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.