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Have you ever seen a 10‑month-old type? It's how I imagine Casualty gets written.

Robert Webb

NHS Consultants?

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From now until the end of the world, we and it shall be remembered. We few, we happy few, we Band of Bloggers. For he who shares his blog with me this day shall be my brother. William Shakespeare ("King Henry V")

Telehealth, & Jargon

Sometimes as you do a little research for a post you find you have hit a rich seam of material, full of new information, and unexpected connections. When I recently stumbled onto this document I did not at first see it as much more than the basis for a rant about management doublespeak and obfuscation. Persevering through the almost incomprehensible paragraphs I started to understand what it was about. And the more I read the more angry I got.

First of course it is, superficially, a prime example of management jargon. Phrases like “thought leadership, capacity building and system regulation to the NHS..........consistent with delivery of the work programme of the Long Term Conditions Healthy Ambitions Pathway and securing the regional element of the QIPP strategy.” say it all. The document goes on (and on and on) in similar vein. Einstein once said “If you can’t explain it simply you don’t know it well enough” So the author, one Professor Sue Proctor either does not know what she is talking about, or, more likely, she is trying to dress up and obscure something unsavoury.

Telehealth is supposedly a concept of delivering health care without the troublesome business of doctors actually having to see their patients in the flesh. Instead patients would have “telemonitoring, video consultations, and teleeducation”. I think most clinicians can see the flaws with this but Prof Proctor does not, though she does acknowledge the risk that, from Strategic Health Authorities down to individual clinicians there may be a lack of enthusiasm. This does not seem to deter Ms Proctor who enthuses “This is an ever developing market sector with a range of commercial providers and NHS/Foundation Trusts likely to be attracted to a business opportunity of this magnitude.”

I am deeply repelled by this idea that the NHS has come to be regarded as a “business opportunity”, a means for some to make disproportionate profit in a manner far removed from taking an honest days pay for an honest days work.

Ms Proctor also cites proof of concept from Airedale Hospital of all places, which has recently been highlighted for serious failings, leading to police involvement. Further the “workstrand” is being led by none other than Adam Cairnes, the very individual responsible for those failings, whilst CE at Airedale.

So who is Prof Susan Proctor? Her qualifications are listed as RGN, MSc PhD. That’s right, she is a nurse, removed from the one area where she might be of some use, nursing. Looking at her previous positions and relative youth it seems pretty unlikely that she has done much actual nursing.

I have the greatest of respect for my nursing colleagues, but I think the interests of patients are best served when nurses actually nurse. I believe that nursing is primarily a practical, and not an academic subject and that the change of nursing to a degree course was detrimental to the profession. I know many nurses who agree with me.

It seems to me that Ms Proctor has used nursing as nothing more than a vehicle to attain for herself a position far far beyond her intellectual capabilities, where she feels she is qualified to pontificate on how to deliver medical care.

Telehealth is in my view an abomination. It is the ultimate separation and alienation of patient from doctor. Those who advocate it seem to understand nothing about the doctor patient relationship and the importance of proximity in a consultation. The ability to physically examine patients, to make eye contact and to be able to shake or take the hand (without gloves!). As Jacob Bronowski once said “We have to touch people”

Farewell JD

Jobbing Doctor has announced his retirement (hopefully temporary) from blogging. I only discovered his blog recently and have been an avid reader. It has been very valuable to me as a hospital consultant to get some insight into the working lives of our general practice colleagues and he has dispelled a number of my preconceptions.

He was also one of those who inspired me to start my own poor offering here.

Enjoy your rest JD, and come back soon.

The Chief Medical Knight

The post of Chief Medical Officer was created in 1855. There have been fifteen incumbents, all of whom have been male, and all but one has received a Knighthood. The role of the CMO is set out here by the Dept of Health.

In the 2002 New Year Honours List, Liam Donaldson, CMO since 1998, received a knighthood in recognition of his achievements in health and health care.

So what are his achievements. They are set out here in a positively glowing document, again by the Dept of Health. At first site it looks pretty impressive but look again more critically and most of it is waffle and hype. For example he has received an award “in recognition of his achievements in the field of patient-centred care” Of course we were not doing that before he came along. Then again “The country's first comprehensive health protection strategy (Getting ahead of the curve)” I am afraid when people start using phrases like “getting ahead of the curve” and all the other business and management jargon that permeates the NHS today I just think “oh no, he is one of those!” In fact most of the achievements listed are in a similar tone.

His list of achievements also includes leading the drive for revalidation, which I have commented on before.

Finally his list for some strange reason omits his most memorable achievement. One which has had more effect on many doctors than anything else he has done. I am of course talking about MTAS. Now why do you suppose that is not on the list?

There is a more impartial appraisal of his performance here, but I would take issue with some of the positive points mentioned here. It is stated that “The smoking ban in public places, introduced in 2005, will be remembered as Sir Liam’s greatest success.” Firstly the ban in England was introduced in 2007, not 2005. In 2007 the prevalence of smoking in England was 21%, since when it has not fallen, and may even have increased, so how does this constitute a success? While it is true that enclosed public places are more pleasant places to visit we now have the unedifying sight of smokers huddled outside every public building like naughty schoolboys behind the bikesheds. Also even though I am a non smoker I think a total ban in pubs was a ban too far. Most pubs have a separate room which could be set aside for smokers and the total ban has had unintended consequences. Pub closures were running at 100 to 200 per year before 2007. In 2008 there were 1400. For many pubs on a financial knife edge the smoking ban was the final straw, and many rural communities, instead of having a smoke free pub now find themselves with no pub at all.

Donaldson is also campaigning aggressively for minimal pricing on alcohol. I think this is an oversimplistic approach. It ignores the fact that many countries with cheaper alcohol than the UK do not have the same problems. It is also very likely that hardened drinkers, the ones who are the greatest concern, will economise elsewhere in order to maintain their habit.

I do not see that treating smokers and drinkers as pariahs is somehow “a success”.

As for swine flu, preparedness is one thing, but can anyone explain why the government bought 130 million doses of vaccine, when a single dose is adequate and the total population of the UK is only 65 million. Presumably this was on the advise of Donaldson.

So all in all I have to agree with the comment made by Orthopod on the Hospital Doctor article. “He was never a ‘leader of the profession’, just a senior bureaucrat who happened once upon a time to have been to medical school.” A suit full of bugger all then.

Patients

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Rome did not create a great empire by having meetings, they did it by killing all those who opposed them.

Unknown

The GMC Knight

The GMC was formed in November 1858, All of it’s presidents except two have been Knights or Lords either prior to or subsequent to appointment. No GMC President has vacated the post untitled since 1892.

Graeme Robertson Dawson Catto succeeded Sir Donald Irvine as President of the GMC in Nov 2001. He was knighted within weeks. Irvine had been forced to stand down or face a vote of no confidence.

No appraisal of Professor Catto’s performance as President of the GMC could exclude consideration of his role in revalidation. Revalidation was first proposed after Harold Shipman was convicted of murder in January 2000. Despite him being the only Doctor in British history convicted of murdering his patients it was felt necessary to introduce measures to prevent a recurrence. This was a pure knee jerk response, but typical for the last government. The GMC made initial proposals but these were criticised by the Shipman enquiry and replaced by proposals from the enquiry. Sir Graeme and the GMC did not initiate these proposals but have been at the forefront of a propaganda campaign designed to have the medical profession accept them, and impose them regardless. Sir Graeme has been deaf to many valid criticisms of the proposals, not the least of which is that revalidation would almost certainly not detect another Shipman. The majority of the profession remain sceptical, suspicious and unconvinced, and finally the BMA have responded to their members’ concerns.

The new government appears lukewarm about the entire concept and the future of the revalidation project is now most uncertain.

So, let’s take a while to look at Sir Graeme’s other achievements as GMC President.

Well that didn’t take long now did it!

This is a pity as there many areas where the GMC could stand some improvement. Sir Liam Donaldson himself has written a report accusing the GMC of inconsistency, “the council causes distress to doctors over trivial complaints while tolerating poor practice in other cases”. It accuses the Council of being "secretive, tolerant of substandard practice and dominated by the professional interest, rather than that of the patient"

There is also the scandalous practice of “draft determinations”,

“its use of draft determinations and predetermined sentences of erasure. It has now been admitted by the GMC’s own solicitors that the assistant registrar, who was also the secretary of the professional conduct committee, would either write or direct clerks to write draft determinations some weeks prior to the professional conduct committee sitting. The draft would then be handed by the committee secretary to the chairman and the panel to be read out as the final determination. In these cases, the draft also contained the predetermined sentence of erasure, which basically means that many of these hearings were effectively a complete sham.”

Hansard 16 March 2009.

This way of conducting hearings is similar to that of the Queen of Hearts from Alice in Wonderland. "Sentence first!, verdict after!." It constitutes a breach of article 6 of the Human Rights Act 1998.

Also in 2008 the burden of proof required for the GMC to convict a Doctor was reduced from the criminal standard (beyond reasonable doubt) to the civil (balance of probabilities). This is grossly unfair. Doctors under investigation are not in dispute with another individual over some civil liability. They are accused, by an enormously powerful authority, of what the GMC considers crimes, with the most potentially disastrous punishments. The only purpose behind this change is to make it easier to convict a doctor without having to bother with troublesome concepts such as evidence.

In summary the GMC has suffered such a (deserved) fall in it’s reputation that even a past President, Sir Donald Irvine, has called for its abolition.

So Sir Graeme Catto, for a complete failure to reform an organisation badly in need of fundamental change, and allowing the GMC to sink deeper into total disrepute, in my view easily qualifies for the description, a suit full of bugger all.

Foundation status again

I see yet another hospital, Airedale, has been found to have had serious failings as a result of managerial obsession with acquiring Foundation status. A report has stated that the managers lived “In a parallel universe” and that the goal of Foundation status “became an end unto itself” It also accused management of “losing sight of their overriding goal of serving patients in the best way possible."

If you look at Airedale hospitals website it introduces itself thus.

“Airedale NHS Trust is an award winning NHS hospital trust. Our vision is that by 2016 our distinctive ability to provide safe, high quality, compassionate and affordable care, will have placed us among the top 10 health care providers in England.” Parallel universe indeed!

The newspaper article refers to “management” in bland anonymous terms. But they are not anonymous. They are individuals with names and we should know who they are.

The chief executive until just a few weeks ago was Adam Cairns. Mr Cairns does have some achievements in Airedale. In 2008 he gave himself the biggest pay rise (33%) of any NHS CE in Britain. So is this parasite retiring into well deserved obscurity for his role in Airedale? No of course not. Having screwed up one hospital he is going to a new post as CE of Shrewsbury & Telford, to an even bigger salary.

The Trust Chairman is Colin Millar who appears sorry to see Mr Cairns go. Perhaps Mr Millar should follow him.

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If you treat the people who do the work badly it is the best of them that leave.

David Colquhoun

The NICE Knight

Sir Michael Rawlins has been chairman of the National Institute of Health & Clinical Excellence (NICE) since its formation in 1999. He was knighted in June 1998 so it can not be said that his knighthood resulted from his role at NICE. What can be said is that, since he has been the only chairman, NICE must have developed into it’s present form greatly influenced by him.

NICE is never going to please everyone, since its role is to obtain value for money in the NHS and inevitably some treatments will fail to meet the (arbitrary) figure of £20,000 per year or less for a Quality of Life Year. This does not mean that the treatments are ineffective, only that they represent, in the estimation of NICE, poor value for money. To complicate matters further many PCTs regard the £20,000 figure as far too high.

A great deal of what is said about NICE is mythology. For example Trusts will often hide behind NICE and refuse a certain treatment because it is “not NICE approved” as if this constitutes some sort of ban. “Not approved” does not however mean “disapproved” and the Department of Health has said that it has 'made it clear to PCTs that funding for treatments should not be withheld simply because guidance from NICE is unavailable. Sir Michael himself has pointed out that there are no penalties on doctors who fail to follow recommendations.

On the other hand some treatments are applied far more commonly than NICE guidelines support. A good example of this is the guidelines for Statin use. If you read these it becomes clear that many patients receive statins in spite of the guidelines, not because of them.

Probably the greatest error of NICE was in it’s formulation of guidelines for the treatment of chronic back pain. David Colquhoun has summarised this fiasco far better than I could, but to take one small quote, “The panel consisted of a surgeon, psychologist, osteopath, acupuncturist a physiotherapist and an academic; not one pain consultant!” The presence of quacks on this panel, is inexcusable and is a decision for which Prof Rawlins must take responsibility, as is the endorsement of therapies unsupported by a jot of evidence. Further the calls for the guidelines to be recalled and completely redrawn have been completely ignored.

NICE have also started to intrude into areas arguably beyond their original remit as shown here.

So, is Sir Michael Rawlins a worthy Knight or a suit full of bugger all?

Certainly much of clinician dissatisfaction with NICE is based on misunderstanding of the level of authority conferred on NICE by others. To be fair Prof Rawlins has attempted to put the role of NICE in perspective as seen here. This excellent article highlights the role of clinical judgement, complemented by but not dictated by evidence.

This article alone, in my view, sets Prof Rawlins more to the worthy Knight end of the spectrum.