. They have destroyed the best feature of primary care. GPs used to be responsible for their patients day and night. They did a good job. It was extremely arduous. They worked day and night. Now managers are responsible. They do not do a good job. They do not work day and night. This is how GPs used to organise cover when they wanted a rest. This is the way managers want it to happen now. The system used to rely on good will. An awful lot of good will. Sadly, now there is no good will.

That, Bill McCarthy, is just one example of why ministers should be ashamed of what they have done. They have taken advice from the wrong people and done the wrong thing. The PM's reading of Dr Grumble is admirable but he does not seem to take any notice. And, frankly, it is too late.

Radio 4 covers the saga of Dr Scott

You will be able to listen again for a while here.

Hot tatties

There are some topics that are too hot for Dr Grumble. The unfortunate tale of Dr Scott is one. Dr Grumble has been described as 'weighing in on the issue' which is interesting as Dr Grumble has been very cautious on this topic. His 'weighing in' amounts to posting a picture of a national flag, a picture of some pieces of tartan and the banner of the Inverness Courier. Dr Grumble has been described as a well-mannered blogger. He is. Dr Grumble rarely loses his temper. When he does he always regrets it. It is always best to stay calm and argue your case carefully. That, undoubtedly, is the lesson to this whole sorry saga. Sometimes you can even achieve something by saying absolutely nothing. So who was it that described Dr Grumble as 'weighing in' on the topic of the poor Dr Scott? It was the BBC. Can you believe that? It's amazing the power of no words. And it is amazing the damage just one taboo word can do.

PCTs reject Darzi polyclinic model

When the government is hellbent on doing something the best you can do is ameliorate the situation. U-turns are not desirable in the world of politics. They make you look as if you have not thought things through properly. U-turns highlight when policy has been made on the hoof. They show up when you have taken advice from a surgeon when maybe a GP would have been a better person to ask.

If the government is heading off in the wrong direction, damage limitation is all you can do. And damage limitation appears to be what the London PCTs have done over Darzi clinics. Because none of the first wave of London's polyclinics will follow the original Darzi model. That anyway is the rumour.

Endemic bullying

The worst jobsworths in the hospital are in medical staffing. To be fair in Dr Grumble's hospital we now have excellent staff sorting out our rotas in a reasonable manner but it has not always been the case. Below are two posts from desperate junior doctors. The facts are essentially correct but Dr Grumble has changed the details because it would be very damaging if these doctors could be identified. There are quite a few posts like these in doctors' forums. It's a very common problem. It is so common that these doctors cannot be identified amongst the many who are repeatedly bullied in this way. Note how the first post begins "I know it's nothing unusual...." Here it is:

I wouldn't usually add to the forum but I need to rant and there's no-one sympathetic about. I know it's nothing unusual but this kind of stuff really irritates me.

I am getting married next year and I thought it would not be unreasonable to request some annual leave. I emailed medical staffing long before the rota was finalised saying that my wedding was on 2nd August 2009. I spoke to them yesterday - the rota is now final and they will not do anything. Apparently it's my responsibility as a doctor to do the on-calls! Strangely, I am aware of that but I see no reason why my life should be turned upside down because medical staffing are incapable of organising a rota. And I have also been sent a threatening email saying that if I am off sick on either of the days in question, the deanery will be informed.

I hate them....and I cannot believe how many hours I have wasted trying to sort this out.

Is the deanery is complicit in this bullying? Surely not. Below's another one. Notice how this young doctor is also not a forum regular. That shows the desperation.

I've never posted on a forum before so apologise if I do this wrong or have posted in the wrong place. I also apologise if I sound cross. I am cross but mostly upset.

My fiancé and I are both SpRs and got engaged earlier this year and as soon as we had set a date for the wedding set about organising time off. I'll be taking some unpaid leave then so no problems but my fiance will be in acute medicine. We emailed the rota co-ordinator for acute medicine (15 months in advance) who has dutifully been ignoring our emails and phone calls until this week when my fiancé went in to her office (twice) and eventually managed to get a copy of the rota. He's been rostered to work not just during our honeymoon but also on our wedding day itself! The rota appears to be impossible to swap. The co-ordinator doesn't seem to care (although I'm sure if this was her wedding day she'd be off for a month not the 2 weeks we've asked for). Pulling a sicky isn't an option (as 1: its just not in my fiance's nature and 2: i'm sure they'd discipline him and refer him to GMC for bad behaviour). My fiancé has offered to work any other time they want him to just so long as he can have these 2 weeks off.

Does anybody have any advice please? Has anybody been in a similar situation and how did they get round it? Changing the wedding date isn't an option now and to be honest I think 14 months is enough notice. Any help would be gratefully appreciated. Thank you Anna.

Poor Anna. You feel for her don't you. Notice how the GMC and the deaneries are used as threats against these vulnerable young doctors. It is no way to treat a dedicated work force. If you had signed up for the army you would expect it. But outside a war this is unacceptable. But that is the way the NHS now is as an employer. Of doctors anyway. Who allows the jobsworth henchmen to get away with this sort of unacceptable behaviour again and again? Why do the deaneries and the GMC allow their organisations to be used to threaten hapless doctors in this way? Why all the talk of bullying but utterly no action. It's a disgrace.

Dr Grumble realises that he has pinched these posts from a closed forum where the golden rule is that the posts are confidential. But many will know that that particular golden rule has been broken already by very senior people in a much more damaging way. Dr Grumble's intent is good. If anybody thinks he has done wrong say so in the comments and this post will be removed.

Cannulas and catheters

If you arrive in hospital unwell Dr Grumble would bet ten pence to a bath bun that a cannula would be inserted into one of your veins. If you were a actually ill you might find a catheter plunged into your bladder as well. It is something of an assault. On his post take ward round Dr Grumble will ask why the patient has been subjected to these assaults. These days he is lucky if there is a doctor present who was around when the patient was admitted. You have to rely on notes. Quite often there is no note recording these interventions. You can't go back in history and check how Dr Grumble would have done it in his day but Dr Grumble's firm recollection is that whenever he put in urinary catheters he made a note dutifully describing the indication and even the aseptic technique. But now he often finds nothing. He cannot complain to the doctor (or would it have been a nurse?) concerned because there is no name. No nothing. It is unacceptable. As clinical governance has become the focus of management basic clinical practice is deteriorating. It is interesting to consider why this might be. Are the doctors of today not as diligent as the doctors of yesteryear? Is Dr Grumble's memory faulty? Was Dr G the only doctor in his day who bothered to make notes? Was Dr Grumble better trained or more closely supervised?




Of course Dr G cannot answer many of these questions with certainty. Plainly the calibre of today's junior doctor cannot be much different from yesterday's. You might expect training to be better. We now have colonies of plastic pelvises for students to practise on. But wait. Dr G never had a plastic penis to practise on. He was taught as a student by a junior doctor on a real patient. That focuses the mind. And when he learned he was taught to write full notes including the indication for the procedure. He has continued that way ever since.







Dr Grumble wonders if it is the teachers fault. We now teach on disembodied torsos. We focus on the practical elements. There's no reassuring interaction with the patient. There is no patient. There is no indication. There are no notes. Dr Grumble helps at these teaching sessions. It must be his fault.

Anyway the BBC has rumbled our rotten practices when it comes to Venflons though every jobbing consultant in the kingdom must be aware of this issue. In some ways the problem with urinary catheters is worse. You can read the article here.

It's the policies stupid!

The public still want the NHS. Dr Grumble is convinced of that. The government does not. Dr Grumble is convinced of that too. But the policy is not explicit. It is not explicit because the government does not want the public to know that the NHS is not safe in their hands. That's because the government knows what the public wants. If the government knows what the public wants why doesn't the government do what the public wants? That's democracy. Instead the government is taking the alternative line of trying to persuade the public that they do not want the NHS in its present form. There are all sorts of ploys to try and achieve this. They range from talk of choice and heightening public concern about hospital infections to bad mouthing doctors and and encouraging patients to have a go at us. If you can persuade people to buy water at great expense you can persuade them of most things. But Dr Grumble is not so sure you can turn them against the NHS or their GP. We shall see.

We all know that Gordon Brown is in trouble. We all know that he has been responsible or at the very least complicit in some of the most damaging NHS policies. So why doesn't he change his policies. That is very much what Dr G was hoping for when his misguided predecessor left office. It took some time but the public did eventual rumble the hapless Blair. Surely such disenchantment should have been followed by a change in policy and not just a herd of GOATS?

Now that the Prime Minister is reading this blog on NHS247 it may be appropriate to reproduce this letter which he may have missed when it appeared in the Guardian:

Change policy not leader

Dear Sir,

So the government is taking a beating and "the most talked about solution is changing the leader". Have politicians become so out of touch and cynical that they have forgotten it might be their policies that voters are rejecting?

Earlier this month I was at a packed meeting in Edinburgh where Nicola Sturgeon, Scottish health secretary, told the largely medical audience that there would be no place for the commercial sector in providing primary care in Scotland. She received a long and heartfelt standing ovation.

The government could win back a million-plus healthcare voters in England by reversing their deeply unpopular policy of farming the NHS out to commercial companies.

It's the policies, stupid!

Dr Jacky Davis
Co-chair NHS Consultants Association

As Nye said the NHS will last as long as there are folk left with the faith to fight for it. As he anticipated it will not just stay there for ever. It will have to be fought for because there are powerful influences out there that want to see the end of it.

Grrrrr, One Click, No Job, Harsh!

The end of the world is not nigh

This blog has a bit of a theme. The end of the world is not much to do with medicine. But it is important. Especially if it is next week. And there are parallels with medical issues. The public get concerned about all sorts of scientific things they cannot understand. If doctors were to say that the public do not understand medical scientific issues they would be accused of being patronising. But Dr Grumble is quite happy to say that he does not grasp the issues that have been raised about the black holes that are being created on our doorstep at CERN. It is not something that somebody with just an A level in Physics can understand. And most people don't have even an A Level in Physics. This comes down to trust. The public en masse do not always trust doctors as a group of scientific experts. The difficulty comes especially when most doctors are reassuring but a maverick doctor or two raise concerns about something. Often the press whip up the concerns of the mavericks even though their views may be two standard deviations away from the views of the average doctor.

Actually Dr Grumble is surprised that the public are not clamouring for the CERN experiment to stop. There are maverick scientists predicting that we are doomed. But the press don't really seem to be whipping up this concern too much. And there are so far no human stories of a little girl being sucked into a black hole as there apparently were with the autistic children having had MMR (along, of course, with all the non-autistic children). The press and public figures can cause enormous damage and frequently do.

What these things boil down to is trust. We have to trust the very small community of people who can understand theoretical physics (pdf). We have to trust that the world is not going to come to an end as a result of these weird freaky scientists doing an experiment. Even though they plainly do not understant what they are doing. After all if they understood it they would not need to do an experiment would they? How can we trust people who, just like doctors, do not completely understand what they are doing?

Dr Grumble does trust them. He is not having sleepless nights. But he is rather surprised that the rest of society also seems to trust them when, quite often, large chunks of intelligent society do not seem to accept the consensus view of doctors.

Dr Grumble predicts that most of us will be here next week. If we are not he will give you £10 million in compensation. That's fair. CERN should have made a similar offer to reassure us all.

Dr Grumble's last post

Dr Grumble's first choice career was journalism. He failed an exam called Use of English so that put paid to that. His second choice career was Physics. But he wasn't really good enough at Maths so that put paid to that. Since then he has come to know quite a few people who have degrees in Physics. None of them is actually doing Physics. So he is quite glad he didn't do that. But he is still interested in Physics. He keeps up with some of what is going on at CERN. There is a chance that quite soon they will create a black hole at CERN. Now that sounds exciting. Dr Grumble knows a little about black holes. But it's very little. He has some grasp of the concept of this part of space which sucks everything into it. And then Dr Grumble wondered. If they created a black hole at CERN wouldn't we all get sucked into it? Wouldn't that be the end of the world? The end of humanity? Could this be Dr Grumble's last post?

A little knowledge is a dangerous thing? The public have ridiculous anxieties about certain things related to science and medicine. When it comes to black holes Dr Grumble has only a little knowledge. So his anxieties about the CERN black hole are ridiculous. Aren't they?

GPs frozen out

Who do you think might be suitable to run a polyclinic? Lord Darzi? Perhaps not. He's a surgeon, he's an academic, he's a politician and he's a GOAT. He's probably not the best sort of doctor to run a polyclinic. So who would be a good sort of doctor to run a polyclinic? What sort of doctor really knows about primary care? Do you think a GP might be quite well suited to the task? Probably. So how do you think GPs are doing in the bidding war for polyclinics? How do you think the PCTs have responded to their bids? You can find the answer here. Apparently GPs are 'not qualified' to run primary care. How mad is that? These NHS bodies seem intent on ensuring that the polyclinics are going to turn out to be Hollyclinics.

Dr Grumble is not surprised. It's what he expected. But where is the policy that ensures that the PCTs leave GPs out in the cold? And why does our government want to do this? Why? It baffles Dr Grumble, it really does.

Wine and the brain

Have you heard of the Bötzinger complex? It's a part of the brain in the ventrolateral medulla. There is also a pre-Bötzinger complex which is probably a rather important area for anybody reading this because it is the part of the brain where the respiratory rhythm is generated. Who was Bötzinger? Obviously some great anatomist of old wouldn't you think? But no. Dr Grumble is going to tell you the secret of the origin of the name. He was told this tale by a reputable respiratory physiologist so it is probably true. Apparently there was a workshop held in Germany and a group of the sort of people who know about this part of the brain visited a local hostelry and over a bottle of wine began discussing the exact area of the brain that they believed to be important in breathing control. This area had no name. It was getting awkward referring to a part with no name so they took a look around the table and their eyes alighted on the bottle of the not-so-special wine they just happened to be imbibing. It was Bötzinger Spätherbst. And that is how the Bötzinger complex got its name. An area close by turned out to be the rhythm generator and that became known as the pre-Bötzinger complex. Quite possibly this is of no interest to anybody. But Dr Grumble rather likes the story.

Mortality on the tube and the stolen Klodeckel

One of the top doctors in London (a very persuasive man with a rather common name) tells his audiences how if you travel from Fulham on the tube in an easterly direction life expectancy plummets by the mile. People live much longer in Fulham than they do in parts of the East End. He will then go on to say that this is all to do with the health service and that we need polyclinics to sort out the poor delivery of healthcare to the deprived. Not, of course, that it is deprived patients that the likes of Virgin would want to target but that's another story. Of course it is utter nonsense that deficiencies in the NHS have much to do with these differences in mortality. In Glasgow's Calton area average life expectancy is 54 compared with 82 in Lenzie just eight miles away. That's a 28 year difference. It is a remarkable difference. It is far too remarkable to have much to do with doctors or the provision of health care. Politicians might just be naive enough to think it is the poor local GPs who are responsible for the differences. It's unlikely that the top London doctor who peddles this ludicrous tale believes it. Most probably he has an agenda. Dr Grumble is not taken in.

Any sensible doctor must know that such differences in mortality have more to do with social factors and people. Some people listen to the doctor and religiously do what they are told. That probably helps. But it is not even just that. There is good evidence that if you hand out dummy pills patients who take them according to the instructions do better than those who do not. That may surprise you. It does not surprise Dr Grumble. While he cannot prove it Dr G thinks that those who take pills properly also look after themselves properly in other ways.

In large cities rich areas can be remarkably close to poor areas. The people in rich areas behave very differently from those in poor areas. Some might say that you don't eat well if you cannot afford to. And your housing will be worse. But it seems you are also more likely to smoke even though smoking costs rather a lot and poor people really could do with the money. And staying slim by eating less doesn't cost you anything. You save money. Exercise too can be cheap.

Mrs Grumble had a practice which spanned rich and poor areas. A neighbouring practice set inside a council estate had even more deprived patients. Mrs G used to visit it. On one occasion she also visited the practice loo and was surprised to find the loo seat firmly chained to the wall. She asked why. It was to prevent the loo seat being stolen. Less than a couple of miles away in a rather better part of town such measures were just not necessary. People who steal loo seats are not likely to look after their health. They still have access to doctors (the doctors in the deprived area were excellent and highly motivated) but they will be less likely to listen to them and look after themselves. Their bodies are more likely to be subjected to the assaults of tobacco, drugs, excessive alcohol, couch potatoism and junk food to name but a few. Incidentally the extremely rich are also at risk. They tend to indulge in rich pastimes which can be highly dangerous. Richard Branson is a good example. So far has got away with it. But enough don't for it to show up in the statistics. That's why life insurance costs more for the extremely rich.

Dr Grumble has always thought that the story of the chained up loo seat was a little odd. But apparently the problem of loo seats being stolen by patients is not just a UK problem. Those who speak German will see that they have similar troubles over there.




In case you're wondering, Klo is the German for loo and Deckel means cover making Klodeckel a compound noun meaning toilet lid.