31 January 2009

Speaking out is not recommended

Long before the Jobbing Doctor entered the blogosphere there were those that suggested in their comments that Dr Grumble sometimes holds back. In the words of the Jobbing Doctor himself, Grumble is very circumspect about his own views. Dr Grumble pleads guilty.

Over the years Dr Grumble has often suggested that perhaps we do not have enough beds in our hospitals. This is not something he has held back on within his own trust. He has sent an email to all and sundry arguing the case for more beds. Since then the beds have been cut. Ranting can vent ones wrath but it often achieves little.

Instead Dr Grumble is going to post some words from the Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust. Read these and form your own opinion. Here they are:

The infection control team was keen to isolate patients with C. difficile but the scarcity of side rooms made this difficult.

Many of the wards did not have sufficient ...... hand basins, making the control of infection difficult. The beds on several wards were much too close together, making it difficult to clean between them.....

When we visited, we observed levels of contamination that were unacceptable, such as bedpans that had been washed but were still visibly contaminated with faeces.

...it took four months to establish an isolation ward. It is our view that this was largely because of the pressure on beds and the requirement to meet financial and waiting time targets. The same pressures led to some patients moving from ward to ward. The other patients ..... were at risk of catching the infection and some of them did. This was not acceptable.

[Patients' families] told us that when patients rang the call bell because they .... needed to go to the toilet, their call often wasn't answered, or not in time. Particularly distressing, nurses had told patients to "go in the bed", presumably because this was less time consuming than helping a patient to the bathroom. Some patients were left, sometimes for hours, in wet or soiled sheets, putting them at increased risk of pressure sores (pdf).

Dr Grumble's views on this are superfluous. The problems are obvious. The action that is needed is obvious. But has that action been taken?

27 January 2009

Connecting for health

This project was set on its flawed way by Tony Blair after a 10 minute briefing during one of his sofa sessions at 10 Downing Street. It was ill-conceived and ill-executed. Well, not really executed at all so far (pdf).

There is only scanty documentation (pdf) confirming that this brief meeting ever took place. As was typical for Blair, there were no minutes. How can you do that when deciding on a project which is to cost £13,000,000,000 of tax payers money -some say £50 billion? Dr Grumble keeps minutes of even tiny departmental meetings. Only this morning he has written a record of a meeting yesterday when there were only three present. There are good reasons for minutes - including accountability. But Blair thought he knew better. Or did he not want accountability? Dr Grumble's view is that since Blair had never even run a burger bar he just didn't know how to do things properly and was arrogant enough not to listen to the civil servants put in number 10 to help him.

Dr Grumble did not like Tony Blair. He still doesn't. When he looks at the opposition parties he sees more Tony Blairs. Is that why Ken Clarke is back?

23 January 2009


If you don't like negative politics do not click here.

Did you click? Probably you did. If you didn't the link is to a rather negative video about Gordon Brown on a blog written by Rachel Joyce. Rachel is a doctor. She is also the Conservative Party Candidate for Harrow West.

Dr Grumble sometimes comments on these political blogs but his comments do not always appear. Perhaps the blog owners find Grumble's comments offensive.

Grumble has wised up to this censorship. He now keeps a copy of his comments. Below is the comment Dr Grumble made in response to Rachel's negative post about Gordon Brown. Is it obscene? Is it offensive? Are the points made unreasonable? Judge for yourself.

Many of the things in the video have a ring of truth about them but a strategy of negative politics is high risk. Your post should have been accompanied by a well researched account of how the Conservatives had anticipated all of this and issued appropriate warnings. It is not just you, Rachel. This is a major problem for your party and, presumably, why Gordon has gone up in the polls while the economy has gone down.

We have had the same problem with other Labour blunders like Iraq. When people like Dr Grumble wince at New Labour's policies we look to the Conservatives and wince yet again. We need a real opposition who can think for themselves, see when mistakes are being made before and not after they happen and can formulate better policies.

That's your problem, Rachel. Tell David.
OK. Perhaps it is offensive. But it is true.

18 January 2009

Lessons from the Hudson

The likes of Richard Branson complain that hospitals get it wrong when pilots don't. There is nothing new about this. Pilots have check lists. It is widely believed that doctors and nurses should do the same. And it is happening. Protocols and tick boxes abound.

But pilots get it wrong too. Dr Grumble has sat on committees which have investigated certain aspects of safety in the air. He became closely involved with one particular accident when lives were lost. The pilot made mistakes. More than one. The aircraft should never have taken off because it was outside limits. But that had nothing to do with the accident. People make mistakes quite often. It does not always matter too much. Pilots make mistakes just as doctors do.

When Dr Grumble heard that the aeroplane which has recently ditched in the Hudson had some special button to press to stop the water coming in he commented to Mrs Grumble that he would be surprised if the pilot had remembered to press it. It might have been on some check list somewhere but did they have the ditching check list readily to hand?

Acute medicine is more like ditching than a normal landing. There are a lot of uncertainties. The right decision to make is often not obvious. And decisions may need to be made quickly. The right check list for each set of complex circumstances you may encounter does not exist and even if it did it would not be realistic to consult it in the time available. That's the reality.

Now when the aeroplane ditched in the Hudson, despite the circumstances, the first officer would dutifully have gone through a three page check list to ensure everything was in order for landing. There wouldn't have been much time to go through this check list and he would have had more important things to consider like trying to restart an engine or, preferably, two engines. It might not even have been the ditching check list. That's the trouble with check lists. You need the right one for the circumstances. In medicine that is not always realistic.

The orange arrow shows the ditch switch.

So did the pilots remember to press the wonderful button the designers of the aeroplane put in to ensure that the water was kept out? Dr Grumble was not surprised to hear on the grapevine that both pilots forgot. Their lives and that of their passengers might have depended on their pressing that button but Dr G is told they did not. It is not a criticism. It is a fact of human life. Dr Grumble has made mistakes. We all make mistakes. Protocols and ticking boxes may help but they can be more trouble than they are worth and when you are ditching they may be plain impracticable.

Just think how mad you would feel if you were the plane's designer. You fit a wonderful button to turn the aeroplane into a boat and the pilots forget to press the wretched thing. But it was predictable. Dr Grumble predicted it. Fortunately no harm came from this omission. But it might have been otherwise.

17 January 2009

A shot across the bows?

Some years ago now Dr Grumble had dinner with Lord Warner. OK, Dr Grumble was not actually at Lord Warner's table but he was there at the dinner. Lord Warner was introduced by a surgeon. Not exactly a jobbing surgeon but a surgeon anyway. Surgeons are good at cutting to the chase and when Lord Warner was introduced he casually mentioned how perplexed he was by the terms 'plurality' and 'contestability'. Dr Grumble had also been struggling with these strange words. Plurality and contestability come from the Department of Health buzz word generator but they are more sinister than that. They are really a form of newspeak. They are designed to get you thinking in a certain way without actually knowing what you are thinking about. After all, when you look up these words in a standard dictionary you do not find the meaning that the Department attaches to them. When Dr Grumble first tackled this topic he came to the conclusion that these words really meant privatisation. He has since learned that 'contestability' is in fact a technical economics term which refers to the concept that monopolies will buck up their ideas if you threaten them with competition. Lord Warner did not say that. Presumably if you reveal to the monopoly provider that these are just threats and you are not really going to pass the business elsewhere then the threat has no effect. Anyway, Dr Grumble has since heard directly from a most senior source in the NHS (forgive the Chatham House rule) that some of these initiatives were indeed just intended to shake up the NHS monolith. So all that money wasted on independent treatment centres was not money down the drain at all. It was simply a ploy to get the NHS management to buck up their ideas. Is the world really this mad? Is this the only way of getting our NHS house in order?

Enter now the world of the Personal Health Budget. What on earth is the aim here? Dr Grumble is perplexed once more. Is this yet another ploy to galvanise action from the NHS management? Or is this the beginning of privatisation? Is the government really intent on putting the NHS into private hands? Here too Dr Grumble's thinking has moved on. He is now of the view that it's not necessarily the Bransons of this world the government has in mind to run the NHS. It's not privatisation they want so much as denationalisation. New providers could include any non-NHS organisation. Charities for example. If this is really the policy what could be the real purpose of Foundation Trusts? Are they intended to be bought by the likes of Branson and run like private companies? Or will they become or be taken over by charities? Or will some become parts of academic organisations? We cannot tell from the impenetrable newspeak. How will these major changes be supported? Could charities even do that? What evidence do we have that these new ways will be more efficient or better than what we already have? The answer as always is none.

One thing is for sure. Giving people the money to buy their own health care cannot possibly be a sensible way forward. Unless, of course, it is just to galvanise some action. To learn that this may well be the case you need to read the small print of the Department of Health documents where you will find:

What’s the rationale of personal health budgets?

The main aim of introducing personal budgets is to support the cultural change that is needed to create a more personalised NHS. It may be that only a relatively small number of patients would find that their needs lend themselves to a personal health budget, but their impact on the way care is delivered may be much wider.
Lets hope that they are just trying to get us to buck up our ideas and that this is more a shot across the bows than a real policy.

These are the ideas emanating from Richmond House:
We have already heard that those with long term conditions, those receiving NHS Continuing Healthcare and users of mental health services might be well placed to benefit. We would like to hear your views on where personal budgets would be most useful, for example patient groups, services and circumstances.
So they are going to give money to 'users of mental health services'. Surely users of mental health services are mentally ill? So that means that the Department of Health is going to give money to vulnerable people with mental health problems to buy treatment? Is this really an ideal group to have shopping around?

Tell the people in the Department of Health what you think. They would be really pleased to hear from you (see the end of this pdf for contact details).

11 January 2009

Call for better diabetes services.

Hospital doctors and patients have united to call for better diabetes services in Warwickshire. Now that's a laudable aim. The Asian community are particularly vulnerable and with that in mind the Apnee Sehat project was set up locally with the intention of addressing lifestyle issues in Britain's South Asian community. It drew the attention of Prince Charles. Here's a picture of him shaking hands with a nice looking Asian lady. Now who might that be?

Below's a picture of a group from Apnee Sehat outside somebody's front door. Do you recognise the front door? Do you think that might be the same Asian lady? She must be very well connected.

And could that be the very same lady with John Prescott?

And is that her yet again with Rosie Winterton? Who could she be?

Goodness me, there she is again with Prince Charles.

This lady, whoever she is must be quite something. She must be very highly regarded by the great and the good. That must be because she is trying to help vulnerable people at particular risk. How would she know which people are most at risk? Would she need a database? Perhaps getting in contact with local Asian diabetics and offering to help them would be a way forward. But that might just be difficult. You need to be careful with data. Dr Grumble has only just learned that it is against the law to share your smartcard though some trusts are said to have sanctioned this practice. Curiously enough in Warwickshire.

How the NHS treats young doctors

Dr Grumble thinks that it is much tougher being a doctor in today's NHS than most members of the public think. Here is a post Dr Grumble picked up from a doctors' chat room. It would do no good for this doctor to be identified so certain details have been changed:

I am getting married in July and have requested four days off. I'll be on a rota where leave is fixed. Swaps are not allowed. I applied to get unpaid leave but I have been told to pay for a locum which will cost around £2000. I just haven't got that sort of money at the moment. What can I do?

This problem happens again and again. If you tell people who work outside the NHS they find it hard to believe that any employer can behave in such a way. You might think the young doctor's consultant would be able to sort this out for him. You would be wrong. She is of the old school.

Dr Grumble thinks these poor young doctors need to invoke the Human Rights Act 1998. The first question is whether or not they have a right to get married. This fortunately is covered in Article 12:


Men and women of marriageable age have the right to marry and to found a family, according to the national laws governing the exercise of this right.

So does the doctor have to work when he would like leave to get married? This appears to be covered by Article 4:


No one shall be held in slavery or servitude.
No one shall be required to perform forced or compulsory labour.
For the purpose of this Article the term “forced or compulsory labour” shall not include:
(a) any work required to be done in the ordinary course of detention imposed according to the provisions of Article 5 of this Convention or during conditional release from such detention;
(b) any service of a military character or, in case of conscientious objectors in countries where they are recognised, service exacted instead of compulsory military service;
(c) any service exacted in case of an emergency or calamity threatening the life or well-being of the community;
(d) any work or service which forms part of normal civic obligations.

Is the NHS showing respect for this doctor's family life? Does this doctor have any right to private and family life. This is covered by Article 8:


Everyone has the right to respect for his private and family life, his home and his correspondence.

There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.

So what can these poor young doctors do in such circumstances. Perhaps Remedy can help them. You just should not have to resort to legal action to solve problems like this. But sometimes in today's NHS that seems to be the only way.

10 January 2009

08 January 2009

Shirine Boardman

Warwick Hospital has upheld its sacking of Shirine Boardman a consultant in diabetes who in 2006 won a best practice award for her Apnee Sehat Project. You can read the story here.

07 January 2009


Dr Grumble has received a complaint about the tacky ads on his site. For a variety of reasons Dr Grumble has been considering removing the advertisements.

Here's an advertisement for which Dr Grumble will receive not one cent (yes, Grumble gets paid in dollars). This is the Benylin advert which has been causing some controversy. What do you think? Do you know what Benylin is? Is it anything? Dr Grumble doesn't think it is. Nothing definite anyway.

04 January 2009

£10,000 a day?

How much did the Department of Health pay the likes of Melinda Messenger for publicity? We shall never know. They used our money but the Freedom of Information Act does not allow us to find out.

Do you know who Melinda Messenger is? If you are an old fart like Dr Grumble you may never have heard of her. If you do a google image search (make sure you are not at work) and take off the 'safe search' you can see what she has to offer. They used her in the 5 A DAY campaign apparently. Not that old Grumble saw anything of the campaign. Nor did the Grumble children. What is the justification for 5 a day anyway? Is there any? Melinda Messenger's five times a day sounds too much. Too much for Dr Grumble anyway. But was she paid too much? We shall never know.

Do people trust celebrities, people who are famous for being famous, more than doctors? According to Dr Grumble's favourite parliamentary doctor, that's something else we don't know.

And what does Dr Grumble think of Melinda's performance? She was actually quite good. Certainly up to the Grumble standard. As for the video as a whole, it was easily up to the usual Department of Health standard.

03 January 2009

New Labour in a single utterance

Not Dr Grumble's words but from the Guardian:

A healthcare system that was once the envy of the world now has much to learn from the manner in which people select boutique hotels.

At last the journalists are doing their job. People are no longer being taken in. Read the article here.

Dr Grumble stars again

Dr Grumble is progressing well up the greasy pole and now has three paper publications to his name. The latest is in R-UK Issue 4. Regular readers will have already benefited from the Grumble words of wisdom on this topic. You can read R-UK Issue 4 by clicking on the top picture when the latest magazine reading software will magically unfold.

01 January 2009

Global leadership forum

How would you like to go to a global leadership forum? There can't be many of those. But if you do a google search for that exact phrase you will find over 10,000 results. Managers around the world must be using the same buzz word generator. It's no wonder we don't always take managers seriously.

Recently Grumble attended a meeting at a red brick university. The Vice Chancellor had just returned from a meeting of vice chancellors from around the world that took place in the East somewhere. Each chancellor had stood up and talked about their global aspirations. The Vice Chancellor related this to his audience and then announced that being global was not good enough for their red brick. They were going to go stellar. The raucous laughter showed that this was a leader with some insight. This was a leader who knew that these buzz words not only get in the way, they discredit the people who use them. Who can take managers seriously when they string these words together in the way that they do? We all laugh at them. Or is it just Dr Grumble?

Drs Grumble and Rant are enthusiasts for clinical engagement. Dr Rant knows the failings of managers when it comes to understanding primary care. And how can you manage anything in a hospital without getting senior front-line clinicians involved? But the truth is that unless they are desperate the managers shut us out. Or they did until the latest directives from on high.

Where do they pluck these figures from?

Here are some crucial questions the managers need to address at the Global Leadership Forum which will be a fast-paced, hands-on learning experience:
Why is it so difficult to secure clinician cooperation?

How do you motivate clinicians to “take the helm” and lead the quality improvement agenda?

How do you align clinician perspective on quality improvement?

What does it take to develop clinicians as true hospital leaders?

Can the Grumble readers help with the answers? Do you have a view on how your perspectives should be aligned? Or perhaps you have time to go to the conference which is being held in a magnificent Grade I listed building, in the heart of the West End. Sadly it clashes with one of Grumble's clinics. And he has targets to meet. Perhaps that's part of the problem. Not enough time for perspective alignment.