Right on cue

God, I love it when I am right all the time. After my last post this story breaks. Lansley has stated "Patients have a right to expect that when they go in for treatment that they are looked after properly and that the treatment they are given helps them to recover,”

But Mike Farrer says that these people can be looked after in the community, or they can “self care”.

Well Mr Farrer these are the consequences of cutting back too much on bed numbers, and your idiotic suggestions, if implemented, will make things worse to the point of disaster.

What an utter knob.

Another man with his head up his arse.

This is Mike Farrer, who is chief executive of the NHS confederation. He it is who thinks that 25% of hospital in patients don’t need to be in a hospital bed. It is true that many patients, particularly the elderly and chronic sick can prove difficult to move out due to lack of community facilities, but the proportion is nowhere near that percentage, and it is also true that, even if this were addressed there would still be plenty of patients queuing up to take those vacated beds.

The fact is that there is chronic under provision of acute beds, and the frantic drive to discharge patients as quickly as possible inevitably results in the high readmission rate we currently see.

Despite Mr Farrer’s years in the NHS he seems blind to the fact that both NHS consultants and GPs are increasingly finding it difficult to find beds to admit patients to. 

Medical admission and discharge are clinical decisions, and NHS clinicians have no incentive to keep patients in hospital unnecessarily. So by and large if a doctor thinks a patient should be in hospital he is the one best qualified to make that decision. 

Mr Farrer thinks that we should be moving more towards care in the community, rather as was done with psychiatry, and patient self care, otherwise known as “you’re on your own mate”.

So what qualifications and experience does Mr Farrer have that makes him feel he can pontificate on clinical matters to clinical professionals? Well his first NHS job was as a gardener. Before that he worked for Grand Metropolitan, and was a semi professional footballer. Not a doctor then. His numerous roles in NHS management do not qualify him to venture any opinion on a single hospital patient’s requirement for admission, or readiness for discharge. Perhaps instead of hectoring doctors in both primary and secondary care, and telling them how to do their jobs, he should shut his ignorant mouth and listen.

Prophets?

And so 2011 draws to an end. We are all still here despite the apocalyptic predictions of Harold Camping and his moronic followers. They are not the first failed prophets of doom and their humiliation does not deter those making similar predictions for future dates.

But fundamentalist religious loonies do not have a monopoly on outrageous and ridiculous predictions. A widely reported scientific theory released in 2007 suggested that by now the world human population would be down to less than 2 billion, with cataclysmic disasters wiping out 4.5 billion people. And just like Harold Camping, the response to failure of the prediction is is to claim mathematical error and give a revised date. 

I like to think I keep an open mind on the science of climate change. The science has been delivered by some very clever scientists using state of the art technology. But I can’t help noticing that a lot of their early  predictions that should have now come to pass have not been confirmed by reality. And their response to these discrepancies has been to successively revise the date of the apocalypse, rather like the Jehovah's witnesses who have made no fewer than eight successive stabs at the date. 

Perhaps the problem is that some scientists share yet another characteristic with the fundamentally religious, that of assumed infallibility, the arrogant belief that their most prized “knowledge” is unquestionable. The finality of the word of god or the science that is “settled” are both manifestations of the same mentality. We should remember what Einstein once said; “We still do not know one thousandth of one percent of what nature has revealed to us.”

Merry Christmas

Zorro does not expect to be doing much, if any, blogging over the next week or two.

So whatever you want to call it, and however you choose to celebrate it I do wish you a very happy festive season.

Dream job

Objective 2.5 of the recently released NHS outcomes framework has, as it’s objective, getting people with mental illness into employment. There is no reason why some of these people should not find suitable employment in the NHS itself. Take this unfortunate individual with obsessive compulsive disorder. Had he not died all he would have needed, in addition to his obsession, would be to have fed himself up to a BMI of 42. Then he would have had to cultivate the demeanour of a bad tempered, pre menstrual midwife on anabolic steroids and dexamphetamine. He would then have made the perfect infection control nurse.

Driving

I mentioned recently that I had made one of my exceedingly rare visits to my GP. Subsequently returning to my car in the car park I saw something that left me speechless and scared. There was a very elderly lady also returning to her car. What astounded me was that she appeared to be finding her way back by feel until she found her own vehicle. She then got in and drove off while peering over the wheel. I got the strong impression that she was blind as a bat.

I expect her GP would be aware of her poor eyesight and wondered why he had not stopped her driving. Well I did a little research, and apparently it is not his responsibility. 

Those who drive for a living, HGV and PSV drivers, once they attain a certain age, are required by law to undergo a yearly medical to ensure their continuing fitness to drive. Private motorists however are under no such obligation. Nor are their GPs under any obligation to enforce driving restrictions arising out of the ill health of their patients. The ultimate responsibility to report health related unfitness to drive actually lies with the driver. I think we can see the flaw in this system.

GPs are required to advise patients if they have a condition which requires notification, but how many do. Losing your driving license is a huge loss and I suspect many GPs would feel uncomfortable with effectively removing this privilege. 

Government, and the DVLA have not addressed this problem, nor do they have any plans to do so. So step forward those unlikely heroes at the GMC, who have now stated that doctors should be more pro-active here. It is true I don’t often find much good to say about the GMC, but I agree absolutely with them on this. Because frankly I don’t care to share the roads with drivers who are unfit to drive through age and ill health any more than those who are drunk. 

Organ donation

The ethics of acquiring organs for transplantation is something I have questioned before, with some illustrations of the less savoury means that have been used. Well I have found some more instances, from China, (again) Pakistan and even Holland.

As a youngster I used to read a lot of science fiction, and I recall one story where, to satisfy the demand for organs, the state gradually lowered the threshold of seriousness for which the death penalty was imposed, until you could be executed for speeding, and your organs harvested. Fiction can sometimes become uncomfortably predictive.

Dr Eva Michalak

It is a sad fact that bullying and harassment are rife in the NHS, and consultants are not immune. I have seen colleagues bullied until they resigned, unable to obtain justice because of the sheer weight of legal expertise pitted against them. Often justice in the UK still goes to him with the deepest pocket. 

I have commented before on individual cases and how those who bear ultimate responsibility are the chief executive of the trust, but also the medical director. The medical director is someone to whom the victims should be able to turn but are often deeply implicated in the bullying themselves.

One of the vilest examples of this is what has happened in Mid Yorkshire NHS Trust. Reading this story it is hard to imagine a person less suited to the post of medical director than the incumbent. I can’t say if he is the most malicious, vindictive or mendacious medical director in Britain, after all there is some pretty stiff competition out there, but he is definitely on the shortlist.

Dr David Dawson, described by the industrial tribunal as a “self acknowledged liar”. A man who suspended a colleague, presumably on the urgings of his mates, without even knowing what offence she was alleged to have committed. He is no longer listed on the trust’s web site as medical director. One can only hope that the GMC look into his conduct and make a suitable example of him.

The Chief executive however is still in post and this is she.

Julia Squire is another example of how, in the NHS, failure is consistently rewarded. It remains to be seen whether or not the Trust Board, or the Senior Staff Committee have the integrity to remove her.

Get a gun

For over 30 years of my career I have done my job with, I think, a pretty average degree of competence. My training has been long and detailed, but appropriate and relevant.

So why, all of a sudden, am I expected in addition to relevant CME, to attend presentations on stuff that I have got by without for those 30 years. Manual handling, substances hazardous to health, Riddor and Caldicot. What is the logic behind taking me away from where I am doing my job to lecture me on stuff which is of no use or relevance to that job. I regard finding various reasons and excuses not to attend as something of a sport, but running rings around the intellectually challenged and pointless individuals who run these lectures is something of a hollow victory. rather like kicking a toothless old dog.

So I thought that, just to cheer them up, I would attend just one, and I actually found one that I thought might be interesting. “Handling violence and aggression” seemed to me that it could be worthwhile, as apparently this is on the increase in the NHS, even though I have never seen a single instance.

Well I was disappointed. Firstly, what could have been an interesting topic was presented in as dull and dry a manner as you could imagine. No juicy anecdotes, no personal experiences, no examples. Just a drone on how to recognise and avoid potentially dangerous situations, most of which came under the category of “the bleedin’ obvious.” 

And that was where it stopped short. What, I was waiting to hear, happens next? When all the various actions to recognise, avoid and defuse a potentially nasty situation have failed, what then? When 18 stone of drunken ape is definitely going to hit you, what do you do then? Well that was not addressed. The talk stopped once all the sociological and psychological claptrap had been exhausted. The one bit of potentially useful advice they could have given was never imparted.

What a fucking waste of time.

All together now

Time again for another Streissand effect

Yet another quack, peddling pseudoscientific drivel, has threatened legal action against a blogger making perfectly valid criticisms of his absurd practices, combining classical chiropractic subluxation with faith healing.

Well Dr Dan Golaszewski of Hanover, Pennsylvania is a quack. He is either a deluded nutter who genuinely believes this rubbish, or a cynical fraud who knows full well the worthlessness of his made up fantasy, and is simply using it to fleece the gullible and stupid.

Git!

I find as I get older more things irritate me. Like a patient I saw recently. Born and raised in the UK he has lived and worked in Dubai for several years “so I don’t have to pay tax and national insurance Doc.” So when he needs medical care for an elective condition obviously he gets on a plane and comes back to the UK where it is free.

Well it’s not free you fucking selfish parasite. It is paid for through the taxes of those who live and work here and if I had my way you would have your UK citizenship stripped away, or at least made to pay for the care you get from the NHS you don’t want to contribute towards.

Quote

Don't tell people how to do things, tell them what to do and let them surprise you with their results.

George S. Patton

Enough already

I am not going to go through module 5 of the NHS outcomes framework item by item. It is just more of the same. Empty posturing, badly thought through by people who seem to know nothing of the realities of modern medical practice. A load of public relations bollocks insisting that we must now “do something” along the lines of, did they but know it, what we have already quietly been doing for many years. 

So how does shit like this get written? Quite simple. Various governments have, over the years imposed more and more NHS  QUANGOs, committees, regulatory bodies, working parties etc to regulate a shrinking front line with more and more restriction, regulation and supervision, stifling clinical autonomy, innovation and advancement, and destroying morale and motivation.

And once all these parasites are installed you have to find something to occupy them. And in return they have to produce something to justify their well paid existence. So an entire superstructure is built up of various bodies exchanging meaningless crap back and forth, oblivious to the fact that they are contributing nothing. And they report their worthless documents back to governments of PR men who don’t know shit from shinola, and publish it with a flourish, not realising the contempt it generates in those actually providing care.

Unhappy punters

Talking of patient satisfaction, why exactly are the writers of this report so obsessed with it. It is at such a high level that we are likely to make very little improvement. There will always be a hardcore of career malcontents, determined to find fault no matter what we do and we are not going to make any difference to them either. I have certainly known one patient who was such a prolific writer of unjustified complaints that the trust eventually just refused to acknowledge them any more. And even when patients are justifiably aggrieved they still tend to be very British about it. Although I am told violence against medical staff is on the increase I personally have never seen an instance in my entire career, and even verbal abuse or threats I have seen very rarely. The worst most of us have to deal with is the odd written complaint. When it comes to the actions of dissatisfied patients or relatives our American colleagues have far more serious possibilities to worry about.

Module 4

Module 4 is about improving patients’ experiences. This is going to be as much about patient expectation as service delivery. For example are we supposed to accommodate people who want homeopathy and reiki? Expressed dissatisfaction will be rife but will it be vetted for justification or will it just be used as a stick to beat us, and put on our appraisal.

.....4.1 Improving patient experience of out patient care.

I don’t know what it is they imagine is a problem here. Is it the clinical care itself or other aspects, such as waiting. Here is a suggestion. Patients attending for outpatient appointments are going to be less grumpy if Trusts stop ripping them off for parking charges before they have even entered the building.

.....4.2 Improving responsiveness to in patients’ personal needs.

Ooh yes yes yes, I agree with this one. It sounds to me like a concise rehash of the “Nursing Process” which came and went a few years ago. This was a questionnaire completed for each patient by the admitting nurse. No matter what you came in for you had every aspect of your life documented in order to better satisfy your holistic personal needs. Most nurses wisely skipped the box marked sexuality, but I recall one article in a nursing journal suggesting that this was an important area that should be addressed. There was even a suggestion that young male patients in hospital for any length of time should have their sexual frustrations alleviated by a specially trained physiotherapist who would give them a helping hand, so to speak. So next time I am an inpatient I would like to be seen by the physio, the special one with the hairy armpit and a tube of KY jelly please.

.....4.3 Improving patient experience of A & E

Perhaps you could start by employing a heavy to keep out the drunks, the work shy, the unruly and all those who are there because they can’t be arsed to make an appointment with their GP for that six month old niggle.

.....4.4 Improving access to primary GP and dental care.

Are there really people out there who can’t get to see a GP? As for dentistry who exactly was it who imposed a new dental contract that so alienated dentists that most of them simply abandoned the NHS altogether?

.....4.5 Improving women and their families’ experience of maternity services

This is a particular area where patient expectation is going to affect the experience. It is an area where medical advice is often regarded with suspicion. But when the patient has, at her own insistence, a “natural” childbirth in a pool of water, at home, with acupuncture and herbs for pain relief and has an adverse outcome it will of course be the NHS’ fault.

.....4.6 Improving the experience of care for people at the end of their lives

They have at least realised that asking the dying, or dead “how was it for you?” is not a good idea. So instead they are going to assess the care by asking the carers. I think a little bias might creep in here.

.....4.7 Improving experience of healthcare for people with mental illness

I would imagine that this is likely to be difficult to assess.

.....4.8 Improving children and young people’s experience of healthcare

Another area where an indicator is yet to be developed.

The repeated use of the phrase “improving experience” implies that there is a problem with patient satisfaction. Even measuring as nebulous a factor as satisfaction is hardly precise, but what studies have been done suggest a degree of satisfaction that is already very high. To my mind this entire module presents invented problems, and the individual factors are being used to present an illusion of concern and progress.

Interlude

This is not a quiz as such because I don't know the answer. Does anyone out there have any idea what these three gentlemen are doing.

Module 3

Module 3 is about helping people recover from illness and injury. Most of the specific objectives fall into the category of “Yes, we are doing it already”

.....3.1 Improving outcomes from joint replacement, hernial repair, and varicose veins.

These have been the subject of considerable investigation, improvement and advancement over many years. All done without higher directive. Don’t teach granny to suck eggs Lansley.

.....3.2 Preventing respiratory infections in children from becoming serious.

Again this has already been the preoccupation of paediatricians for many years. UK mortality has decreased steadily for 30 years and a guideline has been published and is regularly updated. What more is this objective likely to achieve?

.....3.3 Improving recovery from injury and trauma.

This is another one where “an indicator needs to be developed.” Bearing in mind the sheer diversity of trauma patients I think developing a single indicator is going to be impossible. And what precisely do they think trauma surgeons and their supporting teams are doing every day?

.....3.4 Improving recovery from stroke.

Again, no indicator, and again being done already.

.....3.5 Improving recovery from fragility fracture.

I think whoever wrote this has never seen the average patient with fracture of the neck of femur. A substantial proportion of these operations are done solely for reasons of palliation and pain relief, and the medical status of many of them is such that simply surviving the procedure itself represents as full a recovery as you can expect.

.....3.6 Helping older people recover independence after illness or injury.

This is about preventing readmission to hospital. The problem only arises because patients are often discharged earlier than the clinicians might deem appropriate, simply because of pressure to vacate beds. It is a problem that is insoluble as long as the powers that be continue in their obsession with keeping patients out of hospital at almost any cost, and as long as bed numbers continue to fall.

So my response to this section is, “Don’t tell us what to do, we know what needs doing, and given adequate resources we are already doing it”

Objective 2.3

Objective 2.6

Tickboxes, module 2

Module 2 is about enhancing quality of life for people with long term illness. This module contains to my mind the vaguest, most imprecise and ill defined objectives of the entire document. A catalogue of sound bites with no substance whatsoever.

.....2.1 Ensuring people feel supported to manage their condition.

“Feel supported?” How is that for a nice, crisp, scientific end point. Bearing in mind the wide differences in inherent self sufficiency, and the huge variability in peoples’ willingness to complain this is going to be impossible to measure with any reliability. I have no doubt that those involved will be able to throw up some figures but these will be utterly meaningless.

.....2.2 Improving functional ability in people with long term conditions. 

What a good idea. I am surprised none of the physiotherapists, occupational therapists, remedial gymnasts, speech therapists etc etc already employed doing exactly that have not already thought of it. A slightly different sort of sound bite this, exhorting us to do something we are already doing. This one emphasises getting these patients in employment. So it’s primary purpose is to get people off benefits.

.....2.3 reducing time spent in hospital by people with long term conditions.

Well of course we can’t have hospitals full of nasty sick people who need looking after. It will make the hospitals less attractive to private sector investors.

.....2.4 Enhancing quality of life for carers

I am fully aware that long term carers have a raw deal in Britain. But this is a problem for government, not the NHS. Your problem boys, not mine. Financial and social support for these people are not something I can do anything about. And if you want to give carers a little time off you are going to have to put the patient in hospital, contrary to 2.3.

.....2.5 Enhancing quality of life for people with mental illness.

I touched on this in module 1. And again the primary aim here seems to get these people in work, and off benefits.

.....2.6 Enhancing quality of life for people with dementia.

This is the first of a number of points which carry the rider, “An indicator needs to be developed” What this means is that the bright spark who thought up this noble objective has not the faintest idea even how to assess quality of life in these patients, let alone how to identify areas and means of improvement. We all know care for these patients is often poor, but that is not the fault of the over stretched and underpaid carers. It is a matter of resources. This objective will be used to berate staff who are doing the work of two for not doing the work of four. The demoralised staff will hand in their notice, and the problem will get worse.

Dying for a fag

While we are on the subject of lifestyle and health, there can be few people today who don’t know how harmful smoking is. Yet, despite the indisputable hazards of smoking the proportion of smokers in the UK has remained stubbornly at 20% for some years now. 

Most people know about the cardiovascular and respiratory consequences of smoking, but there are other risks which may be lower in incidence, but are more dramatic and horrific, and maybe the hard core of smokers might take more notice of these.

For example, I remember when smoking was allowed on public transport, but, on a double decker bus those who wanted to smoke had to go upstairs. So when, as occasionally happens, the driver lost his way and ended up going under a low bridge, those decapitated were mostly smokers.

Then there is the risk of setting fire to yourself like this idiot.

Or how about when the desperate smoker does something inadvisable to try and get his fix, and comes to grief.

There are even bacteriological risks that have probably never occurred to many smokers.

I think we need a more catchy approach to this, like this clever picture on the ceiling of a smoking room.

Sixty tickboxes

It has been pretty obvious that Andrew Lansley, once he gets an idea into his head about the NHS is pretty tenacious. His persistent head down and keep going approach despite numerous criticisms is well illustrated by the proposed NHS reforms. Even though there is evidence of failing support even among those who initially bought the idea, he still blunders on. 

His announcement today of his “sixty steps to health” is yet another example of an ill thought out and pointless tick boxing exercise to distract doctors and trusts from their job. This is set out in a long and tedious document in which we find that the definition of quality has been laid down by none other than that well known fucker up of the NHS Lord Darzi. Why do people keep listening to this pratt, bearing in mind his record.

I have read the sixty steps. Fortunately they are divided into 5 “domains” so I thought I would give my views on these steps one domain at a time.

.....Domain 1, preventing people from dying prematurely. 

They have at least defined what this means. Apparently it means dying before 75. Sounds like a “one size fits all” statement to me. Is this an oblique way of telling us that after this age we are to be considered expendable? If, in dying. we are not, at that age going to breach any guidelines, then does not that give trusts an implicit instruction to not waste any resources on us.

So to the specifics.

.....1.1 - 1.4 Reducing premature mortality from cardiovascular, respiratory, and liver disease, and cancer.

 As is now well known a huge number of premature deaths in these areas are due to patient lifestyle. All the NHS can do in this area is advise. More and more of our patients spend their lives stuffing their fat faces with lard pausing only to drag on a fag and slosh down a quart of vodka. Exercise means hunting for the TV remote and sport is something you watch on TV. What the fuck am I supposed to do about that Lansley? He seems to share the attitude that the punters have, that after a lifetime of bodily abuse, it is my job to rectify the damage, as if it is somehow my fault.

.....1.5 Reducing premature deaths in those with serious mental illness.

Yes these are a particularly vulnerable group. So who exactly was it who decided that these people should no longer be looked after in the safe, warm, well fed and closely supervised environment of a hospital specifically aimed at their needs, and decided instead to throw them all out onto the streets to look after themselves? Care in the community it was called. All too often they were lost to care and ended up living, and dying in the gutter. Still at least closing all those hospitals saved a packet.

.....1.6 Reducing deaths in babies and young children. 

Well who could argue with that. But Britain ranks at 25 out of 197 nations when it comes to infant mortality, and the bulk of these deaths are associated with complications of gestation, which again come down largely to lifestyle or sheer misfortune. Making political statements of intent is one thing. Saying how is another.

.....1.7 Reducing deaths in those with learning disabilities.

Again this statement does not address the why and how. The figures in these people will be skewed by the fact that a considerable proportion will have their learning difficulty as one aspect of a multifaceted syndrome, often congenital. You could achieve a considerable apparent improvement by providing more intensive ante natal screening, and aborting affected foetuses. Anyone for eugenics? 

I will deal with other domains in future posts, if I can retain the will to live, but it looks to me like yet more central diktats, without thought for cause or consequence, to give the illusion that our politicians are achieving something worthwhile. Just more shit basically.

     

Torygraph

The Daily Telegraph is regarded as a right wing newspaper, strongly supportive of the Conservative party, to the point where it has acquired the nickname “Torygraph”. But even it is highly critical of  government policy on health as seen in a plethora of articles today criticising David Cameron for his doublespeak, treachery and total disregard for patients, in his apparent absolute determination to privatise the NHS.

The pretense is now over, the veneer stripped away. The agenda is now clear and being pushed through with all the subtlety of a battering ram. And by the time we can vote again it will be done and dusted.

Alternative career

There can’t be many doctors who have not at some time wondered what might have been if they had chosen another career. Indeed more and more of my colleagues are so disillusioned with the way medicine and the NHS are going that they are expressing a wish to have done just that. Sadly by the time this impulse kicks in it is usually to late to act on it. In my case for example I think I would have been happier as a member of a successful rock band, surrounded by nubile young lovelies. However I don’t think there are many openings of that sort for a middle aged porker such as DZ......... Or are there?

Interesting anniversary

Today, December 3 is the anniversary of the first ever heart transplant. As with many pioneering procedures initial mortality rates were extremely high but medical science has gradually overcome many associated problems and transplants of heart and kidneys are now so common that demand far exceeds the supply of donated organs.

Inevitably some have seen market forces as a way of satisfying demand and this is a prime example of what market forces, without any consideration of ethical behaviour, can do within medicine. (1) (2) (3)  It is arguable that transplant surgery causes more human suffering than it alleviates. Also, if you have ever bought a recycled car part you will know that, with second hand parts, it is a case of "buyer beware".  Not all advances represent progress