Bird Flu and the middle class

Avian flu virus

Middle class dinner-parties in England ground to a halt a few days ago following the horrific announcement here that someone in the UK, a human no less, had contracted “bird flu”

In fact, he had not contracted influenza. He had developed an irritant conjunctivitis, caused by the H7N3 strain of the virus related to the H5N1 but posing no significant threat to humans.

The chatter continues, and the anxiety mounts.

Meanwhile, our dear friends at Roche have clocked up over a billion pounds in profit for adding to the government stock-pile of Tamiflu. Reassuring to know that that nice Mr Rumsfeld has personally profited from theses sales. You cannot keep a good man down.

Profiting from Tamiflu

Well, better than being an arms dealer, I suppose.

It is not only Mr Rumsfeld.

Those equally nice on-line pharmacy companies, who bombard me with emails offering to enlarge my penis, have taken a break from Levitra and Viagra, and are now offering on-line, no prescription needed, supplies of Tamiflu. Go here, and you can buy ten Tamiflu tablets for as little as $125 dollars. Well done, chaps. The pharmaceutical industry at its ethical best.

Meanwhile, Flutrackers.com reveal that down in Ohio, the government has already laid in a stock of body bags should they be needed.

And further advice in "Bird Flu Update" :

“When burying a body in the backyard, don't put it too close to the septic system."

That was one piece of advice offered on Wednesday to a business conference on preparing for a potentially lethal bird flu pandemic.

In Seattle, public health officials are weighing the ramifications of hospitals overwhelmed by hundreds of thousands of sick people and the need for thousands of body bags.

"We talk about how people should bury their dead in their backyards, how far from the septic systems," said Dorothy Teeter, director of the King County public health department in Seattle.

"In case you're wondering, it's $20 apiece for high-quality body bags. In New Orleans (after Hurricane Katrina) they had to double-bag bodies."

That is a whole hour of dinner party natter.

Everyone is cashing in on the anxiety. Those unlucky enough not live in Ohio may worry about the disposal of their loved ones in the case of a flu epidemic. Fortunately, a complete service is offered here:

Wholesale Body Bags Proudly Made in USA
Buy American!

We Serve the US Military, Major City Police Departments, Hospitals,
Medical Examiners' Offices and Funeral Providers Nationwide.

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Customers will be relieved to know that all body bags are made of non-toxic materials and are guaranteed to be non-carcinogenic. Thank God for that.

The middle class, stirred up by the media, has gone quietly crazy.

To date, the death rate from bird flu in the UK and the USA has been zero. Over the last year, there have been more people struck by lightening, more lottery winners and, I daresay, more people who have been abducted by aliens.

What would happen if there really were an epidemic of a fatal infectious disease in the UK and the USA? Eight hundred thousand people dying in Massachusetts and two hundred thousand people dying in Middlesex. A million deaths in one year in the Western World. The governments would respond. A solution would be found.

It has not happened. It is not going to happen.

Meanwhile, and I apologise to all the chattering middle-classes for bringing this up and further interfering with your dinner party, there IS a serious problem with a frequently fatal infectious disease. Unlike bird flu, this disease is a real killer. And we are not talking a few hundred deaths; we are talking between one and two million deaths a year, every year. We know what causes this disease. We know how to treat it. We know how to prevent it. So we have a head start on those virologists currently looking at bird flu.

This disease is called malaria. Three thousand people a day die of it, most of them children.

Anopheles mosquito takes lunch

Why have we not done something about it?

We ignore it because it does not affect the USA or the UK. We ignore it because the people who get malaria are black or dark brown, have unpronounceable names, speak guttural incomprehensible languages and all look the same. So it does not matter if a few thousand of them die every day. No one notices. No one cares.

Who cares if they die?

It was always the same. Remember the frenzy over SARS? A transient media favourite that received far more attention than malaria.

Malaria is not perceived as a threat in the UK. SARs was. Bird flu is. In fact, even in the UK there is no room for complacency about malaria, but the problem is trivial compared with sub-Saharan Africa.

Here are some facts:

• Malaria is one of the planet's deadliest diseases and one of the leading causes of sickness and death in the developing world. According to the World Health Organization there are 300 to 500 million clinical cases of malaria each year resulting in 1.5 to 2.7 million deaths.

• Children aged one to four are the most vulnerable to infection and death. Malaria is responsible for as many as half the deaths of African children under the age of five. The disease kills more than one million children - 2,800 per day - each year in Africa alone. In regions of intense transmission, 40% of toddlers may die of acute malaria.

• About 40% of the world's population - about two billion people - are at risk in about 90 countries and territories. 80 to 90% of malaria deaths occur in sub-Saharan Africa where 90% of the infected people live

• Sub-Saharan Africa is the region with the highest malaria infection rate. Here alone, the disease kills at least one million people each year. According to some estimates, 275 million out of a total of 530 million people have malaria parasites in their blood, although they may not develop symptoms.

• Of the four human malaria strains, Plasmodium falciparum is the most common and deadly form. It is responsible for about 95% of malaria deaths worldwide and has a mortality rate of 1-3%.

• In the early 1960s, only 10% the world's population was at risk of contracting malaria. This rose to 40% as mosquitoes developed resistance to pesticides and malaria parasites developed resistance to treatment drugs. Malaria is now spreading to areas previously free of the disease.

• Malaria kills 8,000 Brazilians yearly - more than AIDS and cholera combined.

• There were 483 reported cases of malaria in Canada in 1993, according to Health Canada and approximately 431 in 1994. The Centres for Disease Control and Prevention in the United States received reports of 910 cases of malaria in 1992 and seven of those cases were acquired there. In 1970, reported malaria cases in the U.S. were 4,247 with more than 4,000 of the total being U.S. military personnel.

• According to material from Third World Network Features, in Africa alone, direct and indirect costs of malaria amounted to US $800 million in 1987 and are expected to reach US $1.8 billion annually by 1995.


Malaria could be eradicated.

It there were half a million deaths a year in Massachusetts and Middlesex from malaria, it would be eradicated. Mussolini tackled the problem in Italy eighty years ago by draining the Pontine Marshes.

It would not be easy to eradicate malaria, but just because we cannot do everything does not mean we should do nothing.

We could make a start. A few millions gallons of unfashionable DDT. Sorry, Greenpeace. Mosquito nets. Education.

Most of all, a concerted efforted from Europe and the USA.

Last month, the Lancet highlighted the scandal.

“April 25th 2006 was designated as “Africa Malaria Day”. It is timely therefore to remember that an article by public health experts published online in…The Lancet on Africa Malaria Day, April 25, blamed the World Bank for failing to make good on its pledge to wipe out the disease by 2010.

In fact, the critics accuse the international aid agency of spending far less than promised on malaria, wasting money on ineffective medicine and cooking the data to make it appear that progress is being made when it isn't." (Muster against Malaria)”

Whilst you have read this article, six children have died of malaria.

Africa Malaria Day has come and gone, and no one noticed.

Nothing has been done.

The Crippen Diaries (Week 17)

Not quite Tannochbrae

Monday 24th April

Patricia Hewitt’s announcement that this is “the best year ever” (sic) for the NHS must go down as the greatest political blunder since Jim Callaghan got off the plane and (didn’t) say, “Crisis, what crisis?” (See here) At least a third of the patients I saw today mentioned it. Most thought it hilarious. One or two were angry and contemptuous.

Do catch the wretched woman on song here.

++++++++++

An email arrives from the PCT.

Dear All

A&E has reached the highest level capacity at St Elsewhere’s Hospital. Please do not direct any patients to this department unless it is an emergency.

The following numbers are an alternative if needed:

Respiratory Care Nurse Specialist 0124......
Heart Failure Nurse Specialist 0124.......

Although this alert has been extended for another 24hrs it is unlikely to change for the current week.

Regards





George Davis

Office Manager
Primary Care Development

This is the sort of thing that Hewitt is doing. Think about it. Do not send patients to the A/E department unless it is an emergency. What other reason would we have for referring patients to A/E?

Do they really think that experienced doctors are going to call nurses about critically ill patients?

Do they really think that they can close the hospital and let the nurse specialists take over?


++++++++++

I.T. is everything these days. The local Radiology department has recently spent squillions introducing a new, computerised appointment system. So this letter was waiting for me. It is being sent out to all the patients who were or might have been on the waiting list for ultrasound examinations. Ultrasound is a common investigation, often used to diagnose cancer. Notice that no doctor or adminstrator has been brave enough to put his name at the bottom of the letter.

St Elsewhere's Hospital

Department of Radiology

Coventry Road
Anytown
CV18 9QZ

24 th April 2006

Dear

ULTRASOUND REFERRAL

We have recently introduced a new computerised system into the Radiology/Ultrasound Department, which has resulted in long delays in individuals receiving their ultrasound examination. We are extremely sorry for this delay; and are addressing this problem in a bid to reduce waiting times for all individuals.

The first step in this process is to determine whether you still need an ultrasound examination as some patients may have had this performed elsewhere. We would be grateful if you could respond to this letter in one of two ways:

1) Complete the tear off slip below and return to the department in the envelope provided

OR

2) Email your name, address and whether you still need your examination to:
xray.appointments@anytownh.nhs.uk

It would help us if you could respond within a week of receiving this letter. If you are unsure about the test, or completing this form, please contact your General Practitioner (GP) or practice nurse for assistance.

We are sorry for the inconvenience this may have caused and will get an appointment out to you in due course.

Yours sincerely,





Ultrasound Department
------------------------

Please complete all relevant sections below and return in the envelope provided. Thank you.

1. Have you already had your ultrasound examination? Please tick one answer only.
Yes  No  Unsure 

(a) If Yes, when and where was the exam performed

Place: ……………………………………………….
Date: …………………………… Private / NHS* (*please circle applicable answer.)

(b) If No, would you like to remain on the waiting list? Please tick one answer only.
Yes  No 


Brilliant. They have lost the waiting list. They do not know who has had scans and who has not. Some patients will have given up waiting and gone privately. One or two will have died of natural causes. Worryingly, one or two may be dieing of the condition that needs scanning, but they will not know that…yet.

And, of course, in the true spirit of Hewitt’s “best ever” NHS they are not missing the opportunity of allowing people to "opt out" of the test. How can the patient make that decision sensibly?

People worry whilst they are waiting for this sort of investigation.

++++++++++

God, I need a holiday.

++++++++++


Tuesday 25 April

Angela is in her late thirties. I do not see much of her, but she presented today in a dreadful state. She found a breast lump in the right breast three weeks ago. She had been too frightened to come to the doctor. Steven, her husband, had virtually frog-marched her down.

Angela’s mother had died in her early fifties of breast cancer that had started when she was pre-menopausal.

When I examined Angela, I found a half centimetre sebaceous cyst on the axillary tail of her right breast.

A sebaceous cyst is a benign swelling. It was not a breast lump at all. It just happened to be on the tail of the right breast. If it had been on her back, or even her forehead, she would not have been worried.

Sebaceous cyst on forehead

I told her what it was. She was partially relieved but clearly, and reasonably, wanted to have the cyst removed as soon as possible. I said I would refer her to the breast surgeon urgently, and I was sure that he would see her and deal with it within a few weeks. Clinically, strictly, there was no urgency about this cyst but, in view of her anxiety and her family history, it seemed a reasonable, or at least a compassionate, use of the word urgent.

Angela and Steven are educated, pushy, middle-class and articulate. They read newspapers. Nothing wrong with that. So am I and so do I.

“It will be a “two week rule referral”, won’t it doctor?” said Steven.

No it will not be. Two week referrals are for patients who I think have, or may have, or have a reasonable chance of having, cancer. I told them that I would make it an urgent referral, but could not classify it as a two-week rule referral as that was not appropriate.

Steven was angry. He started shouting about the failings of the NHS. There was no way of pacifying him, short of agreeing to an inappropriate referral. Angela told him to be quiet. Her eyes were watering. They left.

As they left, Steven turned and said, “You had better be right about it being this sebaceous…whatever you call it.”

I will stress in the referral letter that there is a high degree of anxiety about this lump. Angela will be seen within a few weeks, but not within two.

Let’s hope it is a sebaceous cyst.

++++++++++


Thursday 27 April

It begins.

Slowly. Insidiously. You could easily miss it. Just a few minor cases, here and there.

GPs have been bribed to accept the centralisation of their referrals to an internal committee of the local soviet. This committee’s mission statement is to prevent poor people from accessing hospital care.

A while ago I saw a teenage girl who had had her ears pierced and then pulled the sleepers through, disfiguring her earlobes. Silly girl. Smack bottom. Oh, no, sorry that is not allowed any more. We will have to punish her in a different way. Why do we not leave her scarred for life by her silly teenage indiscretion? That will teach her.


I referred this girl to the plastic surgeons. They were happy to repair her ears. It is not difficult surgery, nor is it expensive. This is how it is done.

Today I have received a copy of a letter to the plastic surgeon, which I reproduce in full:

St Elsewhere's PCT

Mr David Jones

Consultant Plastic Surgeon
St Elsewhere’s Hospital
Coventry Road
Anytown.

25th April 2006

Dear Mr Jones

Re: Teenage girl X

Thank you for your letter of 20 April regarding funding for treatment of this girl’s bilateral torn earlobes. Lobe repair of external ears** is not routinely funded by the PCT, and we would therefore require additional information regarding exceptional circumstantce in order to consider funding.

I would be grateful if you could supply such information if you feel there are any exceptional circumstances I this case. I am also copying this letter to the patient’s GP if he would like to supply information simarly.

Yours sincerely





Abigail Davies
Referral Advice & Information Service

I forgot to say that the Committee to prevent poor people from accessing hospital care is in fact called the “Referral Advice & Information Service.”

There are no exceptional circumstances. This is a typical teenage girl who has messed up her ear lobes. No more. No less. As I say, silly girl. But it could be my daughter. It could be yours.

This girl’s experienced family doctor thought it reasonable that the NHS should repair her ear lobes. So did the specialised consultant plastic surgeon. Neither of us is cavalier with resources.

To get this girl the treatment she needs, I would have to construct some dishonest work of fiction about the psychiatric consequences of scarred ears in young girls and in this young girl in particular. I will not do it. The original referral letter was enough. If this girl had sustained the damage from a dog bite, or in an RTA, or by being assaulted, it would have been repaired as a matter of course. This damage happened to result from an elective cosmetic procedure but is nonetheless accidental. What is the difference?

This year, the NHS wasted £1.6 billion pounds on a computer system that does not work. Lines have to be drawn somewhere, but if the NHS can afford to do this, it can afford to repair this young girl’s ears.

++++++

** Dr Crippen is, as many of you will know, a bit pedantic about the use of language. In particular, he hates “committee speak”. What, then, are external ears? Well, actually, I know the answer to that, but where are the “internal” ears that are implicit in the statement?

+++++++++

Friday 28th April

Duty doctor day. I have not done one for three weeks, so fear and trepidation.

I’m particularly grumpy as I am viral myself. Aches, pains and a little bit of diarrhoea. Oh! God, doctor, too much information… but sadly true. We get bugs too. I am not asking for the sympathy vote. Doctors are appalling patients and we never follow the advice we give to patients. Within the practice, we do not “do” sick leave. If someone takes a day off at short notice that leaves forty to fifty patients to be seen by someone else. So I dose myself up with an inappropriately large quantity of the ibuprofen I find in the discarded drug cupboard and I plod on.

One of my partners had an attack of haematuria last year. He spoke to the local urologist, went up to the hospital during his lunch hour, had a flexible cystoscopy (normal) came back and did an afternoon surgery. Ridiculous. Had he told us, we would have sent him home, but he did not mention it until the following week.

It’s the day before a bank holiday weekend, and so the antibiotic fight is taxing. “I wouldn’t normally have come, but it’s the bank holiday and so I wondered if you could just give me something to throw off………..”

Nothing too stressful during the morning and when I finally finish the phone calls, I go out into the office to collect my visits. None. Really. No visits is akin to a minor lottery win and about as common. No visits! So a long coffee break, gossip and bitch. I feel much better. Bowels now beginning to behave themselves.

++++++++++

Duty doctor afternoon means taking all the phone calls. All the appointments have long gone. I have to speak to all the patients who feel they must be seen before the weekend. Thirty seven phone calls, mostly to mobiles. One of my partners has bought a headset so that he can look at the computer notes, type and speak on the telephone at the same time. I should do this too. It is sensible. Trouble is, he looks like a prat, so pride prevents me.


Of the thirty seven phone calls, ten have to be seen. Nothing too taxing.

Two of the phone calls are visits. I should have realised I was not going to escape.

+++++++

On the way home, I call on a 94 year old man who lives alone in a tumbledown house by a canal. He has lived there since before the war. He has disseminated prostate cancer. He is a grumpy old bugger. He has declined to go into a nursing home, or leave his house. I do not blame him. If I get to 94 I am going to stay in my home and be a grumpy old bugger too. He has got low back pain which has confined him to bed for the last two days. He has been peeing in a small bucket by the side of the bed. There is a large bucket too. The smell is appalling.

I re-jig his analgesia. Part of the problem is that he never takes it regularly in advance of the pain. I phone the twilight nursing service and ask if they can come in tonight. The twilight nurses are nurses not specialist-nurses. They cannot come in tonight. They are short-staffed. They promise to come tomorrow.

++++++++++

Dr Crippen in The Times

Kind words for Dr Crippen and NHS BLOG DOCTOR in The Times tomorrow.

Modesty forbids me from reprinting the article, but I cannot resist referencing it here.

Thanks guys.

Big Brother is watching

Back in February, Dr Crippen was considering who actually owns the medical data stored on the computers in Health Centres and hospitals. He wrote:

“GPs at the moment are fighting to safeguard patient confidentiality. Most GPs records are now computerised. Ours certainly are. The government is setting up a central computer (scarily known as "the spine") and is trying to persuade (? compel) us to download all our data to the centralised system.

Just think of that.

When you were 17 you had a panic attack and saw a counsellor. So you have a so called "psychiatric" history; or when you were 22 you caught gonorrhoea...you have long forgotten about it and are now 55 with grandchildren...but it is on your records.

Do you want Tony Blair to be able to access that?

If the government gets access to medical histories, how long before they are on the magnetic strip on your identity card?

Our practice will not give this data up to the government. Frankly, I will pull the plug and wipe it before I will do that.”

It is a continuing worry. I missed an article in the Sunday Times last weekend, and am grateful to “K”, a regular in the comments columns, for pointing it out to me.

IDENTITY cards are to carry medical details, despite repeated government assurances that concerns about privacy meant it would not happen. A minister at the Home Office disclosed it wants people to put personal health information on the cards to give doctors information for emergencies. Card-holders will be urged to volunteer details of blood group, allergies, and whether they wish to donate organs. Ministers stressed there would be no compulsion.
Read the full article here. (Sunday Times)

What can be done to stop this? Refuse to carry an identity card of course. But you could also instruct your GP in writing not to release your computerised data to anyone without your prior written permission. Your GP would be bound by this, and would probably welcome being so bound.

Tory MP refuses to sign petition supporting NHS

David Davies MP

The statement by the Rt Hon Patricia Pangloss that the NHS is having its “best year ever” is the biggest political gaffe of the year.

One would not expect the Conservative Party to agree that the Health Service is having its “best year” or even a good year.

In fact, it is difficult to find any Conservative MP who has faith in the NHS, or at least sufficient faith to give an undertaking to start using the service.

A few days ago I drew your attention to ourpetition.org, an excellent organisation with a simple idea. Dr Crippen has been saying since the inception of NHS BLOG DOCTOR that we cannot expect health care or education in this country to improve whilst the great and the good, the policy makers and, yes, of course the politicians do not use the services.

The ourpetition.org mission statement is simple but elegant. Let us ask politicians to commit to using the NHS:

“The most effective way for ordinary citizens to ensure NHS reform will be successful is to make certain that those who are responsible for creating the public health system voluntarily agree to exclusively use the same system, without opt-out, in their own medical treatment. This is only possible if the issue is put on the political agenda prior to the next general election.”

David Davies, the MP for Monmouth, has replied:

Thank you for contacting me but I don’t agree with you at all.

Anyone using private health care is doing the NHS a favour by freeing up a space. I say this as someone with no private health cover except for dentistry and I don’t have a choice about that!


David Davies, MP

So, Mr Davies advocates people to go privately so that “there is more room in the NHS”.

More room for the poor folk, presumably. If the comfortable, well-heeled middle and upper classes all go privately, could the NHS be saved?

Is this Tory party policy, Dr Crippen wonders?

It seems not. In his King's Funds Speech of 4 January 2006, David Cameraon said:

"…. the NHS should be a truly national service, not a safety net for the poor while the rest go private."

David Davies (personal website here) may find his beeper going when Central Office finds out that he is off message.

But, to be fair, no other Conservative MP has signed the petition, though one (David Jones, Clwyd West) has expressed general support.

The full list of signatories to date can be found here.

Crippen in the Guardian

Rt Hon Patricia Pangloss

The Guardian has picked up on Dr Crippen's recent story on Patricia Hewitt. In Reality Bytes, in today's Society Guardian and available on line here in The Guardian Unlimited

Sue & Dave and 'Hospital at Night'

You may not have heard of Windscale.

It is a nuclear waste rubbish dump. Got some non-biodegradable nuclear waste? Send it to the UK with a large cheque made payable to the British Government and we will dispose of it for you.

Well, actually, we can’t do that, but we will store it for you.

Windscale is in the English Lake District, one of the greatest areas of natural beauty in the world, and an area where Dr Crippen goes regularly to walk and de-stress

Not the intuitively obvious place to store unwanted radiation, but at least it is situated many miles away from London, the home-counties, the Royal Family, politicians and other nimbeys

In 1957 there was a spot of bother at Windscale. Something escaped. Anyway, the government had an enquiry which concluded that there was not a problem, and if there was a problem, it was only going to affect a handful of in-bred farmers, and a couple of sheep. So that is all right, then. Best not drink the milk for a while though.

To avoid further distress, the government rebranded Windscale. They painted it green (literally and metaphorically), opened a visitor centre, and renamed it. Brilliant. It has become a tourist attraction. (sic)

That is why you have not heard of Windscale. It’s called Sellafield now.

Which brings me on to “Hospital at Night”

When Dr Crippen was a hospital doctor, some of the jobs he did were called One-in-Twos. You did a full working day from 8.00 a.m. until 6.00 p.m. and then you worked every other night from 6.00 p.m. until 8.00 a.m. the next morning, and also every other weekend from Friday at 6.00 pm until Monday at 6.00 p.m. That came to about a hundred and twenty hours a week.

The hours were ridiculous, and the pay derisory but you learned some medicine. The government has stopped this because EU regulations forced it to. Junior hospital doctors are nowadays not allowed to work more than forty-eight hours a week, after which they must be tucked up in bed with a cup of cocoa.

The economics here are straightforward. If you reduce doctors’ hours by approximately two-thirds, you need three times as many doctors to do the same work. We did not need Wat Tyler for that!

The government has not increased the number of doctors.

So at nights and weekends, and particularly over long bank holidays like Christmas, the hospitals are denuded of medically trained staff.

There is a crisis. Do not get ill at Christmas or over Bank Holidays. The doctors have gone home.

How did the government cope with this crisis?

First of all, it hushed it up.

Secondly, it rebranded it, so that if any one does hear about it, it is not a crisis, it is an opportunity. An opportunity for team building.

And it has rebranded it with a comforting, plausible, attractive name.

It is not called, “Oh Christ, I’m bleeding and there are no doctors in the hospital”. It is called “Hospital at Night.”

Don’t be cynical. Say it over a couple of times.

Hum it.

“Hospital at Night”. “Hospital…at…Night”

Admit it. It’s growing on you all ready. It sounds…good. It does not mean anything. It does not promise anything. It just sounds...great!

“Hospital at Night. Hmmm, I like that.”

“New Labour. Hmmm, I like that too.”

Read the protocol from Sue and Dave. Just look what they are up to. Not only are they working on "Hospital at Night", but they are “team building” as well. They are "...ensuring “everyone’s got a picture of the night” at Arrowe Park Hospital"

Hmm, teambuilding. I like that. "Getting a picture of the night." I like that even more. It all sounds...great!

On behalf of NHS BLOG DOCTOR, Dr Crippen hopes you all have healthy Bank Holidays.

++++++++++

This article was orginally published in December a few days after NHS BLOG DOCTOR started. It has particular relevance now, as we are once again discussing dumbing down. Dr Crippen has been thinking of it again as he has just had a holiday in the Lake District. Finally, we are approaching the May Bank Holidays during which, as always now, hospitals will be running on what I will provocatively call a skeleton staff.

Quacktitioner Alert (1)

Quactitioners

This email arrived yesterday from an experienced Consultant Interventional Radiologist at a well-known Teaching Hospital in the north of England. She has recently had a nurse-practitioner foisted upon her.

I have printed her email verbatim, without alteration or addition.

It is technical in places. I have referenced the various technical words and those who wish may follow them up by clicking on them.

++++++++++

"Dr Crippen, I have been enjoying NHS BLOG DOCTOR enormously.

I think the article on nurse practitioners is a classic. It really puts the case for why you can't learn medicine in a few courses and should be sent to Patricia Hewitt. I have recently been bothered by a nutrition nurse, newly appointed, who has taken it upon herself to come and "assist" when I do percutaneous gastrostomies (of which I do many).

She has already changed our nasogastric tubes to a different type that is almost impossible to put down in patients who have oesophageal cancer.

Nasogastric tube in situ

She has lobbied our interventional nurses to order different tubes and wires for the gastrostomy so that for a while I was using a wire that was so long it would reach almost to the other side of the room.

During the procedure she stands at the patient's head watching the oxygen saturation and demanding a change from nasal prongs to a re-breathing bag if the sats drop below 97%.

She is very much against me giving adequate sedoanalgesia and believes that talking to the patient is all that is needed go get them through the painful bits. When I give a bit more pethidine she says something like "how much pethidine have you given; I need to know for the recovery", as if to warn me that in her opinion I am giving too much.

She accused me of overdosing a patient who had been on long term fentanyl patches (and therefore needed lots of pethidine) when I gave her 75 mg when she was begging for pain relief.

I have been giving sedoanalgesia for 20 years and never had a serious consequence. Sometimes I give 300 mg of pethidine or more to patients who are very large or who have been on long term opiates. You can't do some interventional procedures (e.g. biliary) without it.

But this nurse has obviously done a course on sedation and now thinks she knows it all. The worrying thing is that she also claimed that the patient to whom I gave 75 mg nearly had a respiratory arrest on the way back to the ward.

The truth is that this patient, who I know of old, is batty and feigns catatonia from time to time. But you can just see the headlines "doctor warned by nurse that he was giving too much pethidine but would not listen".

I wanted to let you know that I share your views on the topic. I could go on.

Another of my bugbears is speech therapists who have suddenly decided that they have the right to decide if stroke patients are at risk of aspiration or not.

What they fail to understand is that many old people occasionally aspirate a little from time to time. I've seen it frequently on barium studies. But once the speech therapists have assessed a stroke patient (and I think they assess them all now, at great cost and for no proven benefit) and deemed them to be aspirating they stick up a nil by mouth notice and immediately make the patient even more miserable than they must already have been. Or they condemn them to a life of thickened feeds and porridge."

++++++++++

This sort of story is common. It speaks for itself. I make no comment on it other than to say that there is a desperate shortage of nursing care throughout the country.

Quacktitioner Alert

Quacktitioners

When Dr Crippen started NHS BLOG DOCTOR just four short months ago, his great concern was the damage that government is doing to the once great institution of the NHS.

One of the worst problems is “dumbing down”.

Contrary to popular belief, there is not a shortage of nurses. There is, however, a desperate shortage of nurses who are prepared to do nursing. Nurse “specialists” and “consultant nurses” are everywhere. Everywhere, that is, except nursing patients on the wards. Nurse specialists are too clever to do nursing. They want to be doctors.

Nurses are not trained to diagnose, and yet they are running Accident and Emergency departments in hospitals and “minor illness” clinics in General Practices.

It is dangerous to allow nurses to act up as doctors.

It is not just the nurse-specialists.

GPs are being encouraged to be GPwSIs (GPs with a Special Interest) and act up as Consultants. They do not have the skills to act in this capacity.

Ambulance men are being sent on courses, re-branded as paramedics and Emergency Medical Technicians and are running Accident and Emergency Departments.

Why is the government doing this?

To save money. Paramedics are cheaper than nurses who are cheaper than GPs who are cheaper than consultants. So get each group to “act up” and you save money. The Peter Principle. Cheapo-cheapo productions. Re-branded, cut price health care. Hospital at Night with Sue and Dave.

EMDs, paramedics, nurse-specials are all health care workers. The expression “health care worker” sounds plausible. It’s touchy-feely. It’s Nu-Labour. “Health care worker” also means “there is no doctor available.

Private patients do not see “health care workers”. Nor does Tony Blair.

Dr Crippen has been getting an increasing number of emails, mainly but not exclusively from doctors, describing the effect of dumbing down. Of nurse-specialists and others acting in areas beyond their training. And the trouble is, they do not know what they do not know. They are dangerous.

They are Quacktitioners.

Dr Crippen is starting a regular series called “Quacktitioner Alert”. A selection of stories of nurses and others acting in areas outside their competence. Keep the emails coming. A selection of the best ones will be published.

Mad Hatter's Tea Party

Greetings comrades and good news from the Health Commissariat. Commissar Hewitt has announced that healthcare is “enjoying its best year ever”. Millions of roubles have been saved by cutting wasteful expenditure on basic nursing care. Any comrade not enjoying his healthcare will be shot.

Meanwhile, back at the coal face, Dr Crippen has his feet up on his desk again. Returning from holiday to find the best year of NHS health care ever, the only outstanding problem he faces is the difficulty of spending £250,000

The Rt Hon Patricia Hewitt

The NHS faces a financial deficit of up to £800m and some 7,000 job losses have already been confirmed. Nonetheless, all is well.

“Despite huge job losses and mounting financial problems, the NHS is enjoying (sic) "its best year ever" says Patricia Hewitt.

Commissar Hewitt has denied there is a crisis, insisting the deficit amounted to no more than 1% of the NHS total budget.

NHS managers in England have identified 13,000 for cuts since last October.

When polled by the RCN, nearly 60% of nurses said that they did not have enough staff to give their patients the standards of care they would like. Commissar Hewitt said the job cuts - which latest estimates suggest could rise to 13,000 - were in many cases allowing the service to operate more efficiently. (sic)

"Have some wine," the March Hare said in an encouraging tone. Alice looked all round the table, but there was nothing on it but tea.
"I don't see any wine,"she remarked.
"There isn't any," said the March Hare.
"Then it wasn't very civil of you to offer it," said Alice angrily.

Black dog and the Doctor

Black Dog

Meanwhile, somewhere out there in the electronic ether, a doctor who has been away for awhile returns. He writes movingly how he learnt about illness, both physical and mental, not by being a doctor but by being a patient.

Physical illness is challenging for doctors.

Mental illness, in this case depression, even more so.

He feels he “has learnt more about mental health issues as a patient and a carer for a family member than he ever did as a doctor treating psychiatric illness.”

He also says:

"Before launching into this first of many sorties into the travails of a cantankerous, cynical doctor in his adventures as a cantankerous, cynical patient...(I) would like to reiterate that (I am) still definitely a grumpy old bastard."

Make your own mind up here.

A patient writes...

Barely had the ink dried, so to speak, on “Something better will turn up” than something did.

A long comment from Joanie, addressing the issue of GPs pay.

I have been around for a while in medicine and one should never take things like this personally.

Trouble is, these days, my skin is not as thick as it used to be.

I cannot bring myself to draft a reply to the letter. Instead, I print it (from the comments column of "British GPs win the Eurolottery") in full and verbatim.

Does anyone have any suggestions?


++++++++++


Dear Dr Crippen

I'd like to make a few points about GPs salaries etc.

I've been ill since I was 24. I have been fobbed off by numerous GPs over the years who have patronised me and told me I'm depressed, take it easy, maybe you working to hard...... maybe a bit of talking therapy will sort it out...... etc. This went on for 6 years until I became so ill I had to give up my work.

I used to manage a business with a turnover of £100million+ which involved chemical, physical and explosive hazards. I worked 60+ hours per week, sometimes through the night. I loved it. I worked hard and I had many people keen to work for me. I am a well trained and motivated professional (chartered engineer and chartered
scientist) which took 10 years+ of training at both university and 'on the job'. If I was no good at my job I'd get the sack. I would not earn £140,000 per year. One half would be more like it.

Anyway, I went private as I had to find an answer to my illness. I knew there would be an answer. My doc took 10 minutes to tell me that I was indeed ill with a treatable bacterial illness. It can be seen clearly under a microscope. I saw the critters for myself. I also had a gut parasite infection and I have hypothyroidism. None of the above was identified by NHS GPs in 6 years!

So, I took the initiative, found the basic cause of my problem, paid for it myself, and slowly I am getting much better. Good oh. So what about those folks with no scientific training - they have to go to the local GP...... That is what they are there for isn't it? it is near impossible for many good folks of this country to realise they are being sold short.

My condition should have been diagnosed when I was 24 not 30. It is not rocket science. It does appear to be way outside the box of the GP. The GP who is trained to be conservattive, lacks innovation, is partronising and arrogant, is very well paid indeed..... Why?

Why is it that GPs spend their days prescribing drugs to help to eleviate symptoms. Drugs which are sold by pharma companies who want lots of profit. Why are the GPs who see most of us folks with chronic illness not creating a fuss and demanding better treatments based on the basic causes of illnesses rather than sheepishly dolling out the quick stickyplaster fixes? Why are they not shouting? Why do they not understand this arguement? Is it up to someone else to take the lead? I'd respect the doc who shows leadership. For £140k per year should the patient not be expecting this kind of behaviour and attitude in all GPs they encounter?

Why are patients like me given no advice about management of pain?
Even when we ask repeatedly. Is that not the job of the GP? Why do I get smiled at patronisingly when I have developed a new symptom and I'd like to exclude it from my current illness? Lower left side abdominal pain (I was not examined) It kept me awake for 2 weeks non stop and was painfull for 6 months+. I went back twice and still no interest. That is the problem. I am not interesting. My illness is not sexy. Those with my illness are told 'it' does not exist - in their opion. (60% of GPs in Wales reported this in a survey recently). Opinion. Thanks very much. I'd prefer to be told facts based on objective evidence not opinion based on hot air.

We have a poor record of treating and managing the long term chronic sick (MS/ME/FM/etc) in this country. My evidence for this - go speak to those who cannot work, who have MS (80,000), who have ME (160,000), who have fibromylaygia (1,000,000). They have the same or similar bacterial infections to me. The cost to the UK economy is estimated at £8 billion per year (ME patients only)! The GP remains uninterested. They will not benefit (financially) if I stay sick, stay the same or get better. They are unmoved by my physical and mental pain.

These are not new revelations. The evidence for these bacterial infections started to be published in the medical literature before the Second World War.

Can doctors not read? Can they not innovate? Can they not listen and communicate? Is there pressure for GPs to improve their communication skills, work alongside and with patients to get themselves well? What motivates docs to stay up to date. There appears to be no requirement for them to do any of this. I would respect them if they did. GPs pay is not affected if they are good or poor at their jobs.

Dr Crippen - GPs are not all highly motivated, keen individuals with their patients best interestes at heart. If so the patient would be able to see a doctor at a reasonable hour and not have to take time of work to do it. Why can I not see a well paid profesional GP at 8pm at night or on a Saturday? Routinely if necessary. Do we have to pay the GP more if this is to happen? Can they be bothered?

I have admittedly had a poor experience with GPs over the last 8 years. I think that many folks like me too have had simialar experiences.

If my GP was open minded, not patronising, was happy to openingly discuss test results with me and not fob me off with antidepressants (the uninterested GPs cure all pill to get rid of you) then I'd begin to consider that they should be renumberated well. By that I mean in line with other professions. I do not believe that currently this is the situation.

As soon as I have the stamina I will be on the hunt for a new GP. I hope I find him or her. I am willing to keep an open mind and I'm positive I will find one. I would like to have some medical support in my local community. One that I don't have to pay for. I think it will take time.

War and Peace over.


Joanie

Cartoon from wayno.com

Something better will turn up

Micawber

I suffer from persistent delusions.

As I walk away from the car towards the motorway service station, I always have this feeling that I am going to find something new, something exciting and pleasant inside. I have a similar feeling on cross-channel ferries. I roam the ship endlessly, like Micawber on heat.

Returning from holiday to the pile of unopened post, similarly I feel there is going to be something exciting, maybe one of those blue windowed envelopes from Ernie.

So far I remain unfulfilled. Motorway service stations and cross-channel ferries are as awful as ever. The pile of post has no good news from Ernie, just the usual selection of bills and circulars.

My fondest holiday delusion, however, is that something will have changed at work. And changed for the better. Something will have improved in the NHS. The job is wearing and stressful, but as one winds down on holiday, the gloom recedes, and the good part of the job, day to day patient care, comes once again to the forefront as it always was twenty years ago.

Back at home now, with work looming on Monday, I find myself in the middle of an orchestrated hate campaign against GPs. Over the space of two weeks, we have become odious “fat-cats” who used our trades union, the BMJ, to “rip off” an unsuspecting government by “forcing” them to give us absurdly lucrative contracts (see Stephen Pollard here, and Stephen Pollard re-cycled as the "general consensus" (sic) by Wat Tyler here).

I cannot watch television, listen to the radio or open a newspaper without coming across all these GPs who earn £250,000 a year. The general anger, indeed hatred, that is expressed is depressing.

Whilst on holiday we were joined for a few days by a long-standing friend who was a consultant pathologist, and an eminent one at that. He has taken very early retirement. He is currently working for the National Trust. He is hard up, with a very small pension. He has never been happier. He says that it is only since he left the NHS that he realises how badly doctors are treated, both within the service, and by the media.

I did a Radio 5 Live phone in last week. A consultant surgeon reported his anger that his hospital management had stopped supplying milk for him to have in his cup of tea during operating lists.

It takes fifteen years to train as a surgeon. Operating on fellow human beings is both physically and mentally demanding. You cannot relax for a second. One mistake and someone may die. At the end of a two hour operation, you have a twenty minute break. During that break, you have a cup of tea, a couple of the ubiquitous and absurdly named NICE biscuits and a trip to the lavatory. Then you do another two hour operation. Yes, I think the NHS should provide the tea, and the milk, and the biscuits. And the lavatory paper.

It sounded such a trivial complaint on the radio. The surgeon was no PR expert, that is for sure. There was the predictable deluge of texts and calls. I remember one in particular from a hospital cleaner saying the he had to bring in his own milk, so why shouldn’t the surgeon?

Scumbag.

Doctors are a strange lot. We will go into work late at night, or over the weekend, for no extra pay because we are doctors and that is part of the job. We do that without complaint. Then the fuse blows over something trivial like having the milk taken away. It does not go down well. But doctors are not schooled in handling the media.

Mrs Crippen is a consultant. A specialised radiologist working in breast cancer. She goes into the hospital frequently in her “free” time. She is there now, on Saturday morning, trying to make a dent in the work that has accumulated during our holiday so that she is not too snowed under on Monday morning. She does this without complaint.

What she does complain about though is the hospital cleaning. Management has decided that the offices of Consultant Radiologists are not important enough to need regular cleaning. So it has been stopped. Her wastepaper basket will be emptied daily provided she remembers to put it outside her door every evening. The carpet will be vacuumed once a month rather than daily. There will be no dusting.

So Mrs Crippen and her consultant colleagues have clubbed together and bought a vacuum cleaner, and will vacuum their rooms themselves. Mrs Crippen has also taken in a duster and some Pledge, because she is a bit fussy about dust.

The NHS wasted £1.6 billion pounds on an IT system that did not work. To put that in context, the capital value of Marks & Spencer’s is about £8 billion. So that is about a fifth of M & S spent on a faulty computer. I wonder if Stuart Rose gets provided with milk for his tea? I wonder if he has to vacuum clean his own office?

How long will it take the NHS to recoup £1.6 billion from savings accruing from not providing milk for surgeons and not dusting consultants’ offices?

It can only get better. Something will turn up.

Putting your money where your mouth is.

One of the reasons why the educational standards in most comprehensive schools are so poor compared with the private sector is that the opinion makers, the politicians, the great and the good, and the well-off do not use them.

Never mind sending Princes William and Harry to a state school. If there were no private schools and the chattering middle-classes were compelled to use comprehensive schools, something would be done about the standards.

The same applies to the NHS. As it dumbs down more and more, private health insurance goes from being a luxury for the chosen few to being an essential for all who can afford it.

You do not see politicians sitting in accident or emergency departments, waiting their turn.

Or do you?

I draw your attention to an excellent web-site that has appeared recently. The mission statement is simple. Get your MP to undertake always to use the National Health Service.

"We know what makes good healthcare. Quick access; committed care; clean, comfortable surroundings. But what happends if you can't get them? If you've the money, you buy better. That is an affront to every progressive value we believe in."

Rt Hon Tony Blair, Labour Party conference Brighton, 27 September 2005

Quite, Tony. So lets get a pledge from the great and the good to start using the NHS.

ourpetition.org has a simple mission statement:

"The most effective way for ordinary citizens to ensure NHS reform will be successful is to make certain that those who are responsible for creating the public health system voluntarily agree to exclusively use the same system, without opt-out, in their own medical treatment and in the medical treatment of their immediate families. This is only possible if the issue is put on the political agenda prior to the next general election."

Like all brilliant ideas, pleasingly simple. Look at their website here

Ask your MP to sign the petition. Let us know if he declines.

Back to reality

School of nursing

Just arrived home after a refreshing two weeks in the Lake District. Whilst up there, I had only limited internet access.

I have returned to a deluge of emails and comments, some stretching back nearly two weeks. Apologies for not replying before.

I have always replied to emails personally. Sadly, this time, there are so many that the task is close to impossible. I will do my best. Rest assured that even if you do not receive a reply, all will be read.

I have read one short email that draws my attention to a recent article in Medscape. It immediately put me in mind of one of my great loves, the work of the graphic artist, Maurits Cornelis Escher, better known simply as MC Escher.

My regular readers will understand why this article is, for me, the perfect end to a perfect holiday.

Have a look at it here.**

+++++++++

**Sadly, I am advised that it is not possible to read this article unless you are a registered reader of Medscape. For those not registered and who do not wish to register, the article contains a video of "Dr" Donna Hathaway, PhD, RN, FAAN who says:

"By the year 2015, all new advanced practice nurses in the US will be educated at the doctoral level. That is the vision of the American Association of Colleges of Nursing (AACN) and a growing number of nursing schools throughout the country."

Oh! joy. I am so happy.

Those wishing to find out more information about the transition to the 'doctor of nursing practice' are invited to visit AACN's Web site

British GPs win Eurolottery

GP accepts payment for meeting targets

£250,000 is a lot of money.

I wish I earned that amount every year. Sadly, I do not. But I read in the newspapers that some of my colleagues do. Is it true? If it is, how do they do it?

There are some GPs who have managed to achieve this sort of money though they are few and far between. However, it is their income that hits the headline, and their income that will be remembered.

I work in a large, nine partner practice in a middle class, urban area somewhere north of the M25. A full time partner in my practice currently earns about £140,000 year net of expenses. Over the last two years, we have had a pay rise of between twenty and twenty-five percent.

Most of the pay rise has come from chasing QoF data for the government. We have had no choice about this. The targets have been designed and set by the government. They are not totally without merit. Mostly, however, they have been about measuring what we do and recording it. A well-organised conscientious, patient-orientated practice such as ours, has already achieved or nearly achieved most of the targets. Money for old rope. We have had to chase a little data, but mostly this has been an administrative job of organising and presenting data.

Why are we not earning £250,000 like some of our colleagues? How could we further increase our income?

We could probably get it up to £160,000 or so by cynically chasing the outstanding QoF data. But we are not prepared to go round old peoples’ homes nagging elderly women about their cholesterol, and we are not going to cold call people who never come to the surgery to ask them about their smoking habits, or to insist that asymptomatic patients with a bit of seasonal asthma come in for annual spirometry.

Even if we did all that, we would still be about £100,000 short of the highest earners. So how are they doing it?

There are three strategies that these high earning doctors adopt that we will not contemplate. All three mean doctors delegating patient care to others with less experience:

1. Trainee GPs, or GP registrars. These doctors in training work within a practice but are supposed to have protected time and be supervised. Mostly they are themselves experienced hospital doctors in transition, and will manage if left to their own devices. Particularly towards the end of their trainee year they can carry a work load approaching that of a principal.

Trainee GPs are better than free labour; GP trainers actually get PAID to have them.

2. Salaried doctors. Under the New Labour pay scheme, practices get an annual lump sum out of which they pay themselves as they see fit. They may now take on salaried GPs to ease their work load. Salaried GPs have to be paid. But you can get a full time salaried GP for £70,000 a year. That is half the income of the GP principal who, suddenly, by having a salaried “assistant” is free to pursue highly paid private work. If you are earning £250,000 a year, you could hire two salaried GPs and have £100,000 change and no work.

Look in the BMJ adverts here. There are now dozens of adverts for salaried GPs. These suit woman with children who want to work part-time, child friendly hours, and are grateful for the measly £50, 0000 they will be paid.

3. Finally, of course, our friends the nurse-practitioners. They do clinics for asthma, contraception, menopause, well-women, well-man, and diabetes and, a more recent innovation, walk-in “minor-illness” clinics. In other words, they are doing just about all the work that the GP used to do. This is not the time to debate the safety of these clinics. What is beyond argument, however, is that they are cost-efficient. Very cost-efficient. You can afford six practice nurses for each GP.

Take all three scams, sorry, strategies together and you get the modern “super” general practice. Four partners are earning £250,000 a year or more, ten salaried doctors, mainly part-time women with school age children working for small salaries, and countless practice nurses and nurse specialists providing an array of “specialised” clinics and a constantly open walk-in "service" for minor illness.

The fact that the patient and the health care workers are incapable of excluding the occasional serious illness will be forgotten. 95% of minor illnesses are trivial and self-limiting and it does not matter how you treat them. The fact that there is no doctor there to pick of the 5% of serious problems is brushed aside.

An army of poorly-qualified health-care workers measuring cholesterols, recording smoking status and ticking boxes for the great Stalinist healthcare monolith.

+++++++++++

This is the future.

Dr Cameron would be turning in his grave. So will Dr Crippen. Nationalised health-care for the masses driven by a cost-cutting, PR orientated government. They have done it to secondary schools. They are doing it to the universities. Now they are doing it to health care.

It will not affect the great and the good and the privately insured. They will pay to see experienced doctors and smile benignly on the second rate service received by the masses. Let them eat cake.

I will have no truck with it. I shall continue to see the patients myself. I will not delegate to trainees, nurse practitioners, or pharmacists, and I will not exploit and abuse the large number of female doctors desperate for part time work by taking them on at a derisory salary. Fortunately, I work with like minded partners.

The nurse-quacktitioner and the hole-in-the-wall

The hole in the wall

I am angry. Again. I am particularly angry because I am on holiday.

The hole in the wall at the top of Birkhouse Moor is the most famous landmark on the way up to Striding Edge and the summit of Helvellyn. We did not get there. And we did not get there because of a nurse quacktitioner.


Strictly speaking, I suppose, it was David’s fault. David is my brother-in-law. He is 42. He has asthma, and quite severe asthma at that. Well, I think it is quite severe, but I do not know the details as he never talks about it. When David was seven, his mother died of an acute asthma attack. He deals with this by denying the severity of his own asthma. This is a common phenomenon. Ignore it, and it will go away. It explains some of the fourteen hundred deaths we get from asthma each year in the UK.

David used to be on three inhalers. I always assumed that everything was well as I never heard him wheeze, and had never seen him use a salbutamol inhaler, though I knew he carried one.

Three quarters of the way across Birkhouse Moor, David started to wheeze. He did not say anything, but his pace slowed, and he used his inhaler. His inhaler technique was excellent, I noticed.

The wheezing did not stop. It got worse.

We turned back. His wheezing improved with the descent. I suggested he take some more salbutamol. He declined. He said he had only had some a few minutes ago. I asked him if he had been taking his beclomethasone regularly. He said he was no longer on it. Nor the salmeterol he used to take. Knowing David, I feared he had defaulted. I asked him if he had seen his doctor recently. He had not. I said I was surprised that his preventative treatment had been stopped, and then the whole story emerged.

David used to see his doctor at regular intervals. He used to take beclomethasone, salmeterol and salbutamol. Except that when he was on the first two inhalers, he rarely needed the third. When he saw his doctor he said the consultations were brief. The doctor asked him if his asthma ever woke him up at night, if it ever interfered with his exercise or prevented him doing anything and finally how often he used the salbutamol. It never woke him up at night, it did not interfere with his exercise, including the veteran’s football he played, and he only used the salbutamol once in a blue moon. “All he did then was make me do a quick peak flow, and then he would say, 'All is well, see you in six months, or before if there are any problems.'”

Then the asthma nurse arrived. She was "much friendlier" than the doctor. She had half hour appointments. She did "more sophisticated" breathing tests than the doctor. Last year, she told David that he did not need all the preventative treatment, and could just use the reliever (the salbutamol) as necessary but not more than every four hours.

The quacktitioner knows that salbutamol should only be taken every four hours. It says so in her book. So that is what she tells the patients. Because she is a nurse, this advice is set in stone. There is no room for discretion.

In fact, salbutamol is one of the safest drugs around. If you are having a severe asthma attack, you can take salbutamol frequently. The point that the nurse-specialist has missed is not that it is dangerous to take salbutamol frequently but that if you are needing it more than every four hours, your asthma is out of control and you need to see a doctor.

The idea of an asthmatic wheezing his way to a lonely death, with his salbutamol in one hand and his stop watch in the other, waiting for the nurse’s four hours to pass is horrifying. But that is how it works in “Nurseworld”. If you do not believe me, when you are in hospital, try to get two paracetamol from a nurse for a persistent headache, or see how madwives (the archetypal nurse specialists) approach pain relief for women in labour

David always hated taking the beclomethasone. It’s a steroid, isn’t it? It made him think his asthma was severe, like his mother’s. So he jumped at the opportunity of stopping it. For the last six months, he has been using the reliever as necessary. Always before football, and occasionally during. A couple of puffs most mornings, when his chest is tight. Probably once or twice a day on average. He prefers this to “taking steroids”. He used to monitor his peak flow regularly, but does not do it very often these days. He had not bought a peak flow metre with him on holiday. He knows his best peak flow is 460, which is not bad for a chronic asthmatic, but not brilliant for a six foot, otherwise fit 42 year old. I dread to think what his peak flow was on Birkhouse Moor.

Life saving "nasty steroids"

David thinks he has had much better treatment from the nurse specialist. She is friendlier than the doctor. She chats. She spends time with him. She has allowed him to stop those nasty steroids. This means his asthma must have improved and must not be serious like his mother’s.

If asthma is well controlled, you can stop taking the preventative treatment. If the grass is short, you can stop mowing the lawn. Life is so easy in Quacktitioner world. Family doctors see this sort of nonsense all the time. A patient has severe hypertension. You get it controlled, and it remains controlled, on two drugs. The patient then goes into hospital for something else. A nurse records a couple of normal blood pressures and says to the patient, “Why is your doctor prescribing all this for you when your BP is normal?”

The complicated breathing test the quacktitioner has been doing on David is called spirometry. Spirometry is an essential tool for the diagnosis of respiratory disease. It does not have much role as a routine monitoring procedure for asthma. But Patricia Hewitt has made QoF points available for doctors to do regular spirometry on patients. And points mean prizes. More money. So it gets done. Whether or not it is necessary. The doctor does not have to do it. A monkey could do it. It is thus ideal territory for the nurse specialist. Nurse specialists like spirometry. Protocols. Numbers. Form filling. Graphs. Looks important. Quacktitioners like spirometry in particular because it is a substitute for decision making.

It is not, however, a substitute for medical judgement.

Medical judgement is acquired gradually over a long period of time. A bedrock of two to three years scientific training, supplemented by three years clinical experience, followed by many more years of medical apprenticeship before you become an independent doctor working as a GP or consultant.

This process of acquiring medical judgement is also known as training to be a doctor.

It cannot be taught in a two-week "skills acquisition course" with flip-charts and a plate of bourbon biscuits.

It is disappointing that we did not get to the top of Helvellyn. It is terrifying to think that if David had not had a couple of doctors present who insisted on turning back, he might have had a full blown asthma attack on Striding Edge.

David’s experience is an anecdote. Of course it is. You cannot generalise on anecdotes. Of course you cannot. His nurse quacktitioner might be a particularly bad example of the breed. I hope she is. I fear she is not.

At work I see several examples a day of this well-meaning incompetence. I had hoped whilst on holiday to get away from it all, to get away from the stress of seeing the health service being destroyed by this relentless dumbing down.

Why cannot these well-meaning but ridiculous women (they are mostly women) go back to doing the job for which they were trained, and for which they have expertise?

What is happening to health care and, indeed, to education in this country?

I do not want happy-housewife “teaching” assistants, who think that willingness is a substitute for professional training, teaching my children. I do not want incompetent nurse quacktitioners treating my family. And I have taken steps to make sure none of this happens. I pay for my children to be educated in schools staffed by trained teaching professionals, not amateurs. I pay for private health insurance so that my family can be treated by medically trained professionals, not amateurs.

Every time I write about nurse specialists and you think, Oh dear, he is on going on a bit, ask yourselves some of these questions.

Tony Blair made much of the fact that he was treated on the NHS for his cardiological problems. Do you think he was managed by the cardiological nurse quacktitioner? Why not? My patients who have similar problems are.

If one of Blair’s children gets an asthma attack do you think he will be seen by a doctor or a nurse?

If the Duke of Edinburgh gets wheezy, do you think the Nurse Quacktitioner to the Royal Household will be summoned?

As far as Tony Blair is concerned, Nurse Quactitioners are like comprehensive schools. They are for the common folk. Do not expect him to use them.

Fast food and the Lion & Lamb.

The Lion & Lamb

English pubs have quaint, pleasing names. The Lion & Lamb is a classical example. In the Southern Lakes, you can find the Lion & Lamb on the left, as you drive north from Grasmere to Keswick. It is on top of a local mountain. Well, it is not a real mountain because it is only 1329 feet high. I do not do metres, but those who do can multiply by 0.3048

The mountain is called Helm Crag. It is a famous mountain, or mountainette, because, provided you approach from the south, you can see the Lion & Lamb perched on the summit from miles away. Not on this occasion a pub, but a striking configuration of rocks.

Too wet for a major walk today, so we decided to conquer Helm Crag. A short, quick but steep ascent these days made much easier by those nice men from the National Trust who have cut a staircase into the hillside. I do not think Wainwright would have approved.

On the way down, the mountain conquered, the talk turned to food, and with the whole family present, to fast food.

One of the many unspoken attractions of this part of England is the absence of this:



Not in Grasmere, nor Ambleside nor Bowness.

But there is something else. Still fast, but better. The Americans think they invented fast food. Not true. There was fast food in England long before the first Macdonald’s burger had found a bun. Before even those bedraggled old Wimpey Bars. I talk, of course, of fish and chips. The original English fast food, possibly the original fast food anywhere.




Nutritionally, fish and chips is far superior to a Big Mac. I know this because I am a doctor. One should perhaps avoid the temptation to smother the chips in salt and vinegar. If you are truly English, you can also ask for a portion of mushy peas. Sadly, these no longer come from a bubbling vat of light-green marrowfat peas, but from a tin. Modern tinned mushy peas are a luminescent green, redolent of “e” number and to be avoided.

But not the fish and chips. As good as ever and truly nutritious. And now I know that generous dollops of tomato ketchup are preventative medicine at its best. The added salt might be a problem for the medical profession, but I am on holiday and shall forget about that.

Radio 5 Live Phone-in

Victoria Derbyshire : Radio 5 Live Phone-in

Early start.

Invited to take part in a BBC Radio 5 Live phone-in on the financial state of the NHS. Still raining. Passed a snow-capped Blencathra on the way up to the BBC Studio in Carlisle. Never climbed Blencathra. Must do it this time if the weather allows.

Blencathra

And so, an hour of the Victoria Derbyshire phone-in between nine and ten o’clock. Much of the debate centred round whether the NHS should pay for surgeons to have a cup of tea during busy operating lists. The cleaner on the phone thought not.

It seems such a trivial example, but this “death of a thousand cuts” really does affect morale. I would like the surgeons to have a cup of tea, preferably brought to them by the cleaner who phoned in, but it did not seem PC to make that suggestion. So I did not.

I did contribute a few precious words later on. Those who combine computer skills with a desire put a voice to Dr Crippen can probably access the programme on the internet here.

Daily Mail announces a cure for cancer

The epitome of an Englishman on holiday – a cup of tea and last Tuesday’s Daily Mail.

Mrs C bought one, furtively, yesterday. I was appalled. However, glancing through it today over a cup of tea, for once I can say it is just as well she did. I have not been keeping up to date with the Lancet whilst I am on holiday, and so I missed the recent development in medical science.

The bottom quarter of Page 3 of Tuesday’s Daily Mail informs me:

Supermarket tomatoes ward off cancer

CANCER fighting tomatoes go on sale today at Tesco. The specially bred tomatoes are extra rich in a pigment which is believed to cut the risk of prostate cancer. Lycopene – the compound that makes them red – may also ward off cancer of the lung, pancreas, bladder, skin and cervix.

So not just prostate cancer. Cancer of the lung, pancreas, bladder, skin and cervix as well.

The tomatoes are now on sale for £1.99 a pound. That is a bit cheaper than Herceptin. Wait until Patricia finds out. I am sure, whilst I am up here on holiday, my partners will be dealing with hoards of helpful patients arriving with a copy of Tuesday’s Daily Mail.

“Should I buy some tomatoes, doctor?”

“Are we talking salads or cancer?”

“Tesco believe that the British-grown fruit will appeal to the public’s growing appetite for “healthy” foods. (Daily Mail)”

Thank God it’s British!

Thank God for the Daily Mail!

Thank God I am on holiday!

Four seasons

April showers.

Up here at the moment, showers mean rain, hail and snow. Punctuated by bursts of sunshine which is what we set off in.

We didn’t get to Crinkle Crags; the climb up Brown How was too daunting in the hail.

Then, as it does with the micro-climate here, summer appeared for the late afternoon, so out we went again.



“Someone’s phone is going off” said my teenage daughter.

“It’s a bird” said her brother.

“Well, it sounds like a mobile”

What hope is there for anyone brought up in an urban environment?

In praise of Wainwright

Wainwright

Spring is in the air.

And with Spring, and the approaching Easter break, Dr Crippen’s mind turns to the Lake District. Natural beauty is in the eye of the beholder, a subjective matter if ever there were, but I can say without fear of contradiction that the Lake District is one of the most beautiful areas of natural beauty in the world.

There are several million tourists visiting the Lake District every year. Most of them seem to spend their time walking round Bowness, Ambleside or Keswick before driving to lay-bys on busy dual carriage ways to have a picnic. The traffic is a nightmare. And yet, even at the busiest time of year, if you walk for a few minutes, you can be quite alone.

Striding Edge

Admittedly, not if you do the really famous walks such as Helvellyn via Striding Edge. For the skiers amongst you, Striding Edge is the black run of fell walking. More difficult than this, and you are climbing. Just as on any black run in a ski resort there will be a “committee meeting” of skiers standing at the top, discussing the weather, work, anything to put off the descent, so there always is at the beginning of Striding Edge, particularly as you approach the chimney.

No Lake District fell-walker will be without a Wainwright.

Wainwright was a grumpy, curmudgeonly Lancastrian, born in 1907 in Audley Range, in Blackburn, a town recently brought to fame by the visit of the USA Secretary of State, Condoleezza Rice.

Fifty years ago, Wainwright started to keep meticulous handwritten accounts of his walking in the Lake District. He started this entirely for his own benefit. He had difficultly in getting the guides published and, when finally they were published, he continued to insist that they reproduced his own handwriting rather than conventional typeface.

An excerpt from "The Southern Fells" : a route to Scafell Pike, the highest mountain in England

Wainwright was the Borough Treasurer of Kendal, fell-walker, and map-maker extraordinaire. He was a genius.

He was also, Dr Crippen believes, a sufferer from Asperger’s syndrome. Asperger’s syndrome is not that common and, although it has had some publicity over the last few years, most people have still not heard of it.

Hans Asperger

Hans Asperger first described the condition to which he gave his name in 1944. One can debate medical nomenclature endlessly, and there is a lot of discussion as to whether or not Asperger’s is a form of autism. Ultimately it does not much matter. There are similarities.

There is an excellent web-site called OASIS which brings together information from around the world. There are also, I am afraid, a whole load of looney-tune sites run by people with their own obsessions about the causes of Asperger’s and autism. Immunisations, of course. And the “heavy metal chelators”. I do not propose even to reference their sites, but if you are interested in a rational discussion of all these crazy theories, have a look at Left Brain/Right Brain, written by a web site designer who has a daughter who is autistic.

So, what exactly is Asperger’s? The best detailed description of it can be found here in a paper by Lorna Wing from the Institute of Psychiatry in the UK, and also from the introduction to the OASIS site:

Asperger Syndrome or (Asperger's Disorder) is a neurobiological disorder named for a Viennese physician, Hans Asperger, who in 1944 published a paper which described a pattern of behaviors in several young boys who had normal intelligence and language development, but who also exhibited autistic-like behaviors and marked deficiencies in social and communication skills. In spite of the publication of his paper in the 1940's, it wasn't until 1994 that Asperger Syndrome was added to the DSM IV and only in the past few years has AS been recognized by professionals and parents.

Individuals with AS can exhibit a variety of characteristics and the disorder can range from mild to severe. Persons with AS show marked deficiencies in social skills, have difficulties with transitions or changes and prefer sameness. They often have obsessive routines and may be preoccupied with a particular subject of interest. They have a great deal of difficulty reading nonverbal cues (body language) and very often the individual with AS has difficulty determining proper body space. Often overly sensitive to sounds, tastes, smells, and sights, the person with AS may prefer soft clothing, certain foods, and be bothered by sounds or lights no one else seems to hear or see. It's important to remember that the person with AS perceives the world very differently. Therefore, many behaviors that seem odd or unusual are due to those neurological differences and not the result of intentional rudeness or bad behavior, and most certainly not the result of "improper parenting".

By definition, those with AS have a normal IQ and many individuals (although not all), exhibit exceptional skill or talent in a specific area. Because of their high degree of functionality and their naiveté, those with AS are often viewed as eccentric or odd and can easily become victims of teasing and bullying. While language development seems, on the surface, normal, individuals with AS often have deficits in pragmatics and prosody. Vocabularies may be extraordinarily rich and some children sound like "little professors." However, persons with AS can be extremely literal and have difficulty using language in a social context.

Briefly an Aspie is socially inept. He may not respond in a conventional manner to social cues. This may just make him seem shy. It may make him seem objectionable. Wainwright could be both. An Aspie relates better to things than to people. Wainwright related to the Lakeland Fells and to the maps he drew of them.

An Aspie may have interests or, in particular, one overwhelming interest, that occupies most of his waking life. Maps, computer games, train spotting… whatever. Most of us do not use the term Aspie, we have never heard of it. But in the UK we do have another expression. We call them “train spotters” or “anoraks”. The shy teenage boy, sitting in the corner at the party, who says little. But ask him about his hobby and he will give you an exhaustive list of the hundred tallest buildings in the world.

Aspies are not stupid. They are of normal intelligence. A few are particularly gifted. It would be wonderful to be able to say that they were all touched with genius like Beethoven or Wainwright. Sadly, the truth is less interesting.

I believe though, and I have no figures or data to back this up (so I expect to be shot down in the comments column) that some Aspies, albeit without exceptional intelligence, are able to excel in one probably narrow field, because they have abilities of concentration that are denied to most of us. Concentration so strong that it may exclude many of the more normal aspects of life.

The difference between severe autism and “normality” (Dr Crippen uses the word “normality” without defining it but is always interested to receive suggestions as to a working definition!) is a gradation going through a wide spectrum. The severely autistic child presents challenging management problems. There are few people who have never experienced shyness. Most of us are somewhere in between.

Wainwright was an Aspie. He was fascinated by maps from an early age. The fascination was almost to the exclusion of all else. His first marriage was a disaster. He was never there. Read the excellent biography by Hunter Davies.

Recently, Davies has commented:

“His claim to greatness is his Pictorial Guides to the Lakeland Fells. Over 13 years, in his spare time, he climbed 214 Lakeland fells, getting to each on foot or by public transport, as he couldn't drive, then he wrote up his notes in little home-made books. They were miniature works of art, in that he drew everything by hand, the words and the illustrations.

In 1955, he began publishing them, originally at his own expense, exactly as he had written and drawn them, without an ounce of printer's type. By 1985, despite not a penny being spent on advertising, publicity or promotion, they had sold one million copies. Nor did he do any literary lunches, appearances or signing sessions. If he'd been starting today, no publisher would accept him.

Wainwright loved the fells, loved animals more than humans, and always preferred to be on his own in Lakeland” (Hunter Davies, in the New Statesman).

Wainwright’s books have been a constant source of pleasure to me since I was a teenager. The Lakeland Fells seem a lot steeper now than when I first walked them, but I shall be up there over the next couple of weeks, whatever the weather, with my Wainwright.

Thank goodness for Asperger’s syndrome.

+++++

More details on Wainwright from The Wainwright Society

The complete set of The Lakeland Fells available here

Helvellyn in Winter from Ann Bowker's "Mad about Mountains"

The Crippen Diaries (Week 14)

Not quite Tannochbrae

Monday 3rd April

A thirty-nine year old lady who has been getting intermittent attacks of abdominal pain for six months. She gets an associated tingling in her left foot, which she finds strange. She is just "not feeling right". And her back is not so good and she has been getting headaches which occur after lunch most days. She has had the headaches for over twenty years and “it is not right, is it” and the neurologist she saw two years ago did not do a scan and told her it was tension…

…and the symptoms go on and on. As a general rule, the larger and more disparate the collection of symptoms becomes the less likely there is to be a serious underlying problem. But the main reason for the visit today was the abdominal pains. As I went to examine her abdomen, she closed her eyes. Patients who close their eyes when a doctor palpates their abdomen are unlikely to have anything seriously wrong with them. It is known as “the closed eye sign”.

The “closed eye sign” has always pleased me. I think it is a good one. But despite the large collection of disparate symptoms and the closed eyes, this lady was remarkably tender over her gall bladder, and so there may be something going on. It needs checking out.

++++++++++

A twenty-year old girl down from Cambridge for the vacation. She has the most appalling tonsillitis. It looks like someone has sprayed Pizza mix over the back of her throat.

Tonsillitis

She saw one of my partners on Friday night and was started on penicillin and told to gargle with soluble aspirin. By Saturday night she was much worse so she phoned NHS Redirect. They were “ever so nice”. They told her that maybe the aspirin was making her throat sorer and advised her to stop it and go to see the pharmacist. The pharmacist sold her some Bonjella and advised her to go back to the doctor. Bonjella contains an aspirin derivative. Probably OK.

Her throat looks dreadful. She looks dreadful. The penicillin has not helped. I bet it is viral. The really bad ones often are. May well be she has glandular fever, so throat swab and blood tests, and restart the soluble aspirin.

NHS Redirect **cost £22 million to set up and about £80 million a year to run. About 60% of the calls to NHS Redirect are passed on to the doctors on-call service. These are expensive too. The government says that NHS Redirect is not losing money. By what criteria is that conclusion reached, I wonder? And the BBC reports today that the Goverment is to lay off staff from NHS Redirect. Why would they want to do that if it is so "successful" and not losing money?

Pharmacists are only just stretching their diagnostic muscles at the moment. Maybe they should be allowed to prescribe. That would relieve the pressure of work on the nurse practitioners.

** Entirely co-incidentally my economic advisor, Wat Tyler, has been looking at NHS Redirect today. It seems NHS Redirect is now going into show-business. Check it out here

+++++++++


Tuesday 4th April

I think that the British taxpayers out there have a right to know that I have just conspired, with malice aforethought, and with an equally culpable colleague from another practice, to spend £1000 of your money.

On your behalf and at your expense my colleague and I met for an hour’s chat at lunch-time today. Two of Stuart Rose’s excellent sandwiches, a cup of freshly percolated coffee, a good chat, and we earned £500 each.

Marks & Spencer Sandwiches

I would just like to say thank you to you all.

I am talking, of course, about my Annual Appraisal. This system was introduced some years ago in the wake of Harold Shipman. You will recall, as described here, how successful the government was in their campaign to identify patio builders who were also mass murderers. It seems very reasonable to have a similar system for doctors.

If you wish to appraise yourselves, or maybe appraise a friend, the tool-kit for appraisal can be downloaded here. Take a look. Fill it in. If you have difficulty in finding a sucker willing to pay you £500 for your trouble, try here.

It’s a discriminating, challenging questionnaire. It took me nearly ten minutes to complete it. Some of my partners, not having the gift of words, have to devote fifteen or even twenty minutes to it.

Some of you may feel however that the questionnaire is not quite discriminating enough to pick up a Shipman manqué. Fortunately, my appraiser is a canny sort of chap, so he did ask, “By the way, John, is it your intention over the coming year to systematically slaughter your patients?”

Difficult one. Nearly caught me out. After a pause, I said “No.”

I think I convinced him.

There are 30,000 GPs in the country. We all do this once a year. That’s £30 million a year, every year. I don’t think Wat Tyler has spotted it yet.

Thanks again, guys.

+++++++++



Thursday 6th April

Tidy up day because I am off on holiday tomorrow. It’s always amazing how things come out of the woodwork when you are trying to clear your desk.

One of the young female partners, who is herself six months pregnant, has devoted most of the last two days to trying to get psychiatric help for a psychotic alcoholic lady. She sent her into hospital. The psychiatric liaison nurse sent her home. The police picked her up yesterday, drunk and psychotic. The police do their best, but they are not at their best with drunks. They phoned the hospital who advised them to take her to the GP for “an assessment”. My partner did that yesterday and sent her into hospital. The poor patient is bouncing around the system like a pin ball. No one wants her.

+++++++++++

One of our new receptionists was in tears. A man phoned late morning and said he needed to be seen immediately. There were no appointments left. The receptionist gave the standard advice. The duty doctor would phone him at lunchtime and if he felt it was medically essential for him to be seen, would see him the same day. Otherwise it would be an appointment tomorrow. The man told her is was a “fucking disgrace” and that it was a “fucking crappy service” and slammed the phone down on her.

I am glad I am going on holiday.

++++++++++

I saw a young girl with dermatographia. She has hay fever and eczema, but something has happened to her over the last three of four weeks and she keeps coming out in urticaria.

Dermatographia

I wrote her initials on her back with the blunt end of a pen, and a few minutes later they were standing out like a three-dimensional map. Fascinating. Not serious, but needs checking out.

++++++++++

Finished all the reports that I have been pushing to the back of the desk. Dictated all the letters. One of the plus sides of medicine is that, by the nature of the job, you have to hand over the serious problems to colleagues and so it does not pile up waiting for your return. There are one or two patients who will wait and save up their problems…but I know who they are already. Got away two hours later than planned but everything really is cleared.

If I could go on holiday once a fortnight, I would always be up to date. What a lovely thought.

++++++++++

Alice Miles - The shit in The Times

Alice Miles

More doctor bashing in the Times today.

Alice Miles, a well-known commentator, is having a go at hospital consultants. It is an unusually illiterate and offensive article, full of poison and vitriol. The sort of article that a decent editor, a Rees-Mogg, for example, would have spiked. But the Times has gone down the tubes and behaves more like a tabloid newspaper these days, and so I suppose articles like this go with the territory.

“CONSULTANTS ARE an arrogant and stroppy lot, independent-minded, stubborn and clever. The biggest problem that successive governments have faced in reforming the health service has been the attitudes of its senior medical staff.”

“…if you are a consultant, especially in the larger hospitals, you can act like something approaching God: you don’t see patients, you graciously receive them.”

Miles states that there is a shortage of consultants:

“…partially manufactured by the royal colleges, that limited training places so everyone always had jobs (which) ensured that consultants could pretty much do as they pleased."

“Labour changed that, by introducing a contract that for the first time gave hospital managers some control over the output of consultants, who only agreed it in return for a large pay increase — which is where many of the NHS billions have gone. The Government also opened privately run treatment centres, staffed where necessary by foreign doctors, to break the NHS consultants’ monopoly.”

“How the consultants squealed (and still do, claiming sub-standard treatment from foreign doctors; some nerve, given the profession’s refusal to reveal its own individual success rates). But they have lost that fight; patients vote with their feet for quicker treatment at the fast-track centres, no matter who is running them, rather than “better” treatment at the hands of Sir Gerry Fatfingers who can squeeze them in in eight months’ time.”

I am not a hospital consultant so I have no personal interest. But Mrs Crippen is a consultant in a large and well know hospital. I see her work, and I know many of her colleagues.

It is true, as Miles points, that sixty years ago, Bevan had to agree to allow hospital doctors to continue to do private practice in return for their agreement to work in the NHS. It is also true that there have been a handful of consultants over years, usually arrogant alpha-males working in London Teaching hospitals, who have grossly abused their position by leaving their work entirely in the hands of the juniors whilst they slink off to the yellow-brick road.

When Dr Crippen was a houseman at a leading London teaching hospital, he worked for such a consultant. During the whole six months I was there, he did not do a single NHS ward round; he did not do a single NHS operating list; I never saw him in the hospital. Except once. I was assisting the register who was doing the consultant's NHS operating list. I was bleeped by the consultant, and summoned away from the NHS operating list, to assist him with an operation he was doing on a private patient in the adjacent private hospital. His speech was slurred and he smelt of alcholol.

This man was a shit. I do not use the word often, or lightly. But there is no other word for him. Whatever system you have, there will always be people like this who bend and abuse the rules.

The government wanted work initiatives to reduce waiting lists. Consultants offered to come in at weekends to help. But the government would not pay them to do that. After all, we only have waiting lists because consultants are so lazy. So they got the foreigners in. Some were good. Some were dreadful. They caused more problems that they solved.

The majority of consultants work hard, and work longer hours for the NHS than those for which they are contracted. The media may choose not to believe it. Alice Miles clearly does not believe it. Patricia Hewitt certainly did not believe it.

Nonetheless it is true.

And this is why the new NHS contract has cost the blessed Patricia so much money. She set the time and motion men on these lazy, skiving, golf-playing consultants. She knew what they were up to. You are paid for a forty hour week. Now we are actually going to measure what you do and that is what we will pay you for. Not a penny more, not a penny less. The measurements showed that the consultants were doing far more work than their contracted forty hour week. And so they all got pay rises. The blessed Patricia was hoisted by her own petard.

Of course, consultants still earn far less than city solicitors, city accountants, stock-brokers, investment bankers and those nice people who sold you your endowment mortgages, but then doctors are not as important as these people.

If I had to list the government's mistakes in healthcare, and it is a very long list, at the top of that list would be the “blame” culture that they have engendered in the NHS. The NHS is in trouble. Let’s blame the doctors.

Doctors are like any other group of people. They are not perfect. Far from it. And there are a few bad apples. But most doctors are decent, caring hard-working people. And when they read articles like this one, carrying all the weight of The Times, they are upset. It hurts. It is hard to defend. The NHS is already demoralised. This does not help.

We go on holiday on Friday. We want to set of early to miss the traffic, but we will not. Mrs Crippen has been working late every night this week, trying to clear her desk before she goes on holiday. She was in the hospital on Saturday and Sunday, trying to catch up. She will probably “nip in” for an hour, which will turn into three, on Friday morning. It happens like this with every holiday. She is not paid extra for this work. But she is not moaning about it. It is what she does. She is a professional. She is a doctor. Most of her colleagues do the same.

Why does no one believe this?

Poisoning Bread

Isaiah Berlin

"Happy are those who live under a discipline which they accept without question, who freely obey the orders of leaders, spiritual or temporal, whose word is fully accepted as unbreakable law; or those who have, by their own methods, arrived at clear and unshakeable convictions about what to do and what to be that brook no possible doubt. I can only say that those who rest on such comfortable beds of dogma are victims of forms of self-induced myopia, blinkers that may make for contentment, but not for understanding of what it is to be human." (Isaiah Berlin)

The Food Standards Agency has announced the recommendation that folic acid should be added to bread and flour. This is, as Sellar & Yeatman said many times here, a “good thing.”

It will reduce the incidence of spina bifida in new born babies by nearly 50% and it should reduce the incidence of miscarriages.

We could just give it to pregnant women and that would have the same effect. Actually, we do try to give it to pregnant women, but not all of them take it. Some just do not bother. Others hold the view that it is best “not to take anything” when you are pregnant. Ignorant fools! Why should they be allowed to make that sort of decision.

Now they will have to take it. So will I. And I am not pregnant, nor am I likely to be. But it is possible that folic acid supplements will reduce that incidence of strokes and heart disease, and I am happy to avoid those.

Lots of other countries put folic acid in bread. Canada. Chile. Even George Bush puts it in American bread. Well, it is probably the only way to get folic acid into broccoli hating Dad.

In the UK, bread is already loaded up with more goodies than you would find on the vitamin counter at the local chemist’s shop: calcium, iron, thiamine and niacin. All good stuff. Why not add something else?

Fluoride is added to the water supplies if not there already naturally and there is not the slightest doubt that that has improved dental health.

Why stop there?

The editor of the BMJ said

“Light the blue touch paper and retreat 5 metres. That's what we did when we published a series of papers suggesting that if everybody started taking a pill containing six ingredients at the age of 55 then deaths from heart disease and stroke would be reduced by 80%. The pill would contain aspirin, a statin, folic acid, and three antihypertensives at half dose. Versions of all the drugs are now off patent, and the pill could be produced for pence.” (BMJ 2003;327 4 October)

Let’s get that in the water supply too.

Speed limits on the roads? Seems reasonable. Crash helmets and seat belts? Those save lives. Stop cigarette advertising? Seems reasonable. Why not ban cigarettes altogether? Alcohol? That is the scourge of society. The single most identifiable and avoidable cause of road traffic accidents and hospital admissions. Let’s ban alcohol too.

Compulsory medicating the community with folic acid will cause a problem by masking Vitamin B12 deficiency. We will see an increase in sub-acute combined degeneration of the spinal cord. I hope GPs are not going to be “made responsible” for that.

Sub-acute combined degeneration of the cord

If we are, the hospital labs are going to have to gear up to a lot of expensive Vitamin B12 assays as they will become a routine screening test.

There is a bigger principal, though. Negative and positive liberty as Isaiah Berlin would have called it.

Nanny state, to put it in simple terms.

Call me old-fashioned, but I have a deep-seated unease about compulsory medication for the whole population. It gives me exactly the same feeling as Identity Cards.

It is not something we “do” in Britain.

If the utilitarian argument of “the greater good” is to triumph, why stop with folic acid in bread? The number of lives saved or improved by that is trivial compared with the number of lives that could be saved or improved by compulsory immunisation of children.

We force parents to educate their children. We force parents to feed their children. If parents neglect their children, ultimately we will remove the children and take them into “care”.

Why should children suffer because their parents have nonsensical views about immunisation? The evidence base is that routine immunisations are safe. They are in the individual child’s best interests. They are in society’s best interests.

Why stop with bread? If we are going to justify forcing 60 million people to take folic acid, how can we not justify making childhood immunisations compulsory too?

Teenager dies from measles

The fall in MMR and the rise in Measles (The Times)

The first measles death in the UK for over 10 years has just been reported.

This was a teenage boy.

An article in the Times today makes the following points:

• There have been more cases of measles in the last three months than in the whole of last year.
  
  
• UK MMR immunisation rates are amongst the lowest in Western Europe.
  
  
• Six nurses in the Central Middlesex Hospital in North West London are in isolation having caught measles from two children recently admitted to the hospital. More than a 1000 members of staff at the hospital are being immunised immediately.
  

Saving children's lives

Measles is a serious illness. It can cause catastrophic brain damage and death.

It is never too late to be immunised.

I do not know what more to say.

Sacking the organ grinder

Cheeky monkey takes over

It goes on.

It gets worse.

Over on Doctors.net.uk an experienced family doctor recounts how he tried to get help from the hospital for a patient with a quinsy.

For non-medical readers a quinsy is an abcess at the back of the throat. You can die of a quinsy. It is a medical emergency.

Quinsy

The doctor in question phoned the hospital to speak to the on-call ENT surgeon. There was no on-call surgeon. There was no on-call doctor.

Who was on call?

Our friend the nurse-practitioner, armed with her trusty protocol. She clearly did not understand the nature or the problem, so she started cross-examining the doctor about the diagnosis and treatment. The monkey cross-examining the organ grinder. The air hostess cross-examing the pilot.

Meanwhile, there is no one around to treat bed sores.

Stage 1 pressure sore

The skin is intact but shows a persistent pink or red area that does not turn white when you press it with your finger. The wound may look like a mild sunburn. The affected skin may be tender, painful or itchy. It may feel warm, spongy or firm to the touch. Good nursing care can cure this - if you can find one.

Now Dr Crippen is probably getting a reputation for having a bee in his bonnet about nurse practitioners. Well, he has. In his local hospital there are still surgeons in the building at night. For how long, I do not know. There are no psychiatrists. The nurses have taken over. The doctors have long gone. This is Hospital at Night, as the Government calls it.

Not all doctors are as outspoken as Dr Crippen about this. Not in public at any rate. But in the comments column in Doctors.net.uk it is a different story. You have to be registered with the GMC to get in there. The doctors there, in private, are very outspoken indeed. They fear for their patients. Indeed, they fear for the survival of the NHS.

It would be a gross breach of privacy for me to print their names. But I will print some of their comments. Any UK doctor reading this can go onto doctors.net.uk and see these and many other comments. They are all printed verbatim.

on-call ENT nurse practitioner 30/03/2006, 11:23
I've just seen a woman with a nasty quinsy despite 3/7 of full dose pen V. I rang up the local hospital and asked switchboard to bleep then ENT SHO on-call. The person who answered was a nurse practitioner who was on-call for the wards. This is a new development for me. She behaved just like a stroppy PRHO- questioning my diagnosis and suggesting the pt hadn’t tried the abs for long enough! I told her it was irrelevant how long she'd been on the abs for and needed to be seen by a Dr. She then wanted to ring me back as she didn't have the ward attenders book and needed to give the patient a time to come to the ward. I gave her the patient's mobile number and told her to sort it out with her. In retrospect I should have told her the patient needed to be seen asap as she was in so much discomfort.

I felt very uncomfortable referring an ill patient to a nurse practitioner. It’s a slippery slope!

RE: on-call ENT nurse practitioner 30/03/2006, 11:28
She behaved like stroppy PRHO for the same reasons. Lack of confidence, stress, projection of own inadequacies, system failure, lack of perceived back-up. Your patient needs surgical assessment and she's not a surgeon.

shit for you
shit for the patient
shit for the ENT staff
shit for the nurse
11 colleagues voted this a quality posting.

RE: on-call ENT nurse practitioner 30/03/2006, 11:29
You should make a formal complaint to the consultant and insist it goes through the full complaints procedure.

Nothing short of that will make these people behave reasonably.
5 colleagues voted this a quality posting. .

RE: on-call ENT nurse practitioner 30/03/2006, 11:33
...try being the PRHO who has to work with (under!) these types. Misery for all concerned.
1 colleagues voted this a quality posting. .

Refuse now... 30/03/2006, 12:13
Refuse to speak to her, ask to speak to a medically qualified consultant. This will only stop if steps like that are taken. Otherwise people might die.
9 colleagues voted this a quality posting. .

RE: on-call ENT nurse practitioner 30/03/2006, 12:39
Fucking Nurse practitioners (please excuse my French)

I may as well go back to Uni and re train as a nurse..

At least then I can come back and have a job with cushy hours, little responsibility, good wage packet and no threat of ever losing my job.

RE: on-call ENT nurse practitioner 30/03/2006, 17:34
Had a leaflet around yesterday saying referral management centre will be passing ENT referrals to a nurse practitioner.
Conditions he/she will be treating were listed, and included hoarseness - which is currently on the 2 week wait if present for more than 3 weeks.
Phoned PCT to ask how this was going to work.
Still waiting for an answer.

RE: on-call ENT nurse practitioner 31/03/2006, 9:39
Dangerous attitude that Quinsy can be treated with antibiotics without drainage...
Definitely needs formal complaint

Why nurses should stick to nursing 27/03/2006, 16:10
an example from today

I saw a man last week with tinnitus, examined his ears, explained what was happening and gave him a fact sheet on tinnitus. As any doctor can tell you it is a difficult condition to treat and takes a while for the patient to get round to the idea and they can get desperate whilst waiting for the brain to "mask" the noise

So today he attends the Nurse lead Walk in centre where the nurse decides his left ear is completely blocked with hard wax and he should see the doctor urgently to arrange removal (his words... do people die from ear-wax?)

Now I was fortunate enough to go to medical school where we learnt a little bit about anatomy and then I did a bit of ENT as a student as well and spent some time in A&E looking in ears as well as time supervised by my GP trainers. So I know that the ear canal is not straight and if you ram the otoscope straight into the ear all you're going to see is skin... or in this case the thin rim of wax he had on the lower right hand side of his ear canal. If only she had learnt that a gentle tug on his ear would reveal a perfectly visible normal looking tympanic membrane and a patient going away disappointed that his tinnitus cannot be cured as promised by the nurse. Another good use of your taxes


RE: Why nurses should stick to nursing 29/03/2006, 8:30
A lot of this is about nurses seriously losing the plot by making nursing a degree course starting with the ludicrous 'Project 2000'. There are now armies of non-nursing nurses in Mickey Mouse academic departments of nursing training nurses how not to nurse. In my own areas psychiatry and learning disability, the nurse nurse-tutors are a very mixed bunch and a sizable minority hold anachronistic, vehemently anti-'medical model' (sic) views and train their students to be more patient advocates and de facto social workers rather than nurses. Most of their students therefore have to learn their practical skills on the job, and this still includes any information about psychotropic medication and modern nosology. Meanwhile their tutors discuss Laing, Szaz and Lacan in a 1960's time warp, seemingly with non-360 degree impunity from their frustrated students and also, amazingly, the higher education RAE!



It is going on all over the UK and it seems that it is well-established in the USA already. It is attractive to the government because it is cheap. And it only affects NHS patients. You will not see nurse-practitioners if you go privately. You will not see a nurse-practitioner if you are a VIP. It is like the education system in the UK. Comprehensive schools are excellent for the common folk, but do not expect the Royal Family or Tony Blair to use them.

I have asked this before. I shall ask this again. I shall keep asking it. If Prince William gets a quinsy, do you think he will see a nurse practitioner?

There is an internet site, Centre for Nursing Advocacy (CNA), which I highlighted before when we were having fun with the Nurse Quactitioner Doll. The dear people at the CNA are so worried that nurses might have to return to nursing care duties that they devote their spare time to complaining if a nurse is seen on television doing anything remotely concerned with conventional nursing care.

But perhaps I have got it all wrong. Maybe nurses CAN do it all. Maybe we do not need doctors in hospitals any longer. Or anywhere else for that matter. The abolition of the medical profession would certainly save a lot of money.

So a challenge to the CNA. Two questions:

1. What, if anything, can doctors do that nurses cannot do?
2. Now that nurses are doctors, who is going to do the nursing?

I will not hold my breath waiting for a reply from the CNO. I do not think they do rational debate.