Sunday, January 28, 2007

Sack Patricia Hewitt

Nobody likes being walked all over. Nobody likes being treated like a doormat. Nobody likes to have their informed opinions and ideas ignored by people with more power than sense.

If you don't like being walked over, if you want decent healthcare, if you want to do something to try to save the health service, please sign this petition.

If you need any extra incentive to make a stand then Dr Rant explains just a bit about the state of the NHS and what the labour party have done to it.

Saturday, January 27, 2007

Choose your own adventure

Does anybody remember those ‘Choose your own adventure’ children’s books that were popular about 20 years ago? You read part of a story and then had to make a decision about what the character did next. Depending on your decision the story was continued in line with your choice on a different page. I always seemed to choose the option that led to death but let’s forget about that now.

Here’s the new NHS version

Mrs Smith is a 63 year old widow who started feeling dizzy and a bit ‘funny’ one morning. She sat down for a bit and had a cup of tea but it didn’t go away. She told herself to ‘pull yourself together’ but it still didn’t go away. Being a stoic type she didn’t want to bother her doctor and she didn’t want to miss her friend who was coming over later. When Mrs Smith’s friend arrived she thought Mrs Smith looked a bit peaky and persuaded her to:

1. Go to A+E
2. See her GP
3. Phone NHS Direct

Choose carefully, and then read the corresponding paragraph…..

1. Mrs Smith felt embarrassed about being in A+E when she didn’t really think it was anything. When the triage nurse saw her she explained that she just had a bit of a dizzy feeling and it was nothing really. She didn’t have any pain or feel short of breath. The nurse did some observations and noticed that Mrs Smith’s heart rate was only 30 per minute. The nurse took Mrs Smith through to another room and called a doctor over, while connecting Mrs Smith up to a heart monitor and giving her some oxygen. The doctor saw Mrs Smith straight away and she was admitted to hospital with a complete (third degree) heart block. The next morning she had a pacemaker put in.

2. ‘I’m sorry to bother you,’ Mrs Smith said to her GP, and explained about the dizzy feeling. The GP asked if she had any other problems and she said she’d had some heartburn the other night, which was odd because she hadn’t eaten tomatoes which usually brought it on. The GP took her pulse and blood pressure and then told Mrs Smith that her heart rate was dangerously low and that she would have to go to hospital in an ambulance which was rather a shock to her! The next morning she had a pacemaker put in.

3. Mrs Smith had heard that NHS Direct was now available online and decided her broadband connection would probably be quicker than the phone: ‘They might put me on hold with some dreadful music’ she said. On the NHS Direct website she found ‘dizziness in adults’ in the A-Z of symptoms. She didn’t have any pain anywhere, feel feverish (she didn’t have a thermometer), feel breathless, she didn’t think she was going to faint, have any ringing in her ears or any of the other things they asked. NHS Direct told her she should stay at home. She made another cup of tea.

Would it have turned out better for Mrs Smith if she’d phoned NHS Direct and spoken to a real person? Not if they were simply following the website protocol. These people found the phone line even more unhelpful.

What I’m trying to illustrate is not that NHS Direct is useless (although personally I think it is an unnecessary waste of money) but that if you are seen as an emergency in hospital you are being seen by somebody (hopefully a doctor!) who is experienced in seeing emergency patients and has access to a second opinion from doctors who are more senior and/or in different specialties, and has rapid access to blood tests, x-rays and other investigations to help them decide what is wrong and how best to treat you.

If you go to your GP as an emergency you are being seen by an experienced doctor who can examine you, perform some basic tests and decide what to do next. The GPs job in this situation is more difficult as he or she doesn’t have immediate access to specialists and many other tests like the A+E doctor does.

If you phone a helpline you are talking to somebody who, whatever their level of clinical skill, is unable to even see you, let alone examine you and has to rely solely on what you say and the protocol in front of them. They cannot see your lips turn blue as you stoically claim to be ‘not too bad’ or see you sitting comfortably while claiming to be ‘doubled up in agony’. This is why telephone consultations/telephone triage should be done (if at all) by the most experienced, knowledgeable and qualified people available.

Monday, January 22, 2007

The black pit of despair

The black pit of despair has opened up and swallowed several of my colleagues, meanwhile releasing from its depths a miasma of misery and hopelessness. Or to put it another way the MTAS site has opened for applications to specialist training posts - of which there are ridiculously few - from junior doctors - of which there are a lot.

The sense of helplessness is all too obvious around the hospital and in the forums at DoctorsNetUK.

To everybody stuck in this MMC nightmare, good luck, I don't really know what else I can say.

Saturday, January 20, 2007

We don’t need no education (says MMC)

The Bulletin of the Royal College of Pathologists arrived this week with a slick new design and picture of a heart attack on the front cover (a prediction for the NHS in 2007?).

There were a couple of articles about training in it which got me thinking. There was another article that I’m going to blog about soon – but first I need to get down the hospital library and look a few things up (I thought this blogging lark was supposed to be relaxing, not work inducing!).

One of the articles (page 11 if you can get hold of a copy, it's not available online for non-members of the RCPath website) says that histopathology training is typically moving from 48 hours a week to 40 hours, with a slight shortening of the duration and say that this could lead to a 25% reduction in training time. As I’ve already pointed out, histopathology training has shortened before under the Calman scheme, a change that many of my colleagues thought was verging on the unsafe in terms of producing consultants fit for independent practice. The article goes on to discuss ways of trying to train to a reasonable standard in the shortening time available, concentrating on e-learning (for those of us who have broadband at home, since we won’t have time to do it work by the looks of things).

As I flicked through I saw a second article on training (page 22) and spotted in bold type ‘CBT is a process not a product’. My first thought was that trainees now needed cognitive-behavioural therapy to deal with MMC but it appears that it also stands for competency-based training. The RCPath have produced a curriculum for histopathology training, which is nice as now we know what we’re supposed to know and be able to do. The author points out that the curriculum doesn’t really help in terms of things like assessing competency and the potential for independent reporting by trainees. At this point it’s worth saying that currently independent reporting by trainees is a rather mixed up area. In some hospitals trainees are not allowed to report specimens independently (without the consultant checking the slides as well) until after they have passed part two of the MRCPath exam (the part 1 is written only and doesn’t test practical skills) which is only taken as a more senior trainee. In some hospitals there are structured schemes to enable more junior trainees to report certain types of specimen if the consultant thinks they are able to do so. In some hospitals there are similar, but more informal arrangements.

In this article it says that independent reporting would have to be based on objective and clear assessments of a trainee’s ability and that such a scheme could improve training but if it is inappropriately applied could result in demotivation and concentrating on the minimum acceptable standard. I’d like to think that competency based training would motivate us trainees and help us to learn as much as possible in the short time available but with MMC, reduced working hours and understaffed departments where consultants have little time for teaching I’m worried that demotivation and dumbing down may be coming.

Sunday, January 14, 2007

The knock-on effect

I watched the recent BBC series Can Gerry Robinson fix the NHS? and a few things struck me about it. A few things nearly struck the telly during the first episode but the other two weren’t as anger inducing – luckily for my telly.

The first thing that bothered me was the length of time it seemed to take Gerry to realise that the reason that surgeons have fixed theatre lists is that they have other things to do. Surgeons are not like the people on the car production line fitting the parts as the patients are wheeled past. They have patients on the ward to look after, they have patients in the clinic who need seeing, they have admin to do, they have to go to A+E for emergencies occasionally. Just because they’re not in theatre it doesn’t mean they’re not working.

The second point was about the knock-on effects. If the surgeons were operating on more patients, where were they going to put them? Patients generally need a bed to lie on; even a day case patient having a local anaesthetic procedure probably needs to lie down for a bit. So if you operate on more patients you probably need more beds. And nurses to look after the extra patients. And if they’re orthopaedic patients you might need another physiotherapist. If you put an extra theatre list on you need an extra theatre, complete with equipment, anaesthetist, theatre nurses and operating department assistants. If your increased patient throughput leads to an increased number of biopsies (endoscopy for example) then you might need extra lab staff and pathologists. Extra patients being seen in clinic might generate extra requests for xrays/scans, blood tests and other investigations. Of course if the target is purely to see/scope/operate on patients more quickly then maybe it doesn’t matter if the wait is shifted from waiting to be seen to waiting for test results or scans. If you’re the patient it probably does matter.

I didn’t see these two points very well explained or addressed in the programmes. Maybe it was due to the editing, but I think they are important points and should have been looked at more closely. Just as in the body, a change in function in one area of the hospital has effects on other areas which need to be considered.

The last point came at the end of the third episode when Gerry finally got to the bottom of the NHS mystery/disaster – the Department of Health. Now while Gerry suggested rather subtly that this was at the root of many of the problems, he apparently failed to really put his mouth where his money is (as I hear he is a supporter of, and financial contributor to, the Labour party) and give Patricia Hewitt the serious grilling she could really do with.

Overall – he didn’t save the NHS (bit overambitious). Some of his ideas were good and maybe he made an improvement in some areas in one hospital but who can tell when the programmes will have been edited to show what somebody (who?) wanted us to see. An honest and unbiased view from Rotherham would be a welcome addition. Things like this that I see on the telly I usually regard as entertainment only and factually suspicious. That’s what I think about this programme, shame really.

For more views on this series check out Dr Grumble and Dr Crippen, who has 3 posts on it.

I want to complain

I don’t normally talk too much about money or politics, other people do it so much better. But this week I’m feeling like a bit of a whinge (even more than normal!).

This week the BMJ tells me that according to the BMA the
number of medical students has increased by nearly 10,000 in the last five years which seems rather inadvisable considering the current increasing unemployment amongst doctors in this country.

They also say that the number of medical academics, who are supposed to be teaching these students, has
decreased by 25% - not so good for the students. On the other hand, since the total spend on medical research has been cut by pooling the amount spent by the MRC and the NHS and reducing the total a bit, at least the academics (oh yes, they need to produce high quality medical research as well as teaching students) might not see their own cut of the funding fall too much. However, hospitals aren’t always keen to employ medical academics (yes, they need to look after patients in the NHS as well as teaching the students and producing high quality research) because (unsurprisingly) they can’t spend as much of their time on direct patient care.

The BMJ also tells me that the
average debt for a graduating medical student these days is £21,755 and if universities raise tuition fees this is likely to increase, so maybe we will come full circle when few people can afford to go to medical school, numbers fall and the remaining medical academics (if there are any) have less teaching to do.

This doesn’t strike me as a very good solution. We are spending a lot of money training doctors who may well end up unemployed (waste of money, not to mention the time and hopes of the individuals involved). We are allowing the numbers of medical academics to decrease (short-sighted cost cutting – medical academics contribute directly to patient care by looking after patients, training future generations of doctors and producing world class medical research which leads to improved patient care). We are reducing spending on medical research even though it is one of the things we can still do well in this country.

Meanwhile millions of pounds are being wasted on the
NHS IT system, NHS Direct, and Choose and Book. I know where I’d rather my taxes went.

Friday, January 05, 2007


In 2002 there was an outbreak of infection in the UK. Nearly 200 people were affected and there were seven deaths. This outbreak of disease was well publicised and there were calls for punishment for those felt to be to blame for it. Every year in the UK there are around 100-400 cases and up to around 40 deaths due to this infection. Most cases of this disease are preventable and effective drug treatment is available. After the 2002 outbreak the people considered responsible for providing the conditions which allowed the infective agent to multiply and infect members of the public were fined for breaching health and safety legislation. Manslaughter charges against them were dropped.

In the first five months of 2006, in the UK, there were 449 cases of another infection, and one death from it, over five times the number of cases in the same period one year previously. Worldwide this disease affects around 30 million people per year and kills around 1200 people per day. Most cases of this disease are preventable, lucky as there is no specific treatment for it and only supportive care can be given. Nobody was charged or prosecuted in relation to this disease in the UK and there was less publicity and little public outcry about it.

Have you guessed what they are yet?

The first condition is Legionnaires’ disease. Read a news report about the outbreak here and see the UK case statistics here.

The second is measles. It is a worldwide problem as described by the WHO and is on the rise in the UK. The Health Protection Agency has some statistics on cases in the UK here and here.

I wouldn’t fancy catching either of these diseases. There is no vaccine available for Legionella pneumophila, the cause of Legionnaires’ disease but there is an effective vaccine freely available in the UK for measles. As a healthcare worker I regularly get blood tests from occupational health departments in the hospitals I work in, to check that I am immune to common and potentially dangerous infections. A couple of years ago one showed that I wasn’t immune to measles. Luckily there is a solution to that – I went and got my MMR jab.

Dr Crippen has more thoughts and interesting links on the subject of vaccination, as well as a request for other bloggers – check it out.