Saturday, 1 May 2010

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.


  1. Thanks for the anecdote.

    Frighteningly believable.

  2. Sadly, there's another reason for a Trust board agreeing to PFI. They may have rubbish buildings and the only way they are allowed to get new buildings may be PFI. They don't like it, but it's the only way the government lets them have the facilities they need. Nasty.

  3. Hmmmm...local formularies are often an endeavour to establish some sort of order from the anarchy of clinical autonomy which can be summed up with the expression that asking 12 consultants about the same patient gets 13 opinions.

    Some things are sensible even if they get up your nose.


  4. I don't accept that. The motivation behind local formularies is purely financial, and is based on a "one size fits all" mentality. It takes the decision on prescribing away from the front line clinician, who can take all patient factors into consideration, and puts it into the hands of those who often have no expertise in areas where their decisions are felt. That is the only anarchy in the system.
    There is also the small fact that, in light of the Herceptin judgement, enforcement of local formularies is unlawful

  5. Come on you guys! My dad went to war at 21 to fight against totalitarian rule - you can surely get it together to tell these bastards where to shove their interference? Surely there are some consultants who went to school with Cleggeron? Can't you get together and do something?