In the know

A typical exchange on the ward. I approach the Sister in Charge. “Excuse me, do you have a patient Charles Watkins (name invented), post op above knee amputation?” She looks up coldly from her clipboard and stops ticking boxes long enough to say “Never heard of him.”

I wander off and find a senior Staff Nurse. She is writing something that no-one will ever read. “Excuse me, do you have a patient Charles Watkins, post op above knee amputation?” “Don’t think so, not my end, try down the other end”

At the other end I find a less senior nurse and ask again. She consults a tatty piece of paper “Maybe but he is not my patient” Is the response

I try the SEN (Yes I know they don’t exist any more). “Yes , but I don’t know where he is.”

Finally I try the auxiliary (OK OK the HCA). “Oh Charlie?’ she says. “Yes that is his bed over there but he is not there, he has just hopped out for a fag. He will be back in 10 minutes cos that is when lunches arrive and it’s fish & chips today which is his favourite.”

I know who to ask first next time.

Knighthoods

In three weeks time the attention of a small number of our colleagues will be diverted to the Queen’s birthday honours list. I won’t be looking. It is a safe bet that my name will not be on it. This might sound like sour grapes, but my own view is that the whole concept is antiquated, anachronistic and arbitrary. Like Clinical Excellence Awards we all know of deserving non recipients, and undeserving (in our opinion) recipients.

Outside medicine I am constantly bemused by the sight of knighthoods, MBEs etc being given to such deserving types as entertainers and sportsmen for doing no more than a very well paid job, while the auxiliary ward nurse (or whatever they are called these days) up to her elbows in shit every day for a pittance goes unrecognised.

It is apparent too that many honours, particularly knighthoods, frequently seem to be awarded automatically to those who have attained a certain post, not only in medicine but also the civil service, the military, law etc. I think this devalues the entire concept. Just get to the top of the greasy pole and you get a knighthood as an added bonus. There does not seem to be any requirement that you will have achieved anything special or worthwhile. Just sit at your desk for a while, do your (highly paid) job without screwing up too badly, and you end up a “Sir”

In my next few posts I am going to look, one by one, at some of our medical knights. What have they achieved. Have they earned it, or are they, in the words of Ben Elton, just a suit full of bugger all.

Now, who shall I start with?

Accountability, part three

Having posted my last rant about the managers at Stafford hospital, it hit me that I have completely failed to mention one other group of people who should take some responsibility for what happened there.

The medical Consultants must have known full well what was happening at the sharp end. Unless they were blind and deaf they can not have been unaware of the avoidable suffering and death being inflicted upon their patients. Patients to whom they owed their ultimate loyalty. They as much as anyone let their patients down.

It could be argued of course that they were, like other staff, intimidated into silence, knowing full well what would happen to any individual who spoke out.

But...............Most hospitals today have a committee, the membership of which is made up of all the Consultants in the hospital. They have various titles but a common one is Senior Staff Committee. These provide a regular forum where members can take their concerns and present a united stance to management. They can be immensely powerful and in the past votes of no confidence from this committee have resulted in sackings of Chief Executives and Chairmen of Trusts. This power has been wielded as recently as 2009. A united Consultant body can not be intimidated or subjugated.

So what happened in Stafford. One can understand why individuals would not speak out, but Consultants will certainly have grumbled amongst themselves. Why did they not protest as a united body.

The answer is simple. Cowardice. Craven, inexcusable cowardice for which they should be thoroughly ashamed.

Accountability, part two

I have recently posted commenting on the scandal at Stafford hospital and the fact that the three individuals who occupied the post of Chief Executive over the relevant years have not only escaped the consequences but have suffered no block to their further careers.

No CE can act alone however, and the rest of the managerial board will have supported his actions.

Let’s have a look at who some of these people are, and where they are now.

Jan Harry was the Trust’s Director of Nursing from 1998 to 2006. She it was who told the Trust Chairman that axing 52 Nursing posts “would not harm patient care” She told the Mid Staffs enquiry that “It was not her job to monitor standards on the wards” and she had “no major concerns about the care provided” This is pure denial. As a nurse she can not possibly have been unaware of the likely consequences of staff cuts or of the situation on the wards. She chose to ignore these and fall in behind the CE, presumably in the interests of her own self advancement. Since leaving Stafford in 2006 she has worked in Dudley, and then Salisbury though she left there in 2009. She now seems to have gone to ground.

Helen Moss was her successor. In the years after 2006 she made no improvement to Stafford and, like her predecessor, toed the line. She is now with NHS East Midlands running the Leaders Development Placement Programme. Apparently Dr Moss will be responsible for “planning training and organising the numbers of nurses needed in trusts across Leicestershire, Derbyshire and Nottinghamshire.” Perhaps while they are at it they could appoint Gary Glitter to run their child protection service.

Toni Brisby was Chairman of the Trust and has been allowed to quietly resign without censure. The same is true of Dr Val Suarez, who was Medical Director and has now gone back to being a jobbing pathologist, for the time being at least.

You might wonder what, if anything, it takes to actually get a Manager sacked. Well according to this article doing a good job, and pressing for things to be done correctly will do it.

GMC gets it right for once

Best news I have heard for some time.

Draw Mohammed Day

Threats to freedom of expression is not an issue confined to NHS staff. Thursday was apparently "Draw Mohammed Day"

Since I can't draw for toffee I have reproduced this cartoon from "Pharyngula" as a gesture of support.

Accountability

In my previous two postings I have highlighted the increasing difficulties which Consultants are encountering in their work. The ultimate example of where this can lead is seen in what happened at Stafford. Here all staff were silenced by the knowledge that the management would turn viciously on anyone who spoke out, and yet, by not speaking out medical staff were arguably in breach of GMC good practice guidelines. They were thus in a position akin to a man walking a tightrope while wearing a straitjacket, and a gag.

So let us see what happens to managerial staff when they have misbehaved. What better place to highlight this than Stafford.

For those of you who have been living in a cave Stafford Hospital is the subject of an independent report which can be found here. The report found that, between 2005 and 2008 the hospital board was, through cost cutting exercises, responsible for appallingly poor levels of patient care which may have resulted in as many as 1200 excess deaths. They also found that during this period NHS regulators reported that the Trust was performing well, and it was granted Foundation status.

In fact the problems probably go further back than this. A CHI report as early as 2002 was also highly critical of the Trust.

You might reasonably think that for any manager to be associated with this disaster, would mean their career was finished. Think again.

Although the recent report confines itself to the period between 2005 to 2009, the state of affairs at Stafford probably pre date this period and the executive decisions responsible go back even further, perhaps as far back as 2000. During this period the Trust responsible for Stafford hospital had three chief executives.

From 2004 till recently the post was held by Martin Yeates. Yeates, by resigning has escaped any responsibility for his actions, and did not even give evidence to the enquiry. He seems to have parted on very generous terms. His predecessor was David O’Neill in post from 2001 to 2004. It is clear that he too was making decisions which contributed to the scandal. A search for him on Google yields no results showing his present position. There is no suggestion that he will ever have to answer for his actions at Stafford. His predecessor was David Fillingham. It is probably he who sowed the seeds of destruction during his tenure from 1998 to 2001. Subsequently he was appointed as Chief Executive in Bolton in 2004, introducing something called “lean thinking” in 2005. In 2009 Bolton was highlighted as one of the seven deadliest hospitals in Britain. You have to admire his consistency. He has now been appointed to head AQuA, a new NHS organisation created to improve the quality of health services throughout the North West by supporting NHS staff in improving skills. You could not make it up. Improving quality of health services, entrusted to a sort of NHS peripatetic grim reaper, leaving death in his wake wherever he goes.

In my next post I am going to highlight some of the other angels of death who contributed to the scandal of Stafford, and how their careers have progressed since. Remember at Stafford alone as many as 1200 deaths may be attributed to mismanagement. That is six times more than were killed by Harold Shipman.

Regulation

Until just a few years ago the GMC was the only regulatory body we had to worry about and they were in the past criticised, with some justification, for being perhaps too sympathetic to the unfortunate medical practitioners who came to their attention.

Step by step things have changed.

Firstly there are now more bodies that a doctor can fall foul of. NCAS, MHRA, CHRE, NHS counter fraud service and others can all make life difficult for doctors, as explained here, in addition to an increasingly belligerent attitude from Trusts as highlighted here.

Secondly the GMC has over the years become less and less sympathetic to doctors and is seen by many as biased against them. Doctors who feel they have been poorly treated by the GMC have no route of complaint. Complaints about the GMC can only be made to the GMC and the outcome is then predictable. The legal principle of “nemo debet esse iudex in propria causa”, meaning no one should be judge in his own cause is clearly ignored by the GMC. In fact the GMC often behaves as if the law is something that does not apply to them. This is well illustrated in this case. Dr P had brought legal action against the GMC for breaches of Data Protection and Human Rights legislation committed during an investigation. The GMC attempted to have the action struck out. The argument they made to the bemused judge was that they, the GMC had been deliberating for a number of years on how to incorporate the relevant legislation into their procedures, but that they had not yet come to conclusions, and therefore these laws did not apply to the GMC. The extraordinary effrontery, and unspeakable arrogance of this argument was dealt with in no uncertain terms by the judge and an out of court settlement followed soon after. It is a shame that the settlement was accepted by Dr P as the GMC were thus able to avoid the adverse publicity of being savaged in court for their attitude. I do not however wish to criticise Dr P. It takes a special kind of tenacity and resilience to tackle a body as powerful, overbearing and underhand as the GMC and Dr P can not be blamed for bringing things to an end.

The GMC can only be challenged in the high court, and they rely on the financial and emotional disincentives to this action to get away with highly questionable actions. If you google “GMC high court” what is apparent is that the GMC almost always lose on those occasions when they are challenged.

And this is a body that is gradually acquiring more and more powers. It is now two years since the burden of evidence used by the GMC to convict doctors was changed from the criminal standard where guilt has to be proven beyond reasonable doubt, to the civil standard of probability.

And soon we will have revalidation. We are going to have to prove that we are are competent, without any suggestion of misdemeanour or lacking performance. I predict that before long perfectly competent and amenable doctors will be finding themselves in difficulty simply because they have not been able to tick a few boxes.

Clinical autonomy

Something I have noticed over the years is how increasingly restricted we have become in our clinical practice. Once upon a time our employers allowed us, as Consultants, total clinical autonomy. Indeed this was one of the conditions demanded by the BMA before they would agree to co-operate with the formation of the NHS. Increasingly this clinical autonomy is being lost, as managers control clinical practice by over rigid enforcement of protocols and guidelines many of which have little evidential base. Another example is referral management as described here. The concept of clinician discretion is gradually being lost. This culture of resigned obedience culminates in the sort of bunker mentality which afflicted the staff at Stafford hospital, too intimidated to speak out. The BMA of 1948 considered clinical autonomy one of its highest priorities. The BMA of 2010 is not the same.

Foundation Trusts

Once the dust has settled and we have a functioning government again, attention will quickly turn to addressing the UK’s huge budget deficit. Although Mr Cameron has promised to preserve front line services it would be naive to assume the NHS is going to escape the axe.

Foundation Trusts were announced in 2002 by Alan Milburn.

There are now some 170 acute hospital trusts in England of which more than half (89) have acquired Foundation status.

So what is the difference between a Foundation and an “ordinary” trust? Foundation trusts are overseen by (yet another) government body called Monitor. The differences between the two types of trust are set out on their web site here. Perhaps it is just cynical old me but the differences described don’t fill me with enthusiasm. It looks mostly like window dressing and waffle to me. Although Monitor suggests that Foundation trusts “can be more responsive to the needs and wishes of their local communities” they don’t say how or in any way support this assertion.

So is there any evidence that Foundation trusts provide a better service than other trusts. This report shows that of 25 trusts apparently having excess death rates 15 have foundation status. The report also highlights the unsurprising discrepancy between self assessment and external assessment of trusts’ performance. This report points out that two of the most criticised trusts in England have Foundation status. If Foundation trusts did provide a better service, then by definition the NHS would provide a two tier service, totally contrary to founding principles.

So why are chief executives so keen to acquire Foundation status. It certainly doesn’t come from front line staff most of whom see no advantage, or patients whose expectations tend to be far more mundane. This report I think might hold the answer “According to the IDS research the median salary for a chief executive of a NHS foundation trust stood at £157,500 for the year to March 2009, compared to £147,500 for a chief executive of a non-foundation NHS trust.”

So a tip to the incoming Health Minister. Dumping this failed experiment will probably save money and encounter precious little opposition.

Election euthermia

Well the election is over. I think expressions of political opinion tend to alienate half your readership, which would take mine down to one. Because of this, and my total lack of political inclination, I am not going to make any comment. Trying to second guess the consequences for the NHS is inviting the embarrassment of being totally wrong, rather like these nutters who periodically predict the end of the world. Why not just wait and see?

Freedom of speech

I wrote in my very first post about freedom of speech. It seems that our cousins across the atlantic take this far more seriously, in this extraordinary judgement by the US Supreme Court.

Do not read this if bad language offends you.

Actually I don't think this can possibly be real, it has to be a spoof...........I think.

Election day

Election day at last. Not a lot to say really. I have had my own sitting MP on my doorstep during the campaign, and was not impressed. He seemed to be incapable of independent thought. Without his party dogma he was a bit of an empty vessel.

On her blog site the Witch Doctor has said that she “was always under the impression that the brains of politicians had the capability of independent thought.

She was surprised therefore to discover that the brains politicians utilise seem to be those of others, rather than their own.”

I have evidence that this is literally true in this picture smuggled out of an exclusive neurosurgery unit for politicians.

I have been sent an anecdote by an old friend. It might only seem like a small matter but I think it illustrates a growing attitude of disrespect that professionals are experiencing from Trusts.

Apparently a Trust has sent a circular round aimed primarily at nursing staff. The tone is rather hectoring and includes the phrase “staff who work a four hour shift are reminded that they are NOT entitled to a break” The capitals are theirs.

I don’t know about you but I find this a little disturbing. Our nursing colleagues are mostly responsible professional people. We have seen them work through breaks and work on past their finish time, just as we do. This is something for which they receive no recognition, no thanks, no acknowledgement. The employers enjoy the benefit of this goodwill but ignore the fact that the balance of time owed is most definitely in favour of the nurses.

To communicate with them in this way is, I think, oppressive and insulting. It can only serve to further alienate and disillusion a dedicated workforce. It shows a lack of appreciation, and tact, and is piss poor man management.

Beds

I wondered initially if I would be able to find enough to write about to keep this going but I find I have more than I can keep up with and so will have to prioritise.

Perhaps the most pressing and worrying is in this article from todays Times. To put these suggested cuts in bed numbers into perspective I have done a little digging into the trend over the years. These are the number of NHS beds in England only, in thousands since 1974.

1974 396

1989 270

1997 199

2007 167

2009 160

?2011 130

What are the consequences of these cuts. As far back as 1999 it was estimated that 57000 operations were cancelled on the day of surgery for non medical reasons. In 2008 it was reported (admittedly in the Daily Mail) that in one 28 day period 150000 over 75s had to be readmitted within 28 days of discharge.

Whatever the figures I think all of us can vouch for the problem. I have personally seen surgical patients kept in recovery all night post operatively because no ward bed was available. The situation is inevitably going to get worse.

The perils of canvassing

I have recently started rereading "The Citadel" by A J Cronin. I think this should be compulsory reading for all doctors. Cronin lived and worked in the same area, and hospital as Aneurin Bevan and almost certainly had an influence on the formation of the NHS. The book gives an insight into the practice of medicine, and the mindset of the doctors and medical institutions in the years before the war. The more I read it the more I come to the conclusion that depressingly little has changed.

First post

Inevitably given the date I have to start with the General Election. None of the three main parties have given much attention to the NHS and in what attention they have given there seems little to separate them. Each gives dire predictions about the consequences to the NHS under their opponents but these are pure speculation. The only hard facts we have relate to the record of the current lot in power. Certainly on the issues I see as important I seem to be on my own. What are they?

1. The loss of clinical autonomy. Management have to manage, I acknowledge, but increasingly they are dictating clinical practice. Policies, guidelines, protocols, local formularies, tick box practice and the pursuit of targets only remotely related to patient care have all been imposed, usually under the pretence of “governance” and “patient safety” I can not adequately express how wrong I think this is. They do not have the expertise, the knowledge, or even the proper motivation. They do not seek advice from those who do. We as consultants are in no small part to blame as we have simply acquiesced and let them get away with it. The BMA have never seen this as an issue, but then expecting any useful function out of them is naive to say the least.

2. Private Finance Initiative. There seems to me to be something here that is blindingly obvious. If a private company can do some sums and work out that a PFI scheme will make them a lot of profit, why can’t the NHS do the same sums and see that that profit can only come from the NHS budget. These schemes inevitably represent a loss of capital from the NHS to the private sector. Those who sign off these initiatives do so for only one of two reasons as far as I can see. The first is utter incompetence, if you accept that they have not done the sums, or do not realise the significance of the answers. Alternatively they know the maths full well and proceed anyway, and the only motivation I can see for such action is to divert NHS funds to their mates in the private sector. If anyone has an alternative explanation I would love to hear it.

Those two will do to start with, but I will finish with an anecdote illustrating how government initiatives can pervert proper clinical care. What I describe below I saw directly and I know it to be true.

A busy NHS hospital 0800 on a weekday. A morning theatre list with two inpatients on it. Patient A has a minor benign condition for simple surgery. Patient B has a primary malignancy and is for more major surgery. Problem. There is only one inpatient bed, so one of these two patients has to be dumped. The clinical imperative is clear, patient B is the more urgent. However if patient A is dumped he will breach waiting list targets. So who goes home? You guessed it, the management intervenes and patient B goes home. Surgeon and Anaesthetist both grumble, but do as they are told. Patient B is not even told why his operation is cancelled. We should all of us be ashamed that we allow this sort of thing to happen.