28 January 2010

Burnham's people-centred charade

"By putting power in the hands of people we have created a powerful engine for reform. Where once we had to rely on national targets to drive improvements, we can now drive change through the influence of patients. This will be the basis on which we renew our vision for the future." (pdf)

Katharine Whitehorn on the right with the placard.

If power is in the hands of the people why are respectable people like Katharine Whitehorn out on the streets protesting for only the second time in her life? Answer that Mr Burnham. Or maybe we could have a comment from the opposition about how they might genuinely listen to what people really want from their NHS.

25 January 2010

Peas in a pod?

A good few of Dr Grumble's readers take the view that the NHS is an inefficient behemoth and the more it can be privatised the better. It is a reasonable view to take. They could be right. They might well be wrong. What grieves Dr Grumble most is the lack of public debate on the topic. Reading between the lines of what New Labour has done and what the Conservatives seem to think they should have done more of, it seems to Grumble that the only major difference between the two parties is the rate at which they think the privatisation process should proceed. But you have to read between the lines. Privatisation of the NHS is not something either party wants to be explicit about.

One of Dr Grumble's colleagues, Professor Parrot, takes the view that it has been easier for New Labour to move towards NHS privatisation than it would have been for the Conservatives. Rightly or wrongly Labour is more trusted as a custodian of the traditional NHS than the Conservatives. The paradox is that the NHS could just be safer in Conservative hands. Whatever they say we all know the Tories are not really the party of NHS. In the event of a Conservative government an untrusting public would be on the lookout for shenanigans and privatisation of the NHS would be high on their watch list. Any 'progress' in this direction would have to be very cautious.

How far has Labour be able to expedite its covert privatisation plans? The figure below from the Department of Health gives an idea. Since the election of Tony Blair, spending on the purchase of healthcare from non-NHS bodies has gone up over fivefold.

Click the table to enlarge

Many of the Grumble readers might think this is a good thing. And they could be right. But health services managers might not be so enthusiastic. Take a look below at the views of these top managers on the role of markets and competition to increase quality.

Click the graph to view.

OK. Dr Grumble can hear his critics. The table just shows the views of health service managers. What else would these people say? But they weren't just NHS managers. The managers whose views were surveyed came from Australia, Belgium, Canada, Denmark, Finland, France, Germany, Hong Kong, Italy, Malaysia, the Netherlands, Norway, Poland, Singapore, Slovenia, Spain, Sweden, Switzerland, the United Kingdom, and the United States. Just like Dr Grumble they do not think that the use of markets and competition is a particularly good way of improving quality. Top of the list for improving quality the most was better coordination of care. How is piecemeal privatisation going to achieve that? What kind of structure would you think is best to achieve better coordination of care? Dr Grumble will leave you to decide.


Department of Health Annual Report 2009 (pdf)
You get what you pay for (pdf)

23 January 2010


Mrs Grumble is thinking of cooking chilli con carne for supper tonight but she hasn't got any red kidney beans. Which reminds Dr Grumble of an incident many years ago when the hospital where he was working was severely incapacitated as a result of an incident concerning, yes, red kidney beans. Dr Grumble's readers are very knowledgeable so some of you may guess what is coming. One or two of you may even have been involved in the incident.

The story goes like this. When Dr Grumble was quite a junior doctor working in a hospital on the South Coast a pharmaceutical representative offered to treat the whole of the junior doctors' mess to dinner. In those days most of us were on call most of the time so going out was difficult. One of the girls offered to cook chilli con carne so we could eat in the mess. The rep would pay for the ingredients. Dr Grumble can remember now the large cauldron the young house physician used as she cooked for what turned out to be the bulk of the junior doctors in the hospital. The dish turned out to be excellent. A good evening was had by all and the rep had an opportunity to peddle his wares.

Phytohaemaglutinin - the cause of the trouble.

It was then the trouble started. Within hours of the first mouthful of the chilli con carne each and every junior doctor who had partaken of the meal was struck down with severe vomiting followed by diarrhoea. At first we were perplexed. Then it dawned on us. The red kidney beans had not come from a tin but were dried. Red kidney beans are notorious. Unless you prepare them properly they will poison you just as they poisoned us. The hospital ground to a halt. Somehow we struggled to look after the sickest patients between trips to the loo. Nobody died. Neither patients nor doctors. Not that the doctors were really at risk. It was just that they felt like death. And nobody had a plane to catch. The worst time to be struck with severe vomiting followed by diarrhoea is if you are about to go on a long journey. And it was while we were all thinking that things could have been worse that it dawned on us that the drug rep who had set off just before we were all struck down had come all the way from Cardiff. We never saw him again.

10 January 2010

David Cameron on the NHS

This is what David Cameron said today:

We do not want to see the state withdraw from [the NHS] in any shape or form at all.

Yes. That is what he said on The Andrew Marr Show. Does this mean what it seems to mean or was this some very clever use of words? Is it a genuine reassurance or is it false? You could look at the draft manifesto to check but electoral manifestos are written to court popularity and, according to Wikipedia, "the status of electoral manifestos has diminished somewhat due to a significant tendency for winning parties to, following the election, either ignore, indefinitely delay, or even outright reject manifesto policies which were popular with the public". So where should we look for the truth? Perhaps a policy document not so widely read as a manifesto would be the place. And that is what Dr Grumble has done. This is what the Conservatives say in their Renewal/Plan for a Better NHS (pdf):

Over the past eleven years Labour have missed a golden opportunity to work in partnership with the private sector to provide better care, not privately, but free at the point of need on the NHS. Despite believing that market mechanisms work, they have failed to open up the market for the provision of NHS care so as to drive up standards.

We need a level playing field. All NHS patients should be free to choose any provider of care for their treatment – so long as that provider can provide treatment at the NHS price. So that could be an independent hospital or an NHS Foundation Trust, depending on the patient’s preference. Moving to this system, driven by patient choice, means people will get treatment more quickly and there will be a far stronger incentive for standards of care to improve.

Dr Grumble's patients cannot choose a private provider for their care. Not without paying anyway. Actually, and this is the truth, Dr Grumble would not necessarily advise them to obtain private care even if they wished to pay for it. Private care is not necessarily better and Dr Grumble is quite certain that it can be worse. Some of the very best doctors work for the NHS. Getting to the top in the NHS is not easy but any doctor is free to set up privately. It has been like that since 1948. It is one of the great strengths of our health service.

So Dr Grumble is left confused. Apparently David Cameron does not want the state to withdraw "in any shape or form" but we know from the policy documents that NHS patients should be able to "choose any provider of care" which could be "an independent hospital or NHS Foundation Trust". That presumably means a choice of either NHS or private provision or maybe third sector provision. How can that be achieved without "the state withdrawing from the NHS in any shape or form"? You work it out.

OK. If you have read this far you will now be wanting to know exactly what the wording is in the draft election manifesto. Here it is:

To give patients even more choice, we will open up the NHS to include new independent and voluntary sector providers – if they can deliver a service that patients want, to a high standard and within the NHS tariff, then they should be allowed to do so.

So there you have it. Essentially the same thing twice. No real obfuscation - except from David Cameron himself. There will be more independent and voluntary sector providers - full stop. The plans of the major parties for the NHS seem to to be much the same. When David Cameron says "We cannot afford to carry on like this" he is right. He can't. He needs to find something different. Not more of the same.

03 January 2010

02 January 2010

Should we give it the elbow?

Since the devastating 'flu pandemic Dr Grumble has been dutifully sneezing into his elbow and washing his hands frequently. His suit elbows are now in quite a state but that is the price you have to pay for halting the spread of disease. But now Dr G has learnt that there is actually no evidence that washing your hands prevents the spread of flu. So what about sneezing into your elbow? Is there any evidence for that? Because Dr Grumble is thinking of buying a new suit and he would prefer not to have his dried-up nasal discharge coating the elbows.

Who was it that thought up the idea of sneezing into your elbow? What is the evidence base? How much money has been spent on spreading this mantra? Does anybody out there know? Can you believe that there is a sneezeintoelbow.com web site?

01 January 2010

For the victims of peer review

Dr Grumble has a research paper on his desk gathering dust. He is fairly sure that its publication would save lives. Unfortunately the reviewers do not agree. The results of Dr Grumble's experiments were so dramatic that Dr G is suspicious that the referees just did not believe them.

The peer review process can be very frustrating. Dr Grumble has frequently had papers reviewed by anonymous 'experts' who revealed their incompetence in their comments. This video says it all.

With thanks to Dr Aust.