31 December 2010

Happy New Year

Once more the same procedure as last year:

Charming though it is, it is inconceivable that Dinner for One could ever catch on in England. But why should that be? Is it the Englishness about the film that foreigners find so entertaining?

22 December 2010

How silent monks sing

You need to stand up to watch this:

Happy Christmas Everybody!

18 December 2010

Wants and needs

Dr Grumble has a good decorator. He is more expensive than most decorators but he does a better job. He has never advertised. He doesn't need to. People recommend him to their friends and his small business thrives. Dr Grumble likes these artisan types. They are mostly self-employed. They provide something people need. They are honest Johns we trust.

If you run a business you need to make sure there is a demand for whatever goods or services you offer. If you want to sell something people don't need you somehow have to create a demand from nowhere. Regular readers may know that bottled water is the example Dr Grumble likes. When Grumble was a child bottled water was something foreigners had because their water supplies were unsafe. Now it is an essential item for youngsters. Even younger consultants go around the Grumble hospital with an emergency supply of water just in case they get stuck in the lift or the hospital's heating overcomes them. Go to the hospital shop and you will find several brands of water. Each contains, well, water. And it costs more than petrol. It is a collective lunacy on a massive scale. Yet if you challenge this behaviour it is you who will be seen as mad.

What you want.
(With a cleverly hidden message in its name.)

What can we conclude from this? It is that people are very vulnerable to the powers of advertising and more subtle efforts to influence their behaviour. Don't think that Grumble considers himself immune. The Grumble children all waste their Grumble's hard earned money on water. Dr Grumble would surely have been inflicted with the same lunacy if he hadn't been born too soon for the malign influences of the bottled water industry to take hold.

If you can persuade people to buy water when they could drink it for free you can probably persuade them to do almost anything. In the Great War when people felt vulnerable there were lots of volunteers for the trenches. And in the Second World War Japanese volunteers for suicide missions were so numerous as to be compared with swarms of bees. When people become patients and are worried about their health they are particularly vulnerable to unscrupulous persuasion. The GMC recognised this in Advertising (1995) where it states:

People seeking medical attention can be particularly vulnerable to persuasive influence. (pdf)

Curiously, Advertising (1995) was withdrawn in 1997 about six months after Tony Blair took power. It didn't last long at all. Now why do you think that was?

As it turns out, Dr Grumble has been a patient recently. He broke a premolar. The NHS dentist had obviously been trained that he must give patients choice. Grumble was given four treatment options. One was private and three were NHS. One of the NHS options was immediately dismissed by the dentist because of the location of the nerve - so one wonders why this option was offered. The private option was 'unlikely to last as long'. Dr Grumble did not quite grasp the difference between the other two options. In any case he didn't have enough knowledge to make the choice between two possible treatments about which he knew very little. Dr Grumble gently made the dentist decide what was best. He is more likely to make the right decision than Grumble. Dr Grumble just wants his tooth fixed. And he trusts his dentist.

Most patients are like Dr Grumble. They have a problem and they want to be made better. Quite often there are various options. The occasional patient wants to know about all of them and wishes to weigh up the pros and cons of each treatment. These people tend to make themselves unhappy with their agonising over things they do not know much about. And if they need help in their agonising who will they ask? Dr Grumble of course. So Grumble will dutifully go into it with them and, at the end of the day (and it can take a long time), they will make a choice which would be the very same treatment option that Grumble would have chosen for them. Which is hardly surprising because the patient's information all came from Dr Grumble. The choice they think they exercised was really an illusion.

Our governments seem intent on developing wants. They tell us patients want choice. Patients want GPs open all hours. They want information. It all seems so reasonable that Grumble hesitates to question this mantra. Dare he suggest that the NHS should be giving patients what they need and not what they want?

The argument goes like this. People want bottled water. They don't need it. Patients may want antibiotics. But they may not need them. An insomniac might want sleeping pills but they are often not needed. Giving patients choice and dealing with their wants rather than needs is superficially laudable but it is not what the taxpayer should be paying for. And it is not good medicine either.

What you need.

Needs are fixed. You need to drink water. You don't need to drink lots of bottled water. Bottled water is a want that has been cleverly created. It is a waste of money and resources generally. If you want to buy bottle water, you can. It is your money. But in providing universal healthcare we must distinguish unnecessary wants from essential needs. Governments should avoid generating wants which, in a system that is free, can never be met. It is the needs that matter.

It was like this with Grumble's broken tooth. It needed mending. The dentist, following the NHS mantra, thought Grumble wanted choice but choice was not needed. Wants are things private businesses create. Needs are what governments should identify and provide to their electorate. In dentistry a set of pristine expensive new teeth is a want. Having a broken gnasher mended is a need.

Dr Grumble's dentist could have made some extra money from the private option if he had been less honest. He needn't have been quite so frank about the drawbacks of the private treatment. But he did what a professional should do. He was scrupulously honest. His talking down the private option made Grumble feel comfortable. Being given choice did not. He would have been even happier if the dentist had just told him what he was going to do. But that is not allowed any more. It is all about the market in healthcare. And that is much more about wants than needs.

11 December 2010

Off with their heads

Grumble dreads being on call over those long public holidays we have at around Christmas. It is not necessarily that he minds working when everybody else is merrymaking. There used to be times when he quite enjoyed Christmas in hospital. In Christmas past there was an invigorating camaraderie. On Christmas Day the consultants would come in to carve the turkey properly kitted out with an enormous carving knife and a starched white chef's hat. Consultants would bring their families along and presents were exchanged. Grumble knows because his father would take him on Christmas Day to several hospitals. He saw how pleased the staff were to see him. He saw the joy of hospital life in those days. His memory is of there being masses of nurses everywhere you looked and there seemed to be very little work going on. Very occasionally, but much less commonly, he would see the junior doctors. He can still remember their pristine white coats. Everything was always spotlessly clean and hospitals smelt like hospitals. To this day Dr Grumble does not quite know what that smell was. It's not there any more.

So why does Dr Grumble dread the long holidays so much? Hospitals are no longer the places of merriment they once were over Christmas. Staffing levels don't allow any downtime these days. Turkeys have mutated into twizzlers and the kitchen was separated from the ward aeons ago. That's the modern world. More nose to the grindstone. Less joy. More a contractual relationship. Less duty. Minimal loyalty. Do these things matter? Of course they do. In the Grumble hospital sickness levels are rising. In the past junior doctors were never ever off sick. It's all about the loss of joy, duty and loyalty in the workforce. You can get a lot of work out of people just by stroking them a bit. They just need to feel valued, to love their work and have a sense of duty and loyalty to their patients and colleagues.

These things matter. They matter a lot but they are not the cause of the dread Grumble feels when there is a long public holiday. What worries Grumble about hospitals and holidays is patient care. As luck would have it, Dr Grumble used to work alternate Christmases. One Christmas he remembers an extremely sick man in his early fifties who was transferred from another hospital for Grumble's care. This was now some years ago but the patient's name is still etched in the Grumble mind. The details don't matter except that the patient was very ill and looked as if he would die. His chest radiograph is reproduced below:

OK. It's not the real radiograph but this is what it looked like.

The patient arrived just before the long Christmas and New Year holidays. Dr Grumble knew that there would be a race against time to try and make a diagnosis because, in hospitals, only the front-line workers work over the Christmas break. Any patient reading this might think that it is just a question of having a few scanners working and a single Dr Grumble to interpret the results but hospitals are much more complicated than this. It's people you need not just scanners. It's the expertise to work the scanner and interpret the results that matter.

For those who cannot read chest radiographs, the image above shows appearances consistent with widespread metastases. In other words the patient looked to be riddled with cancer. It would be wrong to go into any details but as Grumble has said the patient was very ill. It would be a struggle to keep him alive. And, if the cancer was essentially untreatable, keeping him alive would not be a kindness. Whatever we did he would probably die anyway.

But it was nearly Christmas. Dr Grumble needed more information. There were all sorts of options for getting this information but none of the expertise he needed was available over the long Christmas break. What should poor old Grumble do? Should he keep the patient alive on the off chance that there would be some treatment for this poor man? Or should he assume that, on the information available, no treatment was going to help? As luck would have it, on Christmas Eve, Grumble managed to get a CT scan carried out. And he was able to discuss the result with the top chest radiologist in the Grumble hospital. She agreed. The patient was riddled with metastases. Nothing else could realistically account for the appearances.

Dr Grumble would have liked a tissue diagnosis. He would have liked to have known that this cancer was not a sort of cancer that might melt away with the right treatment. But none of this was an option over Christmas. He would have to meet with the patient's relatives and he would have to convey all these uncertainties. Patients don't like uncertainly. Relatives certainly don't. Nor does Dr Grumble.

The case was much more complicated than this and Dr Grumble has no intention of giving you the full details of a real case. His purpose here is only to convey the sort of dilemmas that arise over public holidays when patients just cannot get the urgent tests that they need.

And so, Mr Cameron, you have gone down in the Grumble estimation. Because no Prime Minister should announce a new public holiday on the hoof without thinking through the consequences. Patients will die because of your decision to allow us a day off to celebrate a wedding. Did you check which day the wedding would be held on first? Why didn't you lean on those wretched royals and persuade them to hold their wedding at time when it wouldn't damage patient care quite do much? Did you look to check how many Bank Holidays there are then? Have you seen how few working days the hospitals will have that week? Do you know how difficult it will be for Dr Grumble and his colleagues? And do you know how many of Grumble's patients will die as a result of your decision?

Oh. I nearly forgot. Against all the odds Grumble fought tooth and nail to keep his patient alive over the prolonged holiday period. Some thought it would have been kinder to allow him to die. But Grumble had a clinical hunch that the appearances might all be due to infection. And the happy outcome was that the patient miraculously improved and the cannon ball 'metastases' just disappeared. It could so easily have been otherwise.

07 December 2010

A hurtful comment

Dr Grumble doesn't really know why but he hates those Christmas circulars that come with a few Christmas cards every year. There is something really ghastly about them. So here is an early warning to all Dr Grumble's friends who insist on sending these ghastly missives, please desist.

Why does Grumble hate these things so much? He is not really sure. He thinks it is something about people being determined to show off in some way. They want you to know that they have climbed Machu Picchu and seen the lost city of the Incas. They want you to know how cold it was when they hiked along the Great Wall of China. And they want you to hear about their sea sickness as they voyaged from island to island in the Galapagos.

Dr Grumble is not that interested in holidays especially other people's holidays. He even wonders that these long-lost friends have the audacity to tell old Grumble just how dirty their carbon footprints have become. And he is even less interested that little Johnny has taken up the piccolo and got top marks in his grade 1 exam.

All these things show just how curmudgeonly Grumble has become in his old age. We all like to tell other people about how happy our lives are and how well our children are doing. But you do need to have a little bit of insight into the fact that other people may not be that interested in the performance of your offspring in the long jump.

And now for the hurtful comment. It was passed on to Dr Grumble by a correspondent who has his email address. It was found on dnuk where apparently Grumble had a mention the other day. It was a remark about blogs. Here it is:

They're kind of like those horrible Xmas circular letters - just all the year round!

It is very hurtful. Worse, Mrs Grumble, who never reads the blog, apparently agrees. Perhaps Grumble should be grateful. It has given him some insight.

06 December 2010

Brickbats and bouquets

You get feedback on everything these days. Dr Grumble is not at all sure that it quite does what it is intended to do. In the old days teachers used to mark the students. These days students mark the teachers. They are not afraid of putting the boot in when they want to. Sometimes it is not at all justified. Sometimes it seems destructive rather than constructive. Sometimes it is cruel. Often it is inconsistent. A brilliant teacher one month can be dismal the next. Enthusiastic students bring out the best in teachers: the better students tend to be more positive about the teaching.

Dr Grumble's last group of students were better than average. They were more mature, more understanding of the difficulties of teaching in a clinical setting and more appreciative of the efforts that were put into their teaching. Here is the online feedback about one of the teachers:

Dr Grollen has been a wonderful teacher. Patient and yet discerning of where we can improve, rigorous and yet v. v. kind. And he made a point of going through history-taking and examinations, as well as presenting with each one of us (including submission of clerkings in his pigeon hole); same with his teaching ward rounds.

The teachers who we remember the most though are ones who are both -

a. clearly masters of their own subjects, and yet hugely humble with other professionals, and

b. boundlessly kind to their patients - and, this is perhaps why his next firm of students are going to be v. lucky to have him...

Although this feedback was doubtless typed into one of those ghastly online boxes, perhaps in a hurry, this student has produced a beautifully crafted comment. Teachers sometimes feel unrewarded and unrecognised. They need a little stroking from time to time. So thank you, dear student, for these nice comments. Dr Grollen will be fortified by them. Dr Grumble is sure of that.

04 December 2010

Grumble and the tramp

Regular readers may have read Dr Grumble's tale about a bag lady he encountered on his way into work earlier this week. She had been sleeping in the ladies' toilets and Dr Grumble suggested that security was called. Grumble knew that security would throw her out onto the streets. Comments following the post suggested that the NHS might be better off if they looked after patients like the bag lady to prevent her getting frostbite or pneumonia. Dr Grumble used to think the same. But you develop a thick skin if you work in a hospital. People you try to help quite often let you down and it is for this reason that hospital staff can sometimes appear a little uncaring.

Many years ago Dr Grumble worked as a medical registrar in a small teaching hospital in London. The main hospital block was on the other side of a small park from the nurses' home where Dr Grumble had his on call room. In those days you worked all night and all day. You snatched sleep when you could day or night. Often Dr Grumble would have to walk on cold nights alongside the park from one building to another. Sometimes it was bitterly cold. Most nights on one of the park benches Grumble would see a tramp curled up fast asleep. He had only one leg.

One night when Grumble was on call it began snowing. Cold weather portends more admissions so Grumble was not pleased. He needed his sleep. Emergency admissions, for some inexplicable reason, always seem to begin to peak at around bedtime but by about two in the morning on that night all those years ago there was a lull and so Dr Grumble trudged through the snow past the park on his way to the on-call room for a few hours sleep. That anyway was what he hoped. As usual the tramp was on his park bench. This time he had a few sheets of cardboard over him to help keep out the cold. The wind was bitter. Even Grumble felt it in his bones as he hurried through the snow from one building to another. He felt utterly exhausted and prayed for at least a little sleep. He consoled himself with the thought that his life of constant day and night work was not quite as bad as the life of that poor tramp on the park bench.

Grumble climbed into bed. The room was not as warm as usual and the sheets felt cold. Dog tired though he was he couldn't sleep. Patients do not know how much their doctors worry about them. But doctors worry a lot about lives that they are responsible for. Grumble had done his best for the day's medical admissions but he was still worried about some of them. He ran them over in his mind wondering what rare diagnoses he might have missed what test he might have forgotten.

Just as Grumble passed into the land of nod he awoke with a start. Was he dreaming that his bleep had gone off? He often did that. He would ring switchboard only to find out that he had not been bleeped at all. Those days were tough. Always on call. Always worrying that the telephone would ring or that a shrill bleep would cruelly terminate the Grumble reverie. But this time it was real. There was a very sick patient in what was then known as casualty. Grumble quickly pulled on some clothes and went out into the dark night. The wind seemed even colder. He tugged his white coat around him tightly to try and keep out the cold. The tramp had gone. The night it seemed was too cold even for him.

Dr Grumble arrived in casualty. There were the usual drug addicts lying around. The staff weren't worried about them. They were regulars. Once their heroin had worn off they would be on their way only to return the following night via casualty's ever open revolving door.

Grumble asked where his patient was. He was in room 3. Room 3 was used for the VIPs. Earlier in the day Dr Grumble had seen a noble lord in just this room but this was not the time of night for lords or ladies. And it was even a bit late for the drunks. There was usually a bit of peace at between 3 and 4 a.m.

The casualty officer had done the usual crap cursory clerking. Even in the days when doctors had more experience the casualty staff never seemed to be thorough. They knew that somebody more senior would have to see their patient anyway so they didn't really try. Doctors who do not really try do not learn. It's like that more often now. Junior doctors know that a consultant will soon see the patient so they don't really try. It's bad. Very bad.

Dr Grumble went into room 3. He shouldn't have been surprised but somehow he was. There on the trolley was the tramp with one leg. They had put him in the VIP's room because of the smell. Nobody had yet cleaned him up. It was Dr Grumble's job to try and work out what was wrong with him despite the stench and the filth and the scabies.

The diagnosis was actually quite straightforward. A chest radiograph had been done. The patient had middle lobe pneumonia. There was loss of the right heart border.

Doctors will have spotted that this cannot possibly be the
tramp's radiograph but it does at least show the silhouette sign.

Dr Grumble's patient was not at all well and there were other quite dangerous problems such as his low body temperature. Younger doctors would be surprised to learn that despite the severity of his illness Grumble treated him with intravenous benzylpenicillin. It used to work well in lobar pneumonia and Dr Grumble's patient got better.

Now in those days doctors, even junior doctors, had some leeway. If you felt a patient needed a bit more time you could keep them in hospital a little longer. If you felt that they needed to stay in while social issues were sorted out you could do that. And that is was Grumble did. He felt sorry for the tramp. He told the consultant, a somewhat dour Scot, that he was going to find him somewhere to live. "You're wasting your time, laddie," said Dr Blunt. But he didn't interfere. And that was how the tramp ended up with his own small flat to live in.

The winter that year was cold. On countless nights Dr Grumble went back and forth in the night between the hospital and the nurses home. And each night Dr Grumble felt good because the park bench was empty and he knew that the smelly one-legged tramp was now tucked up warm and clean in his own bed. Until one night when Dr Grumble was walking back from casualty he glanced into the park. And there he was. The one-legged tramp was back on the very same bench covered once again with cardboard. "I told you you were wasting your time, laddie," said Dr Blunt.

Dr Grumble sees his former self in his junior colleagues. They fail to understand why Grumble kicks tramps and bag ladies out of hospital. They want to help these people. It is only natural. That's what medicine is about. Sometimes Grumble lets them because he knows that they need to learn the hard way - just as Grumble did all those years ago.

03 December 2010

A letter from the rector

Here with a few minor changes to help Dr Grumble maintain his anonymity is a letter from his old Oxbridge college:

Dear Dr Grumble,

I am writing to let you know how we at Grumble's Old College believe the latest Government proposals on University Funding are likely to affect us. The review into Higher Education published by Lord Browne in October proposed that responsibility for funding the cost of teaching should pass to the beneficiaries, i.e. students, in the form of higher tuition fees for home and EU students. The scheme proposed by Lord Browne is inevitably complicated, and the Government’s white paper has not yet been published. However it seems likely that from 2012, students at Grumble's Old College and elsewhere will have to take out loans for significantly higher tuition fees, as well as making separate arrangements for maintenance.

At the same time, the Government has completed its comprehensive spending review for Higher Education, and confirmed that funding for teaching (as opposed to research) will be dramatically cut from 2012/13. In the case of Grumble's Old College, this means that teaching support will be cut by some £40m per year. In theory, this loss will be compensated for by the higher tuition fees paid by students and their families. The proposed tuition fee, to be set between £6000 and £9000 per annum, would be shared between the College and the University in a manner yet to be determined.

So far as Grumble's Old College is concerned, we remain strongly committed to the tutorial system as the cornerstone of teaching for our undergraduates and are determined to maintain it. Almost uniquely, we hold both tuition of undergraduates and supervision of post-graduates in equivalent regard to research. Equally, we are determined to ensure that we continue on a path of needs-blind admissions to our courses. However, given that Grumble's Old College already subsidises its undergraduate teaching by a significant amount per year, even the highest proposed tuition fee will not compensate for what we stand to lose. Indeed, without the College endowment and fundraising, it would have been impossible either to maintain the tutorial system in recent years, or to continue it, whatever the future arrangements.

These are undoubtedly hard times, and we shall have to rely ever more on our investments and fundraising to ensure that we can retain the essential character of the College. In the longer term, our Trust, of which I write in the forthcoming College Record, is precisely intended to contribute eventually towards self-sufficiency for Grumble's Old College. In the meantime, however, we will urgently need to increase the amounts available to support teaching and our students. There will of course be many ways in which our alumni and friends are able to help us if they so wish. Over the coming months we will gradually be able to move to detailed arrangements for funding both teaching and student support, and I shall endeavour to share these with you at the earliest opportunity.

Yours sincerely,

Rector of Grumble's Old College

The Devil's Work?

This letter makes Dr Grumble very angry. He is not angry that Grumble's Old College is softening Grumble up for a begging phone call. He is angry that it has come to this because of the policy of the ConDem government which tries to make out that there is no alternative when plainly there is.

Look at the figures mentioned in the letter. From these a medical student may well leave medical training saddled with a debt of over £50,000. And that is just for the fees. On top of this there is maintenance or, in other words, the money we all need to live on.

Make no mistake. There are other ways to do this. The financial crisis is not forcing this upon us. A political decision has been made by the ConDems that the cost of teaching has to be borne by the students. It is wrong, wrong, wrong. It condemns our students to starting their working life with a yoke of debt. And it is debt that got us into our current financial mess in the first place.

30 November 2010

It's snowing outside

Dr Grumble arrived a little earlier than usual at work today. He left home a lot ealier because of the snow. As he trudged into the hospital he was met by an agitated cleaner. A homeless lady was in the hospital toilets and she couldn't do her cleaning. What should she do?

If you're a doctor in a hospital you will find that you are expected to be able to deal with most things. Dr Grumble took a look in the toilets. There she was: a bag lady. Around her feet were polythene bags tied at the ankles with string to keep the snow out. She was frantically trying to do her hair in the mirror because she knew what Dr Grumble would recommend.

Tuppence for a rope
These days all hospitals seem to have security men. They never used to. Security was called on Grumble's advice. By now the bag lady will be out in the snow. And it's all Grumble's fault. He can't get on with his work for thinking about her.

27 November 2010

Old members are now alumni. Why?

"I'm turning into a grumpy old man," Dr Grumble said to one of his distinguished and even older colleagues from Cambridge recently. The distinguished older man explained to Dr Grumble that old men become grumpy because they know more. The longer you have lived the more experience you have and the more you can see the folly of what is going on around you. When you are young you think others may know better than you. Quite often they don't.

There is one advantage Dr Grumble has over younger people that they will never have. He can remember what it was like before they were even born. That is not something they will ever be able to do. No one can ever go back to the time before they were born. You can read books about the past but it is not the same as having been there.

Dr Grumble can remember when students used to protest about anything and everything and when Afghans were coats. Dr Grumble has always been one to make up his own mind about things. In those days he never protested and he never owned an Afghan. Now that protesting is less fashionable Dr Grumble sometimes does now go on marches. But he still doesn't have an Afghan.

Protesting is necessary. The political class do need to be made to listen. The only time Grumble has ever heard David Cameron speak to a group of doctors was on a protest march. If you can make a prime-minister-to-be come out into the street to talk to you, surely that makes your own efforts worthwhile.

Living a long time enables you to see change that young people are oblivious to. Dr Grumble has a lot of contact with young people. It's part of his job to teach and he works closely with young doctors. He listens to what they say. He reads their blogs.

The other day Dr Grumble overheard a final year student from Lily's medical school telling a another student not to sign on for the alumni. "They're just after your money ," she said. Can this be true? We never thought that way in our day. We never had any fears about given our contact details to our medical school so that they could keep in touch.

Here is the beginning of a letter Dr Grumble has just received from the Rector of his old Oxbridge College:

Dear Dr Grumble

I have asked a current student to ring you in the next few weeks - not to ask you for money, but.....

What a relief. They don't want Grumble's money. Lily and her friends clearly do not need to be concerned.

OK. Dr Grumble is playing with you. The letter does rather give it away in the first line. A polite way of asking for money is to say that you are not asking for money. It may not be a straight lie but it is somewhat disingenuous. The details of the letter are very interesting. It would appear to have been written by a professional and it uses the word alumni which is quite American. We always used to be called Old Members. Why this change? Was this letter really written by the Rector? Probably he was given guidance by the experts who know about this sort of thing.

The last time they telephoned from Grumble's old college it was in the evening. Dr Grumble was still in the hospital working. He was busy. A student telephoned the Grumble home and asked for Dr Grumble. Mrs Grumble, thinking it was a junior doctor that needed Grumble's help, gave the caller his mobile number. She seemed determined to talk and Grumble just didn't have time. As she plainly wasn't going to take a polite hint and Grumble did not want a long phone call while he was on call for emergencies, he gave the student an earful. In response the Rector wrote a polite letter saying they would not phone him again. Plainly they have forgotten.

A mysterious gargoyle

Dr Grumble has a lot of affection for his old Oxbridge College. He does felt indebted to Oxbridge and repays that debt by teaching his own students more than he might otherwise. Only yesterday he received a card from his latest group with a golden THANK YOU emblazoned on the front. They realise Dr Grumble is trying to enthuse them and pass on what he knows before he retires or worse.

What grieves Grumble about all of this is that his old college, which happens to be relatively poor, is having to go cap in hand to old members to try and balance its books. Oxford and Cambridge are national assets. There is a case for our government to support them. But the ConDems (just like New Labour) seem to want them to become like businesses with hefty fees. And Dr Grumble does not feel inclined to bail out a business - not that he has the sort of money to make a difference.

But unfortunately this government, which is beginning to show a nasty streak, does seem to expect old members to keep their Oxbridge Colleges going. In response to this there appear to be private money-raising enterprises advising these academic organisations how to squeeze money out of their old members. Raising money for Oxbridge colleges is now a money-making business which employs, yes, Oxbridge graduates. Dr Grumble knows one. He does not like the job much but it pays handsomely.

There is something rotten about this. It is connected with the increasing Americanisation of Britain. Our governments no longer see it as their job to support important academic institutions. They have abandoned them. In these circumstances you really cannot blame them for turning to desperate measure such as phoning Dr Grumble on his evening ward round.

Grumble has kept in touch with some of his old Oxbridge mates. More than a few are now earning silly sums of money. One was head of a company in the footsie 100. Another owns one of those enormous town houses alongside a famous London park and is regularly heard on TV and radio. These people really do have enough spare money to make a real difference to Dr Grumble's old, small and impoverished Oxbridge College. Dr Grumble does not blame the Rector for asking them. He has to do things the way our government wants things to be done. The problem is with the way our governments have not wanted to tax the better off in order to support good causes like worthy academic institutions. We are gradually being turned into America and Dr Grumble doesn't like it one bit.

Dr Grumble's old college was founded in the early 1400s. He is concerned about it. He wishes it well. He doesn't blame the Rector for bribing students to phone him on his ward round. But it grieves him very much that it has come to this. It never used to be like this. Lily's friend is right. Whether you are Oxbridge, London or red brick, these days they are just after your money and is it very very sad. And to add insult to injury they now call you alumni.

21 November 2010

Another Commonwealth Fund Survey

Here are some results from a telephone survey, conducted from March to June 2010, of adults ages 18 and older in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. These are top countries with excellent healthcare systems. For comparison purposes they also included the United Kingdom. Comparison with the UK is not really fair as we tend to spend rather less on healthcare.

Click for a better view

Now take a look at the overall views of the healthcare system.

In the UK we spend less and are more satisfied with our healthcare system than other countries.

If it ain't broke don't fix it. Don't think, Mr Lansley, that by privatising it you will get more bang for your buck. People from Big Business will tell you that but these figures certainly suggest otherwise.

For the sceptics out there who think Dr Grumble has been selective with the data (and he has) you can look at a full slide show of the results in this ppt.

With very many thanks to the Commonwealth Fund. Why do we have to look to the US to find an organisation prepared to praise the NHS?

14 November 2010

13 November 2010


Over the last few years Dr Grumble hasn't had the opportunity to buy a poppy. So this year Dr Grumble gave much more than he might otherwise have given and was offered a silver poppy. What a silver poppy looks like he never found out. Grumble settled for the usual paper version.

  • You can support the victims of war without supporting the wars they had to fight in
  • You can remember the consequences of conflicts without glorifying war

  • You can condemn the politicians who created wars without forgetting those that did their dirty work

More BBC garbage

Here's an article from the BBC on brain cell cooling which 'could save lives'.

According to the BBC:

In the UK, while some hospitals have introduced therapeutic hypothermia on an experimental basis, it is yet to be accepted as standard practice.

Only a few UK hospitals use the therapeutic hypothermia technique on some patients.

Which rather makes the UK appear backward compared with the US. But what is the truth? It took Dr Grumble just a minute to find out. The answer can be found here.

Another shock-horror cancer story

What is the National Cancer Intelligence Network? Dr Grumble has no idea. Perhaps they are one of those quangos that have bitten the dust. Perhaps cancer is seen as so politically important they have been saved. Probably our taxes pay for it.

Anyway, according to the shock-horror story on the BBC web site this organisation has discovered that one in four cancers are detected at the emergency stage. In acute leukaemia half of cases were only discovered at a critical stage. And the same was true of brain cancer.

So yet another story telling us about how bad we are in the UK at diagnosing cancer. But it doesn't really bear much scrutiny. Acute leukaemia by definition comes on acutely. It has a rapid, short and severe course. You cannot diagnose it early because before you have it it is not there. As for 'brain cancer', contrary to popular belief, very few headaches turn out to be a symptom of tumour. Headaches are so common that people with headaches and no other signs or symptoms are said to be statistically no more likely to have 'brain cancer' than people without headaches (Mitchell et al 1993). It follows that 'brain cancer' will inevitably tend to present when the patient has a seizure or develops more worrying symptoms or signs.

The next question to ask in all of this is whether it actually matters if there is a delayed diagnosis. There is only any point in diagnosing 'brain cancer' early if earlier treatment would help. The same goes for conditions that we could more easily diagnose early such as prostate cancer. Of course, as is clear from the US versus UK survival figures, your survival will be longer if you are diagnosed early with prostate cancer. Just as the journey from Birmingham to Edinburgh is longer if you board the train in Exeter. But you might, at a cost, be able to cure it too. With earlier detection come the questions. These are the issues we need to be addressing.

The other side of the story

One of the biggest problems Dr Grumble comes across in his clinical work is blinkered thinking. These days lots of elderly people are admitted and sometimes, more often than not even, it is not very clear what has been the cause of their fall or whatever it was that led to their being brought to hospital. Managing uncertainty is an important part of being a doctor. Neither patients nor their relatives like uncertainty. It makes them feel uncomfortable. They are uncomfortable with not knowing. They are uncomfortable with a doctor who admits he doesn't know.

Even the system we now work in is uncomfortable with uncertainty. There are no protocols to follow for the patient with no diagnosis. These days everybody is told to follow the policy. Pneumonia has to be treated with antibiotic X or Y and a urinary tract infection with antibiotic Z or W. The reality is that, especially in the elderly, it is often not entirely clear whether the problem is in the chest or the urinary system or something else altogether. But these days a single diagnosis is made rather than the traditional and necessary differential diagnosis. And once a diagnosis is made and the protocol is followed the blinkers are put on. Sometimes Dr Grumble's juniors seem puzzled by his worrying about what the patient hasn't got. He has deliberately taken his blinkers off. Everybody else seems fixated on the label that has been put on the patient. Failing to take the blinkers off is a cause of medical errors. Doctors should always keep their minds open. Otherwise mistakes will happen.

It is in this vein that Dr Grumble, who was once described in one of our former colonies as a 'socialist blogger', provides a link to a deceptively convincing video. Do watch it. Some very important points are made. But don't get blinkered by it.

01 November 2010

26 October 2010

An article courtesy of red pepper

Dismantling the NHS

Behind the technicalities, what do the government’s plans for the NHS really mean? Stewart Player and Colin Leys expose the reality of the health service white paper

The coalition government’s plans for the NHS represent the final conversion of healthcare into something to be bought, with really good care going to those who can pay for it and only a defined ‘package’ of free treatments, of declining quality, for everyone else.

What has already occurred with dentistry, physiotherapy, podiatry and other services will start happening across the board. ‘Top-ups’ and ‘co-payments’ will become standard. Some treatments will cease to be available freely on the NHS and have to be paid for – if you can afford it.

It’s already happening all over England, as staff and services are cut to meet the government’s demand for £20 billion ‘savings’ over the next five years. GPs are being told to refer many fewer patients to specialists.

NHS North London has decided to cut back on cataracts and hip and knee replacements. The government’s plans mean that this will become the norm, not just one-off cuts justified as a response to a crisis. Under the new plans, by 2014 NHS hospitals will no longer be answerable to the taxpayers who have paid for them over the years, and will no longer have the overriding aim of providing the best possible healthcare for the their local community.

By then they will all be businesses, competing with private hospitals and clinics for NHS patient income. To stay afloat financially they will have to cut costs, reduce staff, lower the ‘skill mix’, reduce levels of pay, focus on profitable treatments and neglect or even abandon high-cost and unrewarding ones in order to match the for-profit sector. There will also be many fewer of them.

The aim is to take chronic care out of hospitals and deal with it in non-hospital settings – ‘super-surgeries’ or clinics, largely owned and run by private companies. It will be a healthcare market, very like that in the US.


All hospitals, public and private, will be answerable only to the central regulator, Monitor, which is concerned only to ensure that they stay solvent and behave competitively.

They will be supervised for safety and quality by the Care Quality Commission, but the CQC is notoriously feeble: it gave mid-Staffordshire top marks when several hundred patients had been dying there from neglect.

The white paper says the CQC will become more demanding. But if in future it tells a hospital to raise its standards, and the finance director replies that the required improvements are unaffordable, what is supposed to happen? There will be no ‘bailouts’. The government’s view is that the hospital should either cut some services, or even close altogether, leaving patients to be treated by ‘better’, privately-owned hospitals – or perhaps in the same hospital, after it has been taken over by a private company.

That is the logic of the healthcare market the white paper envisages.

But closing a medical department or even a whole hospital isn’t like closing a department in a department store, or the store as a whole. There are rarely adequate alternative facilities within reach. Letting hospitals fail means chaos, anxiety and serious risks for patients and their families.

And what if the private company’s services turn out to be no better? The quality record of the privately-owned Independent Sector Treatment Centres (ISTCs), set up and subsidised at huge public expense by Alan Milburn during his time as health minister to treat NHS-funded patients, is notoriously worse than that of NHS hospitals doing similar work.

Whether it is healthcare or home care or schools, good public services for all must come in the end from a service ethic on the part of staff who are not in it for the money, and management who are not in it for shareholders (or forced to compete with companies that are run for shareholders). Outside regulation has a part to play, but without the core commitment that comes from being part of a national service that expresses the solidarity of society – in the case of health, the solidarity of all the well with all the sick – equally good services for everyone will soon be a thing of the past.


The proposed change that has attracted most attention is the shift of commissioning from Primary Care Trusts (PCTs) to ‘local consortia of GP practices’. This is being done on the grounds that ‘primary care professionals’ are best placed to know what is best for patients, and will engage in ‘more effective dialogue and partnership with hospital specialists’. Who could object to that?

You do wonder why PCTs haven’t previously been told to organise such a dialogue between GPs and specialists; but the more important point is that GPs can’t in fact do commissioning.

‘Commissioning’ is Department of Health-speak for purchasing, and what it means in practice is setting the terms of what exactly will be paid for: what services will be covered, how they will be delivered, by clinicians with what sorts of qualifications, following what protocols, with what limits on length of stay in hospital, prescribing what drugs and rehabilitation programmes, and so on. These so-called ‘care pathways’ are at the heart of commissioning, or buying healthcare. The payments are per-patient, at pre-agreed prices for each kind of treatment package.

And to ensure that the deal pays off, any variation from the agreed protocols must be cleared with the commissioner or purchaser. This is the meaning of the ‘managed care’ operated by America’s notorious HMOs (health maintenance organisations), in which doctors have to plead with the HMO to be allowed to go ahead with a needed treatment that the HMO says is unnecessary, in reality because it will cost more than the HMO wants to pay.

Viewers of Michael Moore’s film Sicko will remember a doctor who used to work for an HMO telling a congressional committee how she was paid a bonus according to how often she denied treatments to patients. The new ‘GP consortia’ may not go so far as to reward their staff on this basis. But they will have limited budgets, and the way they are supposed to reduce costs is precisely to involve themselves in the details of all the treatments they are going to pay for. Someone will have the job of denying something.

Two big deceptions

1 Who will really run the new GP consortia?

Some GPs are said to be keen to take on commissioning. But the work involved is essentially commercial, not medical. The new consortia will have to employ large teams of administrators, lawyers and others to negotiate, make contracts, monitor performance, send out bills, do audits, deal with disputes, and so on – as PCTs are already doing.

That is the first big deception involved in this change. It sounds as if GPs will be doing the work, when in fact the essential job of buying hospital and other services involves a vast range of tasks that practising GPs can’t possibly do, and aren’t trained to do – even if they decided to stop treating patients altogether.

In fact, the work calls for skills developed in the managed care industry in the US. The English healthcare market is going to be run on the principles developed there, not by the GPs whose ‘pivotal and trusted role’ is supposed to be central to it.

The change will also mean that GPs will be nominally responsible for the £20 billion of service cuts that are already starting to be made. How trusted will they still be after that? That remains to be seen.

2 The cost of commissioning

The second big deception is that focusing on who does the commissioning prevents a crucial question from being asked: that is, why do commissioning at all?

Running health services as a market is far more costly than running them as a public service. The Department of Health commissioned a study of the NHS’s administrative costs. Based on 2003 data, the authors found that administration absorbed about 14 per cent of the total budget, up from 5 per cent in the 1970s before the marketisation process began.

The department sat on the report for five years. It only came to light in 2010, by which time ‘payment by results’ (payment for every individual completed hospital ‘episode’) and other major additional market elements had also been introduced. The share of administrative costs is now probably more like 18 per cent or more.

The ideologues behind the Tory plan maintain that competition makes healthcare providers more efficient. But the evidence from the US suggests the opposite.

There is a good reason why this is so. Good healthcare is above all a matter of having enough, highly-trained staff; yet employing fewer, cheaper staff is the only way to make money out of it.

In reality, the plan to turn the National Health Service into a healthcare market does not rest on rational arguments but material interests. Any realistic strategy to resist the Tory plans must start out from that fact: the plans are not really new, but are the culmination of a decade-long campaign by the private health industry to get its hands on the NHS budget.

How otherwise could the white paper have been produced so fast – a mere two months after a general election during which none of its far-reaching proposals was even mentioned (let alone made an electoral commitment) by either of the two parties now in office? It’s hard to imagine that even the overall shape, let alone the detail, of the white paper, was put together in two months. So where did it come from?

The HMO/market model: how its foundations were laid

The reality is that successive Labour health secretaries, working closely with the private sector, had already constructed almost the entire edifice of a healthcare market. The Tory plan merely speeds up the final stage and makes it more clearly visible.

The idea that New Labour planned to replace the NHS with a US-style market, complete with HMOs, may come as a shock to some readers. But the fact is that HMOs have been the inspiration behind practically every element of the ‘system reforms’ pursued by New Labour since 2000.

One HMO in particular, California-based Kaiser Permanente, the largest HMO in the US, has been intimately involved in shaping the Department of Health’s strategic thinking. New Labour’s ‘reforms’ have been worked out in constant discussions with and visits to Kaiser. This includes the conversion of NHS trusts into independent businesses (foundation trusts); the introduction of ISTCs; payment by results; giving NHS work to private hospitals and clinics and encouraging NHS patients to choose them; changes in NHS staff contracts; and, not least, the development of HMO-style commissioning.

The US example

These changes have been introduced in a largely piecemeal fashion, concealing their overall intent. But when looked at with reference to the Kaiser model the various elements assume their true significance.

A defining feature of the US healthcare market and its HMOs is its complexity, with myriad forms of organisation and bureaucracy fragmenting provision, and with thousands of different ‘plans’ (i.e. insured packages of care) confusing customers, concealing profits and adding hugely to costs. It was precisely to avoid this expensive dog’s dinner that the NHS was created. But the basic structure is clear enough.

An HMO like Kaiser receives insurance premium income from its ‘enrollees’ (and for over-65s, from the US state’s Medicare programme), and then ‘manages care’ for them through three basic ‘arms’: 1) It owns hospitals and primary care/ambulatory facilities; which are 2) staffed by physicians, who, while nominally independent, are tied into an exclusive relationship with 3) the company’s insurance arm.

How do the New Labour/coalition plans correspond to the US model?

  • At the level of infrastructure, hospitals are being progressively removed from public ownership – all NHS trusts are to become foundation trusts and are then to become ‘social enterprises’ owned by their staff, not the taxpayer. Meanwhile privately-owned facilities are subsidised (sweetheart deals for ISTCs, charitable status given to Nuffield hospitals, etc).
Some struggling NHS hospitals will close, while others, such as Hinchingbrooke in Cambridgeshire, will be handed over to private companies to be run for profit. Mark Britnell, who was the Department of Health’s head of commissioning under New Labour and is now lucratively installed in the private sector, says Hinchingbrooke is ‘only the tip of the iceberg’ and anticipates perhaps 20–30 more such transfers over the next year.

ISTCs, too, provide ready-made privately-owned venues for ambulatory and short-term secondary care, while some 150 private hospitals and clinics in the ‘Extended Choice Network’ that are already available to NHS patients under the ‘choice’ agenda form the nucleus of an expanded network of private suppliers.

  • In terms of staffing, the Kaiser model calls for market relationships with independent teams of consultants, primary care physicians and nurses. In order to develop these, staff must be disengaged from the NHS and redeployed into the above-mentioned teams.
The main initial lever to bring this about will be the significant numbers of hospital doctors who become redundant under the cuts programme. At the same time, GPs already have a semi-independent status and can more readily be included in such teams, which have already been emerging in parts of the country. While such teams may initially have some autonomy, it is unlikely that they will be able to compete with the major providers in the long term; it is more likely that most will end up working for one or other of them, on the Kaiser model.

  • The third arm of the HMO model, the insurance function, will be the work of the new commissioning consortia, advised by – or, more likely, progressively outsourcing the work to – private health insurance companies, and some American HMOs. There are also indications in the white paper that patient choice of GP will in due course extend to choice of commissioning consortium – since all GPs will be required to belong to one, so free choice of GP means free choice of commissioner – and that the consortia and hospitals will become free to compete on price and not just on ‘quality’ as they do now.
It is likely that competing healthcare ‘plans’ will eventually be a feature of the market here too, as consortia begin to compete for patient income.

The insiders

Pushing through these changes is a tight-knit ‘policy community’, comprising a number of leading private sector figures, some doctors and some health policy think-tanks, working closely with a group of strategists within the Department of Health. Among the latter, a highly influential figure has been Professor Chris Ham, who was for some years head of the Department of Health’s strategy unit and is now director of the King’s Fund. Ham has been a long-term champion of Kaiser, organising a series of visits to the company’s California headquarters and being instrumental in setting up a number of ‘Kaiser beacon’ projects within the NHS to introduce and ‘normalise’ Kaiser’s aims and methods among NHS managers.

Even more emblematic is Dr Penny Dash. After working briefly for Kaiser in the 1990s, Dash was appointed head of strategy and planning in the Department of Health, and co-authored the NHS Plan of 2000, which initiated the marketisation process.

Since then she has served on the board of Monitor, led Lord Darzi’s recent review of health services in London, and is currently vice chair of the King’s Fund.

But it is Dash’s function as placewoman for the global consultancy giant, McKinsey, that is probably most significant. McKinsey has been described as the gold standard for the provision of corporate strategy advice to the Fortune 500 companies, and as ‘global thought leaders’ in the areas of strategy and operations management. The company has played a central role in ‘system reform’ in the NHS under New Labour, and Dash is now a partner in their London office.

One of her initiatives, the Cambridge Health Network, is essentially a McKinsey front for exchanges between private health corporations, financial institutions and the Department of Health. Sponsors of the Network include some very big game: Halliburton, General Electric, and Perot Systems, as well as our very own GlaxoSmithKline, BUPA, Assura (now owned by Virgin), Mott McDonald and Carillion. McKinsey has been in many ways a key architect of the reforms that have prepared the way for the coalition. It was also, not coincidentally, McKinsey who came up with the figure of £20 billion that is now starting to be cut from the NHS.

Resisting the destruction of the NHS

As everyone recognises, successful resistance to the Tories’ plans to cut back public services permanently will call for a mass mobilisation with exceptional levels of solidarity, organisation and commitment. But, as Gregor Gall has recently pointed out, the defeat of the poll tax – the last time anything on this scale was successfully attempted – is not a good analogy with the situation we face now.

The poll tax affected everyone; its injustice was massive and obvious; and it required people to co-operate by registering and paying the tax, which they could and did refuse to do in vast numbers. None of these conditions applies to the complex, uneven, protracted process of dismantling the NHS that the Tories intend to push through.

Yet the injustice that will flow from the loss of the NHS will be massive. It will change the face of English society more profoundly than the poll tax. And it will be for all practicable purposes irreversible – unless we stop it now, all of us resisting in whatever way we can.

— -

Summary: what the coalition’s plans means for the NHS

  • Hospitals that ‘fail’ will be left to go bankrupt and close, or be handed over to be run by private companies.
  • GP ‘consortia’ will run the service, in theory. But doctors don’t have the time or skills to do the large amount of administration required – and these are the contracts the private health companies are after.
  • There will be £20 billion of cuts. On top of that, the more complex the market system gets, the more money will be spent on administration instead of medical care.
  • The consortia will end up trying to reduce costs by denying certain treatments. And if they are to make money, they will do it by employing fewer, cheaper staff.
  • In place of a public service we will have a profit-driven healthcare market.
— -

Who’s taking over the NHS?

The main actors in the new GP consortia

The earlier attempt to encourage GPs to take on commissioning roles through ‘practice-based commissioning’ has been widely acknowledged to be a failure, mainly because most doctors prefer to focus on patients. This allows the 14 major US and UK health corporations, consultancy firms and insurers that currently make up the ‘Framework for Procuring External Support for Commissioning’ (FESC) to step in and play an increasingly central role in allocating the bulk of NHS finances. The FESC functions include population risk assessment, procurement and performance management, and data harvesting – but it is in service redesign that their impact will be most felt.

So who are these companies?

Aetna (US); Axa PPP (UK); BUPA (UK); CHKS (UK); Dr Foster (UK); Health DialogServices Corporation (US); Humana (US); KPMG LLP (US); McKesson (US); McKinsey (US); Navigant Consulting (US);Tribal (UK); UnitedHealth Europe (US); and WG Consulting (UK).

How these companies profit from the ‘revolving door’ in senior health personnel

  • At KPMG, the former Department of Health head of commissioning Mark Britnell now leads the company’s European Health Division. Britnell also has close ties with Dr Foster, having previously been one of its non-executive directors.
  • UnitedHealth now employs Blair’s former top health adviser Simon Stevens. It also has the former head of the Department of Health’s commercial directorate, Channing Wheeler, who, alongside Britnell, set up the FESC before being recalled to the US to face the securities and exchange commission on charges of illegally backdating share options at the time of 9/11.
  • BUPA has the services of former health secretary Patricia Hewitt in her role as advisor to the private equity company Cinven, which recently bought out BUPA’s entire hospital portfolio.
  • Tribal’s director of its healthcare division, Matthew Swindells, was chief information officer of the Department of Health and a special adviser to Patricia Hewitt. The company can also call upon Phyllis Shelton, who jumped ship from the Department of Health, where she worked as the lead for measurement on the integrated care organisation programme. Prior to this, she was the founder and managing director of the UK arm of HealthDialogue.
  • McKesson’s UK chairman is Lord Carter. As chairman of the NHS’s competition panel, he is well situated to ensure that decisions on mergers and procurement – including those on commissioning – will follow the privatisation route.
  • McKinsey has the Department of Health’s former head of strategy, Penny Dash. Some idea of Dash’s influence on the commissioning front can be seen in the fact that, in her guise as vice-chair of the King’s Fund, she led a recent briefing for PCTs to cut back on commissioning of what she considered to be ‘low-value’ medical procedures. Sure enough, in June this year, NHS North London proposed cutting back on ‘low priority treatments’.

red pepper has the copyright to this article which they have kindly allowed Dr Grumble to reproduce. Thanks red pepper.

Grumble takes the pulpit

Dr Grumble's father was supposed to go into the church. That was what his mother had planned for him. But Grumble's father wanted to become a doctor and, although he did not go to school until he was 12, that is what he became. He was, without doubt, a much better doctor than he would have been a vicar. Grumble's uncle was a man of the cloth and so was his grandfather but it was Dr Grumble's grandmother who wrote all the sermons. In those days, behind every great man was a great woman. Dr Grumble's mother often told him he was like his granny. It was not intended as a compliment.

Dr Grumble himself never goes to church. He cannot remember the last time he heard a sermon. Probably it was decades ago. But Dr Grumble thinks we do need sermons. There is a need for our minds to be opened to thoughts that we may not get from elsewhere. This is especially true in the modern world where there are malign influences on our thinking generated by people interested only in making money.

It was something Dr Grumble heard on the radio this morning that generated this post. There was a retired army officer on the radio. He was talking about a charity to look after the interests of ex-soldiers. It was something he mentioned that struck Dr Grumble as very important. Essentially he said that problems occurred when soldiers moved from an organisation that values loyalty, dedication and commitment to a society focussed on acquisitive self-interest.

Unfortunately the NHS has moved from an organisation which valued loyalty, dedication and commitment towards one focussed entirely on acquisitive self interest. We used to have secretarial staff who felt that working for the NHS was worthwhile and that the pay was not the only thing that mattered. If Dr Grumble sees that something needs to be done he does it. Some of his younger colleagues, faced with the same problem, are beginning to ask where the money is. An organisation that was happy because it valued staff like Dr G is changing to an organisation that is sad because people only do what they are paid for.

The management consultants would say that all this is right and proper. The only way to get people to do what you want is to motivate them with pay. Every item of work must be paid for. People are expected to work for money and not love.

But it is not money that really motivates people. It is more often love. Dr Grumble has listened to soldiers on leave from Afghanistan. They talk of the horrors of returning to the front line. Doubtless they could get out of it somehow if they really wanted to. They could feign some illness or other. Or they could just refuse. Being locked up would be better than having one's limbs blown off. But they go back again and again. They do it out of a sense of loyalty, dedication, commitment and duty. They are not doing it for money they are doing it for love - the love of their comrades who need them there.

Take now your GP. Is he working for money or for love of you, his patient? Do you want him to treat your cholesterol because he thinks it is right for you? Or do you want him to treat your cholesterol because he gets paid to do it?

Suppose you need to see a surgeon? Do you want him to operate because you really need an operation or do you want him to operate because he gets a fat fee every time his wields his scalpel?

The answers are obvious. Of course your GP and your surgeon work for money. But they should also need a sense of loyalty to you, commitment to you and they have a duty to do what is right. We need a balance and things are going much too far in the wrong direction.

Dr Grumble could have enjoyed himself in the pulpit but he has had to content himself with blogging. Which, of course, is much better because the whole world can hear. But will they listen?

17 October 2010

Competing on tax rates

It's Sunday and on his way to work Dr Grumble listened to that religious programme on Radio 4. The BBC have original names for their programmes: it is called Sunday.

Dr Grumble likes Sunday. Like it or not religion determines quite a lot of what goes on in this world. Whether it is problems close to home in Northern Ireland or the breakdown of law and order in Iraq, often there appears to be some underlying religious dispute. And, most amazingly, in these two examples the conflicts are between people of essentially the same religion.

You might think that religions should favour tolerance but it seems that often they don't. Some might say that the Church of England is amongst the most tolerant of churches yet we find that there is conflict over gay priests and even women bishops. Any outsider aware of the teachings of Christ would be baffled. When it comes to loving ones neighbour as oneself the secular world leads the way. Which is odd.

But one cannot get away from the fact that the basic tenets of many religions are sound. And, although the secular world may be ahead of most religions in trying to achieve equality for women and gays, the malign influence of big business on our society has put the focus on making money, looking after oneself rather than others, and treating oneself to whatever pleasures life has to offer. As Grumble writes this he can almost hear some of his readers wondering whatever could be wrong with that.

But, you know, there is something wrong. We really should not be buying things we do not really need just because, as the advertising mantra goes, "you deserve it". There are more important things than these quick purchases of evanescent happiness. Religion used to teach us that.

Where has the lack of traditional religious teaching led us? It has led to a world where those of us earning a living are told we can no longer afford the taxes to pay for our youngsters to study at university. It has led to a world where those of us in employment can no longer afford pensions for the elderly. It has led to a world where if you want something you must pay for it yourself directly. Yet, when the developed world was a poorer place and the UK was struggling to recover from the Second World War, we could manage all of these things.

Of course they will tell you various reasons why doing things the way we did are no longer possible. There are more students than ever before. The elderly are living far too long. And, thanks to our government encouraging banking in preference to manufacturing, we have run out of money. But it is only partly true. What is the difference between students taking out loans and paying them back and the taxpayer subsidising their studies? One way those earning a good living pay for the next generation. The other way students get saddled with debt at the time when they are likely to be having children and wanting to buy a home. The taxpayer and the grown-up student are the same people separated only by a few decades. Which method of payment would you prefer? Would you like to start life with a debt or would you like to be taxed a bit more when you grow up? And who will benefit most from the new way of doing things? Will it be the student from the comprehensive or the old Etonian? The answer is all too clear.

So why are the ruling Etonians so insistent that we must do it this way? Grumble's suspicion is that it is about competition over tax rates. We are now in a global village. Many of the people society most needs can take jobs anywhere in the world. Even doctors, who have to jump through regulatory hoops to be allowed to practise abroad, move around. Businessmen and entrepreneurs can move even more freely. The ruling class see this as a problem and perhaps they are right.

Where is all this going to lead? Our students will suffer. Our researchers will be paralysed. Pensions will be delayed and slashed. The elderly will suffer and the defence of the realm will be put under threat. And we haven't yet heard what other horrors the ConDems have in store for us.

Could we do things differently? Could we tax more and avoid saddling our students with debt? Could we tax more and ensure the elderly are looked after? Could we tax more and ensure that the realm is adequately defended? Or do we have to compete on tax rates to retain the people we need? Because, if we do have to do things this way, there is the inevitability of progressively fewer public services as public spending is slashed to minimise taxation. Is that what we want? Is anybody offering an alternative way forward?

Is it too much to hope that people might want to come and work here despite high taxes because we have built a fair and just society?

13 October 2010

Andrew Marr should do his job

Instead of criticising bloggers Andrew Marr should be doing his job and criticising the government. Doesn't he realise how he and the rest of the media are being manipulated by the ruling class? That's why we need bloggers. We need bloggers to flag up when we are heading in the wrong direction or at least to point out that there are other ways in which things might be done. It's certainly true of the health service but you wouldn't know from the media. You have to rely on mavericks like the pimpled medical bloggers or the late Clare Rayner whose dying words she wanted to be:

Tell David Cameron that if he screws up my beloved NHS, I’ll come back and bloody haunt him.
Clare Rayner could see what was happening. And she cared. It is a shame people like Andrew Marr do not seem to grasp the enormity of what is happening, don't seem to care and fail to challenge politiicians over their misguided plans for the NHS.

Fortunately there are those who grasp what is happening and can muster cogent arguments. Karen Jennings is an example. You can listen to her interview on the Today programme this morning here.

07 October 2010

A conference on sustainability

Dr Grumble is not by nature an eco-warrior but if you look at the facts we just cannot go on as we are for much longer. If global warming doesn't get us, running out of materials eventually will. It may not affect Grumble but it will affect Grumble's children and his children's children.

Why it is that Grumble should have received an invitation to a conference on sustainability he has no idea. Perhaps he has been muddled with Mrs Grumble who shows more concern about such matters. Here is the letter Grumble has received:

Dear Dr Grumble

On behalf of the International Advisory Board, I would like to invite you to the:


Now that's nice. A conference to sort out the problems of sustainability. But where do you think it is being held? How many people will be flying there? And how far will they have to travel? Let's hope they have located it somewhere near the main centres of population. You can find out where it is being held here.

Will we never learn? If these people do not understand or care about the magnitude of the contribution of air travel to our energy problems there really is no hope for us.

29 August 2010

Stafford extended matching quiz

A little quiz about concerns raised or not about mid-Staffs. Quotes are all from spring/summer 2009. Match the quote to its author:

A) Baroness Young of Old Scone, then The Chairman of the Care Quality Commission

B) Mr Howard Catton, RCN spokesman, to Health Select Committee

C) Dr. David Colin-Thome, Government Primary Care Czar and former Labour Party Candidate

D) Rt. Hon Alan Johnson MP, then Secretary of State for Health and a former trade union leader

E) Dr. Peter Daggett, Consultant Physician,Stafford, to Health Select Committee.

1) "I do not understand why clinicians whose primary role is the safety of their patients are somehow concerned about whistleblowing. Indeed, knowing the number of people in various occupations who are not slow to make people aware of such difficulties, it amazes me that that did not happen at Stafford.”

2)"...between 2005 and 2008 we believe there is in the region of 500 or so incident or accident forms. There was a particular period at the end of 2007 where there were about 200 within a six month period. The concern which has been reported back to us is that people felt those incident forms were going into a black hole or into a waste paper basket. There is one example which was reported to us where a nurse said she did see an incident form in a senior manager's waste paper basket.”

3)“To have no individual clinicians systematically raising concerns is also uncommon and to me hugely disappointing.”

4)"We need to create a culture where doctors are obliged to challenge each other. It is not happening everywhere at the moment. There is a silence among professionals"

5) “I and my colleagues have been raising concerns with management at all levels for some considerable time and certainly around 2006 when I think the present problems arose."

09 August 2010

A press release says it all

08th August 2010

The General Medical Council (GMC) has cleared sacked diabetes consultant Dr Shirine Boardman of any wrong-doing – two years after Warwick Hospital dramatically sacked her in July 2008. That means the truth of what happened can now be told.

Dr Boardman did not transfer medical records to any external organisation, as South Warwickshire Hospital Trust claimed. There was no breach of patient confidentiality, no involvement whatsoever of any “company”, and Dr Boardman did not break any NHS rules.

The facts are that she faxed a list of names and contact details of diabetes patients to her NHS secretary at the NHS clinic called Apnee Sehat. No medical details were included with the list.

The Apnee Sehat clinic was a pilot clinical service provided by Warwickshire Primary Care Trust. It was not an “external organisation” as the hospital claimed. It was not a private or “public benefit” company and Dr Boardman was not a director.

She gave the list to her medical secretary – who was subject to all NHS rules on confidentiality – so that these patients could be invited to take part in a special education programme designed to help them manage their diabetes and prevent serious complications such as heart attacks, strokes, kidney disease and blindness. She was a doctor doing her best for her patients.

Dr Boardman was acting in accordance with official NHS and National Institute of Clinical Excellence (NICE) guidance, which both recommend this sort of patient education as essential healthcare. There was a statutory duty on all NHS bodies, including Warwick Hospital, to provide this healthcare education for their diabetes patients, but the hospital failed to do so.

The Hospital Trust complained that Dr Boardman had ignored: “explicit, repeated and consistent advice” not to share information with Apnee Sehat. But the GMC now admits that she: “complied with all the conditions set out by the Trust”.

“Dr Boardman’s motives seem to have been solely to benefit patients,” they added.

Many of the country’s most senior experts have been horrified by the action taken against Dr Boardman, among them Peter Bottomley, a senior backbench Conservative MP. Dr Boardman has recently been working at a hospital in his constituency. He has been following the case closely and raised it in Parliament. He said:

“This project should have been helped, not hindered. The individuals who were behind the complaint should now be questioned, and if judged appropriate, they and their Trust asked to account for their actions.

“Otherwise the Health Secretary should ask for a review of their actions.”

Lord Crisp, as Sir Nigel Crisp, was the NHS chief executive and Permanent Secretary at the Department of Health when the first, voluntary Apnee Sehat project started some years previously. He said:

"I was very impressed by the work Dr. Boardman did in creating Apnee Sehat. It was just the kind of thing that we wanted to see in the NHS and I was shocked that the Trust allowed this to develop to the point where they dismissed a forward thinking and committed Consultant who was clearly making a difference for patients locally."

Dr Sue Roberts CBE was the government’s leading expert in diabetes – the tsar – at the time the Apnee Sehat clinic was operating. She said:

“As the National Clinical Director for Diabetes at the time this took place, I would have expected the clinical and managerial staff of South Warwickshire NHS Trust to have welcomed the chance for their patients to be offered an opportunity to attend the course provided by the Apnee Sehat clinic.

“The dismissal of Dr Boardman was fundamentally unreasonable in that it disregarded good medical practice in the treatment of diabetes.”

Dr Boardman is understandably relieved by the GMC decision. She said:

“I am thankful this nightmare is finally behind me and my innocence has been proven.

“It came as a complete shock when my efforts to provide culturally appropriate patient education in the community was seen as gross misconduct and led to my dismissal.

“I can now continue with my career with my credibility intact, and would like to thank everyone who has believed in my innocence and supported me through this terrible period of my life.”

Dr. Boardman had previously been awarded four clinical excellence awards by the Trust for going above and beyond her contractual duties to help patients. She has continued working since her dismissal from Warwick as a Consultant Physician in other hospitals.

08 August 2010

The virtue of chastity

It's Sunday so perhaps it is appropriate that it was today that Dr Grumble came across something a patient was wearing that he has never noticed before. It was a red and white cord tied around the middle of a lady he needed to examine. Curious, Dr Grumble asked the patient what it was. It was a St Philomena Cord.

The cord provides marvellous protection against many mishaps. It seems particularly good at safeguarding the virtue of chastity. Had it been effective for Dr Grumble's patient? Ignorant as to the benefits of wearing the cord, Dr G didn't ask.

There's always something new to learn in this job.

24 July 2010

Dicing with death

Once or twice the Jobbing Doctor has commented on how odd it is that he has seen three cases of a condition that he hasn't seen for ages all in one week. The same thing happens in hospitals. Very rare things come in runs. You would think that it couldn't happen by chance but it does. If you listen to radioactive decay using a Geiger counter the blips you hear (listen) are random but they are not evenly spaced. Sometimes the blips seem to occur in runs. So it is with any random event.

If you have ever wondered why it is you have to wait so long for a bus, that too is predictable. Unless the buses are evenly spaced you are more likely to arrive at a big gap between buses - because it is bigger. It's as simple as that. That's why when you travel on the tube they may stop the train to improve the service. It might seem crackers but it is to ensure the trains are evenly spaced which means that people will never have to wait too long. Even spacing is crucial. Dr Grumble has patients whose job it is to control the buses in the same way. Heavy traffic can limit what they can do but GPS gives them the opportunity to try and space the buses evenly along the route. The days of buses coming in threes should be over.

People don't understand statistics. Dr Grumble includes himself in this. It is a difficult subject. Managers certainly don't understand statistics. They spout utter nonsense. We had top management consultants in recently. We paid them a small fortune. They were on about how we should improve our performance to reach that of the best quartile of equivalent hospitals. There was the unspoken assumption that our performance was below par because we are crap. Dr Grumble had been warned in advance to behave. He pointed out serious flaws in the data but was given a stern look. He was tempted to point out that 50% of doctors are below average and should be sacked but he bit his tongue. Mad management speak fools nobody but highlighting the flaws in their thinking is not permitted in today's NHS.

Sometimes though the effects of statistics on individuals are too serious to ignore. Explaining this to managers who just want to cover their backs by sacking poorly performing doctors is a challenge. They cannot understand how sheer chance can make you a killer.