31 March 2010

Hooray for the Health Committee

The public's opinion of MPs is at an all time low. It is all to do with moats and duck houses, bell towers and bath plugs. But they are not all bad. Fairly ordinary jobbing MPs on select committees seem to do quite a good job and quite often get at fundamental truths which seem to escape those in government.

The latest report of the Health Committee will not exactly be an eye-opener to readers of this blog but it does lend some credibility to the views of Dr Grumble and like-minded folk. At times it seems that nobody else is aware of these home truths about our health service to the extent that, just occasionally, Dr Grumble begins to just wonder if it might be him that is mad and not the rest of the world. So it was with some relief that Grumble read the latest Health Committee report on commissioning.

Dr Grumble has strong views on commissioning. He thinks that the quality of commissioning is poor and that PCTs are full of lower calibre, highly paid individuals who are just not up to the job. He thinks that the purchaser-provider market system must cost a lot to run (though Grumble has no idea quite how much) and that while the system might have some benefits these are greatly outweighed by the costs. In essence Dr Grumble takes the view that we used to have efficient process but we now have an extremely inefficient pseudo-market which is a yoke around the neck of a health service that now desperately needs to make painless savings. If, after 20 years, successive governments have not been able to tweak the system to make it work, now surely is the time to abolish the purchaser-provider split and save the NHS some money, perhaps a lot of money, in the process.

The report is over 70 pages long. Read the summary if you have time. It will tell you what you already know but you will feel good reading it. If you really haven't got the time, here are some words cut and pasted from the report and presented here as a few choice bullet points:

  • The service has traditionally scored highly on account of its low cost of administration, which until the 1980s amounted to about 5% of health-service expenditure.

  • After 1981 administrative costs soared; in 1997 they stood at about 12%.

  • An estimate of administrative costs since 1997 has been made by a team at York University, in a study commissioned by the DH but never published. This concluded that management and administration salary costs represent, as a very crude approximation, around 23% of NHS staff costs.

  • We are dismayed that the Department has not provided us with clear and consistent data on transaction costs.

  • The suspicion must remain that the DH does not want the full story to be revealed.

  • We were appalled that four of the most senior civil servants in the Department of Health were unable to give us accurate figures for staffing levels and costs dedicated to commissioning and billing in PCTs and provider NHS trusts.

  • After 20 years of the purchaser/provider split commissioning remains a weak link in the English NHS. PCTs are too often passive, ineffectual players in the health economy.

  • These weaknesses are partly due to structural imbalances in the system, but also to PCTs’ staffs’ lack of skills, knowledge and talent.

  • The current health system with the purchaser/provider split is expensive to run with high administrative and management costs.

  • The abolition of PCTs would generate significant financial savings in a period of considerable financial pressure.

And the last line in the Way Forward reads as follows:
  • If reliable figures for the costs of commissioning prove that it is uneconomic and if it does not begin to improve soon, after 20 years of costly failure, the purchaser/provider split may need to be abolished.

Hey ho.

28 March 2010

24 March 2010

Infection control witches

We all know these witches. They are the people who rudely interrupt your ward round to complain about a tie or a bangle that they deem a health hazard. Despite their rudeness and God-given right to throw abuse at hard-working staff, Dr Grumble complies fully with their wishes. Who would want to cross swords with a witch? Witches are powerful people. And they can caste spells.

Plainly others feel differently. Only yesterday Dr Grumble was told to tell one of his staff off about her attire. That is a new approach. Witches know they are despised so they try to get Dr Grumble to do their dirty work for them. Dr Grumble commands more respect than a witch. Not that that is difficult. Grumble dutifully passed on the complaint. The young doctor concerned took no notice. No notice whatsoever. Dr Grumble was not altogether surprised because he has seen this behaviour before. When the coven makes its wishes known, heels are dug in and the instruction is blatantly ignored. There is something very wrong with an organisation when staff react in this way.

You might think that Dr Grumble's charges must be a rebellious lot but it is not the case. Dr Grumble's own instructions on patient care are followed to the letter. There is never any argument about who is in charge and who knows best. We all know that Grumble could be wrong but we all also know who has to carry the can. What Grumble requires to be done is done. But edicts originating from witches are studiously ignored. The difference in behaviour is quite striking.

Some witches though are worth paying attention to.

21 March 2010

Crippen would have loved it

Every now and then Dr Grumble tries to find a way to draw his blog to a close. Every time he tries there is always just one more thing he wants to vent his wrath over.

One of the things that used to baffle Dr Grumble was that the government's health policies were often so off the wall. It seemed that the only people to benefit from many of the most bizarre initiatives were the rich owners of businesses. Eventually Dr Grumble worked out why this was. If you don't know you may find a clue here.

20 March 2010

Religious sheep take control of NHS

Dr Grumble has been wondering about the sanity of those planning the latest health service initiative: swingeing bed cuts. There seems to be a new belief amongst NHS managers that hospital doctors are admitting patients who could be managed by their GP at home. This is one of those quirky managerial beliefs that has recently become propagated from somewhere on high. Who starts these concepts Dr Grumble has no idea. They arrive seemingly from nowhere and all of a sudden NHS managers throughout the realm slavishly follow the latest edict like flocks of mindless sheep. Whatever the idea is, however batty, the NHS manager will believe it implicitly and without question. Evidence-based management is not in the health service lexicon.

The approach has something akin to a religion. NHS management has much more to do with blind faith than reason. Consequently today's unquestioned mantra is that hospital beds need to be cut and that patients can be managed 'closer to home'. To be fair, there are certainly patients in hospital who should not be there. Most of them needed to be there when they were ill but then cannot go home because they can no longer manage without more social support. But getting that social support promptly can be, to say the least, a challenge.

Dr Grumble's ward round today was a long affair. Five whole hours without a break. He saw all sorts of patients. Some were in their teens. Most were elderly. Some were very rich. Most were quite poor. Some were very ill. Some were not so ill. One was not acutely ill at all. He was an elderly man who lives alone. He struggles to manage. He has some medical problems including long-standing ulcers on his legs. The nurses who look after him phoned the patient's GP yesterday and said that he needed to go into hospital. Yesterday was Friday. Things can seem worse on a Friday.

The GP did not go and see the patient. Perhaps he should have. On the other hand, quite possibly it was not going to change the outcome. If the nurses were not happy that the patient could be looked after at home what was the GP to do? Certainly the GP was acquainted with the patient and knew the situation. And, rightly or wrongly, he sent the patient in. The patient was dutifully clerked by a junior doctor and the patient was admitted to the Grumble ward. The patient was presented to Dr Grumble. Dr Grumble assumed that the ulcers on the ankles must be pretty grim and that that was the reason for the patient's admission. But when Dr Grumble saw the patient he was quite well and the ulcers were clean. There was nothing the hospital could do to make this patient any better. The patient did not want to be in hospital and was keen to go home. But because he is so old and generally frail he really cannot manage at home. Hospitals are open all day and all night and take all comers. There is nowhere else for these people. It has been like this for ever. And our managers have done nothing about it.

14 March 2010

06 March 2010

Why we don't know what is going on

Dr Grumble has to be honest. Sometimes he talks up some of the videos he wants you to watch. People who read blogs want something short and snappy. Some of the videos Dr G would like to have you watch are quite long. And some of them have not been watched by that many people on YouTube implying, perhaps, that they are not exactly riveting.

This next video won't be oversold. It has been viewed just 300 times on YouTube which is pathetic. It is not short and it is not snappy. But if you want to find out why it is that so few people know what our government is doing to our NHS you can find out here:


Like many people who like to consider themselves well informed, Dr Grumble listens to the Today programme most mornings. Unfortunately he hears the beginning and never the end. The best interviews are timed to reach the ears of the important people in the world. Real workers traditionally start work at 8 o'clock. Bosses start work at 9 o'clock - or later. Dr Grumble has never understood why this is. If the time you start work determines whether you are a worker or a boss, Dr Grumble falls into the worker category. Easily.

Today being Saturday Dr Grumble might actually hear the end of the Today programme. There does not seem too much real news around at present so perhaps that's why today on Today they eventually got round to mentioning that 13 hospitals in London are under threat of closure. Dr Grumble has known about this for some time and he was surprised that it was only today that Today caught up with this stale news. Perhaps they don't consider it important. Or maybe it is not contentious. It is political but it is not party political. This is what John Lister says:

The cuts are political. They’re not party political because both Labour and the Tories are committed to essentially the same programme.

Dr Grumble did say that he expected this blog would take a more political direction as the election neared. Dr G actually had it in mind to tell you how to vote. But the problem he has is that he hasn't yet found a party with different policies from the present incumbents. Quite a lot of people are aware of this anomaly which may be why one of the parties is trying to advertise its way out this rather fundamental problem by implying that they stand for change.

Now that Dr Grumble has realised he is a worker it is time to look at the Socialist Worker's take on this. Dr Grumble never thought he would ever become a fan of the Socialist Worker. But our democracy is very weak at present. We do need an alternative view. At present all we really have are the red team, the blue team and the yellow team. Party politics has become little more than one of those games you play at management training meetings when you are allocated to a red, blue or yellow team and plan the future with the aim of reaching the same bottom line.

Party politics no longer has passion. No longer is there real argument about real issues. No longer are there two sides to every story. Is it any wonder that so much in politics seems to revolve around personalities? There is nothing else. Where's the meat?

What we want and so desperately need is something different on offer. But there is nothing different. People want change. We all know that. But one thing is for sure: they won't get it here. They might get something even worse. The electorate are not daft. They see what Grumble sees.

With no other way forward on offer, the NHS we know and love is doomed. It is the most awful tragedy. It will cost us dear. But it seems there is no way out of the direction in which we have been forced. We, the people, have not chosen this route for our beloved NHS. Neither the policies or their implementation have been discussed. In today's parlance there has been a certain lack of transparency if not complete opacity. All this has, of course, been most deliberate. As a consequence the public know little of the true depth of the catastrophe that is about to be unleashed. Compounding the public ignorance, the media show little real interest in the NHS. The Today programme addresses the hospital closure only as the briefest of asides on the quietest of quiet news days. The BMA, not know for its alacrity, has reacted far too late. (Dr Grumble will leave you to guess the reason.) The fate of the NHS is, to be realistic, already a fait accompli.

If you can bear to listen to how New Labour caused this impending disaster by surreptitiously bringing their policies into line with those of their predecessors, watch John Lister in the video. If you feel for the NHS like Dr Grumble, make sure you have a tissue to hand. Or a box of tissues.

04 March 2010

Polysystems and Rich Pictures

Sorry. If you were hoping to find out what a polysystem is, Dr Grumble doesn't know either. It is probably a few months since Grumble first heard the term but he still doesn't know what it means. Words without meaning frighten Dr Grumble. It's perverse for a word not to have a meaning. It is the raison d'être for a word to have a meaning. Sometimes words without meaning have a dangerous purpose. Their purpose can be not to convey a meaning. Not the real meaning anyway. Do you think that might apply to the word 'polysystem'?

What is the essence of the polysystem approach? Ostensibly it is about providing care for patients closer to their homes. That sounds laudable. It is also supposed to be cheaper. Why it should be cheaper Dr Grumble has no idea. If you provide the same services that are in a hospital to patients that are in the community it is not at all obvious to Dr Grumble that it will be both better and cheaper. The MRI in the polyclinic at the end of the road has never been a realistic option. And while handheld ultrasound scanners may get us a fraction closer to the dream of Spock-style Star-Trek diagnostics the reality is that in the 21st century a scanner is only as good as the bit between the ears of the person operating it. Quality diagnostics is not just about providing the necessary hardware at the street corner.

The more you think about the idea of moving care into the community the more daft it becomes. It is not a bad ideal but it just can't be cheaper and better. In the current financial climate it may not even be affordable. So why the headlong rush for a model of healthcare that has never been tried, is totally untested and has not been costed? That is today's big healthcare mystery.

But wait. Dr Grumble is making the mistake of assuming that the primary purpose of polysystems is to move care closer to patients' homes. That after all is what we are being told. But is this the real purpose? Are our masters so misguided as to really believe that polysystems are going to be both better and cheaper? Of course not.

兵不厭詐 (兵不厌诈)

There is only one interpretation that makes any sense to poor old Grumble and that is that this whole polysystem thing is not much about improving patient care. So what is it all about? What is the dangerous hidden meaning behind this ghastly newspeak? Why has this new word with no meaning been contrived?

The horrid truth is that this polysystem thing is about chopping up the National Health Service into lots of little pieces and then getting rid of it. It could be privatisation or it could be something else. Exactly what doesn't trouble our masters too much. What it won't be is the NHS. The components of the polysystem will be called NHS providers and the NHS will pay but the provision of care will come from bodies that are not actually the NHS as we know it. The details are vague and uncertain - quite possibly deliberately so. Vague enough to be depicted as a Rich Picture (pdf). For some it will be a very rich picture. For most of us it will be quite the opposite.