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.