30 December 2008

Compassion in the NHS

One of the good things about being older is that you can remember how things used to be. There is the strong risk of the rose-tinted retrospectoscope and you can't go back to check on your memory or show youngsters how it used to be but you can be pretty sure of some things.

Dr Grumble did a ward round on Christmas Eve. He doesn't usually do a ward round on a Wednesday but his junior staff wanted him to. The timing of the round was their idea. They were worried about the long weekend. So was Dr Grumble. He never likes these long holiday periods for patient care. The worry of the managers was very different. The Grumble hospital has been very full. The possibility of running out of beds over Christmas was frightening them. But it never seems to happen that way. For all sorts of reasons the pressure is off at Christmas time. Nevertheless Grumble thought it was his duty to try and get patients home for Christmas. You might think patients would like that. But you would be wrong. For the lonely Christmas is the loneliest time. The second patient Dr Grumble saw did not want to go home for Christmas nor the third. And so it went on.

Dr Grumble can remember what the consultants of old would have done. They would have been compassionate. They would have invited these lonely people to stay for Christmas Day and we would have had a great big turkey. A real turkey. And Dr G's consultant would have come in on Christmas Day and carved it. We would have had a nice party and presents would be flying in all directions.

But those days are long gone. Dr Grumble had to ask his staff why these patients were still in hospital. The was no reason. Not a real reason. It was just that nobody had had the heart to send them home. Except, that is, Dr Grumble. He wishes it could be otherwise. But you can't turn the clock back. And we must have the beds.

29 December 2008

Second life

Would you like to have a second life? Dr Grumble would. This life has been good to Grumble. But he would like another one. He's not sure what he would do with it. Perhaps something similar only better. And it would be nice to be born into the era of the internet - though having these things to discover towards the end of his working life has been a great excitement for Dr Grumble.

Dr Grumble went to one of those peri-Christmas parties yesterday. It was full of old farts. Dr Grumble is of the old fart era. One of the old farts (a nice old fart actually) began talking about new technologies. Dr Grumble mentioned he had a blog. The old fart seemed surprised. Why? Blogging is not difficult. It's certainly easier than writing a letter. Do the old farts not realise this? It seems they don't even read the blogs. But then Dr Grumble's children don't either. Are we there yet with blogging? Has it gone as far as it is going to go or can we expect more? It's hard to know. It's difficult to see where some of the new web-based technologies will lead us. Sometimes Grumble thinks we are trying to push it too far.

But none of this was the purpose of this post. The purpose of this post was to ask what you people out there think of Second Life. Dr Grumble, being an old fart, is not really into Second Life. He knows what it is. He knows how it can be used for medical education. Research protocols have even crossed the Grumble desk relating to the use of this sort of simulation for education. But Dr G has not yet dipped his toe into the water. Will Second Life become an important part of our lives? It clearly is already to some. Will it become important in medical education? Will we stop going to international conferences and just wander around in Second Life where we will make friends and meet experts from around the globe? Some people seem to think so. What do you think?

28 December 2008

Back to basics

For most of us it is difficult to complain. If Dr Grumble were to take the trouble to complain about something, which he rarely does, he would probably try and start with a compliment about the service. If you are going to complain it is nice to give credit for the things that went well and this might also lend some credibility for when you put the boot in.

Dr Grumble has just read an account by a patient referring to 'good care' at Leeds General Infirmary. By this the patient means the medical treatment was good (which it probably was) but the 'care' was plainly appalling. The patient refers to 'poor facilities' (which they probably were). It easier to criticise facilities as opposed to people. But Dr Grumble thinks there were staff failings. Full bedpans and urine bottles left everywhere may have something to do with facilities but whatever facilities you have these things do not empty themselves.

"Could we nudge them into doing better?"says Paul. No Paul. They need more than a nudge. We need a return to good old fashioned nursing. And we don't need to do away with hierarchies we need to bring them back. We need somebody with status in charge. Somebody who is revered. Somebody who is accountable. Somebody who takes pride in the ward and the staff and ensures that everybody does a good job. We need to do away with the endemic sloppiness that has insidiously crept into our wards. We need to do away with the no-blame culture and get people to do their jobs properly. We need to bring back the benevolent dictators who used rule the wards with a rod of iron. Good basic nursing needs to return. It needs to be valued. It needs to be respected. It needs to be rewarded.

27 December 2008

"Wrong kind of misconduct"

In October Remedy, smarting from the catastrophe of the medical training applications system (MTAS), instructed their lawyers to write to the General Medical Council (GMC). Essentially the allegation was that the doctors in charge of MTAS had fallen below the high standards required and that the GMC should investigate.

The GMC has now rejected the call for an enquiry. According to the GMC:

i) the alleged misconduct is not relevant to the fitness to practise of these doctors, and

ii) allegations of deficient performance must be concerned with poor performance in a clinical setting.

Dr Grumble knows nothing about the law but he can read. Below is a cut and paste job from the judgment relating to the case of Professor Sir Roy Meadow:

....... "serious professional misconduct" is not statutorily defined and is not capable of precise description or delimitation. It may include not only misconduct by a doctor in his clinical practice, but misconduct in the exercise, or professed exercise, of his medical calling in other contexts, such as that here in the giving of expert medical evidence before a court.

Could the GMC's decision have more to do with expedience than the letter of the law?

Remedy and their lawyers believe:

• that the GMC rejection on such shaky grounds is at best absurd and at worst unfairly protective of an unimpeachable elite

• that there are unhealthy double standards of accountability between the profession and its leaders

• that it is the duty of an organisation like Remedy to step up and restore accountability to that leadership

• that a clear precedent needs to be set pour encourager les autres

• that far from being an issue from the past, unaccountable leadership is an ongoing problem for the profession which needs to be addressed immediately

They have some good points but if they want to take this further they will need to raise a lot of money. Lawyers don't come cheap.

For more on this issue visit Remedy.

25 December 2008

Happy Christmas

Dr Grumble wishes all his readers and fellow bloggers a Merry Christmas.

23 December 2008

From litter tsar to patient safety

Logins from the paradise of Necker Island have led Dr Grumble to suspect that no less a person than Richard Branson reads Dr Grumble. It could though be just his minions but Dr Grumble likes to think it is Sir Richard himself.

Sir Richard has been proclaiming on MRSA. Now Sir Richard is not a great expert on MRSA so why should we listen to him? He was not a great expert on litter but that did not stop his being appointed litter tsar though Dr Grumble cannot remember him solving that problem either. But, since Sir Richard reads Dr Grumble, he may have more knowledge on MRSA than we give him credit for. And his great friend Peter Emerson is a doctor and, of course, so is his daughter, Holly. Dr Grumble has met Holly. But that was many years ago when she was something of a tomboy.

So where did Sir Richard get his latest idea on how to tackle MRSA? Could it have been from Dr Grumble?

Spoof or not?

Can you believe that one of these videos is a genuine video from the Department of Health? Can you tell which one?

Is it number 1 or number 2?

What a way to market Connecting for Health and the electronic care record. Presumably even the actors were embarrassed.

22 December 2008

Can you spot madness? Let's Hope so.

Do you think this man is mad? What are the signs? The vacant grin? The confabulation reported in the press? The impending spillage of his coffee? Or his plans for dementia training for GPs? Which of the above is the key to the diagnosis?

21 December 2008

Managing uncertainty, ambiguity and complexity

Do you know what a doctor does? Probably you think you do. Quite possibly it seems a fairly simple job. The patient goes to the doctor. The doctor is highly trained. The doctor knows what is wrong with the patient and delivers the appropriate treatment. What could be easier? But it is not really like that. Even apparently simple things are not really like that. When one of the Grumble children injured his ankle and had to be carried home by his friends it might have seemed likely that it was more than a sprain but Dr G did not know and nor did Mrs G. When he continued to fail to weight bear Mrs Grumble took him to A&E. No fracture apparently. Then it was back to the orthopaedic clinic. Now why do you think that was necessary? There he was seen by a registrar who was dismissive even though he still could not weight bear at all. That would have rung alarm bells even to Grumble. But there was no fracture - apparently. Then the consultant came in. He pressed on one spot and poor young Grumble leapt into the air - or he would have done if he could have leapt. And he ended up having to have his bone screwed together. How could this have happened? Were all the doctors up until that point incompetent? It happened because even orthopaedics, even whether or not a bone is broken is just not that easy. The A&E doctor would have been very junior and, despite years of training, the SpR had had insufficient experiential learning. The consultant got the diagnosis in seconds because he had seen it all before. He had the mileage.

Move now to the GP's surgery where the poor doctor has to deal with absolutely anything that is thrown at him or the physician's clinic where clinical problems that the GP cannot fathom may be referred. The problems there are even worse. Sometimes it can be easy. Dr G remembers as a student being impressed when a patient whose fingers were clubbed came in with an abnormal chest radiograph . Within moments the consultant was as certain as he could be that the patient had lung cancer. The young Grumble might have been impressed but that one was easy. Often it is not like this. The outpatient clinic can be a real struggle. Sometimes the history has to be wrestled from the patient. Sometimes the history gives few clues. Sometimes there are too many clues. Easy it is not. And if you don't know what is wrong from the history, the examination is unlikely to help either. The mental effort you have to put in is substantial. A busy clinic is draining.

The managers of MMC failed to realise that medicine is difficult, that extensive experiential learning is essential and that it is not just a matter of acquiring competences and getting boxes ticked. Many cases are grey. Many cases are ambiguous. And, as patients get older and older, many more are complex. Doctors need to think on their feet from first principles. They need to cope with not always knowing what is wrong with their patient. They need to cope with ambiguity and complexity. They need to help patients and their relatives who cannot handle the uncertainty. None of us likes uncertainty.

Unfortunately those responsible for the management processes in the health service have also failed to realise just how difficult this all is. Not only has medical training degenerated into a tick box thing but the management of patients has headed the same way. ACS protocols are now the order of the day for every sort of chest pain. It's a wonder this approach is not killing people. Perhaps it is. But nobody worries if the protocol is followed. And, if it can all be protocolised, we do not actually need doctors at all. That anyway is how the thinking was going. But that's because few away from the coalface recognised what an enormous issue the management of uncertainty in medicine is and few at the coalface wrote about it. Yet every real doctor will known of the ambiguities, the complexities and the fogginess that forms an integral part of the practice of medicine - whether you are an orthopaedic surgeon, a GP or a grumbling physician.

While doctors have always known this, they haven't said much about it because they really didn't think they needed to. It has been obvious to us. It has been obvious we are needed. It has been obvious that we need to learn from sheer experience and that no course or simulator can make up for lack of experiential learning. But as the mistakes have gone on being made from those in charge who know so little we have now had to tell them what doctors actually do. It's sad this was needed. It is a statement of the bleeding obvious. But Sir John Tooke was right to ask for it because those in charge do not seem to understand the bleeding obvious. Well done, Sir John.

19 December 2008

It's busy

Across the UK the demand for emergency hospital care has been exceptional. Elective work has been cancelled. One London hospital is said to have had to resort to piling up the patients in the endoscopy suite. Ambulances have been queuing outside hospitals waiting for beds to become available. That's no way to treat people needing emergency care. But we are in difficulty. The Secretary of State has had to announce that we do not have a crisis which is what Secretaries of Sate say when we do have a crisis. Yet there is no 'flu epidemic. There is no epidemic of anything. Some 'flu and a bit of norovirus in some places but nothing remarkable. If we have a crisis now what is going to happen when we do have an epidemic?

Why has this happened? It is because NHS beds have been cut and cut. Between 1984 and 2004, the number of hospital beds in England fell by 31 percent, from 211,617 to 145,218. That is a loss of 66,399 beds which is about equivalent to a city the size of Guildford. It's no wonder we are in trouble. Whatever the Secretary of State says.

Money that could have gone to front-line acute medicine and an adequate supply of beds to enable proper bed management has gone to the government's pet projects. Unfortunately the government is keen on supporting black holes.

Potty policies on polyclinics

Here's what Frank Dobson has to say in relation to setting up a super surgery at a London teaching hospital:

There may be a case for polyclinics being set up in under-doctored areas, but this area has some excellent GP practices. The whole idea of setting up polyclinics is to shift services away from hospitals into the community. But this proposal to set up the polyclinic at the hospital was potty

Why can't we have a proper informed discussion on these things? Politicians vowing to 'quash resistance' is not the way forward. Pulse has the story.

14 December 2008

Christmas presents you don't want

Very occasionally Dr Grumble sees a patient with gonococcal septicaemia. As it happens he saw one recently. Dr G was quick to spot it. The junior doctors were not. It was not in their differential. They have probably never seen a case before.

Alcohol and office parties mean that the season for this sort of thing is about to get into full swing. Below's a little ditty for the revellers.

You can also find it here. With thanks to NHS behind the headlines.

13 December 2008

The Bloggers' Bond

Dr Grumble knows the identity of only one of the anonymous UK medical bloggers. There was a time when Dr G felt that he wanted or needed to know who these people were. Now he is content to know them just by their blogging names. It would be sad not to know that you actually were or had been a friend of one of these people and that is why Dr Grumble did eventually unmask himself to one particular top medical blogger. As it turned out it seems we do not know each other. But that doesn't matter because we are blogging friends.

People learn to trust you by your blogging. That is how they know you. They feel that they are thinking in similar ways and that earns you some respect in their eyes. One blogger told Dr Grumble something that was very personal, something that was very hard for her to talk about. Perhaps it was something she did not mention much, if at all, to people closer to her than Dr Grumble. Dr Grumble was touched and flattered. It brought home to him the closeness of the blogging fraternity. To some extent he even wonders if anonymity can bring a frankness and closeness that is more difficult in a face-to-face encounter.

The blogging community is getting even closer because we are now communicating with each other away from the blogs in emails. Dr Grumble's email address is not even on the blog. It never has been. Somehow it has got around and he is being included in some email discussions which are addressing important issues. There is something very wrong when medical bloggers feel there is a need to conceal their identity from each other and discuss things like freedom of speech and the undermining of free thinking. And whether there is somebody in some senior position with a sinister objective or whether the goings-on are all cock-up rather than conspiracy.

Dr Grumble has worked outside the NHS. He has seen a lot of what is happening in the NHS happening elsewhere. It is a phenomenon driven by a blind management mantra that is sweeping the world. Some of what these people spout is nonsense but it is difficult to tell them so. In the summer Dr Grumble read a book about markets. Like most such books it repeatedly extolled the virtues of markets. Dr Grumble accepts that there was quite a lot of truth in the book but he does not approve of the uncritical worship of markets. Dr G has always taken the view that markets have their weaknesses. An earlier post on this very topic was never published. Grumble thought that even the blogging fraternity might not be ready for his views. You see, not so very long ago, it was heresy to suggest that those people in the City who run markets were not actually creating anything useful for society. But that is what Grumble was saying to himself along with criticism of bankers and their unwise lending. A few months later and Grumble's avant garde thinking is already passée. Everybody is thinking the same way. It's an odd world. Why was nobody prepared to speak out before?

In the management book Dr Grumble read there was criticism of doctors and other professionals with their cartels or closed shops. The implication was that this prevents the market working and that what you need is deregulation to allow the market to be opened up to all comers. This, of course, is the standard mad mantra. This was the rotten thinking that led to the banking crisis. This is the very same catechism that is being followed as healthcare assistants replace nurses and nurses replace doctors as they are propelled up the skills escalator. These malignant innovations have all come from the management gurus. But these smart-clad know-alls do not actually know all. We all know that they know very little. But nobody ever calls their bluff. It's like the City and the bankers. We all knew but nobody ever said anything.

The regulation of doctors is there to protect the public not doctors. Just as the regulation of banks should have protected the public. Medicine is not just regulated to prevent non-doctors doing a doctor's job. Cosy cartels are not what it's about. After all the regulation even prevents doctors doing doctors' jobs. What does this riddle mean? Well, Dr Grumble could not just set up as an NHS GP. Nor could a GP become a Dr Grumble. When Dr Grumble goes to his GP he wants to know he is seeing a doctor who has been trained to do the job. Perhaps Joe Public thinks any doctor who has been through medical school would have enough knowledge to be a GP but it is not the case any more than a GP could do a heart transplant. And for heart transplants you do not just need a surgeon. You need an anaesthetist and intensive care doctors and even physicians to tell the surgeon that a transplant is the only way forward. And there are lots of highly skilled nurses and technical staff needed all along the way. Each has their own expertise. Each has a vital and important role. Each task needs the right person for the right job. There's nothing new about this (Smith, A). So why are the malignant management gurus telling us otherwise?

As for markets in medicine, Dr Grumble is not at all sure that they work. The public may like more and more tests and scans and screening and be prepared to pay but that is not necessarily good for them. Yet in a market system there may be pressure for high tech solutions. And if you are a doctor being paid for providing high tech solutions then high tech solutions is what you will get whether it is good for you or not. That's the way of the market.

So who is driving the rotten thinking that pervades our organisations? Where does all this nonsense come from? Why is the same madness appearing everywhere? How can it be that so many are singing from the same rotten hymn sheet? Who is responsible for pedalling these insidious false beliefs? Are we being taken over by some mad malign evil sect? Sometimes it seems like it. It really does.

12 December 2008


You would think that receiving financial compensation for some sort of injury or illness would be a good thing. Dr Grumble is not sure it always is. Sometimes all the wrangling that goes on is distressing. The only certain winners are the lawyers. Sometimes even doctors win. Some of Grumble's colleagues made a lot of money from the miners' compensation. There were those that appeared in court and there were the jobbing doctors that assessed the claims. All got good money. They were paid lawyers' rates. Had Dr Grumble had the right expertise (he is unwilling to say whether or not he did) he would not have helped. He had the strong impression that too much money was being spent on the process and not enough on the victims. It seems he was right. A vast industry had grown up around the compensation scheme. That could never have been right.

Two-thirds of the claims cost more to administer than the cash paid out and some claimants are still waiting for the money a decade after they put in the claim. Others died before they got the cash.

As Dr Grumble has been implying compensation is not always a good deal for the victim. Sometimes despite every effort they end up with nothing or a derisory sum. On the other hand one of the best things you can do for a patient is give them money. It's rare for a doctor to have much influence over this but it does happen. Here's a letter Dr Grumble received from a grateful patient some years ago. Identifying details have been removed but otherwise it has been reproduced warts and all.

Dear Doc,

I hope you are well and and happy in your new career [The patient went to great lengths to track Grumble down].

I am now 65 years old and want you to know the best help and advice in my life came from you, "Well beyond the Call of Duty."

I know the DSS pestered you for reports on my condition and you did a fine job on my behalf. [Dr G was precise and honest.] To give you some idea what this means to ratbag and myself, if we have visitors we can buy extra milk and a few cakes without being short the following week ; and the best of all not to dread Christmas when we could only buy a few cheap crap presents. Now I feel good. We can buy everyone a crap present but affordable.

It took 5 years but you will be pleased to know the following. On turning down my claim for "industrial injuries" they said I had only been exposed to a minimum amount of ................. and by chances of probability it was not the cause of any problem. [Dr G thought this was nonsense and with something of a heavy heart because of the long haul and uncertainty of the outcome he advised an appeal.]

I appealed on both these points and won. In February of this year I was awarded £27-50 a week FOR LIFE and £8089-40 back pay. WOW! Ratbag and I felt we had won the pools. There was however a few pound short from my award and when I went to the XX Board on another matter I told them of this and "Will my luck never end", another £36-62 PW and £1132 back pay.

As you can see, I've had £9221-40 lump sum and am now on £64-12 per week. With my pension on top of this, I shall soon be paying income tax (can't wait).

When ratbag goes to the Post Office every week she asks if I want her to pick up Doc's money - this is how we both think of it because, without you, this would never have happened and both of us are so grateful to you.

I know you will be pleased your work on our behalf turned out so well for us so there is no need to reply to this letter (can't read your writing anyway). I will put my address on the rear of the envelope and then I will be sure if they don't return it that you have it.

Many thanks and best wishes to you and yours.

Of course Dr Grumble replied saying how happy the letter had made him. It really did. The letter had a profound effect on Dr G. It contributed to his returning to clinical work. Another terribly sad incident had contributed to his leaving. But that's another story.

07 December 2008


Doctors are often accused of talking in jargon. The implication is that they do this on purpose in order to create an aura of importance. They are also accused of concealing information from patients by using words they do not understand. Sometimes Dr Grumble feels the same about managers. Even the garage man uses terms Dr Grumble cannot understand. Quite often actually. As he writes Dr G's car has a broken spring of some sort somewhere. Dr Grumble really does not understand the function of this spring. The garage he goes to is a bit upmarket so you speak to a smart man in a suit instead of a bloke in overalls with an oily rag. Dr G feels more comfortable chatting to the mechanic. He's not sure that the smart guy has any idea of what the spring does. It is like one of Grumble's patients getting an explanation of what has gone wrong with his body from a hospital manager. Most of them wouldn't have a clue.

Sometimes Grumble hasn't got a clue as to what the managers are on about. One manager he knows (she is actually quite good) strings management buzz words together into totally incoherent emails. They really are quite incomprehensible. To Grumble anyway. By comparison doctors are really quite good. Dr Grumble has never ever heard a doctor talk about a patient haemorrhaging. Perhaps they do in the US. Perhaps not. But in the UK if blood is pouring out of a patient we call it bleeding. There is a simple English word for it and that's what we use. Curiously, patients often seem to use the word haemorrhaging. Where they pick this up from Dr G has no idea. Is it from the TV? There are plenty of examples of doctors using simple words when longer ones would sound grander. Would you believe that the gastroenterologists have a journal called Gut? And respiratory physicians have, yes, Chest. You can't get much simpler than that. There are others like Bone and Eye and Big Toe. OK. Not Big Toe.

One of the delights of the English language is that you often have the choice of several words that mean the same thing. You can close the door or shut the door. Close and shut mean the same thing. But there is a subtle difference between the two. Close is more upmarket. Odd that. How does Grumble know? He just does. Anyway it is nice sometimes to have a choice. It's the same with medical language.

If you have a blog you probably have some love for language. Dr Grumble certainly has. So do other medical bloggers who even address the wretched split infinitive. Dr Grumble is happy to split infinitives if it sounds right. He's going to tentatively give you an example. There you are. That was it. Quite painless. Not too bad really. But perhaps it is not surprising that Grumble failed his Use of English exam at school all those years ago. He has always split infinitives. And just look at all those sentences a few lines up with no verbs. And two sentences in a row beginning with and. Even one beginning and ending with and. Yes. They were right to fail Grumble.

Of course technical jargon has a function. There are words that Dr G uses that have no simple English equivalents. To do other than use the technical terms would require cumbersome circumlocution. C'est la vie. But management buzz words do get Grumble down. Especially if they are just strung together meaninglessly. The other day one of the young girls put in charge of old Grumble came with some good news about uplift. Dr G took a risk. He put on his best bewildered look and asked what she meant and told her that he had only heard this term in the context of mammary suspension. She was, of course, delighted that she knew a word that Grumble could not understand. She apologised and simplified her language so that old fart Grumble could comprehend. Grumble knew all along, of course. But he didn't let on. Dr Grumble, you see, has played buzz word bingo. If you want to play too click here for a bingo card.