Sherlock Holmes

Dr Grumble's latest batch of medical students are very green. Very bright but no knowledge. Everything clinical is new to them. It's rewarding to teach bright students who know very little. The less they know the more you can teach them. It's like starting with a blank canvass and painting a masterpiece. Maddeningly Dr Grumble has his students for only a month. It's crazy, of course, but nobody listens to Grumble. He used to have them for eight weeks. In that short time if students and Grumble worked hard the rudiments of history taking and examination could be taught. The beginnings of a masterpiece could be created. Some of these students will end up much greater and more important than Grumble. Amongst them may even be the Lord Darzis of the future. And, hopefully, some really good GPs.

The job of teaching is important but there's little reward. Nobody in the hospital hierarchy really cares about how well you do your teaching. They say they do but they don't. Small group teaching is essential when it comes to clinical work but only the small group even knows you have done it. These days they report back online on the quality of the teaching. But sometimes they do not quite know how good their teaching has been. They do not know that the notes they write will forever be better structured than the notes of those who were not taught properly. They do not know know how those difficult questions were not to make them look stupid or to check their factual knowledge but to get them thinking in the right way to be a decent doctor. They do not know what they don't know, what they really need to know and where they are heading.

Eventually Grumble's students do realise what he was trying to do. Sometimes anyway. Just occasionally Dr G will get an email from a student or doctor thanking him for teaching that took place years earlier. Sometimes in these emails they explain that it was only later they came to realise the importance of the Grumble style of bedside teaching. This is Grumble's only reward. It's his greatest reward. It's the only reward he wants. Dr Grumble had teachers he appreciated, teachers he wanted to emulate. He hopes he thanked them.

Some years ago Grumble used to teach Japanese medical students. Don't ask why. Even Grumble does not know. They just turned up and Dr Grumble just taught them. He used to ask them who wrote Sherlock Holmes. They always knew. The home-grown students can look bewildered if you ask them a question like that. They certainly don't see its relevance. But it is relevant. In a way. Because the next question is about how Sir Arthur Conan Doyle got the idea for Sherlock Holmes. And the answer, which they rarely know, is from Dr Bell who used to teach Sir Arthur when he was a medical student. Dr Bell, like all physicians, was a detective. Sometimes he could tell what parts of the world his patients had visited and what jobs they were in. Dr Grumble can do some of this. It impresses students no end.

The other day Dr Grumble met a patient for the first time and told his students in front of the patient that he thought he had been in the army, that he had worked in the past as a coal miner and that the had given up smoking about six weeks ago. The patient dutifully confirmed all this. The students were visibly impressed. Dr Grumble thought that from then on they would be taking him seriously.

How did Dr Grumble do this? It isn't that difficult. Patients who call the doctor 'sir' have usually been in the armed forces, coal tattoos in old cuts are common in previous coal miners and if fingernails grow at 3mm a month it is easy to work out from the tar staining when the patient stopped smoking. Now doesn't that sound like Sherlock Holmes explaining his deductions to Watson? It's easy to see how medicine lay the foundations not only to a series of good books but also to modern detective work. As Sir Arthur says himself in the only surviving recording of his voice. The recording is a bit stilted and there is only a hint of the admiration and gratitude Sir Arthur showed for his teacher, Dr Bell, without whom there may never have been a Sherlock Holmes.

Unforgivable, inexcusable and dangerous

‘I don’t think they care,’ was Hubby’s summation of the nurses' behaviour, 'I just think they are thick'.

Sadly, there are times when Dr Grumble has felt the same way. Read the story here.

Computer chaos

Have you ever had your broadband connection fail? These days if that happens you feel really deprived. Dr Grumble got his connection on the very first day his local exchange was enabled. It seems ages ago but it was only a few years back. Now, if his connection fails he cannot blog, he cannot email, he cannot read the newspapers, he cannot bank, he cannot do his shopping and so on. We have become very dependent on computers. If you call in at the petrol station and the computers are down there is no way you can pay. If you are in a hurry and offer to leave them some cash they threaten to have you arrested. They can't even work out the change without the electronic till. In a very short time we really have become extremely computer dependent.

When it comes to computers the NHS is behind. In hospitals anyway. GPs, being empowered, have been ahead of the game. Primary care in the UK is heavily computerised compared with, say, the US. (UK 89% v US 28%). Why are hospitals so behind? There are various reasons but one problem is that they haven't been able to get on with the job because of all the national initiatives going on around them. When it comes to computing government has a bad record. Sadly there are no signs of improvement.

Some of the recent problems that have been encountered seem familiar to Dr Grumble. They arise from a failure to engage clinicians. Take the issue of smartcard sharing. Dr Grumble thinks this is unforgivable but he believes this sort of behaviour in the NHS to be rife. Only last week Dr Grumble was tentatively asked to give his login details to somebody else. He declined. People about to leave the hospital may agree and that is how they can be found to be logging in long after they have emigrated to work in the antipodes. These things happen all the time. And if you are a clinician it is easy to see why. It's even easy to see that it is inevitable.

What happens is this. A locum doctor arrives at 11pm on, say, a Sunday. Locum doctors tend to plug gaps out of hours so there is less than a 24% chance of the doctor arriving during normal working hours. He arrives without being sure of where he has to go or what he has to do. He takes over from a departing doctor who is keen to get to bed and he asks how to get into the computers in order to access the information he needs to manage the patients. Getting a smartcard is either not possible out-of-hours or nobody actually knows how it should be done. Just at this moment there is a cardiac arrest. The inevitable then happens. The smartcard along with the PIN is quickly passed to the locum who will leave it in a drawer for the morning. That's how it happens. There is no other way.

In reality it is much worse than this. In some hospitals multiple programmes are needed for patient care and there are multiple log-ins and passwords. They time out rapidly. Doctors in outpatients will look at a radiograph, then blood tests, then, say, the appointments system or a recent discharge summary, then there are a few tests to order. Each requires another programme with another set of log ins. By the time the next patient is in all these programmes have timed out. Logging in takes an eternity. If you tell people about this problem nobody listens or they don't want to listen because they will be responsible if computers are left idle and unauthorised people can get in. It is worse than this because you have to keep changing your passwords and they cannot be synchronised. Dr Grumble cannot even work out for sure how many hospital passwords he has on the go but it is at least eight and they keep changing.

Computing in the NHS is a dog's dinner. It needs sorting. One thing it doesn't need is any more money spent on it. What is needed is real clinical engagement.

One rule for them, another for us

We all love to hate politicians. There is one that Dr Grumble particularly hates. Can you guess who? You will have to guess if this blog is to become regulated. Below is what he says about his views on preserving his liberty to speak out:

"........I think it is in the interests of democracy to preserve the liberty of politicians to speak about current issues and public figures in expressive language that is all part of the cut and thrust of political debate."

Below is what he says about his views on preserving our liberty on the web:

"It is not just about copyright or intellectual property but [things like] taste and decency in the online world. The time will come to say what are the direct interventions [needed, if any]."

So it's in the interests of democracy to preserve the liberty of politicians to speak about current issues but the common man with a blog has to be regulated on the grounds of things like taste and decency. That makes sense. If you are a politician.

Watch out Dr Rant. There are words you use that Andy Burnham may find in bad taste. He wants to prevent people like the sensitive flowers in the deaneries from ever reading your stronger words. Could that perhaps be a good thing? Think. We can protect the delicate types in the deaneries from ever knowing what these words mean. It would be just like the good old days when these words were not even in the dictionaries so we couldn't ever use them and people could not possibly be offended.

£50 billion

The government is going to have to borrow up to £50 billion to support the UK banks in by far the greatest banking crisis Dr Grumble has lived through. That is a simply vast sum of money. But it is a simply vast crisis.

So compare the greatest banking crisis in recent history with the greatest computing crisis in history - Connecting for Health. How much is that going to cost? Can you believe up to £50 billion? Perhaps you can't. Just think of this. If we had not had Connecting for Health, health care now would be, well, much as it is. And we would have been left with enough money to bale out the banks in the greatest banking crisis we have known. How can this be? Who created this crisis of computing? How can 50 million health records be costing £50 billion? It cannot be.

Just so you know

Open up the NHS to new healthcare providers

Whose policy is this? It could be New Labour's. It could be a Conservative policy. It's hard to guess. Find out whose policy it is here. And have a think about why it is that the policies of the major parties are these days so very similar.

Alan Johnson at the NHS Alliance 2008

Here is the speech made by Alan Johnson last year to the NHS Alliance. What do you think he will say to the assembled multitude in Bournemouth on Thursday?




Wasn't Bournemouth where Lord Darzi was booked for the GPs' conference? But he couldn't make it. He sent a video instead. That's understandable. He is busy.

It couldn't happen twice could it? No. It couldn't. Mr Johnson has a 45 minute slot. People would be disappointed. They might think he doesn't care. No. It couldn't happen twice. Not at the 'leading event for primary care.'

No more intravenous cannulation

In some hospitals junior doctors are no longer allowed to carry out intravenous cannulation. Some have asked why the deaneries are not protesting about this? Dr Grumble has some bad news. There may be infection control reasons for these initiatives but this sort of thing actually comes from the deaneries. Dr Grumble became aware of these proposals recently and protested loudly. He protested to a senior personage in the deanery. He argued that putting in an intravenous cannula could be a life-saving procedure and that it was not a bad idea for the most junior doctors to get a lot of practice at it. So what do you think the response was? Did the senior personage show some sympathy for the Grumble view? Not a bit of it. She tore poor whimpering Grumble to shreds in a most dismissive way. They are powerful these people. Very powerful. She told Dr Grumble that he was old fashioned and out of touch with the way things are going. Junior doctors were not to be rushing around doing chores at the behest of tyrannical consultants. There was an unpleasant implication there about how she seemed to think Dr Grumble behaved. Now Dr Grumble would agree that junior doctors should not just be doing chores. But his junior doctors are still rushing around doing mostly purely administrative tasks. Those are the tasks that should be taken away from them. The things that could be done by a reliable clerk. But stopping them acquiring life-saving skills is plainly crackers. But nobody listens to Dr Grumble. He's not tyrannical enough. You can't argue with the deaneries. They have an agenda.

It's not just doctors

Deb Acle over at the Jobbing Doctor has pointed out that the sort of things the government has been up to in the NHS it has been up to all over the place. Dr Grumble is aware of this. He has friends who are teachers and lawyers. When Dr G moans to them they chorus that the government is doing the same to them. There was a good example on the Today programme this morning.

If you are a doctor you may not have heard of Criminal Defence Service Direct. But it may sound familiar. If you are a criminal in trouble you used to be able to phone your very own solicitor. And you could have a face to face meeting with him. In future you will phone Criminal Defence Service Direct for advice. They won't come and see you. They will give advice. The advice may be from somebody who is not a solicitor. Does that sound familiar? You used to be able to have your very own solicitor come and see you but in future you will get somebody who is not a solicitor over the phone. The similarity with NHS Direct is striking. The common factor is that this has been imposed by the government according to the exact same formula dreamed up by policy wonks who have probably never worked as a solicitor just as those who advised the government on general practice have never worked as a doctor. The powers-that-be probably think it will be cheaper. Many doctors think NHS Direct was money down the drain. What do the solicitors think about Criminal Defence Service Direct? They certainly seem to think it offers a dumbed down poor quality service that their clients just do not like. And Dr Grumble would be surprised if it really saves money. Paying people to do a poor job rarely saves money. As Red Adair said:

If you think it's expensive to hire a professional to do the job, wait until you hire an amateur.

Concentration and pluralism in the media

Dr Grumble does not want to lose his readers. So why does he raise the tedious topic of a Motion for a European Parliament Resolution on concentration and pluralism in the media in the European Union (2007/2253(INI))? What is there to fear from this superficially innocuous document? Prompted by a post from the Witch Doctor, today is the second time Dr Grumble has perused this impenetrable product of Brussels. He still finds it heavy going. The first sentence of the paper is the longest sentence Dr Grumble has ever read. Any document which has 23 paragraphs in a row beginning with the word 'whereas' cannot be intended for the likes of Dr Grumble. There are also six paragraphs in a row beginning 'having regard to'. Plainly this is not the sort of document a mere mortal like Dr Grumble could possibly summarise here. But he thinks he understands the implication of the words 'having regard to' and 'whereas'.

As Dr Grumble has already revealed he failed Use of English so he finds trying to explain the significance of these words a challenge. By way of illustration, here is a sentence written in the style of a Brussels bureaucrat.

Dr Grumble,
- having regard to the law on the welfare of animals,
A. whereas dogs are a man's best friend, it is recognised that they may foul paths,
1. Urges the EU to have all dogs destroyed.

The above example does not read well but, frankly, nor does the EU document. It is quite difficult to extract the meaning from Dr Grumble's short paragraph but what you can see is that where it says 'having regard to' and 'whereas' the scene is being set. There is some motherhood and apple pie stuff there but it is meaningless as the sting is in the tail. What this means is that all the nice talk in the EU document about the Human Rights Act and Civil Liberties is not at all reassuring. That's just the preamble. What one needs to look out for is their proposals. Here is just one:

The European Parliament,
9. Suggests clarifying the status, legal or otherwise, of weblogs and encourages their voluntary labelling according to the professional and financial responsibilities and interests of their authors and publishers; (pdf)

We already know that the EU has become very concerned about the political influence of bloggers. Taxpayers money has been spent analysing the effect bloggers may have had on the outcome of the Irish referendum. Is that proper use of our money? Would they have bothered if the result had gone the EU way? Why do they want to 'clarify our legal status'? How can you have a legal status if nobody knows who you are? Doesn't having a legal status inevitably mean loss of anonymity?

We can chat to each other in the pub. We can chat to strangers. We don't have to reveal who we are before we open our mouths. We could post anonymous pamphlets through letter boxes if we could be bothered. So why shouldn't we express our views in our personal blogs, anonymously or otherwise, without let or hindrance from the superstate European Union?

Blame the doctors

Dr Grumble has only just caught up with this weird story about payment for visits to the GP. This is not the patient paying the GP. It is the GP paying the patient. It all hinges on concern about differences in life expectancy between certain social groups. Dr Grumble has covered this topic before. Regular readers may remember that Dr Grumble has regularly been told the tale about how life expectancy plummets as you travel on the tube from Kensington to the East End. That anyway is roughly the story that gets trotted out. There is the strong implication that this is all the consequence of poor access to doctors and that we must roll out polyclinics to address this issue.

In Glasgow there is a 28 year difference in life expectancy between areas that are just 8 miles apart. Can this really be due to differences in medical care? Can this possibly make sense? Is the fact that in the worst areas of Glasgow they smoke and drink to excess, mash up and inject sleeping tablets, sniff glue, get fat, take little exercise and get involved in fights really the fault of the local GP? If you pay these people to go along to the GP is there any chance that they will change their ways or will they take the £20 and buy heroine?

Amongst the people who come to get their £20 there will be some who are overweight. If the doctor advises them to lose weight what is the chance that they will be able to do so long term? If he finds people who smoke will it be news to them that smoking is bad and they should stop? If he finds people with a high blood pressure would the sort of person who can't be bothered to go to the GP unless they are given £20 take the necessary pills reliably? If the doctor finds their housing is cold and damp will he be able to persuade them to pay for heating with the money they don't have? If they are single mothers with more children than they can cope with will he be able to persuade them that the contraception they didn't bother with last time might be a good idea? Or might somebody already have made that point to them?

Who is responsible for the creation of these deprived communities? Does the fault really lie at the doctor's door? Or could it lie at the door of Number 10?

Standing ovation for Donald Berwick

Who is Donald Berwick? And why the standing ovation? Donald Berwick is from the US and he has been talking to GPs. And they liked what he said. So you can conclude that he is probably not from one of those big US healthcare organisations that are continually lobbying politicians to persuade them that the only way of sorting out the NHS is to move to a more American system. It's odd that the politicians listen to these people because the American system has failed. But unfortunately they do. They don't seem to listen to people like Donald Berwick. But GPs do. And they gave him a standing ovation. Was anybody there? What did he say? Was it something like this?

Sheinwald leak

If you are Britain's Ambassador in Washington one of your jobs is to brief the Prime Minister on American presidential candidates. You need to produce a frank pen picture. It's a bit embarrassing if it gets out. This time Barack Obama's pen picture has got out. Now why should that be of any interest to Dr Grumble? Well, the ambassador is Sir Nigel Sheinwald and Lady Sheinwald is a doctor. According the the newspapers she is an internationally renowned paediatrician. Dr Grumble thinks they just googled Dr Julia Dunne and guessed the rest. She always used to work in medicines regulation. Dr Grumble used to share his sandwiches with her alongside the tramps in a small London park in Vauxhall. It's strange how things change. Presumably Lady Dunne is now entertaining the great and the good in the British Embassy in Washington. No more sandwiches in the park. But Dr Grumble still eats his sandwiches in the park. Alongside the tramps.

Wellington Avenue

If you live in Wellington Avenue in Aldershot and need a GP you would be well provided for. It seems about 18 GPs are based in Wellington Avenue. Could it be that there is a polyclinic there? Could they have closed a whole hospital and replaced it with a polyclinic? How much would that have cost?

Aldershot Centre for Health is among the first of a new wave of private sector provided one-stop health centres . As large as many community hospitals and up to 30 times bigger than a conventional health centre, it will provide front line healthcare for about 45,000 local people, as well as specialist services for around 250,000. (pdf)

So let's get this right. Eighteen GPs are now based in a Centre for Health which is as large as a hospital. It's 30 times bigger than an ordinary health centre and it provides specialist services for a quarter of a million people. And it has a CT scanner. What is this place? It's not a hospital. It not a GPs' surgery. Is it a polyclinic? Is it sensible?

How has it been financed?

The Wilky deal represents a highly innovative financial structuring. I’m sure other property groups will be very interested in the potential offered by this exciting new market. (pdf)

Dr Grumble also thinks other property groups will be very interested. After all it did cost £28 million of taxpayers' money.

A private clinic, airport, hotel and the 'Hilton Health Centre' - these are just some of the comparisons/comments made by patients when they have visited the brand new Aldershot Centre for Health for the first time.

Sounds good. But what about the old lady who wanted her own GP at the end of her road. Will she need to move to Wellington Avenue? Yes. That's it. Get all the old folk and disabled to move to Wellington Avenue and everything will be just fine.

Come to think of it the old lady could go on her bike.

Car parking is limited on site and there is a charge for on-site car parking. There are 50 covered cycle parking spaces provided on-site.

It's quite big (pdf) compared with the average GPs' surgery. In some pictures it resembles one of Darzi's virtual polyclinics. I wonder what the old lady thinks. Do you think she will appreciate having the CT scanner there? Just in case.

Private Eye

Anybody interested in the story of Dr Scott and related matters should read Medicine Balls on page 10 of Private Eye.

With thanks to Dr Aust who alerted Grumble to this article.

Friends in high places

The GPs are whinging again. About polyclinics. Who makes this accusation? None other than the Primary Care Czar. Is he out of touch? Does he actually do any general practice?

• Does he really fail to understand the genuine concern about polyclinics?
  
• Does he really think that all doctors are interested in is pay?
  
• Does he really think that traditional general practice can survive unscathed if the government puts all the resources into Darzi clinics?
  

Is he loyal to traditional general practice? Or could his loyalty lie elsewhere? Who knows? Perhaps he believes what he says. It's possible.

37 thousand

Dr Grumble has had to abandon his early morning work. The reason is that when he opened the patients' notes they were all empty. Some clerk somewhere has opened a new file on each patient. Not a temporary file but a new file. That means that each of these patients has two sets of notes. One set is completely empty. It also means Dr Grumble cannot make decisions this morning. Dr Grumble was so angry he told a passing surgeon. To Dr Grumble's amazement, according to the surgeon, a neighbouring hospital is even worse. There they have 37,000 sets of duplicate notes. It is simply not acceptable. It is dangerous. Dr Grumble used to put each empty set of notes into an envelope and send it to a manager to make his point but they got fed up with him. So he has now given up. Like everybody else.