Solicitors ripping off the NHS

Those solicitors are at it again. We have all lost count of the £millions of compensation that was meant for coal miners but ended up lining the pockets of our not so learned friends. If solicitors are not ripping of the miners, they are out chasing ambulances or grave robbing. Compensation for medical mishaps is big, big business and a lot of solicitors have jumped on the bandwagon.

Liverpool solicitors E. Rex Makin acted for some of the parents in the Alder Hey Organ scandal.

They slipped a bill into the NHS for £4,479,957.06

As NHS BLOG DOCTOR regular readers know, the best way to make a fortune out of health care is to sell things to the NHS. NHS purchasers meet most of the criteria for brain death and usually accept all estimates, however large. But this bill from E.Rex Makin was so large that even the NHS blinked and issued a challenge. They said they would take the matter to court for independent costing. E. Rex Makin hummed and hawed a little and then , according to the BBC, voluntarily agreed to reduce their bill. By £4,049,957.06.

Strewth!

For full details of this and other outrages interested taxpayers should listen to File on 4, BBC Radio 4 2000 BST, Tuesday 30 June 2009, repeated 1700, Sunday 5 July 2009.

Dr Crippen meanwhile is interested in the precision of the original bill. What advice will a solicitor give you for 6 pence?

Gordon Brown admits that Labour health and education policies have failed

Mr & Mrs Tyler are on holiday

A brilliant bit of bile from the DK.

There is a serious point, though. There usually is when the DK is bilious. The point is quite straight forward. The government is to recruit, and finance, 100,000 personal private tutors to supplement the education system.

Personal fucking tutors? I though that the education system under NuLabour was the best in the known world—what the hell do you need personal tutors for? Unless, of course, you have bollocksed up the education system which then begs the question—why the bloody hell do you think you'll be able to run a system of personal tutors, using yet more money that we don't have?

The Devil's Kitchen

Quite. But it does not stop there.

The government has also instructed PCTs to fund private health care for any patient who might have cancer if a "specialist" is not available within two weeks. Er...just a minute, the government has been boasting about the success of the TWR system. And, to be honest, it is not working badly - as far as it goes. And it goes as far as the door to the local hospital, where our consultant colleagues are faced with a log jam of referrals, many of which turn out not to be urgent, which cannot be processed within two weeks or even, sometimes, within two months. And just wait until every women with a tummy upset or flatulence demands a TWR referral to the gynaecologist to make sure she does not have ovarian cancer.

The NHS and the state education system have failed. The conclusion is obvious to all. All that is apart from our Prime Minister who, as my currently thong-clad economic advisor observes, continues to lie through his teeth.

Dishonest paramedics

May be safer than an ambulance

I was called to see Mrs Johnson today. She is 78, lives with her husband, and suffers from COPD which is troublesome but stable. The details on the call request were "bad diarrhoea". She was, as always, apologetic when I arrived. But she looked unusually frail. Her husband said she was not drinking. She had had the diarrhoea for two days. Yesterday, Sunday, she was so bad that her son called an ambulance. I looked at the paramedic report. The box next to "Refused hospital admission" was ticked, and the form was signed by Mrs Johnson.

I asked Mr & Mrs Johnson why she had refused to go to hospital. They both looked baffled. They had not refused admission. The paramedics had told her that it was the weekend, that the hospital was short staffed (true - it is always short staffed at the weekend) and that she would be best to stay at home. She had agreed. She had indeed signed the form, but she had not read it, and had no idea that she had signed a statement saying that she had refused admission.

Let us not mince words. The paramedics were lying. Lying to cover their ass. They were being fraudulent. They purport to be omni-competent and well able to carry out medical assessments, but they are not prepared to take responsibility for their decisions. I shall make a formal complaint. Again. The ambulance service is not interested. Maybe they are under pressure not to take people to hospital. Maybe they are on bonuses not to take people to hospital. Whatever the reason, they frequently do not take people to hospital and they often fudge the paperwork thinking that will cover them.

Mrs Johnson needed some i.v. fluids so I sent her in. By ambulance.

This is yet another barrier to health care. Another way of keeping sick elderly patients out of hospital. Maybe this only happens in the area in which I work. I would be interested to have some feedback from other family doctors, or from other patients to whom this has happened.

The Pink List

The short post below, "Cultural Differences", attracted a lot of attention. Gender will never be irrelevant. Sexuality should be. Today, the Independent on Sunday publishes its annual "Pink List". Peter Mandelson is, of course, at number one.

Our very own Iain Dale slips in at number 26, up from last year's position of 49. He writes an accompanying article entitled Tory bedfellows can be anything but homophobes. The Pink List makes Iain less eminent than David Starkey, Gok Wan and Ben Bradshaw but more eminent than Alan Duncan and Nick Brown. He will have to live with that. (He seems to be coping!)

I don't like it. People should not be classified according to their sexual preferences. The concept of "eminent homosexuals" may sound "right-on" but is in fact patronising, closet homophobia. The main purpose of this list is to sell more newspapers by tempting middle England into putting down their Daily Mail for a moment to exclaim over the breakfast table, "Good Lord, I didn't know that "........." was gay." Peter Mandelson's pre-eminence is nothing to do with his sexuality. It is to do with the fact that, like him or not, he is a consummate politician. It is to do with the way he combines the comfortable, superficially benign presentational skills of Michael Parkinson with the underlying political skills of Dick Cheney, Mephistopheles and Rasputin.

Ranking people according to their sexual preferences is as meaningful as ranking them according to the cars they drive. The fact that Jeremy Clarkson might approve of such a classification shows just how nonsensical it is. Roll on the time when people's sexual preferences are truly irrelevant.

Cultural differences

We have four female partners. They are all part time.

One was on maternity leave. One was on holiday. One was not on that afteroon. The other had finished her early afternoon sugery and was off doing the school run. So, as occasionally happens, there were only male doctors available. I was "duty doctor". A female patient phoned to say that she had been in an RTA that morning. A car had driven into the side of her car. Not hurt. A bit shaken up. She was 29 weeks into her second pregnancy. No pain. No bleeding. She felt that the baby was "more active than usual".

Does not sound too serious, but you have to be sure. I offered her an appointment within the hour. She asked if I would want to examine her abdomen. I said I would. She said she was not prepared to be examined by a male doctor and that she usually saw the female doctor who was on the school run. Would she not be back at work later? I wish.

We ended up with her having an appointment with her female doctor tomorrow morning. She was happy enough with that, but I was not. It is not ideal. She could go up to the hospital, but there is no guarantee of a female doctor there, and seeing a midwife out of hours is next to impossible unless you are fully dilated and, these days, even then it is not easy.

What can you do? Why do I feel bad about it?

Still, soon it will not be a problem because before long, all doctors will be female. If you are male, and that bothers you, best get your scrotum checked now.

Summer solstice : the Druids & the Chiropractors

Thanks to Planet Chiropractic for the photograph above. Good to know that the American chiropractors recognise that they are visiting from a different planet. Meanwhile, for us Earthlings, it is the Summer Solstice, the longest day. For those of us with sub-clinical SAD syndrome, this is the harbinger of longer nights, shorter days and the long, hard haul to the winter solstice on 21 December (for those as anal as Dr Crippen about this, at exactly 17.47)

The sun-worshippers and Druids are even now gathered on Salisbury Plain. Dr Crippen pauses awhile to wonder why Planet Chiropractic is so interested in sun-worship. Mr Justice Eady has decreed that one should not use words like “bogus” when discussing the …er interesting claims made by British chiropractors. I wonder if even now our chiropractors, dressed in ancient robes, are prancing round Stonehenge with the Druids. It would seem appropriate.

Darzi Wars : the end of the NHS

A lunchtime phone call from a godson.

He qualified as a doctor last year. He has just coming to the end of his F1 year. He wants to be a surgeon. A properly trained surgeon. There are a total of 41 F1s in the region in which he works. Twenty of them (he knows for certain, there may be more) are applying for jobs in Australia. He is one of them.

Doctors in Australia

Australia is enthusiastically welcoming our newly qualified doctors. In fact, it is actively recruiting them. It will not pay them as much as they will get paid here, but it will treat them decently, train them properly, and offer them a stimulating career. Many are going. Doctors.net is full of adverts such as this.

Why is it happening? What is to be done?

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This brilliant take on NHS bureaucracy gives some of the answers : Kafka's NHS

"The State of ME" by Nasim Marie Jafry

velo-gubbed legs

(velo = bike, gubbed = exhausted, velo-gubbed legs = the way your legs feel when you have M.E, as if you've been doing the tour de france, except you haven't been near a velo)

++++++++++

What I like about The State of ME is that it is refreshingly free of cod-science.

Though notionally about “Helen”, Nasim Jafry’s carefully titled book is unashamedly autobiographical. It tells the story of a fit, intelligent modern languages student who, part way through her university course, is stricken with a chronic, disabling and undiagnosable illness. So often, books about myalgic encephalomyelitis are written by the militant wing of the “ME brigade” and are angry, self-indulgent, outspoken and intolerant. One of the most eminent ME militants, and certainly one of the most preposterous proponents of cod-science, is “Jodi Hummingbird” (really) who believes that:

M.E. is similar in a number of significant ways to illnesses such as multiple sclerosis, Lupus and Poliomyelitis (polio).

the brain stem…is always damaged in M.E.

ME…is primarily neurological, but also involves cognitive, cardiac, cardiovascular, immunological, endocrinological, metabolic, respiratory, hormonal, gastrointestinal and musculo-skeletal dysfunctions and damage. M.E. affects all vital bodily systems and causes an inability to maintain bodily homeostasis.

causes a list of symptoms so numerous as to cover just about any serious illness you care to mention

...the hearts of M.E. patients only pump barely pump enough blood for them to stay alive. Their circulating blood volume is reduced by up to 50%.

A Hummingbirds’ (sic) guide to ME

I didn’t know that hummingbirds bark. Poor old Jodi. She doesn’t understand apostrophes either. Before I bought the State of ME, I read Jodi Hummingbird’s review. When Jodi isn’t barking, she is being a characteristic militant ME pompous git. You are not entitled to your opinion unless you agree with Jodi. Only Jodi understands ME and if you don’t agree with Jodi, she has no time for you. Heaven forbid that Nasim Jafy, who has suffered from ME for over twenty years, should have her own opinion.

3/10 for the quality of the information given about M.E. It was almost entirely inaccurate. Almost all of the medical information given related to 'CFS' rather than M.E., and these are two very different entities!

Jodi Hummingbird’s review of The State of ME

It is people like Jodi who give ME sufferers a bad name. Thank goodness there are some, like Nasim Jafry, who do not share her views. Nasim Jafry writes with wit and gentle good humour about her illness. It is a long illness and it is a long book, perhaps a little too long. She does not burden us with too many medical details. Her family doctor is none too sympathetic but then Helen/Nasim comes under the care of a sympathetic consultant, a rheumatologist I suspect. He takes Helen/Nasim through a number of treatments including plasmaphoresis and “kick the television” ACTH therapy. None of the treatments is successful. There is the suggestion that the “diagnosis” was made on the basis of a muscle biopsy. If only it were as simple as that.

Helen/Nasim is spared the endless suggestions of graduated exercise programmes that are now Nicely in vogue. Any doctor who is contemplating recommending such treatment to patients with ME would do well to read the State of ME first. It is far more persuasive than Jodi Hummingbird’s pseudo-science about cardiac output.

Those doctors from the Simon Wessely school of thought might well ask if Helen/Nasim was clinically depressed and thus might have benefited from treatment with anti-depressants. There is nothing to suggest that Helen/Nasim was depressed before the onset of the illness. Her account is transparently honest and convincing, and I do not believe that she is suppressing details of any pre-existing psychiatric condition. A more interesting question is whether, during the course of her illness, she develops a secondary depression which might have benefited from psychological or pharmaceutical intervention. I reached a conclusion on that. You must reach your own.

We must assume that Helen/Nasim was never offered CBT (thank God!). Maybe it had not been invented then. (It had, but it wasn’t trendy). She has a supportive family but she does not seem to have been offered outside psychological support and there is nothing in the narrative to suggest that she would not have accepted that sort of help or indeed any sort of help from someone sympathetic. She does dabble occasionally with the quacktitioners but to no avail.

The State of ME is also a story of young love told around an increasingly intrusive illness. Jafry’s account of Helen’s various relationships are, notwithstanding some self-consciously twee descriptions of oral sex, convincing and, like all good love stories, one wants to finish the book to see with whom, if anyone, Helen settles down. The end may surprise you.

There is so much about which Helen/Nasim could be angry and yet this book is free of anger and free of bitterness. It is a balanced, non-didactic account of a young person grappling with a dreadful illness. All doctors will benefit from reading the State of ME. It may make those doctors who are not "believers" pause awhile before calling in the psychiatrists.

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A list of NHS BLOG DOCTOR articles on myalgic encephalomyelitis may be found here

Health care "rationalisation" : the cruellest cut

When you go to the hairdresser you know there are going to be cuts. Sometimes the cuts may be savage; a short, back and sides. You would not tell the hairdresser to choose the cuts. You would not believe a hairdresser who said he could shorten your hair without cutting it.

There are going to be cuts in public services. Of that there is not the slightest doubt. There is only one person in the country who says there will not be any cuts, and that is our discredited Prime Minister. His performance at today's PMQs was dishonest. He lied. Like the barber purporting to shorten your hair without cutting it, he fools no one. Balls is lying. Liam Bryne, the Chancellor's rotweiller, is lying. Look at this glorious double speak:

"You've got to separate two kinds of spending here. You've got to separate current spending, that is the day-to-day cash in hand. In real terms that grows by 0.7%...

It is a bit of a red herring, I think, to try and mix up capital spending and current spending. You know, if you put the two things together you get the numbers that you talk about. Because of course once you've got a school, you've got a school. Once you've got a hospital, you've got a hospital. The thing that really matters is what happens in the day-to-day current spending. The overall envelope rises by 0.7%."

Liam Byrne, the Chief Secretary to the Treasury.

Neither party dare admit that some of the impending cuts will be in health care. But, behind the scenes, the government has already appointed the health care barber. He is none other than Matthew Swindells. Swindells used to work within the NHS. Now, as so many others have discovered, he can make far more money by working for the NHS as an independently contracted management consultant.

Matthew Swindells, managing director of the health division of Tribal and former special adviser to then health secretary Patricia Hewitt, said GP services would not face cuts if practices took on more secondary care work.

‘Some 30%-40% of patients in hospital don’t need to be there. There is a huge gain to be made. It needs a step change, not to replace primary care services, but extend what they are doing.

PULSE

What a c.v.! Patricia Hewitt's spad turns into a management consultant and sells his dubious wares back to the NHS. He now works for TRIBAL, a super smooth, slick, top of the second divsion management consultancy which makes its money advising the public sector how to improve thier efficiency. Swindells is not medically trained and has no experience of primary health care. But he wants to force GPs to take on work much of which they are not trained to do. And if they refuse? He will pass it down the food chain to the pharmacists.

Tribal, appointed as one of the Government’s key advisers on healthcare spending, warned PCTs were ‘remarkably tolerant’ of variations in GP referral rates, and said a clampdown could bring ‘very substantial benefits’. It also warned GP services could face ‘rationalisation’ if practices did not take on complex hospital work, with ‘more cost-effective’ providers such as pharmacists to be commissioned to take on a greater proportion of frontline work.

Don't you love the use of the word "rationalisation"? And when the pharmacists make a mess of it, what then? Pass it down to the nurses? Then to the auxilliaries? Then to the cheapest and most ignorant of all the independent health care providers, the "expert patients" If they could take over, the NHS would cost nothing.

Do not despair. There are ways of making cuts. My colleague, the Jobbing Doctor, shows how £350,000,000 could be saved at a stroke, and I am with him on that. I too have a simple ploy. A front end charge of £20 each and every time you wish to see a doctor. That charge would, at a stroke, reduce waste and would generate a vast amount of money. But it will not happen. Every time I suggest it, there are howls of anguish. Utterly wrong and utterly misplaced but demonstrating so clearly why no political party dare make the suggestion. Instead, they will stealthily dumb down the service. You can have two pharmacists for the price of one doctor (that figures - four to five years to train as a pharmacist, nine to ten years to train as a GP).

You, the common folk, may continue to celebrate your "right" not to have to pay a front-end charge to see the new, stealthily dumbed-down, untrained, health care professional. But do not expect to find Gordon Brown, or Margaret Thatcher, or Patrician Hewitt, or Mark Swindells or Dr Crippen queuing behind you. We will all be elsewhere, seeing a doctor.

Margaret Thatcher : "let them eat cake"

Baroness Thatcher will stay in hospital for "several days" as a "precautionary measure", her spokesman has said. Lady Thatcher was "very comfortable". She was able to sit up in a chair and talk to visitors but doctors would assess her condition over the coming days. She was taken to Chelsea and Westminster Hospital on Friday after she fell, fracturing her arm. On Saturday Lady Thatcher's son Sir Mark said she was "in good spirits". He said his mother was "relaxed" and had "a bit of mischief about her".

BBC

A "bit of mischief", eh? What a load of mawkish, patronising guff.

I wish Lady Thatcher well. I voted for her in 1979 and, whilst I did not live to regret that vote as much as I regretted voting for Tony Blair in 1997, I did not vote for her again. She deserves and will, I trust, receive the best medical care the country has to offer. But it hurts that my patients do not receive similar care.

Make no mistake, Margaret Thatcher is receiving far better and far more intensive treatment than an ordinary 83 year old would receive, even an “ordinary” 83 year old with private health insurance. Ordinary 83 year olds are not kept in hospital “for assessment”. Ordinary 83 year olds with broken arms would have been unlikely to have been admitted in the first place. They would have been sent home with a snotty note from the F1 or the orthopaedic quacktitioner (usually a physiotherapist these days) saying “GP to refer to the falls team.”

As to the causes of the fall, well, they would not have been considered by the hospital and, unless the GP gets on it, they will not be further considered.

Tommy, the Devil, the Amish, MMR and single immunisations

I always liked, and still like, the rock opera, Tommy. When I was at university, I saw the definitive (and only acceptable) staged production of it, put on, oddly, at the Oxford Union. It was awesome. (Is there anyone else out there who saw it?) Charles Sturridge, father of another Tom, played Tommy. A few years later I managed to get a ticket for the star-studded but inferior stage version. It was appalling. The touts were out. I was offered £150 for my ticket on the door. I wish I had taken it. And the film? Don’t bother.

Tommy did not have congenital german measles (rubella). He was traumatised in childhood. We do not see many deaf-blind children now, thank God. But take a trip to Pennsylvania and visit the Amish people. You have heard of their furniture. You remember that "Amish" film because Harrison Ford was in it. What you may not know about the Amish people is that they declined to immunise their children against rubella.

As a result, in 1995, one baby in 50 born to Amish parents was born severely rubella damaged

It was a tragedy all the more so because it could so easily have been avoided. There was a similar avoidable tragedy in the UK in the 1970s. There were three epidemics of whooping cough (pertussis) with thousands of hospital admissions and around a hundred deaths. Why did it happen? Because of a groundless media driven campaign about imaginary dangers of the pertussis component of the triple vaccine. On this occasion, parents were offered the option of a single immunisation. Over half of parents chose to vaccinate their children without the pertussis component. Coverage fell from 80% to 30%. It took nearly fifteen years for vaccine uptake levels to recover.

So much for single immunisations.

It has always been an infuriating feature of the media that they provide disproportionate coverage of those who seek to undermine and discredit the immunisation programmes. For reasons that escape me, the hysterical loony-tune brigade at JABS are always asked to put a spokesman when any immunisation issue hits the media.

The arguments in favour of the triple Diphtheria, Tetanus and Pertussis immunisation and the triple MMR are overwhelming. Leaving aside the flat-earthers at JABS, it amazes me that intelligent, rational people continue to ignore scientific data. I found it particularly depressing, therefore, that one of the most eminent of our political bloggers, the DK himself, should decide over the weekend to go off the deep end about single immunisations. He clothes his threadbare arguments in a characteristically entertaining tirade against the medical profession but do not be fooled. The single immunisation option, as seen thirty years ago with pertussis, would, if offered for measles, result in even more deaths.

What the DK does not understand, and what the media does not understand, is the reason that many parents give for wanting single immunisations. Often, Andrew Wakefield is only the background. What many parents feel is that giving three immunisations “all at once” might be “too much” for the immune system of a small child. It is an understandable feeling but is one based on emotion, not rationality, and most certainly not on immunology. Oddly, these parents had no concerns about giving diphtheria, tetanus, pertussis and polio immunisations all together and three times over a period of a few weeks. It is strange that the DK, who has a background in science, does not seem to understand either.

SENSE is an organisation dedicated to helping people who are both blind and deaf

Sense was founded in 1955 as a self-help and support group for the parents of children whose disabilities were neither recognised nor provided for. The children were born deafblind as a result of their mothers catching rubella (German measles) in pregnancy. 'The Rubella Group', as it was known, was founded by Peggy Freeman MBE and the late Margaret Brock MBE, whose daughter and son respectively had congenital rubella syndrome.

The DK may well classify SENSE as a fake charity. You can make you own mind up about that. SENSE has one of the best public data bases available on MMR. There is no clearer explanation than the one they provide of the reasons for giving children the MMR immunisation. There is no clearer explanation than the one they give of the dangers of offering single measles immunisations.

Sense and Mmr

Publish at Scribd or explore others: Health & Medicine Research

I suspect that the DK has not read this document. I hope he will now. And then he can modifiy some of his post. Until he does, though, a few observations

The reality is very simple: concerns were raised over the safety of the MMR jab—those concerns were not beyond the realms of possibility.

“Beyond the realms of possibility” encompasses anything. It is not beyond the realms of possibility that the DK might vote Labour. But the safety of MMR immunisation is proven beyond all reasonable doubt.

The government said that there was no problem but—and here is the fucking crux of the matter—no one trusts the fucking government on health issues (remember Gummer feeding a beef burger to his daughter?).

Hee. Yes, I do remember the appalling Gummer inserting said burger into one of his progeny. It was indeed appalling. But actually, DK, by and large, rightly or wrongly, most people do trust the government on health matters such as this.

And few people trust doctors either, since their representative bodies have been peddling lie after lie after lie, and still the so-called "decent ones" pay their dues to their disgusting, authortarian trade unions.

The DK puts forwards his personal and prejudicial opinion as though it is representative of "the people". The DK may not like it (does not like it) but, as a profession, doctors are trusted.

What should have happened is that the government should have authorised the single jabs: this would have been more expensive but would have avoided the sharp increase in measles rates (costing the NHS more in the long-term). The government expressly refused to pay for this course of action.

Incorrect. Single immunisations would likely have increased the incidence of measles for reasons given above.

Given that the government did not allow single jabs, what should have happened is that the doctors who were so concerned about immunisation rates should have lobbied the government to allow the single jabs. They did not do so, because the only thing that doctors' representative bodies are interested in is curtailing our freedoms as regards drink, drugs and cigarettes and they were too busy doing this to give two shits about important things such as herd immunity. Because they are all absolute stinking cunts.

Hmm. Well. In fact, the reasons that doctors did not lobby for single immunisations was that they knew that that would not be in the best interests of children and would, in fact, have resulted in more children dying of measles. And the incidence of mumps and rubella would have increased.

Finally, I should say this. The DK will read the document from SENSE and will rush to point out the following paragraph contained therein:

Another view, promoted by some sections of the media, is that the people charged with making decisions about public health do not necessarily have the best interests of the public at heart. This phenomenon is described by the Guardian journalist Michael White as being driven by a type of journalistic assumption that “the governing classes are a bunch of third-rate crooks and liars who are in it to enrich themselves and let down the public”

Hee! Hee! Some good debating points to be made from that in view of recent events. But nothing to do with government immunisation policies, which are formulated by doctors, not MPs.

Swine flu news : update (4) "GPs will NOT be going on strike"

An odd report from the BBC today. Naturally, it is provocative. No surprise there. Probably, it is rubbish. Not much surprise there. The report is based upon some odd remarks, probably taken out of context, attributed to Dr Dean Marshall. Never heard of him but he is said to be

“one of the BMA's lead negotiators on flu planning, said of the pandemic”

BBC

Dr Marshall seems to have confused two issues. GPs “death in service benefit” and GPs medical insurance. Or, at least, this badly written and confusing BBC report portrays him as being confused. The report starts provocatively:

Some GPs may refuse to work if the swine flu pandemic spreads throughout the UK, union leaders have warned.

That, if I may use a technical term, is bollocks. I can assure you that all GPs will continue to work as normal. If there is a “real” epidemic (not this definitional pandemic nonesense that is going on at the moment) we are all at risk of catching flu and, frankly, you are just as likely to catch it in Tesco or on a train as you are sitting in a health centre. GPs will carry on. If thousands and thousands of our patients catch flu, we will dole out the Tamiflu which you and the government can pretend will help, and we will do our best to treat any secondary infections.

GPs as a whole are pretty relaxed about “catching things from patients”. Most of us think we are immune to all known disease (we are not) but, in our rational moments, we know that any small increased risk of infection is part of the deal. How many surgeons have stopped operating because of the risk of catching HIV infection?

As regards Dr Marshall’s worries about medico-legal cover, well, I do not understand it. All GPs are members of the MPS or some such organisation, and the cover we get from these organisations is far superior to that provided by so called “crown immunity” that some hospital doctors foolishly rely on.

If the quote attribute to Dean Marshal is correct then he is an ignorant barrack room lawyer. He allegedly says:

GPs, because they are effectively self-employed, have their own insurance but this may not cover them during a serious flu outbreak.

Dr Marshall said: "The problem is that the current cover expects GPs to act in a certain way.

"For example, if someone has a heart attack we should send them to hospital, but during the pandemic hospitals could be full and this may not be possible.

"Our fear is that later on people may sue us."

BBC

Rubbish. If I see a patient with a heart attack, I shall send him into hospital. If the hospital is full, and unable to admit him, that is not my fault. I shall do my best to manage him at home, as GPs did fifty years ago. Far from ideal management in modern times, but that does not make me, or any other GP, liable for anything. One does one’s best in all the circumstances.

Death in service benefit is already covered under NHS pension arrangements. There is, it is true, an issue about a locum sessional GP who contracts flu and dies. His “death in service” benefit is ill defined. Dean Marshall could put some work into that problem.

As to the general issue, however, may I just reassure all that, in the event of a swine flu epidemic, your family doctor will be working as normal and will do his best to provide a good service, however difficult conditions may become. There will be no industrial action, and there will be no strikes.

Trusting Amy

Amy St Johnston

Hard not to feel sorry for Amy St Johnston. When she was sixteen, and a sixth former at boarding school, she went to the Valentine’s Day ball. The school rules say that sixth formers may drink beer, wine and cider in moderation. There is an element of trust in these rules. Parents and teachers cannot follow teenagers around for every minute of the day and night. Amy broke that trust and drank too much. She was unsteady on her feet. A teacher saw that she was unsteady and told her to leave the ball and “cool” off. Amy ignored the advice. She went back to the ball. The staff noted this, and took her back to her room. She then managed to fall out of her window. Her injuries left her partially paraplegic. She can walk, but only with the aid of crutches.

A tragedy.

Amy has done well. She is now a student at Cambridge Univeristy. She has decided to sue her old school for neglect.

Documents lodged at the High Court say that Oundle was in loco parentis, and accuse the school of failing in its duty of care by leaving Miss St Johnston in the room while it was “known she was under the influence of alcohol”.

The Times

Oh! Dear. It’s the blame culture again. Who cannot but feel sorry for Amy? But does a sixteen year old not have any responsibility to behave? Should schools and parents have to place sixteen year olds under lock and key to prevent any conceivable injury? Schools take teenagers on education/cultural trips all the time. All my four children have done it. I know, the children know, the school knows that, whatever the regulations, some of the children will experiment with alcohol. And sex. Does this mean we should never place trust in a sixteen year old? Where does reasonable care end and the nanny state begin?

We should look at a no fault compensation scheme for accidents such as this. We could call it National Insurance. Sadly, that phrase is being used by the income tax gatherers. It is wrong that Amy’s chance of reasonable financial support depends on the lottery of a court decision. Is Amy's injury any worse than a sixteen year old breaking his back playing school rugby? If the court decides in Amy's favour, schools will inevitably clamp down on the freedom and trust they endeavour to give to young adults. Our teenagers will spend their schooldays wrapped in cotten wool.

Government communication

NHS BLOG DOCTOR swaps information on a regular basis with medical journalists in the mainstream media. Unlike such medical journalists, Dr Crippen does not receive regular behind-the-scenes briefing from the government. It is not a problem. Most of the stuff that is churned out by the government is naught but propaganda, and pretty dull propaganda at that. Today, I have received an email from a senior medical journalist who works for a prestigious medical/scientific magazine.

Hi Dr Crippen

For some time now the press releases I get from the Department of Health have been getting so jargon-ridden, meaningless, and frankly non-newsworthy, I have been automatically deleting them, unless the subject heading really catches my eye. But this latest one takes the biscuit. Can you make head or tail of it? Is it really statistically meaningful to tell journalists that the patient experience PSA score has increased by 0.7 points? And what is the patient experience PSA score anyway? At first I thought it was something to do with prostate-specific antigen but it would seem not. They obviously didn't involve any doctors when they decided on that acronym.

Anything to help. I’m familiar with most medical acronyms and I can cut through otiose jargon like a hot knife through butter.

Update of patient experience psa scores
11 June 2009

The following statistics were released today by the Department of Health:

Patient experience PSA scores update based on data up to and including 2008 patient surveys

Background
This publication updates the patient experience scores previously published on 24 November 2008. The patient experience PSA has been rolled forward as one of the indicators against 'PSA delivery agreement 19: Ensure better care for all' for 2008-11.

These figures report initial progress against the PSA target for sustained improvement in patient experience for the 2008-11 spending review period. Results are updated to include scores derived from survey results published by the Care Quality Commission in 2008. There are new data points for 'adult inpatients' and 'emergency department service users'.

Main findings

The overall patient experience score in 2008/09 for adult inpatients is 76.0. This is 0.7 points higher than the baseline score of 75.3 in 2007/08. The overall patient experience score in 2008/09 for emergency department service users is 75.7. This represents the baseline for this PSA measure. This is 0.1 points lower than the score of 75.8 in 2004/05 (the last time this survey was conducted).The score for 'involvement in decisions about healthcare' is higher in 2008/09 for adult inpatients. The score in 2008/09 is 71.3, up 1.0 points since 2007/08. The score for 'involvement in decisions about healthcare' is lower in 2008/09 for emergency department service users. The score in 2008/09 is 76.0, down 1.1 points since 2004/05.


Detailed data can be found at this government sponsored link.

Hot knife? Butter? I spoke too soon. What does it mean? How much does it cost to produce this?

Junior hospital doctors are incompetent

Junior hospital doctor

Those GPs who wake up in the morning listening to the Today programme on Radio 4 are used to the medical stories that always start, or contain, some criticism of GPs. We don’t know this, we don’t know that, we need more training, we are overpaid, we are lazy and so on. It is deeply depressing and saps morale.

The medical story this morning was different. It was precise and to the point. British junior hospital doctors are incompetent, inexperienced, negligent fools who are allowing patients to die of acute renal failure, an illness that is eminently treatable if only it is promptly diagnosed.

“It can be diagnosed at the bedside with a simple blood test”

suggested the egregious twat of an academic who was clearly enjoying his two minutes of perceived fame on the programme. Not famous enough for his interview to be preserved on “Listen again”.

Could I even luxuriate for a second in a little schadenfreude? Sadly not. This nasty, unrepresentative bit of “journalism” made me just as angry as the more usual knocking copy about GPs. As is increasingly typical of the Today programme, the story was unbalanced. No representative of the junior doctors was asked to put their side of the story.

What is the truth?

Are patients dying unnecessarily in hospital because investigations that should have been done have not been done. Emphatically, yes. And it gets worse. The doctors are now under so much pressure to get patients out of hospital as soon as possible that the patients sometimes do not have time to die in hospital. They die in the nursing home to which they have been unceremoniously returned. Either the tests have not been done, or they have been done, but the patient has been sent home before someone has met up with the results.

It is not the fault of the junior doctors. It is the fault of new working conditions, of the EWTD, and of the lack of doctors. This did not happen twenty years ago. Patients think that the most important doctor on the hospital team is the consultant. That may be the case now, but it was not the case in the past. The most important doctor on the team used to be the houseman. Yes, he was the most inexperienced doctor, but he was also the co-ordinador, the progess chaser, and above all the continuity expert. He worked on what was called a “firm”. The firm was headed by a consultant. There would be a middle grade doctor on the firm as well (maybe two in a teaching hospital) and the houseman. When the “firm” was on “take-in” all the patients who were admitted were clerked in by the houseman. He personally saw them, took a history, examined them, ordered the first level of investigations and then, depending on his experience, initiated the treatment. At the end of a “take in” day, the houseman would go round with his registrar who would check what the houseman had done, check the results of investigations, and make suggestions about what else needed to be done. The houseman followed the patient through the whole of his admission, wrote the discharge summary and arranged for the patient to be seen in outpatients if follow-up was necessary.

The houseman kept a note pad in his pocket with a list of all the firm’s patients, with their location, their results and their outstanding problems. When the consultant did his rounds, the houseman led the consultant from patient to patient, wherever they were in the hospital (what do you mean, Crippen, we have a patient on the eye ward?), presented the patient, the problems, and the results of the tests. The consultant would then “fine tune” the mangement. If, as a medical houseman, I had said to the Renal Consultant for whom I worked that I did not know what a patient's sodium, potassium and creatinine (basic tests for acute renal failure) were, I would have been dead.

Nowadays, there is no firm. Housemen, or F1s as they are called, work for a “unit” or a “team” but not for a named consultant. Mr Jones is admitted to the “medical assessment unit” with sharp, non-cardiac chest pains. The on-duty F1 (F1i) examines Mr Jones and sends him off for a CXR. F1i now goes off duty and F1ii comes on. He does not know the patient has had a CXR. He orders some blood tests. Mr Jones is in too much pain to go home (administrator angry already) and so F1ii sends him to Maple Ward. Sadly, when the porters get there, Maple Ward is full, so Mr Jones is diverted to Birch Ward. Neither F1i nor F1ii know where Mr Jones is, and the MAU consultant was tied up with a cardiac arrest and did not see Mr Jones himself. Yes, all the information is on a computer somewhere, but who is going to look? Who is now responsible for Mr Jones? F1iii is one of the junior doctors on Birch Ward and is puzzled about Mr Jones' appearance. He checks the computer and notices that Mr Jones cholesterol is 6.7 and so he writes him up for some simvastatin. Two days later Mr Jones gets muscle pains which F1iv assumes is a side effect of the simvastatin and so he stops it. The CXR comes back and an SpR sees that it shows a little basal shadowing, so suggests some amoxicillin. Mr Jones gets a lot better over the next two days, and it is Friday afternoon and another SpR is pressurised by the nurses to send Mr Jones home. Finally, ten days later, a new F1, F1v, sends a computerised summary to the GP. He never met Mr Jones, so he downloads all the tests that have been done from the computer and prints them out. He notices that the patient has a raised MCV.

No follow up is offered to the patient. F1v finishes the discharge summary by saying “GP to monitor cholesterol, check for causes of raised MCV and arrange a follow up CXR”

Utter chaos. There is not a single doctor in the hospital who can account for Mr Jones' admission. It is easy to shout at the F1s. Occasionally, I pick up the phone and track down some the unfortunate F1 whose name is on a discharge summary and ask him to explain what has happened to my patient. He does not know. He has never met the patient. "I only did the discharge summary from the computer." You cannot nowadays even ask which consultant the patient was under. He was not under "a consultant." He was under the “medical team.”

It’s chaos. But it is not the juniors’ fault. It is the system. Junior hospital doctors are as bright as they ever were. We have destroyed their working environment. We are doing to them what Margaret Thatcher did to her colleagues:

It is rather like sending your opening batsmen to the crease only for them to find, the moment the first balls are bowled, that their bats have been broken before the game by the team captain.