31 December 2009

Happy New Year

The video is for Dr Aust who will understand its relevance. The rest of you will probably be baffled.

We may have the same procedure next year.

28 December 2009

No hope for 2010

The Ferret Fancier links to two important articles: one is about the dramatic increase in spending on NHS management and the the other about how David Cameron has been listening to NHS privatisation campaigners.

The Ferret Fancier says this is to do with the NHS market and privatisation. Who can blame the Ferret for stating the obvious when it seems that neither the present government nor the Conservatives are capable of seeing this fundamental truth even though it is staring them in the face? As a result we have the ludicrous situation of the Conservatives tut-tutting about the increased spending on NHS management while proposing as a solution even more rapid privatisation. It's like seeing a house on fire and hosing it down with petrol.

Whatever the present government or the Conservatives may say about preserving current levels of health service spending we all know that there are tough times ahead. Our only hope is to extract more efficiency from the current funding. That is the one thing we can all agree on. More money needs to be spent on patient care and less on those who manage that care. That's not to say we don't need motivated managers. But they need to be managing the delivery of healthcare not markets. Managing the NHS market is costly. Moving money from purchaser to provider is costly. Appraising competitive bids is costly. Grumble could go on. It could all be justified if these processes could wring better quality and greater efficiency out of the system but we all know that the opposite is the case. Private providers are a wily lot and can run rings around government purchasers. It's inevitable. Given that context is there any good reason to believe that private providers are likely to be better than government providers? Of course not. The private providers of healthcare are like the private providers of computing for Connecting for Health. These greedy people just focussed on milking the NHS cash cow for what they could get while delivering as little as they could get away with - which turns out to have been almost nothing. Why don't governments learn from their mistakes?

Is there any hope? In a way there is. If all this money is being wasted and funding is going to be tight then all we have to do is claw it back from all those very clever people now being employed to run a market that far from helping is actually getting in the way of delivering our core business - patient care. Unfortunately politicians do not listen to the likes of Dr Grumble or his darling, Allyson Pollock. They don't need to. They do need the voters. But when it comes to the future of the NHS the hapless voter has been left with Hobson's choice. Now why do you think that is?

24 December 2009

20 December 2009

How the other half lives

It was about a week ago when friends came round to pick up their dog. Mrs Grumble looks after Fido while they are on their yacht. Not many of Dr Grumble's friends have yachts but these friends do. Miriam is a housewife and Timothy works for a large accountancy firm. You would all have heard of this firm. It's big. It's global and from time to time it is called in by the NHS for audits or to tell us we are inefficient and need to sack staff. That's how they make their money. That's why Timothy has a yacht.

But this is not about jealousy. The weather is too cold for yachting. Dr Grumble would prefer to walk the dog in the snow than be out on the sea. Besides Mrs Grumble gets seasick. This is about something seasonal which irritates Dr Grumble year after year after year.

About a month ago Edward Grumble, who is an F1 doctor, phoned up and in a bewildered voice explained to Dr Grumble that he would have to work over Christmas. Not just a bit of Christmas but all of it. It seems that even Edward Grumble, Dr Edward Grumble, thinks the patients go home for Christmas. This expectation of having Christmas Day off is a new thing. Dr Grumble's own staff seem perplexed that they might have to work on Christmas Day. When Grumble was a house physician he knew he might well have to work at Christmas because we all worked virtually all the time. That may sound bad but things are much worse now. You see in Grumble's time there was a doctors' mess where they really looked after you. On Christmas Day you would get a turkey. An enormous whole roasted turkey to carve. And before your Christmas lunch you would be on the ward with more proper turkeys that the consultant surgeons wearing chef's hats would expertly carve for their patients. Christmas in the hospital was fun. The consultants came in laden with presents. Sherry was drunk on the ward. Nobody minded if you had a tiny glass. There was a wonderful camaraderie.

Fun has long gone from the average NHS hospital over Christmas. Things have changed. Thanks to Timothy's company we now run lean wards. Lean is, of course, a euphemism for thin. Skeletal would be more accurate. The juniors can't stop for a moment any more. Skeleton staffing means they have too much work. Traditional firm structures have been destroyed. There is just no time for fun. Especially not at Christmas. There's no way you will get a turkey to carve. You will be lucky if the food vending machines are filled. Where Edward Grumble works in a large university hospital it must be the same. When Mrs Grumble telephoned him yesterday she asked what he was doing. He was in Marks and Spencer buying a Christmas dinner ready meal for one. How sad is that?

Anyway Timothy and Miriam came back from their day's yachting last week and said they were thinking of throwing a party on 29th December and they might not hold the party unless the Grumbles could come. Now that's a wonderful compliment but it started making Dr Grumble's hackles rise because it was clear that Timothy's company had given him the whole week off. Dr Grumble immediately apologised and explained that he had a ward round followed by a clinic. He would not be back in time for the drinks. The 29th is a normal working day in the NHS; getting to a party is just not on. A look of utter bewilderment went over Miriam's face. It was as if she had never heard of a ward round. She almost seemed suspicious that this was a quickly thought up excuse. Nobody could possibly have work to do between Christmas and the New Year. Mrs Grumble gently explained that she too was working. Like Dr Grumble she has targets to meet. In her case the target is two weeks which is tight. You can't have a week off over Christmas and meet your targets.

Who are these people who tell us that government services are inefficient and their employees mollycoddled? Try telling that to my neighbour whose daughter will be fighting in Afghanistan over Christmas. Compared with some, Dr Grumble and his family are lucky. Very lucky.

05 December 2009

Any clinician will tell you

Here is what one such clinician, an acute admitting physician, told the Joint Committee on the Draft Mental Incapacity Act.

What is the doctor to do if the patient is not incapacitated but merely distressed because of life circumstances? They may have discussed it with friends and relatives, may have written down their request in the form of a suicide note and gone on to take the overdose. We know that the majority of such patients, 19 out of 20, live but regret having taken the overdose. Any clinician will tell you, any psychiatrist will tell you that this business of taking overdoses is part of the very natural history of how distressed and depressed individuals behave. They want out. They want to get out of the situation into a different environment and there are all sorts of feelings of guilt and concern about it. I know from my clinical experience that the next day many of these patients are glad to be alive. It would be a tragedy if suicide notes were deemed valid advance directives. Why do we treat them? For the reasons I have stated. We know that their views are not fixed. Indeed this is part and parcel of the way that distressed individuals behave. They want help, they want a different environment and they want to be surrounded by people who can help them. We know that but at the time that they take the overdose on the Friday or Saturday night their intention may very well have been to kill themselves and they may have thought about that for two or three weeks or even months. I think there are dangers in having advance directives which will freeze in time individuals' so-called wishes when we know in practice that they change over time.

Dr Philip Howard was the doctor who put forward this view on behalf of the Guild of Catholic Doctors. Was that why his views were ignored? Did the committee think he had a religious agenda? Dr Grumble has never revealed his religious views here. He is not going to now. This is not about religion. It is about what is right and what is wrong. It is a shame that the law now views doctors with such distrust that they can no longer act in the best interests of their patients and save their lives when they are in a state of distress.

With thanks to Julie McAnulty

03 December 2009

Why we had to have polyclinics

There you have it. If you live in Westminster you live 7 years longer than if you live in Canning Town. Clearly healthcare in Westminster is better than that in Canning Town. Whose fault is this? As Lord Darzi realised it has to be the fault of GPs. What else could possibly cause such a difference in life expectancy? In Scotland the differences are even worse.

29 November 2009

Medical students who wave

What will we do with Google Wave? Will it be an important part of our lives or will it be one of those things we don't need? Will we use it all the time or just for special applications? It's difficult to know. It's hard not to be excited by it but just whether it will be useful or not is unclear. Dr Grumble thinks that it might be good for developing ideas - planning a research project, for example. But it might not. It remains to be seen. Others have suggested that it might be useful for meeting notes made by everybody at the same time. But would that be manageable? We don't yet know.

Below is a public wave for medical students:

It's not clear yet to Dr Grumble how you can link to these things. Perhaps you can't. But you should be able to find it if you search the public waves. But whether you will find it of any use is quite another matter.

21 November 2009

Who can adumbrate the meaning of "polysystem"?

It's a shame that Dr Grumble has had to turn off the comments because he needs your help. You see Dr Grumble has encountered a new word. The word is "polysystem". Where it came from Dr Grumble has no idea. What it means also eludes poor old Grumble. But it does sound worryingly close to "polyclinic". Dr Grumble is very suspicious of new words - especially when he does not understand them.

People who coin new words without obvious meanings do so with a purpose. The purpose is to bamboozle and obfuscate or even confuse and conceal. This sort of thing happens quite often in healthcare. Do you remember when "contestability" and "plurality" perplexed Dr Grumble? These words were used as a sort of private code in the belief that the likes of Grumble wouldn't understand what was going on. It didn't work. When Dr Grumble finds a word he cannot understand he is immediately suspicious. And if he doesn't find it in his albeit old dictionary he is even more suspicious.

So, applying that test, let's see what the dictionaries have to say when it comes to the word "polysystem":

Not much help from the dictionaries then. So Dr Grumble is now very suspicious. He was minded to set his readers the challenge of finding out what a polysystem is. It is generally a good idea to get people to think for themselves rather than be spoon fed. But the comments are off so maybe that is not such a good idea. Or maybe it is?

20 November 2009

Comments are off

Dr Grumble is being beseiged by spam yet again. They seem to wait for Dr Grumble to go to sleep.

Comments are off and blogging will stop for the time being.

14 November 2009

The Nutts and bolts

Dr Grumble is a jobbing doctor. Until recently he knew very little about the 1971 Misuse of Drugs Act. It doesn't affect jobbing doctors. If doctors like Grumble do not know the details of how individual drugs are classified it is unlikely that those who use illicit drugs take much interest either. The penalties for just being in possession of the least harmful of these substances (Class C drugs) could be 2-year imprisonment. For supply it could be 14 years. That's a long time. Many would think that would put people off taking or trading drugs. But it doesn't seem to. pdf

Patients often tell Dr Grumble they take recreational drugs. Given the penalties he thinks they are unwise. Patients think their notes are confidential. They are. We wouldn't tell the police. We wouldn't tell the patient's employers. We wouldn't even tell the patient's nearest and dearest. But we would tell others with the patient's permission.

Once Dr Grumble had a young solicitor as a patient. He told Dr Grumble's staff that he had taken cannabis. It was recorded in his notes. Which was fine until the young solicitor applied for life insurance and the life insurance company insisted on seeing his records. And then they spotted the single entry recording that he had once smoked a joint. The cat was out of the bag. The patient denied he had ever smoked cannabis and insisted on seeing the original written entry in the hospital records. There it was in black and white. Taking illicit drugs is a serious matter if you are a solicitor.

What is the point of this tale? It is to point out that what Home Secretaries admit to having done in their youth without apparently having suffered any harm can be very damaging to professionals. It is not the drug effects that cause the damage. It is the legal consequences. But whether these potential consequences actually stop the average punter is quite another matter.

What anyway is the point of locking up somebody who is found in possession of a small amount of cannabis? Who are they harming? If they are harming themselves isn't that their own affair?

There was a time when homosexual acts were illegal. Why? Those involved did no harm. The objections were moral. What are the objections when it comes to drugs? Why do we lock these people up? Does it make any sense?

Of course if these strict penalties were to prevent people using drugs that might possibly damage them or others then perhaps the penalties could have some justification. But what is the evidence that this is the case? What, for example, happened in Portugal in the five years after possession of drugs for personal use was been decriminalised? These are the facts:

  • illegal drug use by teenagers declined
  • the rate of HIV infections among drug users dropped
  • deaths related to heroin and similar drugs were cut by more than half
  • the number of people seeking treatment for drug addiction doubled
The Nutt case has opened Dr Grumble's eyes to these issues to the extent that he is beginning to think this is a no-brainer. Many, perhaps most, will not agree. But that is not a reason for silencing those who have the relevant facts. And it is not a reason for stifling debate.

If you are interested in this topic Dr Grumble recommends this article. It is the one that lost Professor Nutt his 'job'.

08 November 2009

The trouble with our time

Politicians' twaddle

Will politicians learn from the Nutt case? Dr Grumble doubts it. They do not want to listen to scientists when formulating their policies on the misuse of drugs. They want to do what they believe the public wants. That is their prerogative. They don't have to accept scientific advice but they should be prepared to meet head on the fact that their policy is not evidence-based. It is wrong for them to try and silence those who wish to point out when the scientific facts do not support policy . It is even more wrong for them to ask for scientific opinion to fit their policy. That is not what science is about.

Politicians can do damage with their misguided policies on drug misuse but it won't be disastrous. They know that. That's why they went against advice. Anything for a few votes from the Daily Mail reader who believes that tougher policies on drugs will make his children safer. The fact that there is not much evidence for this never enters the argument.

Scientific facts often get in the way of what is politically expedient. The public often ask for the impossible. The politicians want to give it to them so start making promises. People begin to believe the impossible can happen. We all want it to be Christmas.

You see this sort of thing in advertising. The adverts for the enormous glossy four-wheel-drive SUVs with a hybrid engine. The electric motor is just there to make the purchaser feel good. The car is no greener. But the buyers don't question it. They don't consider a smaller car. Or a bike. They don't want the truth. They want it to be Christmas. They want that car and they want to feel good about it. They are never going to let facts get in the way of what they want.

In the same way as advertisers, politicians dupe the public. They rarely get found out. Here today and gone tomorrow their misguided policies damage not them but their successors. Does any of this matter? Does it matter that inconvenient scientific facts get brushed aside?

07 November 2009

Where's the problem?

Drug-related deaths in England and Wales 2000 to 2004

Where is Central London?

Date: 11 November 2009
Venue: Central London
Time: 6.30pm

Dr Grumble hopes to go to this. The audience will follow the meeting between the Home Secretary and the remaining members of the Advisory Council which should make things rather interesting.

If you would like to book a place email your name, job title/profession and contact email to: events@crimeandjustice.org.uk


05 November 2009

The Nutt case: Downing Street march

Apparently there is going to be a march of scientists on Downing Street in order to call on the Government to back evidence-based drug policy by respecting and upholding the independence of the ACMD.

Does anybody have any details? Do we just turn up? If so, when?

Here are the details which keep changing so check the latest on facebook (with thanks to Bendy Girl):

Rally for Professor David Nutt and Evidence Based Drugs Policy.

We are calling on members of the academic community, parents, young people, students and concerned members of the public to join us at 1pm on Saturday the 7th of November outside Downing Street. We will be there to show our support for Professor Nutt and to call on the government to back evidence based drugs policy by respecting and upholding the independence of the ACMD.


PS Yes we do have police permission.

03 November 2009

Who has broken the code?

According to the Code of Practice for Scientific Advisory Committees:

“Rules of conduct need not affect a member’s freedom to represent his or her field of expertise in a personal capacity. The committee's rules however should generally oblige members to make clear when they are not speaking in their capacity as committee members."


02 November 2009

Open letter to the Home Secretary

Open letter to the Home Secretary from Richard Garside, director, Centre for Crime and Justice Studies

Dear Home Secretary,

I am writing to you about your decision to dismiss Professor David Nutt as chair of the Advisory Council on the Misuse of Drugs.

It was the Centre for Crime and Justice Studies that asked Professor Nutt to present his analysis at a lecture at King's College London in July of this year. Following the lecture Professor Nutt agreed to our publishing an edited version, which we did last Thursday. A copy of this publication, along with the press release, can be accessed on our website here. The publicity material for the lecture can be viewed on our website here.

In your letter to Professor Nutt advising him that you were dismissing him from his role, you wrote that his contribution went `against the requirements on general standards of public life' required by his position as chair of the ACMD. You went on to write:

`As chair of the ACMD you cannot avoid appearing to implicate the Council in your comments and thereby undermining its scientific independence'.

I would like to make it clear that Professor Nutt gave his lecture, and agreed to its subsequent publication, in his capacity as the Edmond J Safra Chair of Neuropsychopharmacology at Imperial College London. This is stated clearly in the original publicity and in the subsequent paper. Professor Nutt made some references to the ACMD in his paper as it was relevant to his argument. At no point did he make reference to his role as chair of the ACMD, nor did he give the impression that he was speaking on behalf of the ACMD.

I have to conclude that the public confusion between Professor Nutt's academic role and his chairmanship of the ACMD has been sowed by the Home Office, not by Professor Nutt nor by the Centre for Crime and Justice Studies.

Academics who advise government should feel confident that they retain the freedom to act as independent researchers without the threat of political interference or undue pressure of any kind. It is in the public interest that you clarify your thinking on this matter and I look forward to receiving your response.


Richard Garside
Centre for Crime and Justice Studies

2 November 2009

Does Alan Johnson keep a gun?

The Home Secretary, trying to bale himself out of a quagmire of his own creation, has written to the Guardian:

......Professor Nutt is indeed a reputable scientist whose views on drugs policy are well known. However, his role as my principal adviser was to (unsurprisingly) present advice. It is the job of the government to decide policy.

Professor Nutt was not sacked for his views, which I respect but
disagree with (as does Professor Robin Murray, who wrote
in your newspaper on Friday

He was asked to go because he cannot be both a government adviser and a campaigner against government policy. This principle is well understood and long established.

As for his comments about horse riding being more dangerous than ecstasy, which you quote with such reverence, it is of course a political rather than a scientific point. There are not many kids in my constituency in danger of falling off a horse – there are thousands at risk of being sucked into a world of hopeless despair through drug addiction.

Alan Johnson MP
Home secretary

When Dr Grumble was a student he was told never to write 'obviously' in his exam answers. It's certainly a bad word to use in essays. Words like 'obvious' or phrases like 'of course' are calculated to stop you thinking. Alan Johnson uses 'of course'. He claims, it seems, to have sacked Professor Nutt because he compared the risk of drugs with the risk of riding a horse. He says this is 'of course' a political point. Dr Grumble doesn't agree. Even as a scientist you need a yardstick rather than a figure to put risk on a scale which can be understood. This is particularly true if you need to express levels of risk to politicians or the public. But the concept is useful for scientists too. In the assessment of risk this is not unusual. It was not something that was calculated to embarrass Alan Johnson. It was just an aid to understanding.

Professor Nutt chose horse riding because it happens to be very risky. Dr Grumble knew this. He has seen the consequences. Yet many parents - though maybe not in Alan Johnson's constituency - might encourage their children to take up horse riding. Few would do the same when it came to drugs. Yet the risk for horse riding is much greater. Both are probably done for some sort of excitement. One is a fulfilling activity the other probably is not. It doesn't matter. It is just a yardstick.

We need such yardsticks. Parents need to grasp how likely it is for their child to be murdered in comparison to being run over on the road. It's important. Do we need to invest in looking out for child murderers or slowing the traffic? Those are the issues.

The trouble, of course (!) is the Daily Mail. It is more likely to fill its pages with stories of horrific child murders than car accidents. The Mail is unlikely to report many of the deaths related to alcohol and tobacco. There are just too many. The differential reporting of drug-related deaths in the press is something that David Nutt has pointed out. The likelihood of the press reporting a drug-related death depends on the drug. Some drugs, it seems, are more newsworthy than others. But the consequence is that the public's perception of risk is warped. It is important to point this out. The public needs to grasp the real risk and not the risk they perceive from reading newspapers. So do politicians.

Sometimes reporting of crime has a counterproductive effect. It has been claimed that reporting of knife crime increases the number of knives being carried by children. Why do you think that is? It is because the reports frighten children who then carry knives to protect themselves.

Similarly in the US people have guns to protect themselves. Yet, if you look at the data, they or their family are more likely to be shot as a result - because having a gun in the house is dangerous. You won't shoot yourself in the foot if you don't have a gun. Does Alan Johnson keep a gun?

01 November 2009

Marion Walker resigns

Marion Walker is the second to resign from the
Advisory Council on the Misuse of Drugs.

Margaret Thatcher said “Advisers advise and Ministers decide”. But ministers should not completely ignore science and they certainly should not expect scientists to make the evidence fit a predetermined policy.

Dr Les King resigns

Leslie King spent nearly thirty years in the Forensic Science Service (FSS). His responsibilities included examining items submitted for the analysis of alcohol, drugs and other substances in cases of suspected fatal poisonings or those involving offences under the Misuse of Drugs Act or the Road Traffic Act. As a result, he has given evidence in the Criminal and Coroners' Courts as an expert witness on many occasions. Before retiring from the FSS in 2001, he was Head of the Drugs Intelligence Unit for ten years. In that role he was responsible for maintaining a UK drug seizure database, providing technical advice on the chemistry and legislation of drugs and their precursors to law enforcement agencies, forensic scientists and UK Government as well as international organisations such as the United Nations Office on Drugs and Crime and the European Commission.

Before joining the FSS, Leslie King spent eight years in the pharmaceutical industry both in the UK and in Germany. At Loughborough University he carried out research on the analysis of barbiturates and on fluorescence and phosphorescence spectroscopy leading to MSc and PhD degrees.

Leslie King is author/co-author of over eighty papers on analytical chemistry, spectroscopy, toxicology, risk assessment, forensic science and the epidemiology of drug abuse and is also a member of the Editorial Board of 'Substance Use and Misuse'. He continues to work part-time as an advisor to the Department of Health and the European Monitoring Centre for Drugs and Drug Addiction on matters concerning synthetic drugs and risk assessments, as well as providing training to newer Member States of the EU on drug legislation and chemistry.

Sir Liam speaks

"These things are best sorted out behind the scenes so that the government and their advisers can go to the public with a united front."
Sir Liam Donaldson

Which all seems a bit odd to Dr Grumble because the views of the advisers are clearly in the public domain having been published by the government. How can you have a united front when the government decides something that is plainly not consistent with the published evidence? And why have they picked on Professor Nutt because Sir Michael Rawlins said exactly the same? Below is what Sir Michael said as reported in the Daily Mail:

Professor Sir Michael Rawlins, the advisory council's chairman, said drug users did not care whether a substance was in Class A, B or C.

The council's review acknowledged some link between cannabis and mental illness, but said the evidence was 'uncertain', and the connection was 'probable but weak', with the drug playing only a 'modest role' in causing mental health problems.

Prof Rawlins said: 'We estimate we would have to prevent 5,000 young males or 20,000 young females from ever smoking cannabis in order to prevent one case of schizophrenia.'

The advisers accepted skunk was becoming more common, but said there was some evidence users adjusted their intake - smoking less if the drug was stronger.

Prof Rawlins said: 'It's like alcohol - whisky is stronger than beer, but people don't drink pints of it.'

The experts also dismissed claims that cannabis is a 'gateway drug' leading to cocaine and heroin abuse - which they said was based on 'very weak evidence'.

Dr Grumble has seen people die from the effects of alcohol. He has seen people die from the effects of tobacco. He is yet to see a patient die from an overdose of cannabis. He is yet to see a patient even admitted to hospital as a result of the effects of cannabis.

When the government is arguing that black is white what are their advisers supposed to do?

31 October 2009

Granny Smith

There was a time when if you were a passenger on a train you were referred to as a passenger. Now, of course, you are a customer. Managers think this change is important. As a passenger Dr Grumble finds it irritating. It gives him the impression that the railway now just wants to profit from him and not look after him as he tries to get from A to B.

There are those in the hospital, not usually doctors, who insist on calling their patients clients. The implication is that there is something demeaning about being a patient. Dr Grumble is a patient like everyone else. He doesn't feel demeaned by being a patient. Dr Grumble happily refers to his GP as his doctor and Dr Grumble sees himself as one of his patients. He is certainly not a customer nor does he want to be.

In a heavily veiled sort of way this is all about money. Passengers are people who go from A to B. Customers are people from whom you extract money. The managers want the staff to focus on where the money comes from rather than getting people from A to B. Big Business is interested in the corporate customer. BA is interested in Dr Grumble the business traveller but not Dr Grumble the cheapskate tripper.

You can see the same changing focus in healthcare. The people who are sick are the poor and the elderly. They make needy patients but are not ideal customers. Yet NHS provision is moving more towards the needs of the city slicker and the worried well. These people are customers rather than patients. They are vocal. They have power. Their money speaks. Polyclinics for healthy patients with money are attractive for Big Business. They will be easy to privatise. And privatised they should be because the taxpayer should not be paying to meet the needs of the wealthy worried well. It's the impoverished chronic sick that need the NHS and the taxpayer's support.

Contrary to what the vocal worried well believe, the concerns of GPs about the change to Martini healthcare were nothing to do with restrictive practices. Their concern was for Granny Smith. It was to do with their realisation that in today's NHS Granny Smith doesn't seem to matter any more.

The Nutt case

If ever there was a politically bad decision it is the 'sacking' of Professor Nutt. Dr Grumble has met Alan Johnson. He has shaken his hand and heard him speak. He has even been photographed alongside this great man. This wily former postman is too shrewd to make an elementary political mistake. So who would have been behind this decision? Who is the politician intent on shooting himself in the foot? The answer is probably in the video.

Well said, Mike. But you know very well that your advice is unlikely to be followed because there are no good reasons.

24 October 2009

Terms of Reference for the Advisory Council on the Misuse of Drugs


It is the duty of the Advisory Council on the Misuse of Drugs to keep under review the situation in the United Kingdom with respect to drugs which are being or appear to them likely to be misused and of which the misuse is having or appears to them capable of having harmful effects sufficient to constitute a social problem, and to give to any one or more of the Ministers, where either Council consider it expedient to do so or they are consulted by the Minister or Ministers in question, advice on measures (whether or not involving alteration of the law) which in the opinion of the Council ought to be taken for preventing the misuse of such drugs or dealing with social problems connected with their misuse, and in particular on measures which in the opinion of the Council, ought to be taken.

A further duty is placed on the Advisory Council to consider any matter relating to drug dependence or the misuse of drugs which may be referred to it by any Government Minister (as defined in the Act).

Ministers - ordinarily the Home Secretary - are obliged to consult the Advisory Council before laying Orders before Parliament or before making Regulations (or any changes to the same) under the Act.

Quick facts from Canada

Dr Grumble is not a manager. He was once but he isn't now. He has decided to focus on his clinical work. One reason he is not a manager now is that his heart is not in management. He does not think the NHS is heading in the right direction.

Dr Grumble believes that we can still afford universal healthcare but that we do have to keep the lid on spending somehow and that privatisation will have the opposite effect.

Instead of thinking things through most of our politicians just follow the siren voices of those who stand to make money from privatisation. Proving to our masters that privatisation will cost more and not less is a challenge. Private is good. Private is efficient. That's the mantra. It is hard to gainsay.

But what is the evidence? Here from Canada are some bullet points that suggest that Grumble may just be right:

  • The British Medical Journal reported in 2004, that the public health system was charged 47% more for hip replacements performed in private surgical clinics than for the same procedures provided in public hospitals.

  • The for-profit cancer surgery clinic opened by the Conservatives was eventually closed down after the provincial auditor found that it cost $500 more per procedure than public hospitals.

  • Studies reported in the Canadian Medical Association Journal show that meta analyses of for-profit hospitals and clinics show that they not only cost more but they lead to higher death rates as the for-profits skimp on trained staff and quality.

  • The Alberta Branch of the Canadian Consumers Association studied wait lists and costs for cataract surgery in Alberta and found that wait times in Lethbridge with 100% public surgeries were less than half those in Calgary with the majority of the for-profit clinics, and costs were $400 less per eye for the same lenses.

22 October 2009

Dr Grumble's letters

Every week Dr Grumble writes scores of letters. The NHS cannot afford enough secretaries to do all Grumble's typing so the letters get typed in India. They used to get typed in Canada or New Zealand. Dr Grumble's New Zealand secretary was excellent. The one in India is not so good. The Indians speak English but it is their own sort of Indian English and this comes across in Grumble's letters. Dr Grumble checks his letters online. He can check them from anywhere in the world. He corrects the letters and then they get printed out. Letters to a GP are addressed automatically. Software does this magically from the hospital database. It all sounds very modern but the process has a very strange twist which only the NHS could manage.

The letter is printed out. Dr Grumble then checks it again because all sorts of errors creep in as a result of the computerised element of the process. The letter is then put in an envelope and it is delivered by the postal service to the patient and the patient's GP. The GP then has to read the letter. Quite often the letter goes to the wrong GP. The GPs find this annoying but the computer does not understand that it needs to send the letter to the right doctor. What happens then is very odd. The GP scans the letter, puts it on his computer and shreds the letter. A letter that began as computer code in the hospital is turned into something we can read on paper, taken to the GP's surgery and turned back into something a computer can deal with. It does not take a genius to be able to see that there is a better way. It is called email. But where Dr Grumble works we do not use this newfangled system. Which is odd. Very odd.

17 October 2009

The Grumble Credo

In its bricks and mortar, people and services, the NHS embodies something which is truly great about Britain. That something is equity: the spirit of fairness for all and the equal right of everyone regardless of age, background or circumstance to get the healthcare they need.

Those words are a bit cloying but it is what Dr Grumble believes. After all Dr Grumble has been described by overseas commentators as a socialist blogger. Praise for the NHS is what the Grumble readers expect as a general election draws closer. So let Grumble continue:

The NHS really is one of the most precious gifts we enjoy as British citizens.

Perhaps by now you have realised. These words are too sugary to be Dr Grumble's. Can you guess who wrote them? The writer believes them. He has good reason to write these words. Personal reasons and political reasons. The writer is, believe it or not, David Cameron.

Unfortunately people close to David Cameron probably do not think of the NHS in quite the same way.

Here is a clue to the way the Cameron henchmen are thinking:

Despite believing that market mechanisms work, [Labour] have failed to open up the market for the provision of NHS care so as to drive up standards.

You can find all this in the Conservative's NHS Improvement Plan (pdf). Here they laud Labour for privatising parts of the health service, recognise that this policy has failed and imply that the solution is to throw even more NHS services out to the market wolves. The failure of the market is recognised yet the response is to propose more of the same. There is no recognition of the vast sums now being spent on running the costly market processes. There is no mention of how the well heeled bureaucrats employed to commission the services are sucking up the billions that we all know are no longer reaching the front line. Despite all that has happened in finance as a result of the present government leaving things to a market free-for-all (encouraged it would seem by the opposition) there is still the widespread blinkered view that markets will somehow solve the problems of the NHS. It is just not true. Markets are causing the problems.

There are those elsewhere who think even more misguidedly. Take this quote which begins with a wonderful pun:

Focused eye surgery centres, heart health and orthopaedic hospitals, for example, can streamline processes and deliver far higher output and quality than the hotchpotch of services provided in general hospitals.

This fails to recognise that operating on elderly people with multiple pathologies in a streamlined highly efficient centre is not a good idea. General hospitals are not places where you have general doctors who have a stab at anything and do nothing well. They are places where there are teams of experts so that individuals can get the full range of expertise they need. When you fracture your hip and go into heart failure it is really not a good idea to have the heart doctors in their own streamlined centre across town. We need bigger hospitals not smaller. NHS patients have suffered too much already being transferred from one hospital to another because of failures to provide the full range of what patients may need all under the same roof.

Here is another nonsense:

At present, the NHS locks in inefficiencies due to two antiquated models: the general hospital and the general practice – both designed a century ago when medicine lacked evidence-base and was largely intuitive. Far more productive, now that we can make definitive diagnoses in many cases, would be to integrate the diagnostic work across the two, and hive off many procedures that occur after a definitive diagnosis to specialist centres.

This makes little sense to Dr Grumble. Whatever does the author think happens now? If you need your stitches taken out it makes sense for your GP's nurse to do it. If you need your appendix removed this is no longer done on the kitchen table. You go to the hospital. And what about today's news on the increase in children's admissions? What's the betting that that is the consequence of the loss of the antiquated 24/7 care that used to be the responsibility of individual GPs?

Here's more:

Real reform should thus look at the demand side too; at breaking PCTs up into groups of competing social insurers, as already exists to great effect in many European states such as France, Germany, the Netherlands and Switzerland. This is not a threat to universal and comprehensive ideals. With the state paying for, or topping up, premiums for those that cannot afford health insurance or with chronic conditions, these ideals are preserved – just as Europe. The difference is that healthcare premiums are paid direct to insurers, rather than to the state through taxation, and people are able to choose between them on the basis of quality and price. If service is poor, or insurers fail to back innovative providers, declining custom gives a powerful incentive to improve.

Anybody who thinks this will make healthcare more cost effective than the NHS used to be before the recent meddling is clearly living in cloud cuckoo land. But then a lot of people do, it seems, live in cloud cuckoo land.

Dr Grumble agrees that large improvements in funding in the NHS over the past ten years have not brought matching improvements in services. There are all sorts of reasons for this. One major factor has been the cost of running a failed NHS market.

10 October 2009

The law is no ass

Ignorance of the law is no defence. It would take you over 400 years to read all of the law that applies today in the UK. None of us can do this. Doctors cannot even read the parts of the law that most affect their practice. Instead we just do what we believe to be right and, generally, if you do this the law will protect you.

If you keep somebody alive because you believe that is the right thing to do the law will protect you. If you allow somebody to die because you believe that is the right thing to do the law will protect you. If you do what you would not naturally believe in your heart of hearts to be right it is likely that there will be a law that will condemn you. When it comes to the practice of medicine our laws are not that bad.

So if a patient with mental health problems arrives in your hospital having taken an overdose with a note pinned to her chest asking you not to treat her you might feel that she should be treated. You wouldn't worry about the Mental Capacity Act because that is there to protect people who are unable to make decisions for themselves not to condemn them. You remember reading that somewhere. In any case you feel sure that saving the patient's life must be the right thing to do.


Time is of the essence so you really should get on with treating your patient. Trawling around the niceties of the law is not an option. Treat and trust that the law will back you is the only sensible way forward.

But just suppose that for some misguided reason somebody in your team decided to check with the hospital's solicitors that it was alright to treat such a patient. What advice would you expect? How do you think they would deal with the apparent conflict between the Mental Capacity Act which requires you to do what the patient wants which is to die with the Suicide Act 1961 which prevents you from aiding and abetting the suicide of another?

The lawyers would, of course, reassure you that there is no conflict between the Mental Capacity Act and the Suicide Act 1961. Nothing in the Mental Capacity Act affects section 2 of the Suicide Act 1961. That should be obvious but to avoid any possible doubt the scope of the Mental Capacity Act was clearly stated in the Act itself:

Scope of the Act

For the avoidance of doubt, it is hereby declared that nothing in this Act is to be taken to affect the law relating to murder or manslaughter or the operation of section 2 of the Suicide Act 1961 (c. 60) (assisting suicide).

Which means that section 2 of the Suicide Act 1961 applies the key part of which reads:
A person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be liable on conviction on indictment to imprisonment for a term not exceeding fourteen years.

Which rather means that the doctors who allowed Kerrie Wooltorton to die were rather poorly advised. One thing is for sure. Nobody is going to go to jail over this. Certainly not the solicitors who gave the rotten advice. And the coroner doesn't seem to have got the law right either. Or is Dr Grumble completely wrong? After all he knows nothing about the law.

07 October 2009

A Myth and a Fact

04 October 2009

Alan Milburn attacks Andy Burnham

So Alan Milburn has attacked Andy Burnham for making the NHS the preferred provider. Now why can that be? Does this hold a clue:

Interestingly, former health ministers have done particularly well. The ex-health secretary Patricia Hewitt earns more than £100,000 as a consultant for Alliance Boots and Cinven, a private equity group that bought 25 private hospitals from Bupa. After leaving the department, her predecessor, Alan Milburn, worked for Bridgepoint Capital, which successfully bid for NHS contracts, and now boasts a striking portfolio of jobs with private health companies.

When I rang Milburn yesterday to ask whether he saw any conflict of interest in his directorships, he swore and hung up........

It is a peculiar change of policy. Dr Grumble has witnessed how the private sector has been wooed under ludicrously favourable terms. When it comes to private providers the term "level playing field" is not in the government's lexicon. As a result the private companies have been on a runaway gravy train rife with nonsenses - such as being paid for operations they haven't even done. And all this has been carefully but surreptitiously crafted by Burnham and his henchmen.

So why the change of heart? Has Andy Burnham really seen the error of his ways? Or has he realised that the great British public is beginning to rumble what is going on? Or is there another explanation?

Whatever the real reason, mark the Grumble words. The policy will drift back after the election. Probably more quickly under a Labour government than a Conservative government. The Conservatives are distrusted when it comes to the NHS so have to tread more carefully. Unfortunately the same malign interests lean heavily on both parties. All three parties actually. What the British public want does not really enter into it - except just before an election. For we are now entering the period known euphemistically as the post-democratic era. Those in charge know what is best for us and just get on and do it. But they don't expect doctors to behave like that. Rightly or wrongly. Odd that.

01 October 2009

A flawed Act

Dr Grumble has never been entirely comfortable with the Mental Capacity Act. He preferred the law when it was vaguer. He always felt that if he acted in good faith and documented carefully the reasons for the decisions he had made the courts would protect him.

When the Mental Capacity Act was introduced Dr Grumble was specially trained by a barrister on what it would all mean. She made it quite clear that if Dr Grumble ever treated a patient against their wishes he would be guilty of assault. That's fine. Dr Grumble has never had any difficulty allowing patients to reject treatments they do not want even if it causes their death. Not usually anyway.

But there is one situation when Dr Grumble would be very uncomfortable about following the law and he put this to the barrister. He asked what would happen if a silly girl came to the Emergency Department having taking a potentially fatal overdose and declined treatment. Silly girls do this. They do it quite often. The next day they can feel different. So Dr Grumble has treated them against their will on many occasions and they have never in the past taken any action against him. But that was in the past when the vagueness of the law offered more protection and acting in good faith was always looked upon favourably.

Dr Grumble asked the barrister to clarify what the position would be following the introduction of the Mental Capacity Act if he decided to prevent the death of a young girl who refused to be treated having taking an overdose. The answer, insofar as lawyers will ever answer a question, was not reassuring. It seemed that even if the patient was depressed Dr Grumble would be required to let them die.

To allow a patient to die in such circumstances is so obviously wrong that Dr Grumble has decided to ignore the law in such a situation, save the patient's life and accept the consequences. If the patient dies they won't complain and if they live they are quite likely to be grudgingly grateful. And if Dr Grumble got it wrong they can always have another go at killing themselves. After all killing yourself is not that difficult if you really want to do it. The strange thing is that many people who try to kill themselves turn up in the Emergency Department where treatment can be offered. There is a reason for that.

Not all doctors are as brave as Dr Grumble. This was predictable

Some of Nutty's comments have been removed at her request.

24 September 2009


They will be no further posts from Dr Grumble until he has had his broadband connection restored.

If anybody at Tiscali wishes to fix the problem (and it seems nobody does) the job number is UKHD00002990901. At the moment it looks as if the best bet is to give up on Tiscali and find another service provider. Hey-ho.

19 September 2009

Teachers know no neuroscience.

Sometimes Dr Grumble's patients seem very surprised that he is not aware of some latest miracle medical breakthrough. This is usually because Dr Grumble does not read the Daily Mail.

Recently Dr G was asked to comment on a story about a wonderful new operation being conducted on the other side of the globe for a common problem. A journalist wanted to know if the operation was available in the UK. The hack was unable to say what the operation was. He hadn't read the scientific publication and seemed incapable of accessing it. So Dr Grumble read it for him. The truth was nothing like the stories being reported by other journalists who, presumably, also cannot have read the original publication. Sometimes journalists do not want the truth to get in the way of a good story but in this case the journalist listened to Dr Grumble and no article appeared. The Daily Mail has now gone up in the Grumble estimations.

It is very unfair to the public to tell them some wonderful new operation is available when the reality is something different. Desperate patients are vulnerable. When it comes to matters of medicine, people tend to believe newspaper articles which is unwise. They are even more likely to believe their friends which is equally unwise. It is something to do with trust. Building up trust takes time. Perhaps that's why patients over and over again say they like to see the same doctor. Doctors certainly find it easier to see the same patient. The trust that has been built up is part of this.

Knowing the very latest about scientific research is not essential to the practice of medicine and is even less important to patients. How many times have you read about a cancer breakthrough on the front pages? Things that initially appear to be wonderful, on reflection, can turn out to be not quite what they seem. Altering practice on the basis of the very latest publication is not always wise. The most junior of doctors may want to do this. Their problem is that they have not lived long enough to have seen things go in full circle.

Some journalists overestimate the importance of scientific news. Here's a sentence from a recent editorial in New Scientist:

HOW would you feel if you discovered that your child's doctor was unaware of recent findings in neuroscience? It's likely you'd be worried.

Hmmm. The article goes on to have a go at teachers who are apparently pretty ignorant when it comes to recent findings in neuroscience. Dr Grumble is a teacher and recently he has become interested in research into teaching methods. Being initially very ignorant himself on the topic he was surprised at the lack of an evidence base for the different ways you can teach. At first he thought that medicine must be way ahead of teaching with the concept of controlled trials forming an evidence base to support best practice. But the reality is that most medical decision making cannot be read off from an evidence-based protocol. And when it comes to exploring different methods of teaching it turns out that it is very difficult to do a controlled trial. The reason is that if you compare two teaching methods the students that are given the poorer method tend to plug knowledge gaps with work outside the classroom making it very difficult to show a difference between groups.

Journalists can be a bit harsh on professionals. "I blame the teachers" is their populist clarion call. It is a shame New Scientist should stoop this low. You can drive a car from A to B without knowing what is under the bonnet. You can be a good teacher without being familiar with the latest research. And your doctor could look after your child while being unaware of "recent findings in neuroscience."

18 September 2009

Burnham banishes boundaries - but only for GPs

At the King's Fund event at which the health secretary announced his ill-thought-out plans to allow patients to have a GP tens of miles away from where they live, those gathered at the briefing were asked who would take the opportunity to change their GP, if offered the freedom to do so under the new rules. Not a single hand was raised.

One of the things that drives Dr Grumble crazy is the compartmentalisation of many other NHS services for which there seems to be no good reason. Quite often Grumble offers his patients some service or other only to find they live on the wrong side of the road and it is not available to them. Why doesn't Mr Burnham do something really useful and breakdown the boundaries for services like mental health, physiotherapy and the like?

Unfortunately Mr Burnham is only interested in young healthy people and not sick elderly people. Now why do you think that is?

13 September 2009

Painless ways to save NHS money

Just occasionally the people who are in charge read this blog. Dr Grumble has been thinking of listing for them the ways the English NHS could make enormous savings without adversely affecting patient care. You might think that our masters have no idea how they could save money and that that is why they have brought in management consultants. Reading between the lines of what some of them say (Dr Grumble is not going to embarrass any of them by putting in a link) it seems likely that quite a few of those at the top do know how money could be saved. The problem is the thought police. Both the present government and its likely replacement are heavily blinkered and there are some solutions they will not countenance. Our masters' minds have been poisoned by outside advisers with their own private agendas. The politicians either do not realise how they are being used or they are prepared to be used in order to bolster their party coffers.

In short there is no hope. Dr Grumble knows that. But whether anybody was going to listen to him or not Dr Grumble has been planning for some time to list the many painless ways the NHS in England could save money.

But happily there is no need. There is just one lone voice in the wilderness who has done the job already. This is just one of her suggestions for saving money:

Take for example the costs of the new market bureaucracy; for more than 40 years administration costs were in the order of 6% of the total budget a year, they doubled overnight to 12% in 1991 with the introduction of the internal market. We have no data today for England, but what we know from the US is that the introduction of for-profit providers increases administrative costs to the order of 30% or more.
So why hasn't McKinsey advocated making savings along the lines of Scotland and Wales by reintegrating trusts into area-based planning structures and thereby abolishing billing, invoicing, the enormous finance departments, marketing budgets and management consultants, lawyers, commercial contracts? In this way one could project savings of anything from £6-24bn a year for England.

Who is this lone voice? Find out here. She's Dr Grumble's heroine. Do you think she knows?

12 September 2009

Even learners can see the problem

One of Dr Grumble's sons, Edward, is now a Foundation doctor. The system prefers to call them 'trainees'. From the start doctors are made to feel small in today's NHS. You can't help but think this is deliberate. But it is not good management. You should make your staff feel important. And you should persuade your patients that your junior doctors are important and able. Patients need to feel confident in the people looking after them. They don't need to see the L plates.

Before Dr Grumble refers a patient to a colleague he tries to build them up. He tells the patient that they are going to see a real expert. It's good to build up trust and confidence. When doctors were in charge we knew this. Our junior doctors were called House Physicians, House Surgeons, Senior House Officers, Registrars and Senior Registrars. GPs made the mistake at one stage of calling their junior doctors 'trainees'. It did not engender confidence. The fresh-faced young doctor does not have his confidence bolstered by being reminded of his lack of knowledge and it is not such a good idea to emphasise it to the patient either. It is much better to introduce yourself as a Senior House Officer than a Foundation Trainee. Not that that is allowed any more. In fact it has been expressly forbidden.

In any case we are all learning all of the time. Dr Grumble's staff might think he knows almost everything but he doesn't. We are all trainees. None of us knows everything. The differences between the junior and senior doctor are just differences of degree. The important thing for both is to know when you don't know and when to ask somebody else. The weak doctors are those who cannot recognise when something is beyond them.

Strangely the management know the importance of building people up. Look at your hospital's news letters. You will find the management are forever bolstering their own images with columns in their propaganda sheets with titles like Talk from the Top or Head Honcho Headsup (OK that one was made up). They know the importance of making themselves seem important. So why don't they realise that the same is important for their staff - especially clinical staff who interact with the public?

None of that was the purpose of this post. Dr Grumble went straight off on one of his tangents. The point of this post was to tell you that Edward Grumble has been on the phone to Mrs Grumble expressing his concerns about continuity of care. He has only just qualified and already he realises that patients are so complex you cannot easily pass on everything that needs to be known about them to the next jobbing shift worker. It is another one of those things that managers cannot grasp. They think hospital shift workers are just like factory workers. If they had their way they would be.

The problems, as we all know, have stemmed from shift working forced on the profession by various initiatives including the European Working Time Directive. Remedy is concerned. Junior doctors, some on paltry pay, are not being paid for all the work that they do. Yet there are ways around this pdf . We really do need to address these issues. It is not just about doctors. It is about patient safety pdf.

30 August 2009

Why is the NHS being privatised?

The answer is in the last sentence on this film clip. [Sorry the clip has now vanished and Dr Grumble can no longer remember what the last sentence was!]

Perhaps you cannot believe that, as the Americans are looking for a different way to fund their healthcare, we in Britain are moving towards a system more like theirs. But we are. Hospitals now put bills in. One part of the government system is paying another part of the government system. It is very inefficient. It is inefficient because you have to spend a lot of time commissioning services and invoicing. At one time we had absolutely no idea how much things in the NHS cost. We often still don't.

When an outside manager was brought in to look at the NHS he must have been gob smacked. The NHS had no real continuous evaluation of its performance against normal business criteria. Little was known about:

  • levels of service
  • quality of product
  • operating within budgets
  • cost improvement
  • productivity
  • motivating and rewarding staff
  • research and development

Precise objectives for management were rarely set.

  • There was little measurement of health outcomes.
  • There was little evaluation of clinical practice
  • There was less evaluation of the effectiveness of clinical interventions.

Perhaps that is why, at the time, the NHS was easily the most cost-effective healthcare system in the world. But you couldn't ever really prove it because the data were, to say the least, somewhat lacking.

Any young person who reads this now must wonder how the NHS could have worked at all. But it did. And, given the level of funding at the time, it unquestionably achieved a big bang for its buck.

How could this be? In those days junior doctors worked all hours that God gave. Why? Ward sisters ruled their wards with rods of iron. Why? Clinics were conducted in a mad frenzy of work. Why?

Managers from Big Business might think that people with no rewards producing a product that was unmeasured would have no motivation. But there was a lot motivating those who worked in the NHS at the time. Junior doctors were more motivated then than now. Jobs, contrary to what today's juniors might think, were more scarce then than now. Your future depended very much on your latest clinical performance which was closely monitored by tiers of more senior juniors and a very small number of consultants, often just one. If your performance was below par it would be known about.

But people don't just work for money. People in healthcare see the 'product' before their eyes. They see the distress of disease or the distress of a patient lying in a pile of shit. Doctors have always wanted to make people better as soon as possible. Nurses have always wanted their patients to be comfortable. In those days matrons or sisters would be appalled if they ever found a patient left lying in a pile of poo by the then plentiful student nurses. If they saw that happening they would feign a swoon in front of the laggardly learner, pick themselves up and then clean up the patient immediately themselves to demonstrate the seriousness of the matter. That's why Dr Grumble stops ward rounds to do rectal examinations himself. It is to demonstrate the unacceptability of sloppy practice.

The NHS of old seemed a bit like the army at times. Quite possibly we could have continued this way just as the army continues this way. All our NHS really needed was the funding it is now getting. But instead we have gone along the lines of private business and, with that, vast amounts of money are being squandered on commissioning and billing and measuring and bonuses and, bizarrely, even advertising and PR.

Why, for God's sake, are we advertising? Why are we whipping up demand for ever more healthcare? Why are we creating unnecessary demand when we should be meeting necessary needs? Why do we have one part of the system purchasing services from another part of the system? It is like Sainsbury's buying produce from farms that it owns. Of course we all know that the supermarkets give the farmers a tough time. They are always screwing a better deal out of them. Better produce at cheaper prices. That makes sense. But driving through these deals takes time and effort. If you buy your produce direct it might actually be cheaper. There is more than one way of doing things. Really.

In many private hospitals if you have an aspirin they will charge you for it. Keeping tabs on it all is costly but that is the system. In the NHS they do not (yet) bother about the little things and the bills are called coding. It is an enormous effort to get it right and we often don't. Dr Grumble's hospital has some missing millions which may be because we haven't 'billed' for everything.

Why are we doing this? It is because somebody somewhere thinks that it would be better if we operated healthcare like Sainsbury's. We set up enormous expensive bodies to commission healthcare and we get them to bludgeon hospitals to give them good deals just like Sainsbury's bludgeons the farmers. The patients, like shoppers, will go to the place they think is best and inefficient hospitals will go to the wall. It's simple and obvious. Dr Grumble has almost convinced himself of the benefits.

But there are very many flaws to this model. The cost of running such a system is enormous and nobody has sufficient knowledge to do the commissioning to a high enough standard. Purchasing healthcare is not quite as simple as buying apples from a farmer. And for all the government's rhetoric about plurality, contestability and choice, the reality is that you are only likely to have your hernia fixed once. Shopping around is not really what most of us do when it comes to a stay in hospital. And generally the hospital down the road will be the one you are taken to in an emergency and the one you will want to go to if you need elective surgery.

None of this has ever really been thought through. Our government, to its cost, worships markets. Even the baled-out bankers are regrouping and once again are spinning the roulette wheels of the flawed money markets. And in the NHS, private providers, despite their very poor track record, are still the order of the day. The NHS as we know it is doomed.

With an election looming it is well to remember that getting Sainsbury's to tell us how to manage the health service was, originally, a Conservative Party idea. Just what can we expect from the next government?

Sometimes David Cameron looks rather like lipstick on a pig.

23 August 2009

What's my line?

Dr Grumble's youngest son James has a summer job. It's quite a responsible job looking after the disabled. He gets paid £4.59 an hour. Young James does not consider this to be good money but he says that it is all to do with supply and demand. Apparently quite a lot of people want to do his job. He has a friend who has a better paid job. His friend gets £16.00 per hour. Both James and his friend are just 17. What job do you think a 17 year old can do that brings in £16.00 per hour? Perhaps you have guessed. He mans a phone in one of the swine flu call centres. At the age of 17, with scarcely any training, he decides whether the caller has flu or meningits or otitis media or pneumonia or pyelonephritis or one of the many other conditions that can masquerade as flu. It is incredible.

Do you think he works hard in the call centre? The answer is no. One day he received just one call. On that day the government paid a 17 year old £128 to advise a member of the public on their symptoms. It really is amazing how taxpayer's money can be wasted.

21 August 2009

The computer says *!**&

How do you think they mark medical students' final exam papers? The extended matching questions are marked by computer. The students use an HB pencil to give their answer and a computer dishes out the marks accordingly. Do you think the computer might get it wrong? Do you think they might have had a problem with the computer in Cardiff? Do you think it could be that they have had recurrent problems with the computer in Cardiff? No, that cannot be the case because if they had had problems before they would be sure to mark them manually. There is no way a faulty computer could have been the cause of the Cardiff catastrophe. Or could it?

20 August 2009

The ten day doctors

Just imagine the excitement you have when you first qualify as a doctor. All those years of toil and sacrifice finally pay off. You get allocated a job and on the strength of your modest income you take out a mortgage on a tiny flat which you share with your girlfriend who is better paid. Can it be true that you have finally made it? Many doctors think that way when they qualify. But eventually the day dawns when you first work as a doctor.

Imagine the shock if ten days after you have started work the Trust calls you in to tell you that they are suspending you. There has been a mistake and you are not a doctor after all. In fact you failed one of your many exams by one mark. The certificate you were given in a grand ceremony is worthless. Somebody in an office has made a mistake. You will need to fund yourself for another year. You will lose the income you never had. You will lose the home you will no longer be able to buy. It is a disaster. Perhaps you will have to just give it all up.

Mistakes happen. Mistake happen particularly at Cardiff University. Dr Grumble works in another country. He is not close by but even he has heard of the Cardiff chaos. These are not the only mistakes they have made.

Cardiff is not the only medical school where teaching is insufficiently valued and teaching support is inadequate. Unfortunately when there is pressure on budgets it is always teaching and teaching support that gets cut by medical schools. It's odd that. You would think a school was for teaching. But you would be wrong. Medical schools are for research. They do teach but it is not seen as important. It is certainly not their raison d'etre. So teaching gets cut and cut. They think nobody will notice. They think the students have no clout. They think that somehow the students will muddle through. And they know that NHS doctors will, in their own time, plug the teaching gaps because they feel sorry for the students and they have a sense of duty. Getting that to happen is the deliberate policy of one medical school. Allegedly.

15 August 2009

Under 5 mortality rates

There are various ways of measuring the performance of a country's healthcare services. One good one is the under 5 mortality rate. There is not much argument about it. If you are dead you are dead. The data are unambiguous.

In the US they spend 16% of their GDP on healthcare. In England we spend just 8.3%. You cannot expect to get as good results if you spend half the amount. So, with that warning preamble, what are the under 5 mortality rates for the US and for England? The answer is that out of every 1000 live births in the United States there will be 9 deaths before the age of 5. In England out of every 1000 live births just 6 children will die before the age of 5.

It has been alleged that in England we do not look after the elderly or disabled. So how long do we in England live compared with the average American? The answer is that in the US your life expectancy is 77 and in England it is 78. Not bad given that we spend relatively so little.

The inverse care law

Those most likely to need good healthcare are the least likely to receive it.

JT Hart, The inverse care law, Lancet 1 (1971), pp. 405–412.

The [NHS] still operates as a gift economy despite the most vigorous efforts of governments to change it into a business.
Dr Julian Tudor Hart

How do you think Dr Tudor Hart will be voting at the next election?

13 August 2009

What would happen if the government were to dismantle the NHS?

Dr Grumble thinks the government has been doing its best to try and make as much of the NHS as it can private or private-like. New Labour has felt its way forward with private providers and private finance initiatives (PFI). None of these innovations has been successful. The greatest of all the disasters has been PFI. Today's new hospitals will be paid for not by us but by our children and maybe even our children's children. It was a political sleight of hand. New hospitals today to buy tomorrow's votes and hang the cost which will fall to governments trying to bale us out long after New Labour is dead and buried. It is a very selfish policy from a government preoccupied with spin and newspaper headlines.

From time to time it has worried Dr Grumble that the public might be wooed into accepting privatisation of healthcare in the UK - especially from a party right of New Labour. What do you think would happen if a new government set about dismantling the NHS? Dr Grumble thinks he knows. Tony Benn thinks the same. You can listen to his views in the video clip.

12 August 2009

Would you let the NHS take care of your car?

Here's one view of what NHS style car repairs would be like - though it is not a picture Dr Grumble recognises:

Now lets look at how an insurance system might work for car repairs. You buy an old car and you insure it for unexpected repairs because you are worried it might break down. The car is essentially a banger so you pay a lot for the insurance - more than you can afford. If you are employed and need your car for work you may be lucky enough to have your employer buy the car and pay the insurance for you but he will deduct the insurance from your pay. You may not get much choice in what cover your employer purchases for you even though it is effectively your money.

Then, unfortunately, one day you hear a funny noise from the car's engine. You take it to the garage. The garage man thinks it is nothing much but when you tell him you are insured for repairs his eyes seem to light up and he says that he will take the engine apart just to be sure there is nothing wrong. It's inconvenient and expensive but you want to get your money's worth from the insurance and you are a bit anxious that it might break down so you agree to have the engine inspected. The garage man takes the motor to bits and he finds some of the parts are a bit worn. He replaces these and one or two other components that look a bit suspect. It will all be paid for by the insurance. Everybody is very happy. Except that there are lots of forms to fill in and there is some delay before the customer gets his money from the insurance company. The only odd thing about the transaction is that there wasn't actually a lot wrong with the car in the first place.

It is a very odd thing that when it comes to healthcare as the Americans contemplate moving towards a system more like ours we seem to be heading towards a system more like theirs. What is not being adequately addressed on either side of the Atlantic are the reasons for the enormous and rising cost of healthcare. Keeping the lid on spending while ensuring that everybody gets the necessary care is the forgotten challenge. However you pay for your healthcare you do not want to be paying more than is necessary.

On both sides of the Atlantic there are unseen powerful influences all pushing in the same direction - towards private provision. Somebody is making a lot of money from healthcare. Enough to pay for some rather amusing videos. Keeping a lid on healthcare expenditure is not their aim.

26 July 2009

Bad news: We are all going to die

It must be true because Karol Sikora says so. He says so in an excellent article which you can read here. Not a great supporter of socialised medicine, Karol Sikora does at least support the values of good general practice and calls for the return of Drs Finlay and Cameron. For once he is right. We are all going to die and we do need good GPs.

If the government had got less involved in the management of individual patients with possible 'flu and had left it all to the judgement of GPs Dr Grumble thinks the public would have been a lot better off. And if the powers-that-be hadn't wound the populace up and created all this hysteria the GPs might just have been able to cope. Most important of all the patients with 'flu-like illnesses would have had decent doctors diagnosing their problems accurately instead of window cleaners. Getting the Tamiflu out is not the important thing here. What is important is finding amongst the worried-well and those with flu-like symptoms those who really have meningitis or pneumonia or pyelonephritis or malaria or typhoid or one of the 101 other things in the differential diagnosis of influenza. How many will be misdiagnosed by window cleaners and given Tamiflu when what they really need is an antibiotic? We shall never know. But it certainly seems possible that the government's untested 'flu line is killing more people than it is saving.

Mrs Grumble who used to be a GP says there was no alternative. Dr Grumble is not so sure. He is sure Dr Finlay would have coped somehow. As it happens Dr Grumble has had two Dr Finlays who have worked for him quite recently. He asked if patients remarked on their name. Only if they are of a certain age was the unkind retort.

So, for those too young to know, Dr Finlay was the creation of the author A J Cronin who was himself a doctor. The books spawned a television series which Dr Grumble remembers seeing as a child. The best stories were early in the series and were written by Cronin himself. They always had a medical story line which challenged the diagnostic skills of any watching doctor. As the story evolved clues to the diagnosis gradually emerged and it would become increasingly apparent that the local village of Tannochbrae was suddenly in the grip of some terrifying and incurable infectious disease. Does that sound familiar?

25 July 2009

The best prepared country in the world

The Jobbing Doctor will tell you that swine 'flu is mild. He is sort of right. It was mild for Dr Grumble's two registrars who were back at work after a few days. But if you work in a hospital you may see one of the tiny number of patients in whom the disease turns out to be far from mild.

What happens, for example, if the dreaded 'flu virus invades your lungs? The answer is that your lungs won't work too well. But when you eventually get better from the 'flu your lungs should get better too. All your doctors need to do is keep you alive until you cure yourself of the 'flu. But keeping you alive if your lungs are riddled with 'flu virus is a challenge. Widely inflamed lungs cannot do their job. If they get really bad there could be only one option for you and that is to plug you into an ECMO machine that does the job of your lungs for you. Does it work? Probably. How do we know? We know from research done in the UK. Will you get this treatment in the UK? Probably not. Because in the UK we have only five ECMO beds for adults in the whole country. If you are very lucky you may be able to get treatment in another country.

Was the possible need for ECMO in a 'flu outbreak predictable? Dr Grumble thinks it was. Did the Department of Health plan for the 'flu? Yes. According to Alan Johnson, along with France, we are the best prepared country in the world. As is Australia by the way. How many ECMO beds do you think they have in Australia?

Of course ECMO doesn't come cheap. If you are not familiar with ECMO take a look at the video and then decide if you think it is worth it.

It is not easy to get funded to provide an ECMO service:

There is no funding stream for adults with respiratory failure at the time of writing (pdf).

There is money for 'flu planning ad nauseam, for unnecessary bottled water, for Connecting for Health, for Darzi clinics, for 'flu lines, for NHS Direct, for Walk-in Centres and for running an internal market. But ECMO funding is limited. Very limited. You could argue that to be right were it not for the very large sums of money wasted elsewhere on electoral bribes.

The Jobbing Doctor may be busy and Dr Grumble may want access to ECMO for his sickest patients but all most of us need is a good GP and not a window cleaner.