Champagne

It's the weekend and Dr Grumble has taken the bottle of champagne he was given by a patient earlier in the week home. The plan was to celebrate one of the Grumble children's birthday. No worries. What a nice present. But then Dr Grumble took a careful look at the champagne. It looked rather special. It is rather special. A quick googling and it is apparent that this is no ordinary supermarket champagne. It is from a good house and from a top vintage. It sells for up to £100 a bottle. Is that OK? Dr Grumble is uncomfortable. What are the rules? Is he allowed to accept gifts of such value from NHS patients? Is he allowed to accept gifts at all? He actually doesn't know. As is often the case gifts from patients can be rather unexpected and turning them down is awkward, very awkward. Dr Grumble's patient was plainly not wealthy. Dr Grumble did very little for her. He made her better but any competent doctor could have done the same. He treated her well but he did not spend long with her. He did not give her anything extra. And she is so well she has been discharged from the Grumble care. But it is worrying that the bottle she gave is worth £100. It's very nice that she thanked Dr Grumble but a nice letter would have been just as good. But she obviously wanted to do more than that. And Dr G thinks she should be allowed to. He has photocopied the champagne label and put it in his appraisal folder. He is not going to keep this gift a secret. It will be above board and if there is any trouble he will offer to send the patient a cheque for the champagne that Grumble is now intent on drinking.

Do such things happen often? It seems they do. A GP acquaintance has been given £1000 by a patient to spend on a holiday. The GP is uncomfortable. The patient has no relatives. She is grateful to the GP. Her money will be left to a charity when she dies. She wants the GP to have a holiday with her money. But do the rules allow that? Dr G certainly has no idea. What could be the best solution to this problem? Surely it is to put the money to a good cause within the GP practice. Yes, that's the answer. Buy some medical equipment with the money. But when this was suggested to the old lady tears welled up in her eyes. It was not what she wanted. She wants her GP to enjoy herself and take a holiday. Now, if the GP refuses this lady will certainly be upset. And surely there is nothing stopping her from leaving some of her money to the GP when she dies. And presumably there is nothing stopping the GP from accepting it. But how much nicer for the patient to see her GP take a holiday while she is still alive. But what about the rules?

A couple of weeks ago a patient came to see Dr G privately. Until recently Dr Grumble did not see any private patients but there is a need. This particular patient was not eligible for NHS care. He was a very ordinary man from abroad and plainly not well off. Dr Grumble put in a small bill. As it turned out an English friend was paying and a letter came back to Dr G with a cheque for three times the amount Dr Grumble had charged. The friend had clearly realised that Dr Grumble had wanted to undercharge this patient and the friend was having none of it. He wrote thanking Dr Grumble for the care he had given and stated firmly that the advice was worth three times what Grumble had charged and enclosed a cheque accordingly.

These things do happen. There are actually a lot of nice people in this world. Sometimes it does not seem that way but there are. People sometimes want to give to others. Dr Grumble wanted to undercharge his impoverished patient. The patient's friend wanted to pay Dr Grumble more. The GP's elderly patient wants her to have a holiday and wants to pay for it. Sometimes human beings want to do things that are very nice. It is a very nice feature of human beings when you see it. It doesn't happen all that often but it does happen. We should allow it to happen. Rules or no rules Dr Grumble is going to drink his champagne.

Yesterday's clinic

There was nothing particularly odd about yesterday afternoon's clinic. The usual mix of patients. The usual patients inexplicably sent to the wrong clinic by Choose and Book. Nothing odd. Except one thing. A whole series of patients in a row thanked Dr Grumble. Not just a polite thank you but something much more. One went on about how all her friends who came to visit her in the Grumble hospital thought she was going to die and how well the Grumble hospital had done. Another told Dr Grumble that he was the only one after many years to have diagnosed his rare condition. And then he went on to praise many others in the NHS who had cared for his family over the years. He told the story of how when his father was dying the food was not just dumped in front of him but a nurse came to help him eat it. Perhaps this was some time ago. Dr Grumble didn't ask. There wasn't time. Then a patient brought Dr Grumble a bottle of champagne. Dr Grumble had only seen her three times. She was not a patient who knew Dr Grumble well. But she had been made better and that was her way to say thank you. Dr Grumble was glad to have the champagne. He will drink the champagne this weekend to celebrate the birthday of one of the Grumble children. But most of all Dr Grumble likes to be thanked and he likes it when he can take real pride in the organisation that he works for: the NHS.

All this adulation in just one clinic was just a little odd. It's not completely out of the ordinary but Dr Grumble does not usually get quite so much praise all in one afternoon. It buoyed Dr Grumble up for his long drive home. And then he heard the news that Ivan Cameron had died. And then it all made sense.

Good people and bad people

There are good people and bad people in this world. As a doctor you are privileged to meet all strata of society. Some people don't. Dr Grumble has many patients who have been been in prison. He has recently had patients who are in custody. He talks to them. Some are innocent. Some tell Dr G they have been assaulted by the police. They don't expect Dr Grumble to believe them. Usually he does. It is the people who do wrong and should know better that are the evil ones. The inadequates of this world who have had everything against them from the time of their birth may deserve to be forgiven. But how can you forgive the Madoffs of this world who, it is alleged, ruin the lives of others while leading their own lives of luxury? How can you forgive the managers of radio stations who encourage the sowing of dangerous memes which may cause the deaths or maiming of children? How can you forgive those who threaten democracy because they, like many others in the past, think they know better than Common People how the world should be run?.

Some years ago one of the good people of this world came to visit Dr Grumble. He brought his dog with him. The dog's name was David. He was a Norfolk terrior. Dr Grumble looked after him. As it happened, during his sojourn in the Grumble household, David fell ill. Dr G told the story here.

David's owner was a man called, Bill. Bill was an ex SAS man. He was very interesting to talk to. He sat at Dr Grumble's kitchen table. Dr Grumble can remember now which chair he sat it. The most striking thing about Bill that Dr Grumble immediately noticed was that his left hand was missing. Instead he had a piece of metal. Not exactly a hook but the modern version. Bill sat at the kitchen table and unselfconsciously plonked his 'hook' on the table while he drank a cup of coffee. Most people would probably have felt awkward about commenting on the 'hook' but Dr G asked him how he had lost his arm. As far as he can recall he lost it in some lesser known but successful skirmish in Oman. Since leaving the SAS Bill had been doing lots of interesting things involving humanitarian work in other trouble spots around the world. He wanted to build up a little nest egg for his retirement.

There wasn't time to talk for long. Bill had to leave. Dr Grumble had noticed that he had arrived in a manual car. He wondered how Bill could change gear with the 'hook'. He never did quite see how he did it but Bill happily shunted back and forth in the Grumble yard without any difficulty. That was the last time Dr Grumble saw Bill. He was a nice man. One of the good people.

A few days ago Dr Grumble heard on the radio that a retired army major had shot himself after losing his retirement savings in the Herald USA Fund and Herald Luxembourg Fund. These were bogus funds run by Mr Madoff. When Dr Grumble got home last night Mrs Grumble told him it was Bill. She was in tears.

Smallpox

Smallpox is something that has been forgotten. Dr Grumble's students puzzle over smallpox vaccination scars that are an incidental finding in many patients over a certain age. Amazingly, Dr Grumble is yet to find a new student who can even guess what causes these scars.

Dr Grumble is not an expert on smallpox but it is one of the first diseases that he learned about. He remembers well the fearfulness, almost terror, smallpox caused in 1962 when he was a young child in South Wales. Dr Grumble can remember his father telling him that a South Wales obstetrician had contracted smallpox after attending a post mortem on a pregnant patient who had died unexpectedly. It turned out that she had had smallpox. Smallpox, you see, does not necessarily present with all those ghastly pustules you see in the pictures of old. As far as Dr Grumble can recall, the disease had been spread around by the index case, a recent immigrant from Pakistan, who had visited various prostitutes. This made any idea of contact tracing awkward.


Medical people don't much get frightened by medical scares that appear on a regular basis in the press. Dr Grumble works daily alongside patients with nasty pathogens. It doesn't worry him. But it used to. He can remember, as a student, trying to hold his breath as he went into cubicles in the infectious diseases ward. He used to wonder how the old professor that used to teach him so well could possibly have lived so long working with infectious diseases every day.

But smallpox is another thing altogether. That still frightens Dr Grumble - even though it is long gone. And in 1962 the Grumble family was, well, scared. Dr Grumble's father was, you see, an obstetrician so it could easily have been him. Except that, unlike the obstetrician who died, Dr Grumble's father had been vaccinated many times. But, though a live vaccine, immunity following smallpox vaccination wanes. In a very short time Dr Grumble's father came home with some vaccine and he immunised us all. The public, some of whom had previously unwisely shunned vaccination, were soon clamouring for it and 900,000 people were eventually vaccinated. But 25 people contracted smallpox and 9 died.


Smallpox was a most terrible scourge which used to cause widespread fear, maiming and terrible death on a grand scale. Its eradication has been a most fantastic achievement. We have Edward Jenner and his vaccination and the World Health Organisation to thank.

Dr Grumble saw one of the very last cases of smallpox while working as a medical student in Ethiopia. He hopes he has seen his last case of measles. He hasn't seen one for a very long time. We must eradicate this disease. We owe it to the people of the third world. There is hope. Here's what they have achieved in Yemen.

From 2006 to 2007, reported cases of measles nationwide plummeted from 30,000 cases, 5,000 of which were fatal, to 13 cases only.

“In 2008, there were three reported cases of measles, and no fatalities,” said Dr Mohammad. (Source)

Well done Dr Mohammad. Persuading primitive people to be immunised can be a problem in the third world where you may have to combat ignorance or strange traditional beliefs.

How to kill fairies

How many of you have read Peter Pan? Do you remember Tinker Bell? Do you remember her saying that every time someone says that they do not believe in fairies, a fairy dies? It is the same with immunisations. Every time someone says they don't believe in immunisations, a child will die. And if that "someone" is on the radio or the television, it may be more than one child. A statement made on the radio or on TV has spurious gravitas. Ben Goldacre is furious with LBC's Jeni Barnett because someone, somewhere will, as a result of that broadcast, decide not to give their child the MMR immunisation.

So says Dr Crippen. It's the nub of why Jeni Barnett and the resulting attempts to silence well meaning bloggers worry us so much.

Is there hope?

According to the Jobbing Doctor there may be. Here's what the Secretary of State for Health has to say on the topic of denying health care to failed asylum seekers:

I understand all the points made by the clinicians we consulted, about the public health risks, the sheer inhumanity of refusing to treat people who are ill in primary care.

He is right. The clinicians were right. It is our willingness to do our best to look after the sick, all of them, that is part of what our country is about. Dr Grumble does not have a full grasp of the rules but he has had to take on the unenviable task of having to deny treatment to undocumented migrants. Managers don't do this job. It's the doctors. It's the toughest thing Dr Grumble has to do. Others make the rules. Dr Grumble delivers the message. Dr Grumble is happy to give his own time to these poor people but that does not pay their hospital bills. You can understand why taxpayers might want to be tough on migrants but they do not have to see the consequent misery themselves. Perhaps if they did they would care. Perhaps they wouldn't. Who knows?

New Labour has been a disappointment to Dr Grumble. The Blairites did not care much for the poor and needy. They had never been poor and needy themselves. Their main aim in life was to ensure they never would. They cared about the markets, the bankers and the financiers of London. They took the view that these gamblers with other people's money were creating wealth. They had no concept of the real wealth of a nation residing in stability and in its willingness to care for those in need.

Dr Grumble has met Alan Johnson. Last year he shook his hand. Mr Johnson had no idea of his good fortune to be in the presence of a top medical blogger. But good fortune it was because Dr Grumble, in preparation for his meeting, consulted wikipedia on Alan Johnson and from that moment on the Secretary of State went sky high in the Grumble estimation. Sooner or later Grumble was going to give him a well deserved plug. Alan Johnson you see is a real genuine person with a real background that enables him to understand the lot of the deprived. He understands the value of a society that really cares, that looks after the sick and ministers to those in need. He understands that that is a society with true wealth.

Here is the bit from wikipedia which Dr Grumble will always remember about Alan Johnson. It brought tears to the Grumble eyes:

Born in London and orphaned at the age of 12 years when his mother died, Johnson was then effectively brought up by his older sister when the two were assigned a council flat by their child welfare officer.

Alan Johnson left school at 15 and started work stacking shelves at Tesco. Despite those humble beginnings he made it to the top. He deserves it. Alan Johnson understands the world in a way that Tony Blair and his Tory facsimile will never ever be able to grasp. He can grasp what it must be like to be the 12 year old orphan of a failed asylum seeker who is denied health care.

Journalists

It's an amazing thing but Dr Grumble once wanted to be a journalist. It was when he was about ten years old. Dr Grumble was beginning to read what were then known as broadsheet newspapers. Perhaps that is what they are still known as but mostly they have since shrunk in size . The reason Dr Grumble wanted to be a journalist was that, in the days before the internet could even have been dreamed of, journalists were a source of 'instant' information about the world. Journalists knew everything and then told everybody else. How clever is that? Dr Grumble wanted to be clever. Dr Grumble's father said nothing about his son's aspirations. He did though show a slight look of dismay and he said something about running with hares and hunting with hounds. It is never a good idea to steer your kids away from some silly notion. They might react by digging their heels ill. It's best to let them find out for themselves.

It has taken Dr Grumble a long time to realise just how bad journalists and people in the media whose job it is to inform the public are. Perhaps they are worse than they were. There are more media than there were. Local radio, the internet, uncountable TV channels - these things just did not exist in Grumble's childhood. Many of Grumble's patients work in 'the media'. With advertising money swilling around the way it once was there have been insatiable demands to fill the air waves. And, since big audiences are what the media moguls want, the aim of the content is to meet the lowest common denominator. So, the Grumble children watch the uncouths of this world like Jeremy Clarkson and Jonathan Ross whose childlike repartee makes society think that behaviour two standard deviations from the norm is acceptable. Dr Grumble would be happier if his kids went instead to the pub, had a few beers and made their own coarse entertainment with their mates. But Grumble, as his children freely tell him when he sounds forth on these matters, is an old fart. Perhaps, as they claim, it really doesn't matter.

But there are things in the media that do matter. They are things to do with truth. Curiously the Grumble children have no interest in seeking after truth. The Grumble generation was different. We were marching on the streets to set the world to rights. We saw the world as good and bad. We were, of course, on the side of the good. Now if you look at the major political parties there are no goodies and baddies. Perhaps, especially if you look at the current financial crisis, they are all baddies. Who can be taken in by criticism of Gordon Brown when David Cameron seemed to be shouting encouragement from the wings? And with all this political greyness has come media collusion. Knocking doctors and particularly GPs at the behest of the government has become a media pastime. Health journalism, if you can call it that, has become an exercise in regurgitation of some government press release written with a Flesch score of 100. Why do journalists not realise that they are being used? Why don't they probe a bit deeper and find the real truth? Why do they never probe and read the source documents? It is because they are lazy and they do not do their jobs properly.

What has started Grumble on this tirade? It is the realisation that we just cannot go on letting our media get away with the utter crap they churn out. It's not the puerile Clarksons and the rude Rosses that are of real concern. They might rile the old farts but, on the scale of things, they just do not matter. It's the lack of intelligent criticism of our policy makers and the sloppy reporting of science and, for that matter, most other topics that need any intelligence to make sense of them that matters. Where, for example, were the journalists that criticised our bankers? Where were the journalists that raised concerns about dodgy mortgages? Where were the journalists to inform us on the value of the mutual organisation? Dr Grumble could go on. Of course there were some good souls who did their jobs. But most just churned out what was fed to them in press releases from greedy bankers. We have all played this game with journalists to get them to write what we want. Even Dr Grumble has written press releases. Even Dr Grumble has been on the telly and the radio to lobby for his cause. But his cause was a good one. At heart he wanted to inform patients. His professional organisation who facilitated some of this had no money to make from these initiatives. They just wanted to inform the public - accurately.

And if you really want to know what has angered Dr Grumble you will need to listen to this.

(Not hosted here for legal reasons)


But Dr Grumble's advice is not to bother. It is the most despicable radio programme Dr Grumble has ever heard.

How not to waste more taxpayers' money

In the US they are looking at the Canadian system of healthcare. They see some advantages. Here is one:

Each hospital in Canada gets a global budget, a set amount which is all they have to spend for the year. They don’t price things like bandages, drugs or even overnight stays individually. The cost for these things and for doctor service is negotiated in advance. (Source)

Isn't it strange that what we used to have in the UK is being seen by others as an advantage. Why are we fixing something that isn't broke?

Choice, choice and more choice

How many surveys do you think the Department of Health has conducted on the topic of patient choice? Three? Half a dozen? The answer is over a dozen. Fifteen to be precise. How many patients do you think they questioned for their latest survey? A hundred? Five hundred? Five thousand maybe? The answer is 93,000? How much do you think this cost? £50,000? £100,000? £200,000 maybe? The answer is that only the Department of Health knows. If you use the Freedom of Information Act to find out they will tell you that this information is not available because it's to do with commercial contracts. Dr Grumble would say that this is his taxpayers' money so he should be allowed to know.

Why is the Department of Health so obsessed with choice that it has to carry out fifteen surveys of tens of thousands of people on the topic? Is there something wrong with the amount of choice our patients are getting? Let's look at the bottom line from this survey:

• 67 percent of patients were able to go to the hospital they wanted, with a further 23 percent having no preference (pdf).
  

That's how they phrase it. It is almost as if the pollsters have been trawling the data to find something wrong. Because, if you add 67% and 23% you get 90%. In other words, for those people in the Department of Health who persist in spending taxpayers' money on these surveys, 90% of the patients went to the hospital they wanted to go to or didn't care which hospital they went to. Ninety per cent of patients were satisfied. Please, Department of Health, that is not a problem.

It is not worth spending any more of Grumble's money on this issue. It really isn't. Unless, of course, you have another agenda.

LBC sharks

Dr Grumble has been on LBC live. He did it for nothing. He did it not as a favour to LBC. He went on as a favour to patients because he had something important to say to them. LBC have recorded in Dr Grumble's department. The reporter was a nice chap. He did his job professionally.

Dr Grumble will not choose to go on LBC again. He will politely decline. And he will tell them why. But basically it is because they are shits.

Lord Darzi: The fundamental flaw

On the Hardtalk show recommended by the Witch Doctor, Lord Darzi was given a grilling. It was not much of a grilling. Dr Grumble could have done a much better job. And when some of the answers did not hold water the noble Lord was let off the hook.

The hapless interviewer did ask an interesting question in which he essentially referred to the problem of there being more chronically ill and more people living longer and then said that he did not see how Lord Darzi was going to be able to cope with that.

Lord Darzi's answer was immediate and confident. He said that he was going to focus more on prevention. It is a crackers answer, of course. It is prevention of disease that has caused more people to live longer so that bits of them wear away or they develop chronic disease. Even if you can prevent or ameliorate some of these chronic illnesses you will then live even longer and develop something else. Unless you die young as we used to you are unlikely to die quickly after previously having been rather well. You are more likely to die slowly after going inexorably downhill with chronic debility of one sort or another. It is mad to think otherwise. Dr Grumble does not really think Lord Darzi believes the nonsense he spouted. But Lord Darzi would know that you can get away with this stock answer because it has been in use ever since the beginning of the NHS. The idea was always that you spend to eradicate disease. It is nonsense really.

It's laudable that the government promotes prevention by encouraging people to stop smoking and lead healthy lives but if you live long enough you will still get some disease or other that will kill you. Come to think of it if you don't live long enough something will have killed you anyway. We all die. You can't stop it. And the more you are successful in postponing death the more the population is going to suffer from the many degenerative and other diseases that can afflict the elderly.

The interviewer was right. Lord Darzi's answer was somewhat disengenuous. But you can't blame him for not having an answer to an insoluble problem.

Choose and book (yet again)

Now it's official. Patients who use Choose and Book are less likely to show up. Isn't it awful? All that expense and it doesn't work.

If you can be bothered to read one of Grumble's old posts on this topic one reason is here.

Walk-in dementia clinics

Yes. It's true. If you can't remember your GP appointment because you are becoming demented you can drop in to the walk-in memory clinic. You can see the method to this madness.

The lobby groups on this topic have some quotes. Here's one:

Research has shown that a brief four or five-hour programme of support and counselling at diagnosis can reduce institutional care by an astonishing 28 per cent or an average of 557 days compared with those not receiving such interventions. This is particularly crucial considering that much of the cost associated with dementia results from expensive care home provision.

Does anybody know where that comes from? Can it be true? The other sound bites are about how bad doctors are. But we are used to that.

Everybody wants to avoid getting dementia in later life. Nobody wants their nearest and dearest to develop dementia. And everybody wants the best treatment there is for dementia. And, as we know from today's stories, lots and lots and lots can be done. Everybody wants it to be Christmas. But it isn't Christmas all the time. It just isn't.

Sometimes it is difficult to point out to people who mean well that there are flaws in their arguments. There is not much point in early diagnosis if the services in place are insufficient.

Here's another quote:

Professor Banerjee admits the services in place now are not able to deal with the number of people who need them.

Here's a quote from the lobby group:

If community services were sufficient and specialist services similarly boosted, numbers could be managed, as early diagnosis would mean fewer people needing specialist care.

And the gentle retort from the professional:

It is a myth that a growth in community based memory services will mean a reduction in inpatient specialist care.

Sometimes it seems dementia is infectious. Now just where did Dr Grumble leave those keys? Source: HSJ.

Middle class eyes

The trouble with the people in charge telling us what to do is that they have never met a real cross section of our patients. If you are a middle class person in a good job the idea of being given money and shopping around for the doctor of your choice may seem attractive. But not everybody feels this way. If you are elderly with a failing body and, perhaps, mind you may just want to be looked after and have somebody else do the worrying.



What induced Dr Grumble to post this? It was a comment on Health Care Republic news which struck a chord. The article was about over half a million pounds being spent on some GP vascular screening programme. The patient would get referred to a nurse-led programme and the patients would be given a 16 week programme of exercise and health advice. The comment was as follows:

Many people don't particularly care about living a long time.

It's true. Some people don't. There is no earthly point in giving advice to people about how to live longer if they don't particularly care. We do not all see things the same way as our masters.

Dr Grumble has many patients who would live longer if they were to take his advice. Many of them do not take his advice. That's OK. That is their decision. Occasionally some of them actually tell Dr Grumble that they do not want to live longer. That's OK too. Some young doctors get upset when patients persist in doing things that are not good for them. But it's up to them. It really is. If people want to do something you wouldn't do that's OK. As long as they understand. But we shouldn't waste taxpayers money trying to persuade them to look after their bodies if that is not what they want to do.

Personal Health Budgets

Dr Grumble has some serious questions about Personal Health Budgets. So, it seems, do those responsible for their implementation.




And, after an awayday in a posh London hotel, most of these people think it will be more difficult than they thought (pdf).




Dr Grumble thinks it will be extremely difficult. He fears it will be more money down the drain. But nobody listens to Dr Grumble. So we are stuck with this silly idea.

But don't just accept what Grumble says. Read all about Personal Health Budgets here.