Private Practice again

I have commented before on how a minority of Consultants can behave less than honestly when it comes to when they conduct their private practice. There is another aspect of dishonesty in private practice, that of how it is conducted. In NHS hospital practice it is easy to work in the best interests of the patient as for the most part our pay is not in any way affected by what treatments we recommend to our patients. The same is not true of private practice, where some treatments may be far more lucrative for the consultant. This is described well in “the Citadel” where some of the Harley Street set of the time (pre NHS) were described recommending treatments they knew to be ineffective and worthless, in the pursuit of financial gain. Rather like pharmacists and homeopathy today.

This is a temptation that can still today face any doctor in private practice, and is summed up beautifully by Cronin in the phrase “a struggle between all that he believed and all that he wished to have”

Sadly a minority of our colleagues lose this struggle. Occasionally a consultant’s conduct in private practice is so brazenly dishonest that they come to the attention of the GMC. This case is a good example, which should horrify any doctor with any integrity at all. I don’t think anyone could argue with the GMC decision in this case.

But there are many others who get away with it. I have two colleagues in the same speciality, who both sub-specialise in a particular area. In their NHS practice both receive referrals for a particular condition, and both treat these people in much the same way, rather conservatively, in accordance with present evidence and guidelines. 

In his private practice Doctor A treats these people exactly the same as his NHS patients, which, I expect, earns him a reasonable but modest income. Doctor B however has a totally different approach with his private patients, who receive much more aggressive and interventionist treatment. I know, from speaking to patients who have seen him, that the success rates he quotes them for the treatments he recommends are not remotely supported by evidence. Whether he is ignorant or uncaring of the truth I do not know. Dr B is well known to be unusually wealthy.

NHS or private, guess which consultant I refer my patients to.

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People are more violently opposed to fur than leather because it's safer to harass rich women than motorcycle gangs. 

Alexei Sayle 

Freedom of speech again

I posted recently on the readiness with which employers will trample self righteously over human rights legislation. This is just such an example. Mr David Forster, who works for Yorkshire Ambulance Trust, said a number of things on a facebook discussion that his employers took exception to, and he has apparently been disciplined according to the Trust’s internal procedures.

There are five David Forsters on Facebook none of whom has an open profile. It is therefore arguable that his comments constituted a private communication and the Trust had no business acquiring it, let alone taking action against him. Their action probably breaches article 8, (right to private life and privacy of correspondence) of the human rights act.

Secondly his comments were not specific to any individual, made in a private setting and represented expression of opinion, which he has every right to do. If disciplinary action really has been carried out then this is nothing short of bullying and it is a shame that Mr Forster has taken the easy course of meekly submitting to this bullying.

What Mr Forster said was “The NHS has no shame in employing too many who are lazy, unproductive, obstinate, militant, aggressive at every turn and who couldn't secure a job anywhere outside the bloated public sector where mediocrity is shielded by weak and unprincipled HR policies.”

I have to say that in my view Mr Forster’s comments are not without a degree of accuracy and I can certainly think of a few individuals who this could easily apply to.

The (acting) chief executive of the Trust is one Simon Worthington. It is he who must, by virtue of his position, be considered responsible for interference with Mr Forster’s convention rights, which is unlawful as well as bullying behaviour.

Shame on you Mr Worthington.

Goodbye Quangos

I see that no fewer than 9 NHS quangos are to be abolished. Those facing the axe are as follows.

*Health Protection Agency (HPA)

*National Patient Safety Agency (NPSA)

*National Treatment Agency for Substance Misuse

*Alcohol Education and Research Council

*Appointments Commission (CQC)

*Human Fertilisation and Embryology Authority

*Human Tissue Authority

*Council for Healthcare Regulatory Excellence

*NHS Institute for Innovation and Improvement

This has apparently “provoked anger among nurses and doctors' organisations, which warned that public wellbeing would suffer as a result.”

These organisations are not specified but the main doctor’s organisation, the BMA, has not expressed any such thing, and their response has been decidedly low key. Indeed in the past a review of these quangos has been advocated by the BMA. I suspect most of the anger in fact comes from those who stand to lose their jobs rather than the front line staff whose practice has been afflicted by the mountain of tick boxing forms generated by these organisations.

A simple test. Write down on a piece of paper how in practice these quangos affect your day to day work. Then look at the list and see if you will miss them. I certainly won’t.

Reproduced article 1

This article is the first of two that I will be reproducing from the print version of “Hospital Doctor” from 2006. I have reproduced it as a deliberate gesture against those illiberal enough at the time to have expected action against the original author for offending them. Apart from correcting one very minor error the article has not been altered or edited in any way.

Midwives get my goat

Over Christmas I saw an advert for a charity suggesting that instead of buying yet more wine and chocolates for our alcoholic lardbucket friends, we give a gift to someone in the third world on their behalf.

Such schemes are increasingly popular - and a good thing too. The ad listed suggested gifts. Apparently £25 buys you a goat, but a mere £48 allows you to purchase a midwife. I’m sorry - this is irresponsible. As soon as third world farmers realise this, we’ll be inundated with offers to exchange midwives for valuable livestock.

You may sense I am a little negative about midwives. It is the product of miserable years in labour wards as a trainee.

Having said that,there was always something quite satisfying about walking into a room that looked like a scene from the Exorcist, and leaving it looking like one of those mediaeval paintings of the birth of Christ, where everyone is serene and wearing little halos.

But now the Royal College of Midwives (RCM) - or, as comedienne Jo Brand renamed them recently, “The Royal College of Childless Fascists” - have excelled themselves, calling for women to be charged for epidurals in labour, “unless the mother has a definite need of it.”

And who decides? Well, the wise and righteous midwife of course. Can I ask the obvious question? What the hell is it to do with the midwife? Only the mother knows how much it hurts, and only she knows what constitutes definite need. All anaesthetists have seen that look of homicidal hatred in the eyes of a mother whose partner reminds her that the birth plan didn’t include an epidural.

The RCM points to the 40% increased instrumental delivery rate after epidurals, in a craven effort to disguise this naked ideological posturing as concern for their clients. All that shows is that, if you want a sensible appraisal of the scientific evidence on epidurals you’re better off asking the goat. Long, difficult labours cause epidurals, not the other way around.

If you want to disagree you’d better have hard evidence. That means a randomised trial, blinded to patient, midwife and obstetrician. Try getting that through your ethics committee.

How about another randomised trial? Midwives versus goats. After all, goats breed like mad so they’re experts on normal labour, cost half as much, are unlikely to tell someone they can’t have effective pain relief because they’re too poor - and, if they piss you off, you can kill them and eat them.

As a postscript it should be noted that the RCM recommendation mentioned above, quite rightly, sank without trace.

The beginning of the end

The consequences of diverting millions of pounds of taxpayers money into private hands finally starts to have it's inevitable result.

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"As she lay there dozing next to me, a voice inside my head kept saying, 'Relax, you're not the first doctor to sleep with one of his patients', but then another kept reminding me, 'Howard, you are a vet!'"
Dick Wilson.

Freedom of speech 3

I found this on Pharyngula, and thought it worth repeating.

Commissioning, an opportunity?

While reading about commissioning recently my eye was caught by one particular phrase. “Commissioners will be free to buy services from any willing provider” Bearing in mind that secondary care providers will have to be specialists with the relevant qualifications it is initially difficult to see how, in practice, this could mean anything other than the local hospital already providing these services. But think for a moment. “any willing provider”. In theory this could include individual specialists or small consortia of individuals, independent from the local hospital trust. This would not be feasible I admit for many specialities, especially the surgical ones. However there are some specialities where much of the work currently done in the hospital could easily be done, by the specialist, in a primary care setting.

This could have certain advantages. First of all there would be the guarantee of a consultant delivered service. Patients would not be seen by trainees, or nurse specialists but by the consultant, every time. Secondly many of the frustrations afflicting GPs trying to book appointments at the hospital would disappear. No more referral management, or choose & book. You simply book your patient into the next session when the specialist visits. Also there is the convenience to the patients of being seen in their own local surgery, rather than trekking all the way to the hospital, and getting ripped off in parking charges.

There are also other aspects. I have commented before that there is a wedge driven between primary and secondary practitioners. We are isolated from one another, professionally, socially and philosophically. In my area I personally know only two GPs. There is a consequent failure of understanding between us, an “us & them” attitude which can only disadvantage our patients.

If GPs had their own specialists working in the practice they could gain much more than simply specialist care on tap. They would have access to advice for patients who might not justify a formal referral, and more rapid and personal communication. The specialist too would gain valuable information from the GP. Inevitably visiting specialists would share coffee and breaks and a better relationship would develop. The wedge and the isolation would disappear.

I am aware that doctors are by nature a conservative bunch and this idea may seem a bit radical for some. I expect that the idea would be shot down in flames by colleagues in both primary and secondary care.

But I think for some specialities this could work.

Scientology

Freedom of speech is under attack again. Cardiff Councillor John Dixon is in hot water for describing scientology as "stupid". Seems a pretty accurate description to me. This apparently is contrary to the councillors code of conduct which demands "respect and consideration to others." Once again this constitutes "interference with a convention right" and is I believe unlawful. Once again the invalid excuse of causing 0ffence is used to try and silence someone.

The complaint was brought by scientologist, or looney as they are better known, John Wood. Mr Wood obviously feels that his ludicrous delusion should not be criticised. This cult has a reputation for attacking and harassing anyone who attacks them. I'd better watch out for thetans knocking at my door then.

GMC jailbird

There seems to be on the net questions about why the child abducting jailbird Penny Mellor was appointed to the GMCs child protection working party. There are even suggestions of ulterior darker motives. I think it is as well to remember Hanlon's Razor, "Never attribute to malice, that which is adequately explained by stupidity."

It should be remembered that the Chief Executive of the GMC is Mr Niall Dickson. Mr Dickson's only medical experience is that he was once a "health journalist" or twat as they are more commonly known.

Applying Hanlon's Razor it is clear that Mr Dickson is a pathologically stupid man, as well as a twat.

Commissioning

The government’s proposals for commissioning health care have featured heavily in the media and in the blogosphere, and most opinions seem to be very negative. The overriding view seems to be that GP’s will have neither the time nor the inclination to do this directly and will therefore have to employ some private commissioning organisation to do it for them. Such a system will attract those who see the NHS as a business opportunity and these organisations will, like PFI, skim off the top of the NHS budget diverting yet more NHS funds into private hands.

As hospital consultants it seems that wherever this leads we will have to follow, although there is one interesting aspect which I will explore in a subsequent post.

So what can we do if we wish to oppose these proposals. Perhaps the BMA could organise something. In your dreams. The BMA are toothless, ineffectual, irrelevant and worthless. Not even their own members take much notice of their empty posturing. The idea that they might sway government is laughable. In the absence of any credible opposition it has to be accepted that these changes are probably going to happen, like it or not. The government have got the bit between their teeth on this one and it might be better to look at damage limitation rather than total opposition.

I am of the belief that any reasonable system can be made to work as long as those at the helm are people of integrity and intelligence. That we have systems now that increasingly are working badly is a reflection on those we have allowed to run things because the rest of us don’t want to, rather than weaknesses in the system which could have been overcome by better men.

But the best GPs and hospital doctors are primarily, if not exclusively interested in practising medicine, leaving managerial, & administrative roles to their less dedicated colleagues, many of whom have an agenda centred around personal advancement.

The last thing we want or need is to see, when the dust has settled, the same old parasites running the show that we have now, in co-operation with the private sector, simply rebadged and probably with an even bigger salary.

If our jobbing GPs and Consultants express their opposition by turning their back on the process and refusing to get involved the door will be open for the show to be run by those most interested and least suitable and the dire prophesies will become self fulfilling.

That is why those most opposed and disinclined to getting involved, should get involved. It is the only way we might salvage something worthwhile from a potential disaster. You never know, with the right people at the helm we may be able to keep the private sector at arms length and make it work.

GMC gets it wrong

I did not think my opinion of those contemptible bastards at the GMC could get much lower than it is already, but it would appear I was wrong. Look at this and weep. Jobbing Doctor and the Witch Doctor have already commented on this and I don't think I have anything I can add.

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The art of medicine consists in amusing the patient while nature cures the disease.

Voltaire (1694 - 1778)

Patients

Freedom of speech 2

When exercising the right to freedom of speech the one body an individual is likely to be wary of offending is his own employer. Expressing adverse opinion, publicly criticising and whistleblowing are acts all likely to be perceived by an employer as disloyalty. Laws protecting these individuals are in place but seem to be poorly applied and lack teeth. Fear of speaking out is therefore not unjustified even though any employer taking action against an outspoken employee is acting unlawfully.

The simplest sanction that can be used is the threat of disciplinary action if the employee repeats the “offence” and most employees will take the easy option of shutting up rather than fight their corner. The emotional and financial cost of taking legal action against this bullying should not be underestimated, particularly since the employers are likely to have considerably more money to spend on legal representation. It is still a sad fact in this country that justice tends to go to him with the deepest pocket. So the balance here is heavily in favour of the employer.

As an illustration; A few years ago a NHS Consultant Anaesthetist published, in a since discontinued journal, two articles, one about midwives, and the other about nurses. Both articles made perfectly valid points, presented in a highly scathing manner and inevitably some people took offence. It is worth mentioning here what redress people have in law if they feel offended. None whatsoever. None of us has any right not to be offended, nor any right to expect action to be taken against those who offend us. To repeat the legal judgement “Article 10 applies not only to information or ideas that are favourable and inoffensive but also to those that offend, shock or disturb the State or a sector of the population.” Stephen Fry expresses this concept succinctly here.

If those offended wished to respond they could have answered the criticisms made, or written an equally scathing article about anaesthetists. As always however the small minded and the stupid take refuge in authority. Complaints were made to the doctor’s employer. The correct course of action would have been for the employer to point out to the complainants that the doctor had a contractual (as well as a legal) right to speak his mind, quoting para 330 of terms and conditions. Instead they chose to get heavy and threatened the doctor with disciplinary action. Sadly the doctor succumbed to this pressure.

So the complainants and the employers effectively won. The articles have all but disappeared and it has taken no small effort to find them again. But I have, and as an exercise in freedom of speech I will be reproducing them in full on this site in the next few weeks.

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Some men are alive simply because it is against the law to kill them.
Edward W. Howe

Lean Healthcare

Believe it or not, before writing my rabid rantings, I often engage in a little research on the subject in hand, and during this process one of the phrases I keep coming across is “lean thinking” or “lean healthcare”.
Lean thinking is a managerial approach, first devised by Toyota, and defined here. I can see how these objectives might suit manufacturing industry but is it really suitable for healthcare delivery. To start with the phraseology, I have previously had a go at management jargon and I am afraid the phrase “improving flow and eliminating waste” sounds to me distinctly urological. And the phrase“ the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination” leaves me feeling distinctly uneasy.

The concept of lean thinking as applied to manufacturing industry, and some of the potential pitfalls are fully described here, but there is one phrase that for me stands out in this article. Waste (earmarked for elimination) is defined as “any (human) activity that absorbs resources but creates no value”. Now healthcare consumes vast amounts of resources, but creates absolutely nothing of value, as manufacturers understand the word. Value, in the context of healthcare is a nebulous and ill defined concept and may mean different things to different people.

This NHS web site is very positive about lean healthcare but the jargon runs thick. Just read points 1 to 5. What a load of shite, written by the NHS Institute for Innovation and Improvement. This quango is a prime example of an activity that absorbs resources but creates no value.

So lets have a look at one or two places where NHS Trusts have applied this philosophy. Bolton is one such. Just read this page, written by Ms Heather Edwards, head of communications in Bolton, extolling the virtues of lean healthcare. She seems not to have noticed that since they introduced lean healthcare Bolton has become one of the most lethal places for patients in Britain, with a 22% excess mortality. How do these people get away with such brazen mendacity.

Similarly deluded are these grinning fools trumpeting the success of lean healthcare at that shining example of success Airedale. Compare this with a more impartial view.

It seems to me that applying lean thinking to Healthcare is a recipe for disaster. Management do not seem to understand that that they are not running a factory for profit. The concept of lean healthcare is simply used as an excuse to slash staffing numbers to levels where patients can not properly be cared for. Because after all caring for patients creates nothing of value and is therefore a wasteful activity.

Private Practice again

In my last post about private practice I highlighted the not uncommon abuse whereby some NHS Consultants pursue private work while supposedly working for the NHS. Right on cue appears this article confirming that this practice is not only alive and well but actively supported within the NHS at all levels from Medical Directors to the NHS anti fraud unit. In this case the unfortunate individual who highlighted such abuse found herself dismissed on trumped up charges pretty damned quickly. I suppose I should be inured to it after all these years, but it still appals me how dirty the NHS establishment can be when you scratch the surface. It looks as though justice here is likely to prevail in her case though it will be interesting to see whether any action will be taken against the Consultants who were in breach of contract and then engineered her dismissal. Just so we know who we are talking about, the two Consultants in question are Dr. Miranda Harvie and Dr. Peter Schnatterback, both of Ealing Hospital. The Medical Director is Dr William Lynn.

Remember

The Dearest and the Best

Sick Notes, Tony Copperfield

A few weeks ago, like other bloggers I was asked to review this book, and having now read it here is my impression.
The best of humour often comes, not from jokes and stories but from simple observation and comment on the frustrations and difficulties that afflict most of us. The things that happen to all of us which are funny, as long as they happen to someone else. This book is full of such humour which brings a wry smile of recognition in the numerous anecdotes which most of us can identify with.
The humour however serves to bring to our attention the sources of these frustrations, the numerous and pervasive intrusions of managers and politicians into clinical medicine. As the author puts it, “rules being made by those in offices who don’t know what they are talking about to enforce on those seeing patients who do.
He makes incisive and accurate observations on appraisal/revalidation, telehealth, referral management and other management inventions which I believe would have the agreement of the majority of doctors in primary and secondary care.
I am a little saddened that he sees hospitals and consultants as the enemy (CBT 2). We have exactly the same frustrations and views for the most part as our primary care colleagues and it is clear that a wedge seems to have been driven between us that should not be there. Our problems are simply a mirror image of theirs.
Although I was offered a free copy of the book to review I chose instead to buy my copy. Among other reasons this I think allows me more impartiality than if I had accepted the gift. The cost of the book was money well spent. This book should be read by doctors , managers and patients, and anyone else who is concerned about the state of our NHS.

Freedom of speech

A Citizen’s freedom of speech is considered one of the most important rights in any civilised democratic society. In the United States this right is guaranteed by the First Amendment to the Constitution. In Europe, and the UK it is covered by article 10 of the Human Rights Act 1998. Despite freedom of speech being a right guaranteed in law there are bodies and individuals who seem not to understand what this means, and will attempt to silence or punish those who choose to exercise this right.

For example if you are familiar with this site, it will be apparent that the author does not like pharmacists very much, and has expressed views likely to offend. That is his right. Anyone offended has the right to express their disagreement, but one pharmacist reported the Doctor to the GMC claiming that what he had written was “unprofessional” and that his “behaviour falls seriously short of what would be expected from a doctor”. Interference with a convention right is unlawful and the pharmacist in question, in attempting to have the doctor disciplined, was undoubtedly guilty of such interference. Further the Medical act does not give the GMC the right to override other laws and in even considering this complaint the GMC were also guilty of interference with a convention right. This was a complaint that should not have been pursued yet it took the GMC six months to finally agree that there was no case to answer. There have been other similar cases where the GMC have shown considerable inconsistency in their approach to article 10.

Article 10 is not however an absolute right. It is a qualified right. What this means is that there are circumstances where Article 10 is overridden. Threatening behaviour is one example. Incitement to violence is another.

There is one body, and one body alone, that can specify when article 10 does not apply, and that is Government. There is one means, and one means alone, by which they may do this, and that is by legislation. Circumstances where article 10 does not apply must be clearly and precisely defined in law, and it is not open to the GMC or any other body or individual to themselves decide what constitutes acceptable behaviour in the field of freedom of expression. They may not pursue individuals simply because those individuals express views which piss people off. This has been verified in a legal case where it was made clear that “Article 10 applies not only to information or ideas that are favourable and inoffensive but also to those that offend, shock or disturb the State or a sector of the population.”

In a future post I will be looking at how article 10 affects the relationship between an individual and his employer.

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The years passed, mankind became stupider at a frightening rate. Some had high hopes that genetic engineering would correct this trend in evolution, but sadly the greatest minds and resources were focused on conquering hair loss and prolonging erections.

From the film "Idiocracy"

Private Practice

Sometimes, it has to be said, I am disappointed and disillusioned by my Consultant colleagues. Like the time I heard a colleague approaching retirement holding forth on the sheer inadequacy of his pension. Knowing him to have paid for his house, and having no longer any dependant children, I reflected that his pension was going to be equivalent to twice the average national wage, and I remember thinking what a pompous greedy little f****r he was.

The area where I am most often disappointed is in the way some of our colleagues conduct their private practice. Don’t get me wrong, I have no objection to the principle of private practice. What a Consultant does in his own time is entirely his own business. But that is where the problem lies. Some (a minority) seem to have rather strange ideas about what constitutes their own time.

For clarification I checked my own contract, which I imagine is similar to everyone else's. It states quite clearly “You may not carry out private professional services during your programmed activities” That seems pretty unequivocal to me.

And yet relatively recently I have seen three examples of practices which blatantly flout this contactual obligation.

The first and most common is the practice of leaving a trainee to finish a clinic or a theatre session leaving the Consultant free to nip down the road to St Graspers. I fully accept that towards the end of their training senior trainees need their cord stretched a little before it is cut and that managing patients on their own is a necessary part of this process. But if a Consultant delegates such work to a trainee he should at least remain in the Hospital and making himself unavailable is thoroughly reprehensible.

The second and more brazen abuse arises when a Consultant takes sick leave from his NHS post, usually for a perfectly legitimate reason, but still seems to find the resilience to attend his patients in the private hospital.

But to my mind the worst abuse is the following scenario.

A trainee, on duty in the evening encounters a clinical situation where he feels out of his depth and phones his Consultant requesting assistance. His Consultant tells him that he can’t come as he is busy (in the private hospital as it happens) and that the trainee will simply have to manage. There is no excuse for this. On call rotas are arranged well in advance and making arrangements to do private work on your night on call is a disgusting practice. It is not fair to the trainee and is certainly not fulfilling your responsibilities to your patients, It is a blatant and deliberate breach of contract motivated by greed. In my view there is only one appropriate way to deal with this type of practice. Instant and summary dismissal.

Websites

I recently read this article in the Telegraph about government websites. Apparently closing six hundred of them will save £100m. Now ten seconds mental arithmetic gave a cost per website so outrageous that I thought I had lost the ability, and checked my sums with a calculator. This confirmed that a government website costs on average over £165,000. I have a friend who sets up websites for a living and confirms that for most of the sites he charges between a few hundred and a few thousand pounds. That is for designing and setting up. Annual running costs are then much lower. Why is it when taxpayers money is involved no-one seems to care about getting value for money?