30 November 2008

am Klo

Dr Grumble tries to keep his past under wraps. It's too identifying. But, for this post, he is going to have to reveal that, for a short while, he worked in Germany. Dr Grumble still takes German lessons. He is now in the advanced class. But he rarely goes to Germany any more. Mrs Grumble is not keen on Germany.

It was very many years ago that Dr G worked in Germany. The building where he worked is now derelict. But Grumble remembers it as if it were yesterday. One thing he remembers is the toilets. The Germans are very clean. Perhaps obsessionally so. Dr Grumble's German teacher thinks there is a historical explanation for this. Whatever the reason cleanliness is important to Germans and you cannot criticise them for that. Their lavatories are clean too. But they have one very unusual feature. Dr Grumble refers to this as an 'inspection panel'.

All those years ago Dr Grumble pondered over this inspection panel. He called it an inspection panel as a joke and because he could not think of any other suitable term that would adequately describe this extraordinary feature. In those far off days you couldn't google and you could hardly go to a library and asks for a book on German lavatories. But now the wonders of the internet have revealed to Dr Grumble that he is not the only one who has been pondering the design of the German water closet. The Germans are great engineers. They could design much better toilets if they wanted to. But it seems they don't. They like their toilets just as they are. It seems that what Dr G jokingly called 'inspection panels' are just that. The Germans, apparently, like to inspect what they have passed. Now isn't that odd?

What has all this got to do with medicine? The answer is that the way people behave in different countries is very different. The NHS or GPs get blamed for poor cancer survival rates. But British people are a stoical lot and very different from German people when it comes to their health. Dr Grumble's evidence for this is weak (not that he has looked for any). But one piece of evidence is that most British people are not intent on passing their excrement onto a porcelain panel for inspection. And that could mean that we are less likely to notice if we have serious bowel trouble. Or it might not. It is an interesting possibility anyway.

Dr Grumble apologises for being a bit slow off the mark with this post but world toilet day quite passed him by.

One rule for the guilty another for the innocent

Dr ***** **-***** has been named as the locum paediatrician who examined Baby P two days before he died.

The doctor said:

"My professional career has been devoted to the care of children."

The boy's mother and boyfriend have been convicted of causing the baby's death. The law prevents them from being named.

Dr Grumble says:

The doctor's registration has been suspended. The doctor was a locum so, presumably, is now without a job and and has lost her livelihood

Dr Grumble says:

Somebody has to be blamed. It could be the doctor. It could be a social worker. It could be both. It won't be the government.

Did you know there are targets to reduce the number of children being taken into care?

Dr Grumble says:

Nothing at all.

24 November 2008

Sick certification

The GP bloggers are getting angry about the failure of hospital doctors to issue certificates. They write: This is NOT a rant against my colleagues in secondary care and claim we are ignorant or they imply we are lazy. So which is it? Dr Grumble thinks it is simply because we are provided with the wrong form. Here is the one some of us have been using. It only covers the hospital stay.

Here's a quote from the document linked to below:

Until now the Med 3 statement has been used very rarely in Trusts and in the whole of the NHS generally. There is widespread use of the Med 10.

As far back as 2001, Trusts were required to integrate a simple sickness certification procedure into the hospital discharge and out patient process. The reason was so that hospital doctors and consultants would not refer patients to a GP solely for the purpose of obtaining a sick certificate. At that time, it was estimated that 518,000 appointments per year could be saved for GPs plus 42,000 hours. Also, it would ensure a seamless service for patients upon discharge.

Issue date: September 06
[So it has only taken them five years.]

The problem is clear. It's not much to do with laziness. Filling in one form is much the same as filling in another. It makes no odds to Dr Grumble. But in the Trust where Grumble works there are, say, over 1000 inpatients and over 50 wards on more than one site. Getting the right pieces of paper to all these places is a challenge. This is a management failing. It needs a management solution. And it can be done. Filling in forms is a shocking waste of a GP's time and it won't take us any longer. We just need the right piece of paper. That's all.

23 November 2008

Quite Obviously Flawed

If you had asked Dr Grumble whether, if you were to set up a system of performance bonuses (QOF) for GPs they would meet them, he would have guessed that they would. The average GP runs a very tight ship. Practices are heavily computerised. Most patients GPs would need to see for their performance payments would visit their GP quite often. So all the GP would have to do to jump through the hoops and earn extra pay would be get organised and do what the system required. It could be something as absurdly simple as offering advice about smoking and diet or taking a blood pressure. Patients are still smoking and getting fatter and they must know that these things are bad for them - but there is some evidence that a doctor mentioning such issues can help so it may not be quite such a daft way to pay doctors.

How would you negotiate with government over something like this if you were the BMA? Dr Grumble had always thought that the BMA, being dominated by GPs and knowing that GPs would be good at jumping through hoops, would have kept their cards close to their chest in any negotiations with the government. That way GPs would get paid much more than the government had ever intended. But Dr Grumble has now learned that the BMA played with a straight bat. The BMA actually told the government that if you were to give GPs hoops to jump through they would do it. The government did not believe them. They estimated that GPs would only manage to reach 75% (NAO pdf - para 2.11) of their target payments. In fact they got 96.8%. As a result they were paid more than intended. They were paid for doing the job the government imposed upon them. They told the government they would achieve. And they did.

Of course GPs weren't paid for everything you could pay them for. Dr Grumble is not paid for quite a lot of things he does. That is professionalism. But now the Mail claims that GPs 'are ignoring elements of care such as compassion because they do not get extra cash for being nice to patients.' So how would the Mail deal with that unfounded allegation? Another box to tick? What the Mail fails to say, because they are acting in all of this as government rotweilers, is that if anyone is to blame for moving from a professional contract to a jump-through-the-hoops contract it is the government. All this comes, of course, from listening to management consultants who seem to think that people will work only for money and have no concept of professionalism. Professionalism is under threat. It is very sad.

Here in a comment to one of Sam's posts is Dr Grumble's spontaneous tribute to the professionalism of a state school headmaster responsible for educating Dr Grumble's three children. Dr Grumble is not sure he has ever really said thank you to him but he's sure Mrs Grumble has. Sometimes people do not treat professionals well. They think of them as public servants who should be beaten with sticks. The I-blame-the-teachers mentality gets Dr Grumble down. Dr Grumble has noticed when he has visited the schools where his children have been pupils how defensive the teachers can be. He has noticed how inconsiderately long some parents spend with the teacher. He can guess what is going on. These people who have not succeeded in producing successful offspring must be bludgeoning the teacher as if it is the teacher's fault. These imagined encounters always remind Dr Grumble of those relatives who seem to think that you are not going to do the best for their loved one unless they give you the third degree. But Dr Grumble trusts his children's teachers. And he makes a point of thanking them. Sometimes they look surprised.

22 November 2008

Why we need bloggers

One of the reasons Dr Grumble blogs is that he does not think that the truth is always told. Journalists rarely do their jobs as they should. They are lazy. They regularly churn out material that is spoon-fed to them. It's no wonder that they can be so hostile to bloggers. If they cannot do the job properly somebody else will. For nothing.

But it is even worse. Dr Grumble has come to the conclusion that newspapers are in cahoots with the government. Just how this happens is, to Grumble at least, unclear. There must be some sort of trading going on. But there is no doubt that it happens. The evidence is there again and again. Of course, you wouldn't expect a newspaper, if you can call it that, like the Daily Mail to be on board with a Labour government. Or would you?

18 November 2008

White elephants

Have you ever seen a white elephant? Dr Grumble hasn't. Not a real one anyway. But he has seen metaphorical white elephants. An example would be Concorde. Concorde used to fly over Dr Grumble's house. It made a distinctive noise. It was loud. But Dr Grumble still liked it. It generally flew over every day at the same time but always, if he could, Dr Grumble would look up to the sky and admire a beautiful white elephant. Some white elephants are worth Dr Grumble's share of the expense. Dr Grumble is not the only one who used to feel this way about Concorde.

Some white elephants are not worth paying for. But the nature of white elephants is that somebody will pay for them nevertheless. And that somebody is often Dr Grumble and the rest of the British taxpayers.

Do you know why white elephants are called white elephants? You can find out from wikipedia. Do you know which particular white elephants Dr Grumble is thinking about?

Pensioner power

Never underestimate the power of pensioners. Pensioners are patients more often that the rest of us. They experience the NHS more than most. Dr Grumble has seen many of them today on his ward round. At least one thanked him for the high quality care he had received.

There's a lot wrong today in the hospital. Too many patients. Too few staff. And not enough beds. But somehow we managed to give the impression to a pensioner that he had been looked after well. Probably he was. Other patients were not managed perfectly. Dr Grumble admits it. He is angry that his staff did not do better. Probably no harm has come from the mistakes that we made overnight. But it should not have happened. It might have been sloppiness. It might have been communication problems. Perhaps it was just one of those things. But it shouldn't have happened. A young septic patient with rigors should have had blood cultures. But he didn't. It is very basic. Dr Grumble is ashamed.

But on the whole we do quite well. And on the whole the pensioners are right when they say we look after them well. And they doubtless feel the same about their GPs. So when their local surgery is threatened or taken over without consultation they take action. And the action they take has more effect than any of Dr Grumble's grumbling ever has.

16 November 2008

How do diabetics fare in the NHS?

Diabetes can lead to a lot of potentially very nasty complications. Keeping track of diabetics to make sure they get what they need to minimise complications is quite a challenge. So how do we do in the NHS compared with other countries? Some idea can be found in the bar chart below from the latest Commonwealth Fund survey.

On this measure we are not at all bad. But can you believe that in the NHS 75% of adults with a chronic condition reported a medical, medication or lab test error in the past two years and in the US and Canada it is even worse? And these were just the errors that occurred outside hospital.

Richard Branson might condemn these figures but perhaps the errors reported are more equivalent to an airline losing your bags or landing gear failure than a pilot forgetting to put the landing gear down.

Google epidemiology

Have you ever wondered what the Google people know about you? They know who Dr Grumble is. They may even know he was a little off colour this weekend because Dr Grumble was searching to find out what were the active ingredients in the cold cure Mrs Grumble brought home from the local shop. As well as being able to guess that Dr G was a little under the weather Google can also do some real time epidemiology. When the long-feared 'flu epidemic arrives Google may well be the first to know. Here's how.

12 November 2008

Paice, Needham and Dr Scott

Read the latest here. Is Dr Grumble the only one who thinks that a great deal of time and effort is now going to be wasted on this whole sorry saga?

09 November 2008

Hospital 'worse than third world'

That's the worrying claim being made about Birmingham Children's Hospital based on this draft report (pdf).

06 November 2008


When Dr Grumble got into his car to drive home tonight he switched on the radio and thought he heard a familiar voice. The voice appeared to be describing a parathyroidectomy. Sure enough the voice was that of Richard Collins. When Mr Collins started work as a consultant Dr Grumble was already in post as the house surgeon to one of the other surgeons at the Kent and Canterbury Hospital. That was a long time ago. So surely by now Mr Collins should be retired. It turns out that he has retired. But he was called out of retirement to operate on a gorilla. You can read the story here.

02 November 2008

Up to expectations

The new computer system for St George's Hospital in South London is living up to expectations. Dr Grumble's expectations anyway. These stories are so commonplace they are no longer news. How is it possible to waste so much money? Who made the decision to waste money in this way in a meeting on a sofa - a meeting that we know existed but was not minuted? How can such decisions with taxpayers' money at stake be made with no proper record?

01 November 2008

Clinical engagement

'The idea of clinical engagement is a good one," says Dr Rant. Dr Grumble agrees. No more ranting and no more grumbling. Dr Grumble sees definite signs that in his hospital clinicians are becoming more engaged. It is tragic that the powers-that-be ever thought that successful healthcare could flourish without clinical engagement. It's insulting that doctors were considered to be just out for themselves and not enthusiastic about improving the ways they work. But let's not go on grumbling. Let's join with Dr Rant and welcome the concept of bringing back clinical engagement.

Lessons in bad behaviour

No. Not a story about Jonathan Ross and the celebrity culture though Dr Grumble does wonder if the use of his TV licence fee has been contributing to youngsters like Dr Scott not quite knowing how to behave. If the likes of Dr Scott want to behave like drunken teenagers that is their prerogative but do we need to pay large sums of money to people like Mr Ross to encourage this sort of behaviour on national television? And using Dr Grumble's licence money! Should Dr Grumble write to the BBC and complain? Or would that be a waste of time?

We all have some inherent idea of what is right and what is wrong - except, perhaps, Jonathan Ross. For example, hitting people is wrong. We are all agreed on that. Even, one would think, Jonathan Ross. So we all agreed that hitting people is wrong. Every one of us. Of course we are. Do our legislators agree? Amazingly they don't. Not yet anyway. Should Dr Grumble write to his MP again? Or would that be a waste of time? Like writing to the BBC who spend millions employing idiots.

The apparent futility of protesting has not stopped Dr Grumble. He has written to the BBC already. Nobody else need bother. (Grumble hasn't had a reply anyway.) But you might want to write to your MP about the other much more important matter. Or you could do nothing. Doing nothing would be easier.