The next patient has 'flu, Dr Grumble

It had to happen and it has. The notes read H1N1.

"

What do you think, Dr Grumble, do you think you should see her or is this one for the infectious diseases consultant?"

"Looks very much like an ID problem to me."

Phew. Actually Dr Grumble would have been quite happy to see the patient but the problem looked more appropriate for the ID consultant. Really it did.

Perhaps the 'flu is not as bad as we once feared but it would be nice to have a vaccine. It's on its way. But which will we get first? The vaccine or the virus?

The Flu Pandemic Game

The Department of Health is encouraging GPs to play a game. It is called the Flu Pandemic Game. It's been specially adapted by the Department for GPs. How many of you have played it? You can find out what you need to play the game here: pdf.

Jacko's ear

When it comes to medical care Dr Grumble thinks rich people can be vulnerable. Dr Grumble does not see rich people very often. Dealing with the wealthy is not what makes him tick. Unusually Dr G has seen some obviously rich people over the past week. One was an ordinary bloke who had done well in business. He once had 250 bricklayers working for him. His records were full of letters from private doctors he had seen. But he saw Dr Grumble under the NHS. That is a tribute to the NHS service. It is also a tribute to the patient. He had no airs and graces. He did not mind waiting with the ordinary populace. He did not want to dictate his treatment by waving £50 notes. He just wanted good advice.

Another patient Dr Grumble saw the week before was also rich. How rich Dr Grumble has no idea. Perhaps not very rich but rich enough to take himself off to a foreign country as a health tourist. He went to the best hospital in the far away land. Dr Grumble can only imagine what the marbled corridors must have looked like. Every test you could imagine was performed. Loads of blood tests. Umpteen scans. Privately in the UK they would have cost a fortune. As it was the bill ran into thousands. These tests would not have been done under the NHS because they were just not indicated.

If you do lots of tests you will get lots of results that fall outside the reference range. This is inevitable. It does not mean you are abnormal. It just means that your body conforms to the laws of statistics. The patient is discharged with a massive printout of results with comments in foreign hieroglyphics and told that it is good news that the abnormalities have been found. In the UK the private people who do this then either try to extract more money out of the patient to sort out why the tests are abnormal or, more usually, they tell the patient to get their GP to sort it out. It seems the health tourists fare similarly.

Reassuring patients like this must take up a lot of GP time. The GP is onto a loser. How can a humble GP have any clout with a patient who has been advised by eminent doctors in top marbled hospitals the other side of the world? Patients like this also reach Dr Grumble. Recently one GP particularly recommended Dr Grumble to sort out such an issue. Dr Grumble should be flattered but it is a tedious problem to take on. At least Dr Grumble has a bit more clout. But often not much in the eyes of the patient. After all Dr Grumble has never looked after the Queen or Gordon Brown but sometimes the patient has been advised by doctors who have done the equivalent in their own countries. Unfortunately sometimes the tests do reveal something that cannot be ignored and the doctor wishes it had never been found - because usually it turns out to be nothing but proving this may be risky. Patients never see it this way. They always think the private scanning people have done them a favour.

Dr Grumble has had lots of scans. You might think that he does not practise what he preaches. But he does. Dr Grumble's brain has been scanned many times but only for research reasons. Having a brain scan worried Dr Grumble. Supposing it showed cerebral atrophy. Would it raise questions about Dr Grumble's fitness to practise even though Dr Grumble's brain is working OK? What if a little blip was found deep within the brain which might just be an early tumour? A patient might think that was good news because you could have the blip whittled out by a skilled surgeon while it was at an early stage. But it is just not like that. You could whittle it out and find it was nothing to worry about. Or you could whittle it out and find it was a tumour but still incurable. Or you could whittle it out, find it was benign and be left unable to speak. You might have been better off never having had the scan. Patients find this concept difficult to grasp. There are risks as well as benefits to screening. Quite often the risks outweigh the benefits.

If you have pots of money and you demand a scan somebody somewhere in the world will do it for you. They really should weigh up the risks and the benefits on your behalf before embarking on loads of tests but money talks. It is the worst aspect of the market in healthcare. Doctors should be above this sort of thing but not all of them are. It can be difficult to resist a demanding patient with money. Professional standards have changed in the US. Our government wants us to go the same way and calls it patient choice. Professionalism has become a dirty word. The market is to be our master.

The same happens if you want an operation. Supposing you are Michael Jackson and you want your nose altered. You go to a cosmetic surgeon and you explain that your appearance is everything and that your livelihood depends on it and you must have your nose changed. A good cosmetic surgeon should say that your original Jacko nose is actually perfectly normal and that people have grown to love you with that nose. But it is difficult to do. Imagine the kudos of being the surgeon who operated on Jacko. And there's the money. The issue is about giving patients what they really need and not necessarily what they want. And what patients sometimes need is nothing at all. But that doesn't square with patient choice. We are being goaded by our misguided masters into giving them what they want.

Now Dr Grumble has no idea whether or not Jacko ever had nose surgery. He is just using Jacko to illustrate a point. But if you do have nose surgery there can be problems. It is not like having your car fixed. If you spend enough money you can have your car made as good as new. You can't do that with noses. The surgeons talk about remodelling the nose. Dr Grumble talks about crunching up your nasal bones. They may shave off bits of cartilage here and there. And it was the fashion to deglove the skin from the underlying structure of the nose. All this causes scaring. And scaring reduces the blood supply to the nose.

If you weren't happy with your normal nose before the operation then you may well not be happy with the nose you are left with after the operation. So you may have a redo. This time the surgeon has to cut through scar tissue. The skin gets thinner and the blood supply to the cartilage gets still worse. If it becomes avascular the nose may collapse. So the surgeon needs to borrow cartilage from elsewhere such as from the ear. Which may be why Michael Jackson's ears were apparently not too good.



And if you are rich you may be able to persuade doctors to provide prescription drugs that perhaps you would be better off without.

It is not always good to be rich. Interestingly the life insurance companies load very rich people. Apparently they don't live as long as the rest of us.



With thanks to Fishgoth who could probably build you a new nose from paper.

Protect and Survive: GPs told to plant trees

Dr Grumble's GP tells him that she is being advised by the Department of Health to plant trees. Trees are apparently going to prevent her patients from suffering from the effects of global warming. They are so important that the Department of Health even advises planting trees on the top of multi-storey car parks. You wouldn't think there would be enough soil for trees on the top of a multi-storey. Perhaps they will be in pots. In which case somebody is going to have to water them.



Dr Grumble found all this hard to believe but he has found a few pictures of trees on the tops of car parks and he has also found the original Department of Health document (pdf) recommending this.


This solution to global warming is slightly reminiscent of the Protect and Survive advice Dr Grumble's generation used to be given on how to survive a nuclear war. This booklet was so daft Dr Grumble thought it must have dated back to the 50s or 60s. Amazingly, a quick check on Wilipedia shows that it was published in 1980.









Useless Follow-ups

There are important messages in medical blogs. Sometimes you see things written that you have seen nowhere else before. Yet you may have had exactly the same thoughts yourself. This makes you feel very close to the writer because you have the feeling that at long last somebody thinks in exactly the same way as you do. It can make the blogosphere addictive.

Dr Grumble read a post this morning that struck a real chord. It was written by a GP but the message was one Dr Grumble felt he could have written himself. It was critical of a certain aspect of hospital outpatient care. Since Dr Grumble is a hospital doctor you might think he did not take too kindly to this. In fact it referred to a problem that Dr Grumble has been aware of for a very long time. The Jobbing Doctor was having a moan about the patient for whom little can be done who attends the hospital regularly, sees a junior doctor who does not know what to do (because nothing can be done), orders a useless test and arranges for the patient to come back after a few months when the junior doctor will be in another post.

Dr Grumble has no doubt that this has been a problem. Some years ago he discharged a whole swathe of patients with a chronic condition for whom he thought that the trip to the hospital was not worth the shoe leather. They quickly persuaded their GPs to refer them back. If patients have been led to believe that they need frequent hospital attendance it can be difficult to persuade them otherwise. The fault was in ever establishing this pattern of care.

Dr Grumble thinks this is now much less of a problem in the Grumble hospital. The example the Jobbing Doctor chose was of a patient with ischaemic heart disease for whom everything that could be done had been done. Dr Grumble would defend his cardiological colleagues. They rarely follow up patients like this. They rarely have any junior doctors in their clinics. They focus their expertise where it is needed.

Perhaps the hospitals in Jobbing Doctor's neck of the woods are different. The Grumble hospital has tight targets to meet. One of them relates to the ratio of new patients to follow-ups. If you follow up patients that don't need it the hospital won't get paid. Some of Dr Grumble's colleagues complain bitterly about this. Dr Grumble thinks that it focuses the mind on the need for follow up. Dr Grumble's new-to-follow-up ratio is excellent. The Jobbing Doctor would approve.

If professionals don't do things as they should you cannot blame managers for forcing them with targets. Targets are not altogether bad.

Don't panic

Dr Grumble has been away recently. It would be too identifying to tell you just where but it appears not to have been the most healthy of places.

Dear Dr Grumble,

We regret to have to inform you that you could be a contact case of a confirmed case of H1N1 flu, who attended the XXX meeting on XXX 2009 in XXXX.

In case of onset of fever during the next 7 days, please, contact a medical doctor or Hospital in your Country, to do laboratory test for influenza AH1N1, if needed, according to Public health measures of your Contry Regulation.

Thanks for the cooperation

Best regards,

Harbinger Doom

Dr Grumble is frequently in contact with all sorts of horrible germs so this email does not worry him at all. But if the posts dry up you will know why.

Just a rumour

Karol Sikora's negativity about socialised medicine has been causing embarrassment. It has led, so Dr Grumble is told, to some high level transatlantic telephone calls. There were also some difficulties related to his claim to be a professor at Imperial.

This is what he said:

I'm a consultant at Hammersmith hospital, nobody would dispute that. It's true I can't call myself professor of cancer medicine at Imperial........

Is it true that he has now lost his position as consultant at Hammersmith Hospital? That's the rumour that's circulating. Does anybody know for sure?

Unsteady on legs

With a general election coming ever closer and the present government having largely ignored the likes of Dr Grumble there is the possibility that this blog may just become more political. Some people might think that Dr Grumble's views are well to the left of centre. Perhaps they are. But, unlike many, Dr Grumble is prepared to admit that he was a fan of Margaret Thatcher - just like Tony Blair and Gordon Brown. It's a strange world.

It is not giving away any medical secrets to tell the world that Mrs Thatcher had a fall recently. Dr Grumble did notice that she was a bit tottery in the video below. Watch carefully and you will see that she nearly fell coming down the stairs.

Bing

Mrs Grumble asked if Dr Grumble had tried Bing. Of course, he has. She wanted to know if it is any good so Dr Grumble tried it with her. He entered her name, her real name. Mrs Grumble for some reason does not like searching under her real name. Dr Grumble found out why. She is a porn star! Probably Bing has some sort of safe search but Mrs Grumble was unimpressed. So Dr Grumble searched under his own name and found that it appeared next to that of Geoffrey Howe. Amazon has been reading Dr Grumble's posts about markets and he is ranked next to the former Chancellor in the product description of the Best Book on the Market. Let's hope any Chancellors reading the book read it as critically as Dr Grumble. Probably they don't. The book was very persuasive. But quite a lot about its worship of markets was rotten. Dr Grumble knew that at the time he first read the book. Now with the financial crisis the limitations of markets should be clear to all.

Perhaps Dr Grumble will use Bing again. Mrs Grumble may not. First impressions are important. Bing really should default to a safe search. Does Bill Gates read Dr Grumble? Probably not. But he just might. That's the wonder of the web.

Devolution and healthcare

Dr Grumble has always been suspicious of devolution. Why did our political masters in Westminster want devolved government for Scotland and Wales? Was it just to keep the Celts happy? Or was there a more sinister motive? You could be forgiven for assuming it was the former. But why did Westminster want to give up powers to the English regions when there was no clear demand or need for local assemblies? It didn't make sense to naive Dr Grumble at the time but it does now.

In its wisdom the government chose the North East for a referendum on a local assembly because they thought it the region most likely to approve the proposal. But the electorate in the North East, unblinded by any sense of nationalism, shared the Grumble suspicion and wisely voted against a regional assembly. Not, of course, that this was going to stop the government. Oh no.

For Scotland it was different. Many there had long wanted devolution or separation and many others must have felt stirred by feelings of nationhood and nationalism and general grouses about the English. The Welsh, though initially more sceptical, went the same way.

Dr Grumble never saw much for England in all of this. Hiving off chunks of government to Scotland and Wales would surely make the UK weaker on the world and European stage. That seemed bad for all. And there was the bizarre West Lothian issue which means that Scots can exert decisive influences on the government of England. Quite mad really. Not that the English seem to mind very much. The West Lothian question was asked by a Scot not an Englishman. And the English do not seem to be much bothered by the rule of a Scottish prime minister. Well they might be bothered by his rule but it is the nature of his rule and not his Scottishness that is the issue. And in that they may have a lot in common with the Scots.

This is how others describe the regionalisation sleight of hand:

Unelected regional assemblies were set up in the late 1990s as part of the government’s adherence to the agenda of the European Union to break up the power of national Parliaments. England was divided into nine regions, including London. The intention was for each of these unelected assemblies to become elected - and for England to be governed by nine regional Parliaments, each – like the London Assembly - being given powers currently held by Westminster. The plan always was to take some of the powers of national Parliaments up to the various European institutions and others down to a more local level, thus leaving national Parliaments with little to do, hastening calls for their demise. Very few are aware that the official title of the European Union is ‘The European Union of the Regions’ - not of the nations. Source.

What does the devolution of Scotland and Wales mean for England? One advantage for the hapless and disenfranchised English is that it does at least mean that the questionable policies emanating from Westminster are being challenged. Nationalism and distance from the malign influences of the policy wonks and self-interested profiteers of the south allow those in the devolved nations to question the Westminster's health management mantras and show that, yes, there is another way.

The potential importance of devolution in the development of healthcare policy was brought home to Dr Grumble when he read the response from the Centre for International Public Health Policy to the Scottish government's consultation on the European Commission's proposals on cross-border healthcare. Since we don't have an English government the consultation process for England was not focussed on England but UK-wide. Many found the proposal confusing and the response to the consultation was mostly shallow. But in Scotland things are different. There they question things.

If you have no idea what Dr Grumble is rambling on about have a look at what Julie McAnulty has to say on the topic of cross border care. She explains it all rather well. She doesn't actually mention Scotland and she even refers to Brits. These are issues that face the UK as a whole. But if you look at Allyson Pollock's critique (pdf) you will see that devolution may allow a Scottish response to this which will be denied to the English.

Would you believe that Dr Grumble was once a staunch euro-enthusiast? We all make mistakes. Dr Grumble failed to spot that the EU was heralding the post-democratic era. That has to be bad. Could it be why the public are now so very disillusioned with politicians? If you vote you want to vote for change not a new group of managers with the same policies as the other lot. That is the nub of the problem

Why leaders get it so wrong

Dr Grumble has previously touched upon the issue of how doctors may reach a diagnosis, how they may get it wrong and how little is known about the heuristic processes that govern their thinking. Even good leaders can get things wrong. Here's a video outlining how this can happen:



Now this video is plainly a plug for a book. And what's wrong with that? It is a book Dr Grumble would like to read but he hasn't got time. Not at the moment anyway. So he is going to see what lessons can be learnt from this short video clip. It seems there are many.

To try and prevent bad leadership decisions the authors warn of red flags. One of the red flags is a misleading experience. This is a red flag Dr Grumble has spotted in relation to some major decisions which have altered the whole direction of the NHS. He has, for example, pointed out the misleading experience which has driven our misguided leaders to put a market into the NHS. The misleading experience comes from the high street. You go to one shop. They are rude to you. You never go back and shop elsewhere. While you are in the next shop something very attractively packaged catches your eye. You don't really want it but you buy it all the same. They are not perfect but markets work well enough in the high street. That is the misleading experience. Because, as Dr Grumble and many others have pointed out, markets do not work well for healthcare. It is actually quite difficult to go to another hospital when you are acutely ill and you don't want to be sold treatment you do not really need while you are there. Elderly sick people just do not want to shop around. They don't have the information to do so. And loads of websites and stats are never going to give that to them.

Now let's take the example of Connecting for Health, the wonderful national programme for IT. What's the misleading experience here? It is the wonders of computers and the web. Dr G agrees the web is wonderful. He is using it now far away from the UK to deliver this missive to the whole wide world. It is marvellous. Managing patients is about managing information and that is what the web is all about. So when Tony Blair sat on that sofa for half an hour and decided on spending tens of billions of taxpayers' money on a super-duper IT system for the NHS you can see where he was coming from. But he was coming from a misleading experience. Dr Grumble is in love with the wonders of the web but give him a computer alongside a patient and instead of speeding things up it slows him down. Of course computers are the future and one day will help doctors manage patients but the experience of day-to-day use of the internet and email was a misleading one. Just why is not something Dr Grumble will go into here but many others (not just in the UK) have pointed out the difficulties of using ill-designed computer systems in a busy clinic or hospital ward. We will be there one day but Tony Blair couldn't see that it would take much longer than he envisaged because of his misleading experience and his political need for a quick result.

There are other intriguing ideas in this video. How one wonders do emotion, gut feelings and inappropriate self interest apply to Tony Blair? And what about inappropriate attachments? What are they? In the case of Blair and the Gulf War could one have been George Bush? Could another have been his religious conviction? Or was it his misleading prejudgement that caused the loss of so many innocent lives?

This book sounds interesting. If only Dr Grumble had time to read it.

Breakfasting safely in the Wild West

Dr Grumble is staying in a hotel. It's a nice hotel. It seems very safe. The people here seem very civilised. And the sign Dr Grumble spotted while eating his breakfast is very reassuring. No guns over breakfast. That must be good. Then a friend pointed out that the sign referred to the bar area and not where Grumble was breakfasting. It seems that firearms are allowed in the rest of the hotel. To English people that seems very odd. Why should anybody want to wield a gun over breakfast? Or in their bedroom? Or anywhere else for that matter? It's such an odd thing to want to do. And it is even odder to allow it. But they can't seem to see that over here. It's an odd world.

Mrs Grumble has never been to the Wild West. It's a good job she doesn't read the blog. This would worry her. It worries Dr Grumble in a way. But why doesn't it worry the natives?

Not-Kermit

Dr Grumble has been busy in the night drafting an important letter with a barrister. So when he came across this riddle it struck something of a chord. The riddle goes like this:

When is Kermit not Kermit?

Give up? The answer is here.

European Working Time Directive

Remedy has sent Dr Grumble the odd email about the European Working Time Directive with a hint that it might be a topic that old Grumble might like to deal with. Dr G hasn't got time to do this important issue justice but you can hear about some of the problems in this podcast:

The BMA wakes up

The BMA has finally woken up to what is happening to our health service. Sadly it is too late. Powerful forces have lined up to nobble the political parties. Market forces and privatisation of NHS services are the future. There is no stopping it. The public do not want this but many out there are convinced that this will make the NHS more responsive and efficient. The ways of the Soviets have been seen to fail. The Soviet Union has been dismantled. Now it's time for the NHS to go the same way.

Dr Grumble is convinced that these changes will not get the taxpayer more bang for his buck. Quite the opposite. Until all the recent meddling, the NHS was widely recognised as the most cost effective healthcare system in the world. It might not have been the best but that was because until very recently the NHS was starved of money. Now that more money has been coming in more money has been wasted on multiple silly initiatives and the introduction of a market. It costs a lot to run a market. It's all money down the drain. Choice and competition may work in the high street. They don't in healthcare. Mechanisms to try and make it work such as Choose and Book have been expensive failures. But in the current climate with Big Business and other powerful forces lined up to argue the case for privatisation it is a challenge to get the message across that we are heading in the wrong direction. Not even the disaster of the banks has brought home to government that Big Business is like MPs - just out to make as much money from the taxpayer as it possibly can.

So now the BMA has woken up, should Dr Grumble rejoin to show some solidarity? Or should he leave them to waste the subs of his colleagues on an initiative that is doomed to failure?