The Crippen Diaries (Week 26)

Not quite Tannochbrae

Monday 26th June

It seems now to be becoming a regular Monday lunch-time meeting.

The QoF chase.

Today’s topic for extracting a large sum of taxpayer’s money from the government is a depression audit of people suffering from heart disease and diabetes. We are not talking serious psychiatric depression here. We know those people. They are not difficult to spot. We are talking about what the government calls “mild to moderate depression”.

People who might benefit not from drugs but from “talking therapy”.

We know our patients pretty well. We see the ones with ischaemic heart disease and diabetes frequently. We are doctors. That is what we do for a living. Quite a lot of them are fed up. If I had had a heart attack three months ago, I would not be best pleased. But the government wants us to put a note on the computer saying “is/is not mildly depressed” and “is/is not in need of “talking therapy””.

Great stuff. Into battle.

I saw Bill this afternoon. He is a brick layer. He had a heart attack in February. He is still off work. Brick layers earn a lot of money, but most of them are self-employed. Bill is self-employed. Bill also has a great sense of humour. I put on my formal voice and said, “The government wants me to ask you if you are feeling fed up since you had your heart attack and lost your livelihood."

The gist of what he said was “yes”.

I said, “Would you like to see a counsellor?”

Bill looked at me for a while, then said, “Oh fuck off, doc!”

We have 421 patients in this category. Maybe twenty of them are fed up and would be eligible for “talking therapy”. Who knows? I don't. The government are going to pay my practice £11,000 pounds to find out.

Splendid. I will do it.

Trouble is, having identified all the patients in need of “talking therapy”, there is nothing more we can do. The government has taken away all our counsellors. “Talking therapy” does not exist in our area any more. Unless you go privately.

It will be good ammunition to throw at the psychiatric department.

What a waste of money. What a waste of time. But, once we divvy it up amongst the partners, it will pay for this year’s Glyndebourne tickets. We are taking our two oldest children to see Benjamin Britten’s Midsummer Night’s Dream, directed by Peter Hall. Benjamin Britten is one of the greatest composers in the world. After Mozart. And Janacek.

"One of the greatest performances you will ever hear ... Bejun Mehta as Oberon works his magic on Tytania played by Iride Martinez. Photograph: Mike Hoban"

Mrs C and I saw Midsummer Night’s Dream at Glyndebourne a few years ago. We earmarked it for the children. It is as close to the most perfect production of that, or possibly any, opera that could be imagined.

The reviewers seem to agree too.

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Tuesday 27th June

Lila is 78 and has been waiting five months for her hip replacement. To be fair to the government, these waits have come right down. I saw her today. She was in a tizzy. She went in to have her operation on Friday as scheduled. She had had the pre-op assessment by the “nurse-specialist” two days before and all was well. She was changed, gowned and pre-meded and waiting to go to theatre. And waiting. And waiting. By six o’clock nothing had happened and then a nurse appeared and said the operation had been cancelled. She was sent home. The hospital has an obligation to re-schedule the operation quickly and they will do that. But nothing can compensate Lila for the emotional turmoil. She is nervous of hospitals. She thinks she is unlikely to survive the operation. Well, not really, but the thought of death has crossed her mind more than once.

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I did a rectal examination today on an elderly man with prostate cancer. When I pulled my finger out, the glove had split, and my finger had faeces all over it. It happens, I suppose. But it has never happened to me before. Oh dear! I scrubbed and scrubbed and scrubbed. I am not squeamish, or not much. I spent the rest of the day surreptitiously smelling my finger. Oh dear! Oh dear!

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Tony and his wife came to see me to referee a domestic argument. Tony is about two stone overweight, and his cholesterol is raised. He is a non-smoker, with normal blood pressure and no significant family history. He is trying to lose weight. Indeed, he has lost half a stone over the last three months. He does not think that is fast enough. I think it is just right because he has done it by sensible alternation of his eating habits and there is a good chance he will stick with it. Tony drinks two glasses of red wine a day. He reads Dr Tom Stuttaford in the Times (so naturally he has already asked me to check his PSA) and he knows about J curves and genuinely believes that drinking two glasses of red wine a day is good for him. His wife, on the other hand, who is virtually teetotal, thinks he should stop. Two glasses of red wine (particularly the glasses he pours) contain about 400 calories. 400 calories a day is a pound in weight every nine days. His wife wants him to stop. He will lose weight quicker. They have both been out on the Internet. Tony thinks he will live longer if he drinks in moderation and thinks he has data to prove it. His wife thinks that, all in all, it is better not to drink at all.

I rather suspect his wife is right. I tell my teenage children not to drink Alcopops because they are a confidence trick.

Alcopops are the alcohol industry's attempt to dress up poison to make it more palatable to children. They respond by telling me that the same applies to the wine I have laid down in Stevenage. Wine is the alcohol industry's attempt to dress up poison to make it more palatable to adults.

I end up telling Tony that there is not likely to be much serious harm in drinking two glasses of red wine a day, but it certainly will not help his diet. And if he drinks it, he should drink it for pleasure, and not on the specious grounds that he is going to improve his health.

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Thursday 29th June

Those idiots at NICE have told everyone in the country about the recommendations about beta blockers and hypertension. Everyone, that is, apart from the doctors. Four patients this morning appeared, quite reasonably asking if they should have the medication they have been on for years changed.

It is not easy. There is no money for drug companies in beta blockers. A month’s supply of Atenolol, for example, costs a few pence. A month’s supply of Amlodipine costs a lot more. The makers of Amlodipine spend a lot of money flying research doctors to conferences in Paris and Rio to discuss papers which demonstrate which it “the best” treatment for hypertension. Amlodipine turns out to be “better” than beta blockers. That is a surprise.

So we all met for lunch (paid for out of our own pockets) to discuss it. We are going to wait a few months before we start making radical changes.

Those who think we are being timid and conservative should look here and here.


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An 87 year old lady is brought in by her daughter, herself in her sixties, as she has been having “funny turns”.

“I don’t know doctor, I don’t pass out or anything, I just feel a bit woozy for about twenty seconds, and I sit down and it goes off. I worry I might be going to have a stroke.”

This is a nightmare presentation for a family doctor. You could devote a week to it. There is not much else in the history. She has had occasional “funny turns” for a few years. There is nothing to find examining her. Her BP is 158/86 which some would say is too high and one must not be ageist about BP and it should be treated. I am not going to treat it and I do not believe it is too high for someone of her age and I think if I do treat it, she will probably have even more funny turns.

The daughter wants me to “do” something, and I want to “do” something. So we arrange for a few blood tests, including a blood sugar. We arrange for her to have an ECG. We arrange for the practice nurse to see her a couple of times to check on how things are going.

All the investigations are plausible. They will probably all be normal and even if they are not, they are unlikely to explain the “funny turns.” It is to some extent fraudulent. I could give you a list of twenty causes of “funny turns” and then some. Where do you start with investigations? That is easy. Where do you finish with them? That is impossible. So we bumble along and at the back of my mind I worry that I might be missing something. When, finally, something serious does happen, and she is whisked into hospital some junior doctor or nurse-specialist will say to the daughter, “And didn’t the GP check her for…(insert presenting condition)…?

Heigh-ho!

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Friday 30 June

Hot sweaty day. Thank God for the air-conditioning. But duty doctor today and for some reason it is unseasonably busy. Lots and lots of phone calls.

Three patients phone for beta-blocker advice. The NICE guidelines are now on the internet, though we still have not had a piece of paper. Beta-blockers are out of fashion now, no doubt about that, but there is no need to stop them suddenly, indeed it could be dangerous so to do. I am having the same conversation over and over again. Do not panic. Come in sometime over the next few weeks. Yes, it will keep. Honest.


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I have done forty seven phone calls, advised twenty-nine patients, made appointment for next week for ten patients and seen eight patients myself. Some of the phone calls have been nonsense, but some have not, and the patients who come in have perfectly genuine problems. I have no problem with that. It is the job, and I still enjoy being a doctor.

One phone call makes me angry. From the respiratory nurse-specialist. Nurse-specialists knock-off at five o’clock on Friday. Theoretically. But it is POETs day, so they try to clear their desk by about three o’clock.

The respiratory nurse specialist calls. “Sorry to disturb you, would you just leave out a prescription for some ciprofloxacin for Mrs Jones.” No I will not. I virtually never prescribe ciprofloxacin. I do not prescribe antibiotics for patients without seeing them. And I do not prescribe at the beck and call of nurses. Nurse is angry. “I have seen her and she has a chest infection.”

Well, why don’t you prescribe something then, nurse?

“You know I can’t prescribe.”

Why is that, nurse?

She does not answer. So I ask her to describe the problem.

“She has a chest infection.”

When Dr Crippen was doing respiratory medicine he was not allowed to use the expression “chest infection.” It does not mean anything. It was one of the Professor’s pet peeves, and now it is one of mine.

“Chest infection? Do you mean pneumonia, nurse?”

Oh not, it is not as bad as that.

“Do you mean bronchitis, nurse?”

Well, yes, I suppose so

“Why do you want to give her ciprofloxacin, nurse?”

She is already on Amoxil, and I think she needs something stronger”

"Stronger?"

You know what I mean, doctor.

“No I don’t. Why does she need another antibiotic?”

“Because she is still coughing.”

I know this patient. She is a smoker. She has had a chronic cough for ten years.

I do not have the time or the space to explain the stupidity of this conversation. Of the way of assessing chests. Of the appropriate use of antibiotics. Of the nonsense of talking about “stronger” antibiotics. Of the need to avoid prescribing ciprofloxacin. It would take forever. Pop into a medical school for five years and you would understand.

I have no way of explaining it to the nurse either. So I see the patient. Her chest is fine. Her hay fever is a bit troublesome. She needs to throw her bloody cigarettes away.

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Five minutes to go before we close.

A 26 year old young woman, who is not registered, and has just moved into the area from Cornwall, walks in and says she is in severe pain. So I see her.

She had an IUCD fitted three months ago as post-coital contraception. Since then she has had intermittent severe pain, and it has been particularly bad for the last three days.

Why do they always leave it to the last minute on Friday evening? Because she has been at work all day.

She is not systemically unwell. She does not have a temperature. But she is in pain.

She has never been pregnant. I am not keen on IUCDs in young women who have never been pregnant. By the time I have established all this, the nurses have long gone.

I say I need to remove the IUCD but there are no nurses around. Can she cope without a chaperone? She is not in the slightest bothered. I am though. Every time you do this sort of examination without a chaperone, you are taking a professional risk.

Fortunately there are no problems. I remove the IUCD. It does not look infected. I put her on some antibiotics anyway. She is gratifyingly grateful. I will follow her up next week.

If she had accused me of sexually assaulting her, I would have been in difficulties. But what can you do?

I leave half an hour later than I should and postpone, yet again, the wadge of paperwork I was going to clear up.

Marie Antoinette takes over NHS emergency care

Secretary of State for Health

I am grateful to Gav and his Department of Health feed site for drawing my attention to another can of worms that is being opened by the government.

A new species of “Health Care Practitioner” (HCP) (Crippen’s Dictionary of Medical Terms. HCP = “There is no doctor available”) is about to be foisted upon the unsuspecting general public.

Welcome to the “Emergency Care Practitioner”. (ECP)

The Department of Health says here that they are currently consulting about the role of the ECP.

Let us take a quick look at:

Competence and Curriculum Framework for the Emergency Care Practitioner Consultation Document

The government has found that it is far to expensive to pay doctors to look after people with acute medical problems, and so they are going to develop a team of people who are not clever enough to be doctors, but are able to read a protocol, and therefore will be able to function, after a fashion, on the front line of health care. The full training document is here.

Dr Crippen loves this document. It is a joy to see how the English language can be so elegantly strangled to disguise the fact that this is the greatest cut back in emergency medical services in the history of the NHS. It is full of lies and half-truths and, as always with New Labour, oozes jargon.

Let us enjoy some examples. Look for the jargon words like “pathway” and “journey”.


The ECP Mission Statement

A flexible workforce and a flexible approach to skill mix – breaking down professional and traditional boundaries - are central to improving emergency care. This ensures patients receive the highest standard of care, by an appropriately trained person, at an appropriate time, in the most appropriate setting.

The main focus of the role is to enhance the patients’ experience through their emergency, urgent and unscheduled care journey by providing emergency assessment, diagnosis,treatment and aftercare.

(Dr Crippen loves this. "Enhancing the patient’s experience…through their journey." Yum, yum)

Patients can be referred to an ECP by GP’s both in and out of hours, NHS direct, nursing and residential homes, community health teams, i.e. any health and social care worker, either directly or indirectly via the 999 system, the police, the prison service, schools and work places, etc. They treat patients who are unable to leave their home due to poor mobility, have dependants who are unable to be left, and where the outcome would potentially be of greater benefit from an ECP intervention rather than attending A&E or a GP service.

(Sounds plausible, does it not? What it means is that ambulances do not take patients to hospital any more. The ambulance driver will treat the patient himself, even if a doctor has asked for an admission. This is dangerous. Dr Crippen has had a patient killed by this sort of dumbing down - see here)


The Emergency Care Practitioner will:

• Work across current and future organisational and professional boundaries. (pretend he is a doctor, mismanage the patients because he does not know what he does not know)
  
  
• Deliver care that is patient focused. (As opposed to what? Meaningless jargon)
  
  
• Deliver the most appropriate care in the most appropriate place and/or ensure that the patient is referred to the most appropriate health and social care professional. (Often overriding the opinion of the doctor who called the ambulance in the first place)
  
  
• Deliver care to patients in the most convenient and appropriate place for the patient. (refuse to take the patient to hospital)
  
  
• Provide an alternative pathway for the provision of unscheduled care (refuse to take the patient to hospital)
  
  
• Provide appropriate healthcare advice to both their patients and other relevant groups and individuals. (Ignore advice from the doctor and then refuse to take the patient to hospital)
  
  
• Empower patients to take responsibility for managing their own care and treatment where safe and appropriate to do so. (Tell the patient that they have wasted precious NHS resources by calling for help and they should look after their own medical problems)
  
  
• Undertake physical examinations based on a whole systems approach, taking a full and appropriate patient history using a medical model. (Sounds good. But think about it. What does it mean? What “model” other than “medical” would you use?)
  
  
• Treat minor illness and injury in pre-hospital, primary care and acute settings. (refuse to take the patient to hospital)
  
  
• Order appropriate investigations including X-rays and pathological Investigations. (If only they had the competence so to do)
  
  
• Ensure fewer hand-offs between health care professionals and enhance inter-professional communication throughout the patient pathway. (It’s a "pathway", so that is OK, but what does it mean?)
  
  
• Administer and supply medication in line with local Patient Group Directions, (whilst awaiting independent prescribing legislation). (Give out drugs they do not understand)
  
  
• Have the knowledge and skills to access acute hospital beds in specialist units, whenever the patient needs emergency admission as an in-patient. (How do you assess a bed?)

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These ECPs will take over the ambulance service and A & E departments throughout the country. There will be no doctors on the front line.

And consider this. If Elizabeth or Phillip, Charles or Camilla, Harry or Wills, or even Tony or Cherie have an acute medical problem, do you think they will see an ECP?

Forget it. The great and the good, the rich and those with private health insurance, will continue to see some of the few remaining doctors.

As always, the dumbing down of heath care, like comprehensive education, is only for the poor folk. They can eat cake.


(any comments under the related article below please)

The destruction of the British Medical Profession

Let us consider the career pathway of a young doctor on her way to becoming a Consultant Paediatrician at Great Ormond Street Hospital.

At the age of eighteen, Mary has four “A” levels, at grade “A”. She applies to medical school and fights off twenty similarly qualified applicants to get her place. She is a high flyer so she goes to Oxford University. She spends six years there, doing an intercalated degree in pharmacology and therapeutics, and emerges with BA (Hons) Oxon BM BcH.

She is newly qualified. Next, she has to do two years foundation jobs, possibly in Oxford, possible in London. She is 26 and has been studying for eight years, including six years at the finest University in the world.

Mary now embarks on higher specialist training. She first does a couple of years rotating round general paediatrics as a junior hospital doctor, quite possibly in London, quite possibly at Great Ormond Street. At this stage, she needs to spend some time in neonatology, and she decides that she would like a little time out of London. There is excellent post-graduate medical training in Brighton, and so she applies for a job there.

Paediatric jobs in Brighton are highly sought after. However, with her outstanding c.v., and her ten years experience as a doctor, she gets the job.

On arrival, Mary finds she is to report to and be taught by a nurse, who has already been in the job for six months.

You do not believe it.

Have a look here.

Look at what Mary will have to do whilst she is at Oxford here. Look around the site. How do you think this compares to a three year nursing course? Have a look at what the Royal College of Nursing has to say about being a nurse here. Compare the two. Think about it.

The doctors amongst you, if there are any left out there, will be particularly interested to click on the detailed job description. But, for the impatient, here are a few excerpts:

Clinical Responsibilities

Provide supervision, advice, support and training to Senior House Officers (i.e . doctors like Mary) and less experienced ANNPs in the organisation and delivery of clinical medical care.

ANNPs are responsible for ordering drugs from the neonatal formulary; these drugs are then countersigned by the Consultant Neonatologist within 48 hours of the order being made.

(The nurse, who is not legally allowed to prescribe because she has not been trained in pharmacology and therapeutics, is going to “advise” (sic) Mary how to prescribe the drugs that she is both trained and legally allowed to prescribe.)

• Using highly specialist clinical and theoretical knowledge undertake initial physical examination of the newborn which includes the eyes, heart and all major body systems to identify congenital abnormalities in the newborn infant.
  
  
• Using highly specialist clinical and theoretical knowledge assess the condition of the baby, analyse complex clinical signs and investigation results to diagnose medical / surgical conditions and consider differential diagnosis in the neonate and initiate treatment.
  
  
• Using highly specialist clinical and theoretical knowledge examine and assess on a daily basis the immediate and longer-term medical needs of babies on the neonatal unit, postnatal ward and transitional care. Initiate and evaluate clinical management and treatment and make appropriate referrals to other health care professionals.
  
  
• Order medications and intravenous / intra-arterial fluids including blood, volume expanders, total parenteral nutrition and electrolyte solutions. Ensure these orders are countersigned by a medical practitioner within 48 hours according to protocol.
  

"highly specialist clinical and theoretical knowledge". Mary has this. The nurse does not.

This is ludicrous. It is beyond satire.

Putting nurses into positions of responsibility such as this beggars belief.

Why did Mary bother to go to University? She could have done Geography, Meja Studies and Sports Science “A” levels at the local College of Knowledge, three years nursing training anywhere you care to mention, a further year for a quick B.Sc (Bedpan) from the University of Accrington, and suddenly she is a neonatologist.

I exaggerate.

A little.

What we are witnessing is the destruction of the British Medical Profession.

Erectile dysfunction : size matters

Since I wrote the article about the NICE guidelines on hypertension or, to be more precise, since I wrote the article about the confusion caused by the NICE guidelines on hypertension, I have had a lot of emails accusing me of cynicism.

I believe that the drug industry, or BIG PHARMA, as we call it, drives “advances” (sic) in medicine so that they can sell more drugs.

I believe they advertise their products without regard to morality.

Let’s get all the menopausal women in the World on HRT. And they nearly did until suddenly it became unfashionable.

Let’s get all those “naughty” children on methylphenidate. And they are still winning. The Concerta kids are so…er…happy.

Now they have found a real winner. One of mankind’s (and before the women take umbrage, I use the word deliberately, for I do mean mankind, not peoplekind) greatest fears.

Actually, for womenkind, it does not matter. That must be true. I read it on the back of a matchbox.

But that is not what mankind believes. For them, it does matter. And so BIG PHARMA has spotted the chance of another fast buck.

Size matters.

Read: “Bigger and Better: How Pfizer Redefined Erectile Dysfunction” here.

What killed my dad?

R.I.P. - but do we know the cause of death?

There is a sad story reported by the BBC today of an elderly man who died of multiple medical complications after being admitted for a “routine” hip operation. Of course any “routine” operation for a man of 86 is not without risks but nonetheless with modern anaesthetics one would confidently expect the majority of such patients to walk out of hospital in a better condition then when they limped in.

The lawyers always say that “justice must not only be done but it must be seen to be done.” Dr Crippen believes that there is an even greater need for this to apply in medicine.

If there are complications or an unexpected death, patients and their relatives need to understand what has happened.

As discussed here, many death certificates are a work of fiction. If Dr Crippen has a 94 year old lady who suddenly stops eating, fades away and dies, it is easy to write words such as “bronchopneumonia” on the certificate. No one will ever challenge that diagnosis. Dr Crippen used to do that a lot. He never does it now unless he has first-hand clinical knowledge that the patient really did have “bronchopneumonia”. Nowadays, he puts “Old Age”. It is unimpeachably correct, though lacks the diagnostic precision that the gatherers of statistics prefer.

One does not have to talk of death certification for long before the dreaded word “Shipman” comes up. This is a red herring. Shipman could and should have been caught in a matter of weeks by a method that is so simple and so obvious (as described here) that Dr Crippen is still flabbergasted that it has even now not been introduced.

In general terms, the public have to decide if they really want diagnostic precision on all death certificates. If they do, there are going to have to be an awful lot of post-mortems. Do you really want to chop-up granny?

The BBC article reports:

A government report into death certification in 2003 showed that only 55% of death certificates are correct. This meant that 45% weren't. So nearly quarter of a million certificates are wrong.

Dr Crippen is surprised it is only 45% that are wrong.

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"TV producer Angie Mason secretly filmed her dying father in an NHS hospital. During her efforts to find out why he died, she makes a startling discovery about the accuracy of death certificates." (full report here)

Thinking the unthinkable

Since the post a few days ago drawing your attention to the article in the BMJ proposing the de-politicalisation of the NHS, rumours are flying everywhere.

It has been suggested in the comments (here) that Gordon Brown is planning an epoch making political announcement when he accedes to the Throne. A major change in health care financing, throwing health care open to the free market.

Wat Tyler thinks it is unlikely.

Wat is usually right on matters financial…but there are a still lot of rumours around. Too many to be co-incidental.

So Dr Crippen has floated it at LabourHome here.

Let us see what they think.

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Tony Blair, no less, has an article in the Guardian today, in which he says inter alia:

"In my view, renewing the Labour party means taking further what we've done, putting more power in the hands of the service user - power based not on wealth but need. I want to see the public sector become truly enabling, not controlling, breaking up monopoly provision, extending choice and voice, eliminating old barriers that restrict the creativity of the frontline...

...I think we have to be a party of enterprise and business as well as trade unions.

Our model of public-service reform combines ambitious national standards with diversity of providers and giving citizens new choice or a stronger voice in shaping those services. (The Guardian)

As with most "policy" announcements from the PM, there is much blank canvas in this article. But as far as healthcare and the NHS goes "breaking up monopoly provision" can mean only one thing. De-nationalisation.

Is this a 'John the Baptist' role for the Chancellor?

Out of sight, out of mind

Modern British Psychiatric Ward

Things go from bad to worse.

"It's infested with cockroaches, it's got mice, it has sewage leaking into the walls. There are two (men) living in (a room) meant for one. I found a guy who had to empty his companion’s colostomy bag. It's not decent. It's not right."

No, not for once the state of British hospitals. We have not quite descended to that level. These comments are from Ann Owers, the chief inspector of prisons.

Dr Crippen has pointed out before that, as hospitals are closed, prisons in the UK are increasingly taking over a medical role. Dr Crippen is particularly interested in and concerned about schizophrenia.

“There is no area of healthcare more ignored, more under-funded and more misunderstood that the care of the chronically mentally ill. And of the chronically mentally ill, the worst cared for are the schizophrenics. There was a general clear-out of British long-stay mental hospitals about twenty years ago. The “right-on” slogan was “care in the community”. The chronically mentally ill were thus pushed out of the cuckoos’ nests on to the streets.

The government does not even pay for the cardboard boxes."

Many of the tramps you see walking the streets are schizophrenics wandering round the “community” looking for their “care”. Some tramps are alcoholics. Many schizophrenics drink heavily. They do not have much else. They chain smoke as well. The police are not renowned for their compassion for tramps. First they move them on. Then they lock them up.

Prisons are full of schizophrenics.

It could be worse. Prison is a place of safety. The food is better than in hospital. Overall, the conditions are not much worse than on a secure psychiatric ward.

"Prisons are often acting as mental hospitals and that is not what they are designed to be," Ms Owers says here.

"We are reaping the harvest of closing down our large mental hospitals without providing either proper community care or sufficient secure mental health care."

Schizophrenia is not an attractive illness. The media are not interested. The politicians are not interested. The NHS is not interested. Lock them up, then.

Out of sight. Out of mind.

More dead babies

SANDS is working to support bereaved parents and families, and to press for improvements in care during pregnancy and when a baby has died

I do not get the Daily or Sunday Telegraph.

Fortunately, one of my readers does, and she draws my attention to an article here

Midwife centres risk up to 20 baby deaths a year, watchdog warns
By Beezy Marsh, Health Correspondent

(Filed: 02/07/2006)

As many as 20 babies are dying every year because mothers choose to deliver their children in birth centres run by midwives rather than in hospital, an NHS watchdog has calculated.

Nice's experts estimate that between one baby in every 1,000 and one in every 5,000 will die needlessly because of the extra risk associated with the centres.

Rather than the usual bland denials from the Royal College of Midwives, Dr Crippen wonders if now they will agree to mothers having their babies in a place of safety? A hospital. A hospital with equipment and, most of all, some doctors.

It is well and good for the midwife to encourage the mother to have a home birth, or a birth in a "birth centre".

The baby does not get a vote.

I suspect that the midwives will react to this report with the usual bland denial. Or they will they just ignore it.

Prove me wrong. Is there one midwive out there prepared to support a campaign for babies to be born in a place of safety?

There is an horrigying political element to this story. The goverment favours home births. Their focus groups like them and, dare Dr Crippen say it, they are cheaper.

The midwives may thus have some powerful allies.

The Sunday Telegraph can also reveal that the Nice guidance on birth centres is itself at the centre of controversy over claims that it was "watered down" at the request of the Department of Health, because of fears that it would conflict with government policy to promote births outside hospital.

SANDS is the Stillbirth and Neo-natal death society and can be contacted here

Who dares, wins

There is a personal view in the BMJ this week by Layla Jader, consultant in public health medicine

Her view is simple.

Take the NHS out of politics.

“…the NHS needs a system that replaces political dogma with clinically driven decisions, confrontation with consensus, unaccountability with democracy, and short term decision making with long term stability. The NHS is too complex and too vital to our future prosperity to be governed by the self interest of any specific party. The continuing use of the NHS as a theatre for experimentation in management is wasteful.

The continuing use of the NHS as a theatre for experimentation in management is wasteful

Is there a precedent for such a move? Yes: the successful delegation of the Treasury's role in controlling inflation to the Monetary Policy Committee of the independent Bank of England, a move that greatly contributed to the country's economic stability.

The proposed NHS body has similarities with that committee. Economic stability and the health of the nation are major factors in the country's prosperity. Both bodies' decisions would affect everyone in the UK; this is not necessarily true for the Home Office or the Ministry of Education, for example. Since its inception in 1997 people have respected the decisions of the Monetary Policy Committee, and the interest rate has ceased to be the political football it used to be.” (full article in this week’s BMJ : BMJ 2006;332:1518 24 June)


Gordon Brown made the decision to give the Monetary Policy Committee autonomy. Would he be brave enough to do the same for the NHS?

Or maybe David Cameron will adopt the policy first.

A smile and a clean blackboard

Dr Crippen is purging his soul here and explaining why, in 1997, he voted for Tony Blair. Yes, he really did. It seemed...er...reasonable at the time.

Was it a mistake? Whither next?

Advice and comments particularly welcome, under the article.

The Brain Drain

The three young doctors who have had the professional rug pulled out from underneath them are now getting wide media coverage in the UK. Television, radio and the newspaper.

And now the word has spread to the USA.

An American doctor writes:

"If I understand correctly, the medical school program in the UK graduates more doctors than the residency programs have spot for.

In a strange parallel, the US has more residency spots than medical school graduates. Nothing would make me happier than if you sent all of your well educated young English doctors here. Perhaps I should let someone in our government know this. Many of the posts in marginal training programs here are filled by those who graduated in countries much less renowned for their academics than Britain.

Please come here, finish your training and stay. You'll like it."

What is our wretched government doing to medical training?

Take a highly intelligent 18 year old. Train him/her for seven or more years and then put him on the scrap heap.

Crazy.

"The British Medical Association said that up to 11,500 doctors could be left disappointed because there were only 9,500 training posts being competed for by more than 21,000 doctors." (The Guardian)

Crazy.

Thirty years ago a large number of British doctors decamped to the USA and Canada.

Is it going to start again.

Let us hope these three girls decide to stay in the UK. We need them.

Labour Home appears

And then, out of the blue, a new blog appears entitled Labour Home.

Well, not entirely out of the blue. Those of us in the know (a.k.a. those of us who read Guido) were expecting it.

It may be a new blog, but note it is not called New Labour Home. Dr Crippen has trawled the blogosphere without success, looking for a spin-free website that represents what Labour used to represent. Whatever that was. I have forgotten.

Could this be it?

Dr Crippen has not been backward in coming forward with his views on New Labour’s stewardship of the NHS. He was delighted to write an article for Conservative Home last week, looking at radical solutions to health care in the UK.

Labour Home looks promising. They have already dined with the devil. They let Guido in. They even let him write an article. And they have survived.

Will they discuss healthcare and the NHS?

Will they let Dr Crippen in? We shall see. Take a look, here.

More doctors on the dole

You’re sacked

It takes five years to train as a doctor.

Then two years of foundation jobs.

Next, a career choice. Which training scheme? If you want to be a family doctor, and there is a desperate shortage of family doctors, you get onto a vocational training scheme for general practice (VTS) which lasts another three years. If you can find a place. They are much sought after.

There are no grants for students anymore. This is particularly hard on medical students. Most of them start their careers with a debt the size of small mortgage.

A letter from a young, talented doctor who has just had the rug pulled out from underneath her career.

“Wondering if anyone else is in the same position as me. I received a letter from the London deanery this morning telling me my VTS scheme for August has been withdrawn due to lack of funding. Six weeks before my job is due to start I am supposed to find another job in the interim! I have to reply by Monday whether I accept their offer of a deferred start in February 2007 but can they guarantee that job??? When I spoke to my local coordinator she had only just got an email telling her more than half their jobs have been withdrawn. It seems they had no clue this was coming. I have contacted the BMA but would be interested in hearing from anyone else who may be in this situation. I'm not one to make trouble but I truly feel this something that needs to be public knowledge. In no other profession would something like this be allowed to happen and yet it seems that we are treated like second class citizens all the time. Please email me if you are in this situation. Any advice from other doctors out there also gratefully received! Thank you.”

See an interview on the BBC with this doctor and two of her young colleagues who are in a similar situation. (The full interview is here, about half way through the programme, after the football)

We are desperately short of family doctors. Estimates vary, but we need an extra 10,000. Give or take. And yet, as the BBC reports here hundreds of young doctors cannot find jobs.

Why is this happening?

Maybe the nurse specialists are taking over. They are cheaper.

If the government keeps treating young doctors like this, they will leave medicine altogether for better paid jobs in the City.

++++++++++

Elite Trainee GPs are left jobless by NHS Funding Cuts

The story is picked up and reported in detail in The Times here

Home births not NICE

Royal College of Midwives

The National Institute of Clinical Excellence (NICE) has been studying the vexed issue of the safety of home births in the UK. Their preliminary conclusions are restrained and sensible:

"In relation to women's and babies' outcomes for home births, there is a lack of good quality evidence. Limited quality evidence shows less intervention and higher maternal satisfaction with a planned home birth compared to a planned birth in hospital.

"Evidence of overall perinatal mortality is ambiguous. However, there is evidence that a booked home birth has a higher intrapartum-related perinatal mortality [death around the time of birth] than a booked hospital birth." (Report here)

Until further and better information is available, the rational approach must be to counsel caution and to advise woman that a home birth may subject their baby to greater risks.

It would be too much to expect a rational approach from the Royal College of Midwives. The appalling Louise Silverton is on the rampage again. We have met Louise before. Remember, she is the one who does not like women being able to choose to have an epidural.

Science, and the analysis of data, is not one of Louise’s strong points.

Louise Silverton … took issue with the idea that it was safer to give birth in a hospital. She said home birth was a better option for the 60%-70% of women who experienced no complications during labour.

"Remember that the woman is in fact running a marathon when she's in labour. She needs to be fed, needs to be able to move, and needs to be in control of the situation."

"In our hospitals today which are very medicalised - many women don't find that a conducive environment for labour." (BBC)

(The full interview on Radio 4 this morning can be heard here on the Today programme "listen again" web site - Friday 23 June, 07.32 a.m.)

She does not mention that you can only identify the women who have not had complications retrospectively. Maybe she does not know that. Women in labour are not “in fact” (sic) running a marathon. They are having a baby. Presumably by using this ludicrous analogy Louise is proposing to give women in labour a “carb load”. A large plate of Spag Bol maybe?

Glad that she has noticed that hospitals are “medicalised”. They will have the equipment to resuscitate the mother when she vomits and inhales the aforementioned “carbs”.

The government is enthusiastic about home births. It asked NICE to report on them. NICE urges caution.

Why do the Royal College of Midwives not accept this? Why can you never talk a midwife out of home deliveries, even if the baby dies (as here)?

Because the midwives know better. Midwifes always know better. They know better than the government. They know better than NICE. They know better than doctors. They know better than the majority of women who have babies. They do not need science. They do not need research. They just "know".

Have a look at these internet sites from independent, “radical” midwives. They even seem to contemplate and support home deliveries for babies known to be breech, and even for twins. (see here).

Is there a single doctor out there who would support such views?

The Crippen Diaries (Week 25)

Not quite Tannochbrae

Monday 19th June

Another day, another dollar.

A brief meeting with my partners at lunchtime to discuss the new QoF targets. The practice is to be paid £23,500 (approx) for recording which of our patients smoke, and documenting that we have given them some “education” about stopping smoking.

We did this last year. Now we have to do it all again. Most of the data is already on the computer.

What a waste of time.

++++++++++

The final appearance of summer has increased the number of hay-fever sufferers. It can be a wretched condition. We still get a lot of requests for “the injection”. This is a long acting depot of slow-release steroid that will indeed stop hay-fever. It has all sorts of potentially serious side effects and we do not give it out. A few doctors still do and that causes difficulties for us. Sometimes they think we are being mean.

+++++++++++

Another two-week rule conundrum. It is difficult to fit all the patients into a government protocol. A 74 year old woman who is in chronic atrial fibrillation, and thus on warfarin, presents with rectal bleeding. Blood on the paper. Blood streaking the motions. No pain. No soreness when she opens her bowels. There is nothing to find on examination and, in particular, nothing in reach of a finger. Well otherwise. Her father died aged 69 of bowel cancer. Clearly, she needs to be referred to the colo-rectal clinic, but should it be a two-week rule referral? She does not meet the conventional criteria. It may be nothing. Being on warfarin can cause a small internal pile to bleed. But it can also cause an early undiagnosed colonic cancer bleed. We talk about this over coffee. The general feeling is that it should be an urgent referral, but not a TWR. Probably right.

++++++++++

Diabetics do not have to pay prescription charges, and are also entitled to free prescriptions for Sildenafil (Viagra). So be it. We covered this before in State Sponsored Shags. A man came to see me today for an “urgent” prescription for Viagra. He has now had eight tablets on behalf of the taxpayer in the last two weeks. Dr Crippen is not getting involved in telling his patients when enough is enough but, as he said in the original article, this certainly puts the slogan of health care being “free at the point of entry” into a new light.

++++++++++

Tuesday 20th June

Belinda came to see me today. She is only seven, so she came with her mother and father. She sat on mother’s knee.

Father is a chartered accountant. Mother used to work for an estate-agent but gave up work shortly after Belinda was born. There are no other children.

Belinda has come because she has behavioural problems. She will not do her homework when asked. She will not do any reading when asked. She is put to bed as regularly as clockwork at 7.00 pm. She always used to go to sleep but for the last six months she gets up and plays in her bedroom until about 9.00 pm. Mother says this is a worry.

Belinda is happy at school. The parents have not been called in by the teachers, but did themselves ask to see the teacher about the homework issue. Father is not happy with the teacher. “She does not seem to care about the homework.” Furthermore, the teacher says that Belinda is very talkative in class and often has to be asked to be quiet. She is a bit of a chatterbox.

I ask Belinda if she likes drawing pictures. She does. So I take her out to the reception area to our little drawing desk and the receptionists get out the crayons. Back with Mum and Dad, I soon establish that Belinda was full term normal delivery, breast-fed, fully immunised child who has had no serious illnesses. She never refuses to go to school and she is not being bullied.

It is just the homework and the reading.

“Maybe she doesn’t like reading” I say. Dad looks horrified. Mum says she definitely does. “She read ten pages of her book whilst she was waiting to see you doctor”.

I was running fifteen minutes late.

But she will not do her homework and she will not read in the evenings when she is told. "I told her she should just do it and get it over and done with. But she won't. Sometimes it is so bad, I have had to call my husband home from work.”

“Yes, indeed!” says father. And I have tried everything. "Two weeks ago, when the dustmen came, I told her that if she did not read more, she would end up emptying dustbins for a living."

“Did that help?”

It did not. So last week Dad told her that if she did not do her homework, she would have to go to the doctor and he might decide that she needed to be taken away.

I told the parents that in some parts of Scandinavia they do not believe in formal education for children until they are seven. I suggested to the parents that they should ban all homework for three months and not mention it. I suggested also that for a similar period they should not insist that she did any reading. “Just leave the books lying around but don’t mention them”.

And what about the sleeping, doctor?

“Try putting her to bed at 8.45 pm and see what happens” I said.

There was an air of disbelief.

These are caring, decent parents. I do not know if they were convinced, but they will do it. If it “doesn’t work” they will want to see a “specialist”. I feel the top coming off the Ritalin bottle.

It will work.

I went back to the reception area to get Belinda. She did not like doing the crayoning. She was reading her book.

Good old J.K. Rowling.

And then I was an hour behind.

++++++++++


Thursday 22 June

More government targets, this time because Tony Blair was embarrassed on a television programme. Someone asked him what was going on in the NHS. How naïve. How would he know? He does not use it. You might as well ask him what is going on in comprehensive schools. He does not use those either. But he was embarrassed and started to sweat even under the TV pancake make-up. Not a pleasant sight.

The BBC reports the following this morning:

“Primary care trusts (PCTs) will telephone surgeries on a random day every month to find out whether they are adhering to the two-day target. Practices will be asked not only when their first free slot is available, but also their third, to assess depth of access. Currently, GPs know in advance when they will be called by their PCT. This has led to concerns that they are able to schedule their bookings around the call, to give the impression that they are meeting the two-day target, when it might be missed during the rest of the month.”

We are experienced professional people. We care for our patients. I will have no truck with this. I will prioritise my patients’ needs on clinical and medical grounds and see them appropriately. If any patient does not like the service we offer, they are free to take their business elsewhere. There are four other practices in the area, all of whom are taking on patients. We are full. I wonder why that is?

Now the government is going to get a load of pilonidal PCT pen-pushers to phone up to see what we are doing. I have instructed the receptionists that all such calls are to be put through to me.

I wish this wretched government would get of my back and let me get on with my job.

++++++++++

I saw a 63 year old man yesterday and brought him back for follow-up today. He does not come often. No serious illnesses. He complained of a numb area just above the waist line. No other symptoms and nothing else to find. I was uneasy about it, hence the follow up appointment today. Now the numbness goes all around his body and has extended in width. A neurological sensory level. I want to get the man assessed urgently by the physicians. In the old days, I would have phoned up the medical registrar who would have discussed the case and offered to see him. Simple. One phone call.

That has all gone now. Government directives. There are protocols for urgent medical problems and the idea of two independent professionals, two doctors, having a conversation on the telephone and deciding on the appropriate management is too horrifying even to contemplate. It cannot be measured. If you cannot measure it, you cannot achieve a target. And you cannot have a target without a protocol.

I have three options.

I can send the patient into hospital as an emergency. To do that, I have phone the ECC, the Emergency Capacity Centre, at ambulance control and discuss the case with telephonist who will ask me a lot of questions from a protocol and then give me an EC number. She will then phone the hospital and tell them to expect the patient. Armed with his EC number, he may then go up to the A & E department.

EC numbers can be counted.

I don’t want to do that. It is not so urgent that it needs to go up within the hour and in any case I do not want this patient being assessed in the A & E department by an inexperienced Casualty Officer or, worse, a triage nurse or an EMT.

I decide on the second option, which is to phone the MAU. That is the medical assessment unit. They see patients with urgent problems the same day. I speak to the MAU SHO who is pleasant but says it would be better if I phoned the RAC. I am getting sick of all these TLAs*. The RAC is nothing to do with automobiles. It is the “rapid assessment clinic” which is different to the MAU. God knows in what way, but it is. So I phone the RAC and get through to a doctor who is surly and does not speak good English. I explain the problem and he says “why do you not phone the MAU?” Anything to avoid work. I have already done that. “Oh” he says. “Well, can you fax the details through and I will give them to the consultant.” “Why do I have to fax the details through? I have just told you what the problem is.” “That is the system.” “Will you then see him?” “I don’t know, it depends on what the consultant says. It is up to him whether we see your patient.” “No it is not. It is up to me. If I want a patient seeing urgently, that is what is going to happen.” So I give up on that one and phone back the MAU. Nice SHO is sympathetic and asks again “How can I help?” “By seeing the patient?”. That was clearly not what he had in mind, but he agrees.

This transaction took 45 minutes. This is “process”. This is a small day to day example of what New Labour has done to the NHS. It does not sound much. It is causing stress and distress every day throughout the country.

*TLA = three letter acronyms

++++++++++

I put the phone down from that and start the list of “routine” phone calls. The first one is to Mrs Jarvis, a 69 year old diabetic. She has just come out of hospital having had a stroke. She is a diabetic. She is in atrial fibrillation and so she is on warfarin. She says that during the night she got up to go to the lavatory, and had a weak feeling in one leg which lasted about an hour but then resolved. She is worried it might have been a mini-stroke. It is a possibility. I need to see her.

I suggest she gets her husband to bring her straight down and I will squeeze her in and see her immediately. Not possible. He has gone out. I ask where. She is embarrassed. “He has gone for his game of tennis.”

I try to get my mind round the idea of popping out for a game of tennis when there is the possibility that one’s partner has had a stroke.

I still need to see her. So I say I will call at about 2.30 pm. It is about 1.00 pm when I make this offer.

That is not convenient. She has a physiotherapy appointment at the hospital at 3.15 pm. Her husband will be back from tennis to take her. Could I not come at about 1.30 p.m. instead? Instead of lunch she means. Well, she doesn’t, but that is what it means to me.

At this stage now I am cross though I do not show it. I have offered to see her immediately. I have offered to visit her later in the afternoon. None of this is convenient.

So I give her an appointment for 9.30 a.m. tomorrow morning. I would have preferred to see her today.

This is the tyranny of general practice. We have a duty, both moral and contractual, to see people within an appropriate time scale. Do we also have a duty to fit in with a patient’s social and sporting commitments? There is only one of me. I have 2000 patients. I cannot fit in with all of them.

I hope she does not have a big stroke tonight.

++++++++++


Friday 23 June

Mrs Jarvis from yesterday came in with her husband. In his tennis whites. I have got the message. She was fine. She has survived the night. Going into the history in detail, she had got out of her warm bed in the middle of the night, stood up immediately and then gone woozy as she walked to the bathroom. She is diabetic and is on a lot of medication, including BP medication. She has postural hypotension. There is a difference between her sitting and standing BP. It drops when she stands. This can particularly be a problem in diabetics. She knows to take it all slowly and sit on the side of the bed for a while before she walks.

++++++++++

Wat Tyler points out to me an article in today’s Torygraph, showing that the NHS really is delivering for patients with acute heart attacks. Great news in deed. In fact, the NHS has always delivered well for acute problems. Doctors are frequently amused to see patients being wheeled into the coronary care unit with chest pain saying “I have private health insurance, I have private health insurance.” You do not need it at that stage. Your heart attack will be treated better by the NHS than the private sector.

If you need an emergency angioplasty, stent or even a CABG you will get it there and then. The problems come if you need a non-urgent CABG a little later. Then you move into the twilight zone. Keep paying the premiums if you can afford them.

+++++++++++

I phoned Great Ormond Street today. The most famous children’s hospital in the country, possibly in the world. Good old Peter Pan. They are now a tertiary referral centre. In other words, they only take referrals from other hospitals and not from pond life like Dr Crippen. Sorry, it is an irritation, and I have not taken my medication today.

I saw a couple with a child, well, a 12 year old, who has OCD. Obsessed with personal hygiene. Hand washing. Spending twenty minutes wiping his backside and thus consuming rolls and rolls of lavatory paper. Things have come to a head because he has blocked the lavatories at school on several occasions. They parents want him to see a psychiatrist down at GOS.

I speak to the psychiatrist’s secretary. She is snotty. I have not finished the sentence before she cuts in and says very haughtily that Dr Bloggins does not take referrals from “GPs”. I ask her why not. She gets haughtier and gives her explanation. When she has finished, I manage to finish my first sentence. The parents would like a private appointment.

Her manner changes. Could they bring him up on Saturday morning when Dr Bloggins does his private clinic?

You have to laugh. But this is the way the NHS is going now.


++++++++++

In praise of the NHS

Diabetic neuropathy

And then on a happy note.

God knows the NHS is depressing at times. God knows the funding is up the spout. God knows we need to do something about it.

Post code lottery? Not genuinely free at the point of entry? Dr Crippen going on about a front end charge (properly safety netted)? Cannot get hold of Herceptin? Or Avastin? Intolerable waiting lists?

And yet, and yet, there is a good side. A side that we take for granted. Look at the Fat Doctor in the USA who rescues a man from almost certain death. Imminent death that would have been caused, not by the disease(s) from which he suffers, but by the system. Or, to be precise, the failure of the system.

Whatever you (or I) may say about the NHS, this could never happen in the UK

"The first casualty, when war comes, is truth"

"The health service has become a battleground. And remember, "The first casualty, when war comes, is truth". We must fight for our patients, fight for our right to speak out and fight for a health service to be proud of."

"I believe the problems in our health service are much worse than the public realise. There is nowhere to turn to treat patients. There is no available capacity in any part of the system."

"Successive governments have undermined the productive capacity of the health service by closing acute hospital wards, closing units for the elderly, closing psychiatric hospitals, while failing to build alternative capacity by increasing medical school places, training more GPs and creating community care and adding acute beds. We need acute medical units where GPs can refer directly for assessment and admission."

A few random quotes taken, not from anything written by Dr Crippen, but from an article sent in by a reader written by Consultant Physician, Christine O’Malley.

Christine lives and works abroad. But not in the third world, although you might be forgiven for thinking that that is where she was from. She is Irish. Dr Crippen has not worked in Ireland, but it seems that their Health Service is a few years further down the road that we are travelling. Read the full article here.

“The first casualty, when war comes, is truth”.

Despite huge job losses and mounting financial problems, the NHS is enjoying "its best year ever" according to Health Secretary Patricia Hewitt. Full story, including audio interview with the secretary of state, here.

Cancer prevention : the surgical option

Radical surgery to prevent cancer

In the recent discussion on circumcision, some commentators suggested that it was justified on the grounds of prevention of penile cancer. This disease is unheard of in those who have been circumcised.

Then we turn to breast cancer.

"Women with abnormal or mutated BRCA1 or BRCA2 genes have a significantly greater chance of developing breast cancer. In the general population, a woman who lives to age 90 has about a 12% chance of developing breast cancer. But if she has an abnormal BRCA1 or BRCA2 gene, her risk can be as high as 60% to 85%. Researchers continue to look for the best ways for women with one or both of these abnormal genes to reduce their risk of breast cancer." (Full article here)

An increasing number of women in the United States are requesting prophylactic mastectomies to avoid breast cancer. Is this rational behaviour? Rational or not, as our knowledge of genetics becomes more and more sophisitcated, such requests are increasing:

"To prophesy the future we no longer need to examine the entrails of sacrificial animals. Mutant genes predisposing affected individuals to life threatening conditions such as vascular disease and malignancy have been identified. Although the multifactorial and environmental wild cards remain, the genetic card deck is gradually being laid face up on the table. But without effective interventions, knowledge of genetic risk may serve only to fuel anxiety and encourage the adoption of denial behaviour." (BMJ Editorial here)

Women over the age of 40 who have hysterectomies often elect to have their ovaries excised at the same time even if not medically indicated. It means an early menopause but removes the risk of ovarian cancer, a cancer that is nigh on impossible to diagnose until it is too late.

I am grateful to Kevin MD for drawing my attention to a large family in the USA who have a strong family history of stomach cancer. They have all elected to have their stomachs removed.

Ten members of the Bradfield family who had their stomachs removed gathered in Las Vegas. They are, from left rear, Mike Slabaugh, Laura Pollard, Linda Bradfield, Diane Sindt, Connie Gasaway, Rita Cmorey, Jeanni McAbee, Mark Allen and, from left front, Kitty Elliot and Bill Bradfield.

Suffers of chronic ulcerative colitis have a high risk of colon cancer. And colon cancer can develop in the interval between annual colonoscopies. They cannot have one every month. Maybe they should have their colons removed.

Dr Crippen makes no criticism of these people. It is a problem.

But where does this end?

And who is going to volunteer to tell the gentleman in the jar that he has a brain tumour?

Taking the tax-payer for a ride

Your personal limo, sir?

Within days of Dr Crippen challenging the UK health care mantra of “free at the point of entry” the Macmillan service points out that for many the health service is not free at the point of entry.

You have to pay to get there and you have to pay to park.

Macmillan chief executive Peter Cardy said:

"Missing an appointment is not an option for cancer patients - they have no choice but to pay for travel and parking, which amounts to a stealth tax on illness."

The charity said the problem was worsened by the fact that cancer patients already face potentially huge costs in prescription charges. There is a subsidy scheme to recoup travel costs, but it is means-tested meaning only about one in 20 receive it.

The charity said cancer patients should be entitled to free parking and financial assistance from the hospital travel costs scheme.

What does Dr Crippen have to say to Peter Cardy?

Simple.

It is people like you, Mr Cardy, who are bringing the NHS to its knees. Your demands are unrealistic. Your demands are selfish. Why are cancer patients any more deserving than those with heart failure or motor neurone disease? Or those with strokes? Or children with epilepsy? Or the chronically mentally ill?

Worst of all, your demands are couched in emotional terms and they are, in part, dishonest.

“…cancer patients already face potentially huge costs in prescription charges.”

That is dishonest. The majority of cancer patients are over 60 and thus get free prescriptions.

Those not over 60 can buy an annual exemption ticket for £93.20. That gives them an unlimited supply of medication for the year. Cost £1.79 a week. Less than the cost of a pint of beer. How is that a “huge” cost? Go and live in the USA for a year and see how much you have to pay for medication there.

In most of the country, the elderly, the infirm and those unable to travel unaided are entitled to and receive free transport to and from the hospital from the ambulance service.

Why should those who can afford to run a car expect the NHS, a.k.a. the tax-payer, to pay their motoring expenses? Most hospitals supply and maintain a car park. Why should they not charge a reasonable fee for that?

And note, if you are genuinely hard up, “there is a subsidy scheme to re-coop travel costs”.

Even that is not enough for Mr Cardy. He would probably like the NHS to send a personal limo for all the patients.

Dr Crippen despairs. This abuse has to stop.

This reinforces Dr Crippen’s views, as he argued here, that there must be a front end charge for health care.

Going nuclear on abortion

I have written about abortion a fair few times (here - Abortion in South Dakota, and here - Sex Education - don't wait for it) and those of you who have read what I have written will know that I find it a difficult area though I conclude that it is often the lesser of two evils.

Emily writes movingly, with insight and indeed with some humour, about the abortion she had as a young girl.

You may not agree with her decision. Fair enough. You may want to put the other point of view. Fair enough. It is a delicate issue. She was young and immature when she took the decision. So how would you approach the discussion?

Like this, maybe?

“You'd really need a heart of stone not to laugh-out-loud on reading that self-indulgent, confessional crap. How many piss-poor excuses can you come up with for lashing your baby in this day and age?

She ran the full gamut: tipsy, surprised that sex results in conception, leafing through The Yellow Pages, it was the right decision for me, me, me ... and so on, scraping the bottom of her womb.

Yeah, so.

I'm sure the foetus appreciated all those wussy excuses as it was sucked outta the womb and into an industrial incinerator. Tough shit, baby. The dismembered fragments of your life count for nothing against your mother's fear of beholding you, wriggling and alive.

No matter. Mummy has a website on which she can endlessly justify her actions.

But what about the dead baby?”

Read Emily’s original post on the abortion here, and read her reply to the pro-lifer here. She is more temperate than Dr Crippen would have been.

A cry in the wilderness

Sometimes, Dr Crippen feels like a lone voice in the wilderness.

I see the health service falling apart around me.

I shout.

I scream.

Few seem to believe what I say. I am attacking apple-pie. I am attacking motherhood. I might as well be.

This is New Labour. This is the health service dumbing down. I have been sent a report from Ireland.

"Why nurses are no angels"

The public loves them. The Government wants to give them more power. If only you knew what nurses are really like, says Dr Lucy Chapman.

Belfast Telegraph 20 June 2006

Read what Lucy has to say here. Or in The Independent here


And when you have done that, move over to the psychiatric wards to learn some of the reasons why nursing care is so bad. The nurses have gone. They have gone off on the “skills acquisition courses” that we described here and become therapists.

Nurse-therapists are cheaper than real therapists.

Nurse-practitioners are cheaper than doctors.

What do the psychiatrists have to say about the nurse-therapists? :

"Jesus.

I wonder how they choose which drug they are going to learn. My mind's eye shows me a nurse pracitioner randomly stabbing a finger at a page in the BNF with the words "I want that one", a la Andy from Little Britain. Or perhaps a nursery school environment: "No, you can't have risperidone, it's Suzie's turn this week. Why don't you go and play with the quetiapine instead?"

It would be funny were people not going to die as a result."

Read the psychiatrist's report on nurse-therapists in full here.

Something must be done. Does anyone have any suggestions?

Radical change needed in the NHS

Rt Hon David Cameron MP, Leader of the Conservative Party


Dr Crippen has always been politically middle-of-the-road

In 1997 he voted for Tony Blair. It’s “health and education” stupid! He bought into the dream.

Some dream. Over the last ten years the health service in which Dr Crippen has worked all his life has deteriorated beyond recognition. It has deteriorated notwithstanding a huge increase in health care spending. It has deteriorated because we have had a government that assumes that increased spending automatically brings improvement. It has deteriorated because we have had a government that equates target chasing, control and measurement with success.

You do not help a baby thrive by weighing it every two minutes.

Morale within the service is at an all-time low. Money is spent on administration, on process, on “measurement”, on target chasing, on management consultants and upon untried IT.

Money is spent on anything apart from the care of patients.

For those without private health insurance NHS care is increasingly provided by “Health Care Professionals”. Nurse-specialists, EMTs, occupational therapists and so on. Well meaning, highly trained people in their own right, but they are not doctors. And whilst the nurses and others are trying to fill the role of the doctors, who is doing the nursing? No one.

What can be done? Radical change is needed.

Dr Crippen discusses some radical solutions here with the movers and shakers in the Conservative Party.

Quacktitioner Alert (7)

Quacktitioner tales are still arriving. Do keep them coming.

A letter from Anna the Anguished Accident & Emergency doctor. Whilst working a shift in an A & E department she saw a patient with a possibly serious eye problem, and another one with a possibly serious psychiatric problem.

Working in the A & E department is one of the most stressful jobs you do as a junior hospital doctor. The art, and science, of success and safety for a doctor in A & E is to know your own limitations. And you may reach the boundaries of your experience sooner in ophthalmology and psychiatry than in other specialities.

You have done five years at medical school, and then at least two years as a qualified doctor in the Foundation programme. At medical school you will have had training and experience in ophthalmology and psychiatry but you are still only seven years into your overall training and cannot yet be called experienced.

Get some help.

Which is what Anna tried to do. She phoned the on call ophthalmology and psychiatric doctors. On each occasion she was put through to….our friend the Nurse Practitioner. She would “assess” (sic) the patients to see if she could “deal with” (sic) the problem herself.

This is Hospital at Night. Increasingly, too, it is Hospital at Day as well. Unless you go privately, in which case you can see a doctor.

How are nurses trained to carry out these specialist roles? In the past Dr Crippen has talked light-heartedly about “two-week skills acquisition courses” with flip-charts and a plate of bourbon biscuits. He exaggerated.

Bourbon Biscuits

You do not need a two-week course to turn a nurse into a clinician with diagnostic skills. It can be done in five days.

Come with me to Practitioner Associates Ltd (here)

They run a variety of courses for nurses wishing to become nurse-practitioners. Let us look at two of them.

The 5 day health assessment skills workshop

"This challenging but rewarding course is aimed at nurses and other health professionals wishing to develop history-taking and physical assessment skills."

Aims and outcomes
On completion of this workshop, participants will:

• be confident to take a comprehensive health history from a patient
• understand the techniques of physical assessment
• correctly use physical examination techniques
• perform a top to toe physical examination.

It took Dr Crippen six years to achieve those objectives. If only he had realised that it could be done in five days.

Dr Crippen has always been interested in paediatrics. Apart from his undergraduate training, he did a general paediatric job, a neo-natology job, worked as the junior paediatrician on the labour and post-natal wards and finally spent a year as a trainee in family medicine working under the supervision of an experienced family doctor. By the end of that, he was beginning to feel confident about assessing sick children.

If only he had known that he could have acquired all these skills in three days.

For a mere £317.25 he could have attended a three day Paediatric Minor Illness Workshop:

Aims and outcomes
On completion of the workshop, participants will:

• demonstrate the ability to integrate paediatric history-taking and assessment with diagnostic reasoning and management skills
• recognise a variety of common paediatric presentations seen in primary care.

Course programme

• Review of age-appropriate history and physical examination techniques
• Assessing the unwell child.
• Assessment and management of:
  
  
• The child presenting with fever
• Ear Nose and Throat complaints
• Skin related complaints
• External eye complaints
• Respiratory conditions
• Gastrointestinal complaints.

I am sorry, girls, it cannot be done.

Recognising common presentations in primary care is difficult enough, but pales into insignificance compared with the experience you need to be able to say to a mother “there is nothing seriously wrong with your child.”

Then they purport to teach the “assessment and management of a child presenting with fever” in three days. Three days?

Twenty years down the road I still find the feverish child with no definite pathology a challenge.

Where did Dr Crippen go wrong?

Why did it take him so long to learn these skills that can now be doled out in a three day course?

And where are the bourbon biscuits?

Father's day and the dangers of blogging

Dr Crippen has been very busy of late. The demands of being a family doctor, of course, and he has been devoting some of his spare time to writing.

Today was Father's Day. And so a large family lunch after which Dr Crippen was given this card by Mrs C. and our four teenage children

They thought it was extremely funny.




This card, and many others, from Emotional Rescue Ltd here

Beta Haemolytic Streptococcus

Beta haemolytic streptoccus

In the UK, everyone is supposed to be registered with a local GP. If you become ill when you are away from home, you may still consult a GP in the area in which you are staying, by signing on as a “Temporary Resident.” (TR) There is (isn’t there always these days) a form to be filled in, but it only takes two minutes. And GPs are paid an additional fee for seeing temporary residents.

GPs near tourist attractions and the seaside generate significant income from TRs. Dr Crippen is closer to the M1 than the seaside, and so TRs do no represent a major income stream.

Claire was Australian. She had been living and working in London for some years and was registered with a GP there. She was staying in our area to be with friends. She handed me the TR form and sat down. She looked pale, ill and upset. She was fighting back tears.

People often wonder how family doctors can claim to “know” their patients so well when they only see them for a few minutes here and there. But a few minutes “here and there” over many years, coupled with a few minutes “here and there” with all the other family members enables you to build up an detailed picture of the patient and their family. You know their strengths and weaknesses. You know what questions to ask.

It is different with TRs. It is a blank canvas. You have to be careful.

Claire did not say anything. After a while I said “How can I help.”

Three weeks previously Claire’s new born son, Charlie, had died. After an entirely normal delivery, Charlie had developed an infection and, despite intensive treatment, had died on the fourth day. The infection was beta haemolytic streptococcus. Claire was a carrier.

Group B streptococcal infection in the newborn can be fatal. In 2001 there were 376 reported cases in the UK of whom 39 infants died. The bacteria lives in the woman's vagina and back passage and the baby picks it up from these sites. There are several risk factors for the baby to catch the infection:

1. Mothers with previously affected babies
2. Premature rupture of membranes (before 37 weeks of pregnancy)
3. Prolonged rupture of membranes (more than18 - 24 hours before delivery)
4. Women with raised temperature in labour

Claire did not have any of these risk factors, but Charlie was still infected.

Claire was in our area for three weeks. I saw her on several occasions and spent a long time with her. The most difficult question she asked was why, why, why was she not screened for beta haemolytic streptococcus during her pregnancy.

In the UK we do not do such screening routinely. This is not an arbitrary decision. A great deal of though has gone into it. The Royal College of Obstetricians and Gynaecologists report on it in detail here.

They do not recommend routine screening. The vast majority of the pregnant population would not benefit from routine screening. 24,000 women would have to be screened, and 7000 women given intravenous antibiotics, to prevent one neonatal death. The only effective way to treat a carrier is to give those intravenous antibiotics regularly throughout labour. The administration of intravenous antibiotics is not without dangers and would cause an occasional maternal death from anaphylaxis.

Not all agree with the RCOG findings.

There is a UK pressure group called Group B Strep Support (here) They present the alternative view in a sensible and well argued fashion.

Dr Crippen is not in a position to make a personal judgement. But as a family doctor on the front line, it is harrowing to counsel and comfort a bereaved mother in any circumstances. And it is not the time nor is it the place to mention a report, however authoritative, that says “…but we would have to treat 7000 woman to save one baby.”

The cost of such screening would not be huge within the grand scheme of things. And consider this. All pregnant women in the UK are still routinely screened for syphilis. Dr Crippen has never seen an acute case of syphilis in the whole of his medical career. Admittedly, he does not work in an STD clinic, and he knows that syphilis is on the increase, but nonetheless he wonders how many cases of syphilis are found in the UK from all this screening. He doubts it is cost efficient.

The most telling point that Claire made, and the one that Dr Crippen found most difficult to answer, was that whilst she accepted that there might be some practical arguments against routine screening, it was done routinely in the USA, Canada and Australia. Had the UK taken a different view just to save a bit of money?

“If I had had my pregnancy care in Australia, Charlie would probably have survived.

What do you say to that?


++++++++++++++++++++++++

Dr Crippen's attention has just been drawn to an article in The Journal of Medical Screening. The abstract summary can be found here. There is a real possibility of a vaccine to immuise women against this problem.

++++++++++++++++++++++++

Dr Crippen has been contacted by the Royal College of Obstetricians about their latest research and information on GBS, which can be found here

Geriatrics, Plague, Dubya & the North/South divide

Dr Crippen doing a house-call

Philip van Gordon, the author of “Cherubs in the Land of Lucifer”, is a neo-natologist in the USA. He is currently writing an engaging set of essays on the theme of the medieval plague. Obviously a man of taste and culture, he has some kind words for Dr Crippen…except he describes him as a “geriatric” blogger. And I still have all my own teeth. And hair.

Have a look here.

Further down the column look at his reference to an article in Rolling Stone which gives a pleasing assessment of George W. Bush.

Dr Crippen is not a Dubya fan. Most of Dr Crippen’s friends in the USA live in New York or California. He does not know so many in what the Californians call the fly-over zone. Some time ago – actually just after the re-election of Dubya - Dr Crippen was sent an article by a writer friend, a deeply depressed Democrat, who lives in Los Angeles. This article was allegedly written by a New York Times staffer. It was not published for reasons that will be clear if you read it.

Florida Orange Juice - but was it worth it?

The article has been doing the rounds in the USA and deserves a wider audience here. It discusses the resentment that so many in the Northern States felt as the southern based Republicans moved into Washington and took over.

Best read slowly and aloud.

It makes Dr Crippen giggle. It can be found here.

Circumcision

Circumcision is back in the news.

A divorced American couple are having a tug-of-willy fight over their eight year old son. They have joint custody but he lives with mum. Mum’s new partner is Jewish. Mum and step-dad want him circumcised. Dad does not. Dr Crippen’s sympathy was with dad – not to mention with the boy – until he read that this boy has been getting recurrent attacks of balanitis. Not much fun, balanitis, and it is a relative, but not absolute, indication for circumcision. The other indication is phimosis, where the foreskin is so tight that it gets stuck. Not much fun, either.

Circumcision may occasionally be necessary, but it is not an enjoyable experience. Traditionally, it was done without anaesthetic, as the baby does not experience any pain. Of course it doesn't. Those of you who have have broadband and are not squemish can download a video of a circumcision here.

Dorsal cut during a circumcision

Until fairly recently nearly all American male babies were circumcised before they left hospital. Things are changing now. The American Academy of Paediatrics have declared the operation to be unnecessary and most American medical insurance companies will not pay for it to be done, unless there is a specific medical indication, like phimosis.

For once the UK is way ahead of the USA. Circumcision has never been as popular here, though more popular than in Europe. Nowadays it is not done at all on the NHS unless there is a specific medical indication. I dare say there are some private “surgeons” who can be persuaded to do it, but that is Harley Strasse for you.

Religious indications are another matter altogether. Jewish babies will be circumcised routinely on the eighth day and there can be no argument about that. But even the Jews, now, are rethinking and a change may come.

Dr Crippen does not believe in routine circumcision. He was distressed, therefore, to read Dr Thomas Stuttaford’s article in The Times today. Dr Stuttaford has had prostate cancer and likes red wine. He deluges us with articles advising men to have regular PSA tests and to drink red wine regularly. In both areas his advice is suspect. Whilst it is good to see him discussing something else for a change, it is sad that his views on circumcision seem to have been lifted from a 1930’s American Medical Text book. They are nonsense.

He writes:

“Once an uncircumcised boy has a sex life…he will have a greater chance of catching most of the STDs.”

Why do we not cut it off altogether, Tom, that will stop all the STDs … and “cure” masturbation as well. And teenage girls could have their breast off to prevent breast cancer. Where does it end?

Dr Crippen thinks it should not start.

+++++++++++++++++++++++

My attention is drawn to a site here. It contains the most graphic and powerful discussion of circumcision I have seen. I think it is essential reading, particularly for anyone considering a "cosmetic" circumcision for their baby. But please be warned, it contains graphic pictures of surgical procedures and should not be read by anyone who is squeamish.

And now to another site here, that shows that, contrary to received wisdom, penile cancer CAN develop in men who have been circumcised.

The Crippen Diaries (Week 24)

Not quite Tannochbrae

Monday 12th June

My partner who looks after the local EMI nursing home is away on holiday and so it was I who responded to the visit request from the nursing sister. Richard is 83, a widower with no immediate family. There is talk of a niece somewhere but no one has ever seen her. Richard is utterly, hopelessly, irretrievably demented. He is on Arricept and it has not worked. Does it ever? It should be stopped really.

The reason for the call is that they think Richard is in pain. He is refusing to get up, and he is whimpering. He is normally smiling and cheerful.

My partner is good at this sort of medicine. I am bad at it.

It is not possible to get a history from Richard. But when he whimpers, he thumps his right lower ribs. The staff say he has not had a fall. There is no bruising. When I press on his right ribs, he moans, but then as I examine him further, he moans when I press anywhere. His belly is soft, but he moans even when I put a hand on. He does not have a temperature. There are no signs of infection. There are no obvious broken bones. I manage to persuade him to stand up, which he does quite successfully, but then he flops back onto the bed and starts whimpering again.

I want to revert to being a house officer again. I want to clerk him. Examine him from head to foot; get a CXR, a blood count, detailed chemistry, an ECG and so on and so on. The only way I can do all that is by sending him into hospital. That is not appropriate or necessary and it would be cruel. I need to do some sort of test, so I settle for ordering an MSU. Or, to be realistic, something approaching a clean catch. I feel a bit better for that. I write him up for a pain killer even though I do not know what I am treating.

As I sit at home and write this, I suddenly think, “Oh God, I didn’t check his blood sugar.” Silly. He is not diabetic. It would be unusual for diabetes to present at this age. But diabetes can cause abdominal pain. Occasionally.

I will go back to see him tomorrow and he will be better. Or not. If not, I do not know what I will do. I will certainly do a finger prick sugar. And re-examine him. And leave a long and careful note which will stand up to inspection.

And then, of course, he might die during the night. If he does, the coroner will press me for a death certificate and I will not really know what to put on it.

I think this is a flaw in medical training. Or the medical training I received. It may be better now. I was trained to be a problem solver. All problems have a solution if you look hard enough. If a doctor cannot find a solution either he malfunctions or he invents one. How hard do you look in a demented 83 year old? Is masterly inactivity the correct approach with patients like this? It probably is, but I shall worry. What is an objectively acceptable assessment and management of a problem like this? Morally. And medico-legally. What would an American doctor feel he should do in this situation to avoid being sued?

My partner thinks I am a bit of a worrier. Sometimes I think I earn every penny of the £250,000 a year that I am not paid.

++++++++++


Tuesday 13th June

Toby appears with his mother. Toby is 9 and has severe, recurrent migraine. Children get it too, though many, including some teachers, do not appreciate that. Toby has been fully and appropriately investigated both by me and the paediatricians. His migraines were debilitating occurring as frequently as twice a week with a full house of accompanying symptoms, particularly vomiting.

He is currently on regular pizotifen. This has reduced the frequency of the attacks to about once every three or four weeks. He has returned to a normal life. Furthermore, we have found, largely by trail and error, that if he takes 300mg of ibuprofen (that is 15 mls of the children’s syrup) as soon as the symptoms start, it will often abort the attack.

Toby has a bottle of Ibuprofen syrup at home, and one at school. Over the last six months he has taken five doses, and it has worked.

So far, so good.

Last month, however, the County Council wrote to all state schools saying that is was “policy” that no child was to be given medicine containing ibuprofen on the school premises. No reason is given for this decision, and there is no name at the bottom of the directive, so Dr Crippen is frustrated as he does not know who to bite.

I phoned the school and spoke with the headmistress. To be fair, it was not her fault. She thought it was nonsense too. However, she said that if I was to write a letter to her, specifically authorising them to give Toby the ibuprofen, she would then be able to do it.

A letter from the parents to the same effect will not do. Why not? Policy. I gather from Flea that American paediatricians spend most of their working lives dealing with nonsense like this. It is getting commoner in the UK.

I do not mind doing the letter. Not a problem. What bugs me is that this is an abrogation of parental rights. Why do the schools not trust the parents?

++++++++++

I went back to see Richard in the nursing home. I had worked out my plan of action. Increase the analgesia to whatever (within reason) was necessary, give him something to help him sleep, and put him on a broad spectrum antibiotic.

When I arrived the nurse smiled. She too me round to see Richard. He was back to normal. He had woken up this morning and was pain free. Sitting in the day room watching television. Not a care in the world.

I wonder what it was. It was only when I got back to the health centre that I realised I had still not checked his sugar. Next time.

+++++++++++


Thursday 15th June

Doctors are human. Honest. And like all humans, we like to be patted occasional. It really does make the day go better if someone expresses gratitude or even just says “thank you”.

A man in early middle-age with complicated medical problems. Type II diabetes, not well controlled over the last few months. He is about to be changed onto insulin, though I have not broached that with him yet. He has difficult hypertension, which is just about controlled (148/86) on four different medications. Trouble is, “just about” is not good enough for a diabetic particularly if, like him, the renal function is deteriorating. He attends the renal clinic at the hospital and the diabetic clinic at the health centre and is currently on nine different tablets.

He was looking unhappy today. I asked him what was bothering him. He smiled and said he was fine. Then, without being asked, he continued, “And I think the medical care you have been providing has been quite good.”

I think I know now what W. S. Gilbert had in mind when he talked of “modified rapture.”

++++++++++

Doctors are trained to “do” things. There is nothing more frustrating to a doctor, particularly a younger one, than to see a patient who is well-managed and on optimum medication. Dr Crippen may well only have one patient in that state of medical perfection, but that one patient went to outpatients last week.

The SHO who saw him changed his omeprazole to lansoprazole.

There is no difference between these two drugs. We prescribe omeprazole because it is cheaper in the high street chemists. The hospital prescribes lansoprazole because it is cheaper in the hospital pharmacy. They probably bulk bought a shed load last year. So the drug protocols that go out to the juniors say prescribe lansoprazole. Fair enough. That is health care economics.

My perfectly managed patient came to see me today and told me that the “specialist” at the hospital had changed him from omeprazole to lansoprazole because it is a “better” drug than the one I had been prescribing.


++++++++++

I saw a forty year old hairdresser five weeks ago. She presented with a swelling in the left side of her neck. She was otherwise entirely well. She did indeed have a largish – about 4 centimetre – swelling in the left side of her neck. There was absolutely nothing else to find. In particular, there were no other glands anywhere, no enlarged liver, spleen etc etc. She was surprised when I said I wanted to do some tests. Glands come and go in children with monotonous regularity, but persistent enlarged glands in adults are less common and need to be investigated. The differential diagnosis is long, but one worries particularly about lymphoma. I arranged for a battery of blood tests and a CXR and said I would see her with the results.

The blood tests were back the following day, as they always are. FBC normal. ESR 5. CRP normal…they were all plumb normal. The receptionist phoned her to tell her the good news.

Family doctors do not get sent X-Rays. We have to wait for the report from the Consultant Radiologist. In the old days, CXRs would be reported within two days. Not any more. By and large, any with serious pathology will be reported quickly because the radiographer will notice and ask the radiologist for an immediate report.

I received a fax yesterday afternoon from the X-Ray department marked urgent. There is an odd lesion at the top of her right lung (not left) which cannot be explained, and they want to do an urgent CT scan.

I saw her today. She told me that she had herself phoned the X-Ray department yesterday to chase the X-Ray and that was why the report had been sent through.

The gland in the neck was still there. No bigger. No smaller. She is still entirely well. I have asked for an urgent CT scan. Normally the wait for CT scans is two or three months. In the circumstances, I suspect they will do it tomorrow.

It is easy to react to results when they arrive. It is much more difficult, indeed nearly impossible, to monitor results that do not arrive. With 18,000 patients we have hundreds of tests a week going backwards and forwards. If a test does not come back, and the patient does not come back, you may well not notice. In the past we could rely on the hospital to get the information back. Not any more.

I told the patient that I thought the five week delay was unacceptable and I apologised for it. To be honest, she did not seem too bothered. But that is not the point.

If this lesion in the lung is a lymphoma, at some stage she may make a complaint about unreasonable delay in diagnosis. The X-Ray department will bear the brunt of that because it is negligent to leave a chest X-Ray from a family doctor unreported for a month. But I may be asked why we do not have a fail-safe system, checking on a daily basis that all tests ordered have been done within a reasonable time.

Sounds easy but in fact the logistics are horrific.

And would it help? Remember, this is a nationalised industry. We are not fundholders any more. Ten years ago, we could have taken our business elsewhere. In fact, we told the X-Ray department that we would take our business elsewhere if they did not provide a better service. We insisted on having CXR reports back in three working days. And we got them. Then Tony Blair abolished fundholding and took away our freedom of choice. Three days has become four to six weeks.

If we phone the X-Ray department every day and say there are seventy-eight X-Rays outstanding they will just say, "I know, I know, isn't it awful." It is like listening to Basil Fawlty talking about Manuel.

Last year a family doctor was found to be negligent for not chasing up a patient who did not attend an outpatient appointment.

More stress.

++++++++++


Friday 17th June

Another happy little tale of NHS “process” ... and praise for the Daily Mail.

A typical page from the Daily Mail

My partner has an elderly male patient, Joe, who is on renal dialysis. He has the late evening shift at the dialysis unit in the local unit. He goes up there three evenings a week, from six o’ clock until mid-night. It is hard work, but he is used to it and, as he frequently says, it beats the alternative.

Ten days ago Joe developed diarrhoea. A nasty, frequent, semi-formed diarrhoea. There are some patients, much beloved of family doctors, who present with monotonous regularity to up date their doctor on the consistency of their recent bowel actions. It all depends on how you are brought up. There are some families in which defecation is a daily conversation topic. There are others in which it is never mentioned.

Joe is from the latter sort of family, so when he does, for the first time in his life, present with diarrhoea, it is going to be more than a stomach upset. Not only is he going frequently during the day, he is getting up three or four times during the night. This is always significant. Patients who present with “torrential” diarrhoea but say they do not have to get up at night are unlikely to have a serious problem.

Joe does have a serious problem. Cultures show that he has clostridium difficile. This is a potentially serious gut infection and needs careful management. It is also important because the journalists in the UK have just discovered it and, as always with journalists who have just discovered something, they are writing articles to “teach” doctors how to diagnose and manage it. The Department of Health even has an official “policy” on it (here)

Because Joe is elderly, in chronic renal failure, and taking a nasty bacteria up to the hospital, my partner did a detailed biochemical and bacteriological work up and gave Joe a letter for the renal dialyusis unit so that they would be aware of what was going on and would take any action that would be necessary. Joe gave the letter to the dialysis nurse-specialist who read it, gave it back to him, and told him to go to his GP for further investigation and management.

Joe duly presented again the next morning. He said the nurse had not called the doctor, as “diarrhoea” was not “something for the hospital.” My partner re-examined him. He was horrified to find that Joe’s underpants were stuffed with newspapers. He had asked for some pads at the hospital, but been told that they could not supply them. He had to see the incontinence nurse specialist first. We have discussed this before, here and here.

My partner broke into one of the nurses cupboards and “borrowed” an armful of pads. There will be an angry letter from someone about that.

There is one happy side to this story. Dr Crippen has found a use for the Daily Mail.

Pot calls kettle black

Dr & Mrs John Crippen

Nick Genes had a much deserved rest from organising Grand Rounds to take a look here at yet another example of the Health Police at work. It seems that the American medical profession has decided that doctors must set a good example by not being overweight.

Dr Crippen does not see why this should apply just to body size.

Surely, the physician should also be a teetotal, non-smoking, church-going, gym-attending, happily married scout-troupe leader with perfect teeth and perfect children. Like Dr and Mrs Crippen.

Dr. Michael Dansinger, Obesity Researcher at Tufts-New England Medical Center says:

“Is that white-coat feeling a little tight? Many physicians are overweight or obese for the same reasons our patients are. Many of us do not eat right and get enough exercise. We work long hours, making it seemingly impossible to squeeze regular exercise into our busy daily routines. We eat on the run and unhealthy food (often served in our own hospitals) is commonplace.

Physicians rally against obesity, and yet, we are not doing all we can. Sadly, those of us who fail to embrace lifestyle recommendations in our personal and professional lives promote a public perception that lifestyle change is ineffective or unrealistic.

Despite dramatically increasing obesity rates, we have failed to improve our dismal obesity counselling rates. The physicians who fail to recognize and treat obesity are often the ones who personally fail to heed lifestyle recommendations, and these doctors may sometimes lose credibility with their own patients.

I know we can do much better. First, we must recognize that the human body needs at least an hour of exercise daily for optimum health, and every able-bodied physician should strive to achieve this. Second, we should eat at least 5 servings of vegetables and fruits daily, and third, those of us with excess body fat should literally count our daily caloric intake and aim for about 12 calories per pound of ideal body weight.

If we can commit to these goals, both as individuals and as a medical community, imagine the example we would set! As individuals we will feel better and stronger, and as a medical community we'll serve as better role models for our patients. To succeed in healing others, we must also heal ourselves.” (Those of you who have signed up with Medscape may watch a video here of the perfectly formed Dr Dansinger spouting his views.)

Although perfectly formed himself and a role model in all areas, Dr Crippen thinks this is a load of old cobblers. Sorry, that is not a very scientific statement, but that is how I feel.

Doctors are people. They have their own foibles. They are human beings. Patients do not want a lecture on health from a lycra-clad, lunch-box showing Olympic athlete.

Have a look here at the Fat Doctor. She is overweight. She has had a stroke at a young age. She has young children. She struggles all the time with her own health issues.

Which style of doctor do you prefer? Dr Dansinger or the Fat Doctor? Dr Crippen knows where he would go.




Picture of Dr & Mrs Crippen courtesy of Lizette & Jon from "I'll pump you up"

New Labour hypocrisy : stiffling professional autonomy

John Reid MP - hypocrite & home secretary

I saw a patient new to the practice recently. A pleasant, quietly spoken man. He needed some help with his psoriasis which was not responding to calcipitriol possibly because he had been applying it too infrequently. Flicking through his records, which had just arrived, I noticed they seemed incomplete.

“There seems to be a nine year gap in your notes” I said.

“I was in jail” he said.

I asked him what for. He had murdered his wife. “I see” sounded wholly inadequate. Murder is surely the worst of all crimes that one can commit on one’s fellow man and yet I was strangely unbothered by it. Here I was, sitting with a “lifer” out on licence, a convicted murderer, talking about a skin problem.

Intellectually, we all condemn murder. Emotionally, though, we have all said at some stage or other, “I could kill him”. We all have a scintilla of sympathy for someone who, in the heat of the moment, kills a spouse who has subjected them to years of abusive behaviour.

Paedophilia is different. This is a crime with which none of us will identify. There is something particularly repugnant about sexual crimes committed against children. There is outrage in the UK at the moment at the “lenient” sentence imposed upon Craig Sweeney.

Craig Sweeney

This odious man repeatedly sexually abused a three year old girl and finally, when being pursued by the police, threw her out of a moving car.

Judge John Griffith Williams QC sentenced him to life, but with eligibility for parole after five years and 108 days.

The home secretary, John Reid, criticised the sentence as being too lenient. The Red Top newspapers are having a field day “exposing” judges who are “too lenient”.

John Reid’s behaviour is typical of the man, and typical of this dishonest, morally bankrupt government. Reid, seen here, is a political thug. If an underhand ad hominem attack on a member of the judiciary will garner some political popularity, then Reid will be at the front of the queue. Forget Montesquieu; forget the separation of powers; there are votes to be won.

Alice Miles is in good form today in The Times. The last time Dr Crippen crossed swords (here) with her, he called her the “The Shit in the Times”. Oh! Dear. Today he is in complete agreement with her article in which she both demonstrates the hypocrisy and pricks the pomposity of this dreadful man.

The government has not just been stifling the professional autonomy of the medical profession. It is not just us who have been subjected to Stalinist controls and protocols. They have been doing it to the lawyers as well.

Give back professional autonomy to the judges, and offenders like Sweeney will go down for the rest of their natural life. The key will be thrown away. The judges cannot do that now because of government legislation and directives.

Judges are directed to reduce sentences by one third if the villain pleads guilty. No discretion. Surprisingly enough, villains caught in flagrante delicto tend to plead guilty anyway. Then, the government has decreed that all villains shall be eligible for parole after they have served half their sentence. Judges must not take parole eligibility into account when setting a sentence. If they think a villain should serve 10 years in jail, they cannot sentence him to 20 years so that he does actually serve 10 years.

Judge John Griffith Williams QC recommended that Sweeney served a minimum of 18 years.

Then the government directives come into play. 18 is reduced to 12 because he pleaded guilty. 12 will be reduced to 6 if he behaves himself in jail. He did last time. And then 6 years is reduced by the amount of time he has already been on remand.

Why does the government not leave the judges alone to get on with their jobs?

Dr Crippen admits to some schadenfreude here. John Reid’s government has legislated to force judges to sentence by protocol. The judges apply the protocols, as they must, and there is a public outcry. A public outcry led by John Reid, the man who introduced the protocols. And who gets the blame? The judges.

This is exactly what Patricia Hewitt and her predecessor, John Reid no less, have been doing to the medical profession for years.

(Alice Miles : "Get some policies, Mr Reid, and stop hiding behind an odious sex offender" in The Times here)

++++++++++

And see Tim Worstall on this here
And The Vented Spleen here

Data Theft

Dr Crippen continues to worry about personal data being stored on computers and thus being easily available to the police, the security services, M15, the CIA and every 15 year old computer geek in the world.

A doctor in New Zealand writes to draw my attention to data theft. Supposing someone, for their own malign reasons, decided not just to steal your private medical data, but to publish them on the internet for the world to see.

Why would anyone want to do that? It could not happen.

Most patients who visit the hospital probably do not spend too much time thinking what happens to information in their medical records after they leave, but in the age of outsourcing and subcontracting, the path of a patient's medical record can be a long and precarious one.

Consider a recent case at a university hospital in California, where the doctor's notes from a patient visit were first sent to a transcription service company in Florida, which decided to subcontract to another firm in Texas. The Texas firm subcontracted the work yet again, ending up with a woman in Pakistan. This Pakistani woman became upset because her payments for her services were late, so she decided to send an e-mail to the university hospital, threatening to post the medical records on the Internet if she was not paid immediately. It might sound like a nightmare, but it is the reality of outsourcing today.

Medical records are secured under HIPPA standards, but when they leave the United States, these rules may not necessarily apply. (Paul Henry in Science Daily here)

Some weeks ago, Dr Crippen advised his readers here where NHS letters are being typed.

I shall have to increase my medication.

Measles & MMR : children at risk

A child with measles

The Independent reports today that the General Medical Council is considering bringing charges for “serious professional misconduct” against Dr Andrew Wakefield.


His original research paper has now been discredited and The Lancet, which published it originally, has disowned it.

Dr Crippen last heard of Dr Wakefield when he was working in Texas, studying autism. USATODAY.com reported (here)

"Gastroenterologist Andy Wakefield, who moved from London to Austin to head a new autism center, also has drawn attention for his theories about an intestinal disease that he believes produces brain-injuring chemicals in certain children.

Wakefield, of Thoughtful House Center for Children, believes a wheat-free and dairy-free diet will improve functioning for autistic children."

Trying to bring Dr Wakefield to book is a lose/lose strategy for the GMC. If he is found guilty and possibly even struck off, he becomes a martyr. If he is found not guilty, that will be seen (wrongly) as a vindication for his research.

Jeremy Laurence says:

The safety record of the combined triple vaccine is vastly superior to that for the single vaccines. Yet many parents have opted for single vaccines in preference to the triple MMR in the belief that they are protecting their children from a greater harm.

Why have intelligent people chosen to reject mainstream science and listen to far less authoritative sources? Unlike most scientific controversies which flare up and die away, this one has simmered on for eight years. It has been sustained by a mix of public anxiety, public mistrust of government assurances on health following the BSE debacle and sympathy for a lone doctor.

Growing environmental concerns about pollution, additives in the diet and genetically modified crops have conspired to undermine faith in science. Tony Blair's refusal to say whether his son Leo had received the MMR vaccine heightened anxiety.

Dr Crippen thinks it would be best to let sleeping dogs lie.

Dr Crippen believes that Andrew Wakefield is not a crook; and that Andrew Wakefield is not dishonest. He is far more dangerous than that. He is a man on a heart-felt mission. The mission may be scientific nonesense, but Andrew Wakefield believes in it. Believes in it passionately. He will not be frightend off by the GMC. He will argue his case with all the conviction he can muster and will convert many more to his point of view.

Let us not forget that measles is not a trivial illness. Measles can kill. Possibly even worse, it can leave a child with catastrophic brain damage.

Subacute sclerosing pan-encephalitis in a child's brain

Leave Dr Wakefield alone in peace and obscurity.

In the meantime, for any parent still wavering about MMR , let us refer yet again to the benchmark study from Japan. The Japanese stopped using the MMR immunisation for several years. If MMR causes autism, you would expect the incidence of autism to drop. It did not. Nor did it rise when the MMR was re-introduced:

The incidence of all autistic spectrum disorders, and of autism, continued to rise after MMR vaccine was discontinued. The incidence of autism was higher in children born after 1992 who were not vaccinated with MMR than in children born before 1992 who were vaccinated. The incidence of autism associated with regression was the same during the use of MMR and after it was discontinued. (full paper here)

Please read this article.


Report from the BBC here

I am not a number

We want information...

We looked recently at New Labour’s centralised computer data system, The Spine. The money wasted on this project is beyond belief and a scandal in its own right. But Dr Crippen worries that public outrage about the financial stupidity may camouflage the bigger scandal and the most frightening aspect of The Spine.

The erosion of our civil liberties. In particular, our right to privacy.

The ever reliable Black Triangle reveals that Boots the Chemist have recently purchased commercial software which will allow them to tap into the spine.

As names go, The Spine is eerie enough. Look here to see what Boots are going to call their software. When you have stopped laughing, pause a while and think.

Will there be anyone in the country not able to access your medical records at the push of a button?

At the sharp end

"Greetings comrades, it is a while since we spoke. More good news from the Health Commissariat. Medical services throughout the country are working cost-efficiently and at full capacity. I am glad to report that no expense has been spared in restructuring the care of comrade citizens with cystic fibrosis


Meanwhile, at the coal face, Dr Crippen struggles on.

The government imposes targets and protocols on the PCTs who, in their turn, impose them upon us. Nothing can be done without applications in triplicate. If a patient so much as sneezes a full report has to be made and sent to the government. It is never ending.

Adult patients with cystic fibrosis have to inject themselves on a daily basis with a variety of drugs. Glass ampoules, dirty syringes, used needles. What do you do with them? Well, you do not put them in the bin, that is for sure. You put them in a yellow box, called a sharps box, and take the full box to your health centre or local hospital for disposal with other medical waste.



We used to get a free supply from the local hospital for our own use. We gave them out to any patients who needed them. No problem

Then New Labour came to power. There is a protocol now to simplify the system.

See what happened here.



Stalin portrait : Portal Planet

British midwives want mothers to suffer

New Labour

Dr Andrew Doughty, the British anaesthetist who pioneered the introduction of epidural analgesia for childbirth said in 1978:

"Its most impressive effect is to bring tranquillity and humanity to the delivery suite as well as happiness and dignity to a woman on one of the most important occasions in her life"

I mentioned the other day that Second Child Syndrome seems to have appeared out of nowhere. Emily is documenting her trials and tribulations as she negotiates her way through the best (or worst) of the English ante-natal service. She has strong views, and is attracting some vitriolic comments.

Dr Crippen has already visited and left one of his more…er…pithy remarks here about the effect that midwives have on women who wish to bottle feed their babies. The emails are arriving already. I am used to retreating to the bunker after articles I have written on NHS BLOG DOCTOR, but this is the first time I have had a deluge of emails about a comment on another site.

I am accused of “hating” midwives.

It is not true. It would be no more rational to “hate” midwives than it would be to “hate” Welsh dentists or Lancastrian architects.

But “antipathy” towards midwives? That is a different matter.

Midwives were the first nurse-specialists I encountered when I trained as a doctor. I developed an immediate antipathy as did most medical students. I hated the way they patronised the patients. I have never understood why, because a woman is trying to deliver a baby, it is assumed by midwives that she can be addressed by her first name. I hated the way women were made to feel guilty if they asked for pain-relief during labour. I hated the way that, if they did ask for pain relief, a pethidine injection was rammed into their thigh without so much as a by-your-leave and without discussion of the pros and cons. I hated the way that women who asked for epidurals were treated disdainfully. Time after time, I saw midwives delaying calling the anaesthetist for the epidural until it was too late. I hated the way that women who did not want to breast feed were treated as second class citizens and branded as failures. On the post-natal ward, there was a “breast feeding room” but no bottle feeding room. I hated the way that, for all their practical skills, the midwives had little understanding of the science behind their practice.

Many doctors feel the same. Different training. Different profession. There is not much love lost between the two. This is not just a Dr Crippen rant. On doctors.net.uk there is currently a forum with hundreds of comments from doctors who despair of the activities of this unusual profession.

Consider this.

The most effective pain relief you can have during labour is an epidural. Epidurals have been around for a long time. They are now sophisticated. Done by an experienced anaesthetist, women can have what is called a “walking” epidural. All the pain relief of the epidural without being unable to move your legs.

Of course there is a downside to epidurals. There is a downside to any method of pain relief. If you have an epidural, you may not be able to push as well during the second stage of labour, and so there is a higher chance of an instrumentally assisted delivery. That is not a reason for not having one. Your fear of pain may be so great that, for you, it is the only way you can do it.

It should be a matter of choice. Not the midwife’s choice. The mother’s choice.

The midwives will not have it. They do not like choice. They are campaigning against epidurals.

Louise Silverton, RCM Deputy General Secretary, said: "Epidurals provide effective pain relief but, where there is no clinical indication that they are necessary, they can significantly raise the likelihood of other interventions such as Caesarean section occurring.

"The UK already has an extremely high Caesarean rate and, as the acknowledged experts in normal pregnancy, labour and birth we midwives need to debate ways in which we might help to bring this rate down."

Jolly good. They are “experts”. Doctors believe that the most important clinical indication for an epidural is the mother's choice. Midwives do not believe in the mother's right to choose. The midwife knows best. Where is this going?

“Sue Macdonald, the chairman of the committee, said: "There is quite a lot of research around which suggests that although it is an effective form of pain relief, an epidural means women will spend longer pushing the baby out of the birth canal and are more likely to need some other intervention."

Miss Macdonald said: "Epidurals have become a kind of norm for a lot of women. Sometimes women think, 'I just want to get rid of the pain, how fantastic'. "

That is where it is going. Think about that last sentence.

The Royal College of Midwives is criticising women who "just want to get rid of the pain."

This, more than anything I have ever come across, explains the different approach of doctors and midwives. Doctors favour the hospital delivery with appropriate and adequate analgesia.

The midwives? Well, make up you own mind.

Women in labour owe a great debt to Queen Victoria, and her physician Dr John Snow who attended the birth of Prince Leopold. Of course, for an important delivery like that, there was not a midwife within a hundred miles. The doctors were in control.

Queen Victoria : a pioneer for obstetric analgesia

Do you think that the current Queen had her four babies delivered by a midwife? Do you think Cherie Blair had little Leo delivered by a midwife? Forget it. Midwives are the comprehensive schools of obstetric care. A cheap and cheerful option for the common folk, but do not expect the “great and the good” to use them.

If you are one of the common folk and want to have a pain free labour, when the midwife is obstructive about an epidural, remember Queen Victoria.

Her Majesty declared ''It is we who are having the baby; and we will have chloroform!"



(Full medical details of epidurals here.)


+++++++++++++++++

It goes from bad to worse.

In their keeness to reduce the number of epidurals, the midwives are suggesting that the patients should be charged for them. That will reduce the numbers considerably. Only the rich will have them.


Midwives call for epidurals fee

Women having babies would be asked to pay for epidurals under a proposal from the Royal College of Midwives. Its education and research committee says too many have the pain-relieving injection, given to a fifth of pregnant women.


Full story from the BBC here

+++++++++++++++++

The Crippen Diaries (Week 23)

Not quite Tannochbrae

Monday 5th June


A difficult home visit to my patient with lung cancer. He has just been up to the oncology clinic. He has inoperable liver secondaries and has had all the chemotherapy that can reasonably be offered. The oncologist has told him he is “very pleased with his progress, and would he like the Macmillan Nurse to come and see him?” This is the code that the less articulate hospital doctors use when they want to say “there is nothing more I can do for you.” My patient is an intelligent man. He has been given a follow-up appointment for three months in the oncology clinic. He will not be attending this appointment.

People think that dying of cancer is about excruciating pain. It rarely is. It is about a lot of restless discomfort, which is what my patient has. We have a long talk about how to deal with it. His wife is trying to feed him up, and is gently bullying him into doing more exercise to “build up his strength”. It will not work. You cannot exercise your way out of this. One of the worst things about cancer is that it makes you feel tired, and weak and debilitated. The oncologists rarely mention this. The patients and, in particular their families, are oddly surprised when you warn them that, whatever is done, they are going to deteriorate. Gradually possibly. But gradually or not, they will deteriorate. I wish the terminal care industry had not generated this expectation that the process of dying can be pleasant. It is not.

I introduce some morphine and steroids and jiggle with the laxative, the anti-emetic, the sleeping tablet and his cardiac medication. His wife is very keen that he continues to take his simvastatin. I don’t have the heart to stop it.

++++++++++

I mentioned in the diary a couple of weeks ago that I had a bad cough. Here I go, whinging again. I had not been able to cure it. It is a nasty tracheal cough, but not at all chesty. I do not feel ill, but it is stopping me from sleeping. I asked for suggestions, and they did not work, though I never had the courage to take steroids as Angry Doc suggested.

streptoccus pneumoniae

I have been coughing so much over the last week that Mrs Crippen suggested I see a doctor. Obviously, I ruled that advice out as absurd and inappropriate. I am a doctor so I do not need another one. I did however send off a sputum specimen at the end of last week. It came back growing streptococcus pneumoniae. Yuk. I am going to take some Amoxicillin. I have never done that before. Does this mean I should now give amoxicillin to all the punters with a bad cough?

+++++++++


Tuesday 6th June

I had to squeeze two extra ante-natal checks in this morning. The midwife’s clinic was full, and she does not see extras so she told the receptionist to put them in with the doctor. Why ever not.

Which reminds me, I need to draw your attention to a new blog that has appeared out of nowhere. Well, not really. What I mean is that I have just discovered it. Emily is a professional journalist, but still writes well. She is charting her way, blow-by-blow, through her second pregnancy. She gives her take on being a customer of the ante-natal service. It’s a good read, though she has some odd ideas about Dr Crippen’s bedside manner. Take a look at Second Child Syndrome here.

++++++++++

I saw two women this morning, both in their seventies. They are on no medication. They are non-smokers. They are fit and will with normal blood pressure. They are both suffering from Acute QoF Syndrome, a disease that is affecting more and more fit elderly patients.

All over the county, doctors are being paid QoF money for dragging these asymptomatic patients off the street to nag them about their cholesterol levels. In these two cases, 6.9 and 7.3 and neither have budged after six months rigorous dieting.

Do I put them on a statin?

Over the last few months, I have been sent a huge amount of data on cholesterol and the merits of treating it by a biochemist from down-under. It is deeply unsettling.

The knee-jerk “statins are a good thing, let's put them in the tap water” maybe no more than a fashion. Remember, we spent the 1980’s convincing menopausal women that HRT was essential and now, twenty years later, we are having to recant.

Let us hope that we have not made the same error with the statins. In the meantime, may I recommend a little light reading:

"The Great Cholesterol Con" by Anthony Colpo

“The notion that cholesterol and saturated fat cause heart disease is one of the most fundamental tenets of modern medicine. It is also completely false. In "The Great Cholesterol Con" you will learn that: Heart disease is not caused by saturated fat nor elevated blood cholesterol; People with low cholesterol levels live shorter lives; Populations consuming high saturated fat diets often enjoy very low rates of heart disease; Many dietary recommendations made by 'experts' to reduce heart disease have actually been shown in animal and human studies to increase heart disease, cancer, diabetes and obesity; The primary force behind the anti-cholesterol paradigm is not public health, but profit! This meticulously researched book mercilessly demolishes what may well be the biggest and most successful scam in the history of medicine! Most importantly, you’ll discover what really promotes heart disease and what you can do to prevent it!”

Oh! Dear, I am confused. I wish life were more simple.

"The Great Cholesterol Con" is available here.

++++++++++

And finally, hot news straight from the press. The Hippocratic Oaf is not dead. He has survived life-saving surgery provided by the National Health Service and may yet become a doctor. All is revealed here. Good to see that the examining body at Oxford University is as flexible as they were when Dr Crippen was there. Full sub fusc is still mandatory for exams. And quite right too.

++++++++++


Thursday 8th June

A well-spoken middle aged man sits down. I have never met him. I just need a letter. Sorry to bother you. I have made an appointment to see a consultant tomorrow afternoon. This consultant works down in London, in Harley Strasse no less.

Harley Street, London

Dr Crippen hates this. He has never heard of the consultant. Patients are impressed by a Harley Strasse address. It is the UK medical equivalent of the Yellow Brick Road. The only ability a doctor needs to work at that address is the ability to pay the rent. Amongst the good doctors, there are some Harley Street shysters. People do not realise that.

It is a free world. Dr Crippen does not mind people seeing any consultant they wish to see, but he does not write referral letters, and thus make a recommendation, unless he knows the consultant personally.

Well-spoken man is not happy.

++++++++++

A delightful twinkly-eyed Indian man presents with a nasty contact dermatitis on his hands. I go through the history and there is no obvious precipitating cause. In an older, politically incorrect world, it was sometimes called ‘housewife’s dermatitis’ (too much washing up) but no one would dare call it that.

Half way through the consultation the patient lets slip that he is a consultant psychiatrist. Oh! Shit. A doctor. A quick mental review of everything I have said. Has it all been evidence based or is it anecdotal? Have I been flannelling? I do not think so but I am uneasy. How do you think we should treat it? I ask. He looks at me and smiles. “I want to be patient today.” Good for him. So “we” treat it the way we would treat any other patient with contact dermatitis.

I wish he had told me he was a doctor from the outset. It should not alter the way you conduct the consultation, but it does.

+++++++++++

Eric, a 52 year old chartered accountant phones. For two days, he has been having odd, explosive and very smelly flatus. No blood, no change in bowel habit and otherwise well. To put it in a nutshell, smelly farts. And a two day history of same is hardly exciting. But I have known Eric for nearly twenty years. He does not make a fuss. He would not phone me about a smelly fart. So even though he has phoned me about precisely that, I tell him to come in. This is where continuity of care, knowledge of patients built up over years, pays dividends. I cannot imagine NHS Redirect, who will soon be replacing me, getting excited enough about this history to re-direct such a patient anywhere.

About three centimetres in from his anus, Eric has a large, hard craggy mass, and when I remove my finger there is a bit of blood on the glove. There is nothing else to find. Eric still resolutely denies a change in bowel habit and has not himself noticed any blood. Hard to believe, really. He must have noticed something, or he would not have phoned me.

This is a two week rule referral to the colorectal clinic. He will be seen within two weeks. And he will get appropriate and timely treatment. The NHS is not all bad.

++++++++++


Friday 9th June

Friday. Duty doctor day again. And it is strangely quiet. The hottest day of the year so far, so maybe everyone is out in the garden. A lot of people are flying flags from the back of their cars. I think it is something to do with football.

Two dental emergencies today. Both abscesses. Both phoned their dentist, were refused appointments and told by the dental receptionists to go to their doctor and get some antibiotics. I think I am going to start referring all the piles and peri-anal haematomas to the dentist. I wish.

++++++++++

A heroin addict appears asking if I could “tide him over” with a prescription for some Subutex. He says he has not “used” for nearly a week. Looking through his notes, I see he is a diagnosed schizophrenic on depot medication. He was admitted to the local psychiatric last week for re-assessment of his antipsychotic medication and help with his heroin addiction. He says that “they threw me out of the hospital yesterday.” I find that hard to believe. Why would they throw you out? Do you mean you absconded? He looks at the floor. They did throw him out. A mate brought him some heroin and he injected it on the ward. That was a “breach of contract” with the psychiatrists so he had to go. Don't blame them. Lines have to be drawn, even with heroin addicts.

I tell him I am not prescribing Subutex, or anything else for that matter, until I have some information. I ask him to wait outside. The specialist nurse from the drug addiction service does her clinic on Friday. I ask her if she will see him. She refuses. He has broken his contract. I try to argue. He has other problems, he is schizophrenic. Is there no leeway? There is not.

So what do you do? If I do not prescribe Subutex he will get more heroin, by fair means or foul, and inject it. If I prescribe Subutex he will crunch it up and inject it. According to his notes, he injects everything. Heroin gives him a buzz and so, in his little schizophrenic world, he assumes everything else will. He is living rough. He spent last night, or most of it until he was moved on, in a bus shelter. What do you do? Finally, I phone the ward from which he has been ejected and, a stroke of luck, get hold of a sympathetic CPN. She says send him over; she will see if she can get him readmitted.

He has no money, so we give him £2 out of petty cash for the bus. Yes, I know, the principle is crazy. But no one gives a toss about this guy. He will be dead or in jail within the year.

Drug addicts are manipulative, but his guy is schizophrenic as well. How can a psychiatric ward turf him out on the street because he does not do as he is told?

++++++++++

I have a collection of patients who are obsessed with their bowels. Most family doctors do. Some children are brought up to believe that if they do not open their bowels after breakfast every morning, the world will stop turning. Mrs Davidson is one of those. She keeps a stool diary. She comes to see me twice a month on average to discuss minute variations in her output. I have not given her a copy of the Bristol Stool Chart, it would be cruel. She has had several barium enemas over the years (all normal) and two years ago a colonoscopy (normal). She is still terrified of bowel cancer. She is in her mid-seventies so her fear is not totally unreasonable and you cannot prove a negative. So I listen carefully to her symptoms and make a note of them. As with so many difficult, poly-symptomatic patients, I find it therapeutic to take a verbatim note of everything she says. If I were to apply the strict criteria produced by the colo-rectal surgeons for two week-rule-referrals, I would be sending her up to the clinic several times a year. You cannot do that. You have to make a judgement. And so I listen to the endless descriptions of size, shape, consistency, colour, and aroma of every stool that has been passed since the last visit. She worries particularly if any of them float. Or if she sees recognisable food particles in them.

After a while, she stops and asks me what I think. I say that I am sure there is nothing serious going on. She is always relieved and grateful, and off she goes for another fortnight.

It is amusing. It is stressful. I do not want to miss anything. Whatever she does finally die of, please God let it not be bowel cancer.

++++++++++

A small and manageable problem

"It's a problem, but a manageable problem."

Dr Crippen would like to apologise to his readers for the misleading innuendoes in "More financial scandals in the NHS" (below)

The casual reader might have assumed from this article that spending on the NHS was imcompetently mismanaged and totally out of control.

The Secretary of State for Health, the Rt Hon Patricia Hewitt, has issued the following press briefing.
________________

NHS DELIVERING ON CARE AND COSTS

Published: Wednesday 7 June 2006
Reference number: 2006/0213

"I've always been clear that there should be no trade-off between high quality patient care and actions to improve financial management. Sir Ian’ report provides definitive proof that the NHS is delivering for patients.

I know there are financial challenges in a minority of organisations but it is encouraging that the provisional end-of-year figures show that the minority of trusts that are overspending are now focusing on their problems and putting plans in place to tackle the issue. The end of year position is the equivalent of a person on an annual wage of £20,000 overspending by around £160. It's a problem, but a manageable problem." (Patricia Hewitt)

_______________


The full press release is availabe from the Department of Health's website here.

"It's a problem, but a manageable problem" so nothing for the tax-payer to be concerned about.

+++++++++++++++++

Dr Crippen has just been sent "Lament for the NHS" written and sung by some English medical students. It is deeply distasteful and even those of a strong disposition may regret listening to it. You have been warned.

More Financial Scandals in the NHS

There is not much to say about this. It speaks for itself.

Dr Crippen is more embarrassed and ashamed of it then he was of his personal folly of buying endowment insurance policies to “pay off” his mortgage.

The NHS IT bill is already a matter of national scandal. The only thing in doubt is how many billions have been wasted. Dr Crippen has conservatively talked of £20 billion. Wat Tyler, who is more versed in the arcane pathways of public finance, is floating a figure of £60 billion.

When the NHS bought all this useless IT, part of the conditions imposed upon it by the suppliers was that a large number of NHS staff would be seconded to the IT companies – presumable to advise on what exactly was required. Unfortunately, the doctors and nurses and, yes, even the much maligned administrators were a bit tied up with other matters, and could not be released to play computer games. So now the NHS is going to have to pay a penalty:

“But in the South of England, the NHS has been unable to meet a contractual obligation to place the equivalent of about 50 employees with Japanese-owned Fujitsu, and it is to pay £19m to the supplier to be released from the requirement.

This means Fujitsu will receive compensation to the equivalent of about £380,000 per NHS employee – but the supplier could have potentially fined the NHS up to £1.4m per employee over the 10-year life of the contract if it failed to meet the contractual obligation.

The £19m to be paid to Fujitsu will come from hard-pressed NHS budgets.

In the North West and West Midlands cluster, the NHS has a contractual obligation to place about 50 full-time equivalent staff with US company CSC, and papers to the boards of trusts show that managers are struggling to make up the numbers. They face penalties from CSC of up to £6.9m a year, a total fine over the 10-year life of the contract of about £70m. The potential penalty is reduced for each NHS employee placed with the supplier." (Computer Weekly – full article here)

Dr Crippen does not have enough fingers and toes to get a feeling for all these billions. In context, a “mere” £20 million is but a drop in the ocean and so I suppose there is little point in getting angry.

At least there is some common sense coming out of Norfolk:


Reported in the Guardian:

The Tory MP Richard Bacon, a member of the Commons public accounts committee, discovered the fines against NHS trusts. He found that trusts in north-west England and the West Midlands were committed to provide 50 IT staff to work with the US company CSC. They face potential penalties of up to £6.9m a year for 10 years.

Mr Bacon said: "At a time when hard-pressed NHS trusts are having to make painful choices to reduce deficits, they are being forced to pay money they don't have and release staff they can't spare, for something they don't want and which doesn't work ... the NHS is being hit with fines running into tens of millions of pounds, which it simply cannot afford". (full article here)

Dr Crippen cannot put it better than that. He can only cry in the arms of his financial advisor, who says:

"As I'm sure you know, this is a classic problem with IT projects. The contractors always demand you should stop your normal business activities in order to meet their requirements.

The really shocking thing is that the Trusts were unprepared for this. I presume it's because they never wanted the bloody thing in the first place.

Best guess is that the supercomputer will never work and will eventually get left to sink into the sand. Just make sure you never hand over your patients’ records." (Wat Tyler: Burning our Money)

Dr Crippen did not know. It seems that the Government did not know either.

More delays

Free at the point of entry

The wise greengrocer

The thrifty housewife went to the greengrocer to buy some tomatoes. They were £2 a kilo.
"But the shop next door sells them for 50 pence a kilo." she said.
The greengrocer smiled. "You had better buy them there, then."
"But they haven't got any" she said.
"Madam", said the greengrocer, "when I haven't got any I sell them for 50 pence a kilo too."

+++++++++++++++++++

Gladys came to see me yesterday.

Gladys is 72 years old. She was seen by one of my partners during the first week of January with an attack of cholecystitis. 72 is a little older than one would expect for a new presentation of cholecystitis. By all accounts she was not too unwell, and she responded quickly to treatment. My partner followed her up, and on Monday 16th January he requested an ultrasound of her abdomen.

Ultrasound request forms are prioritised by the Consultant Radiologists. The request was deemed to be “routine”. It was done on Thursday 26th May. I received the result today, some four months later.

Ultrasound of cholecystitis

Gladys has gallstones. I already knew that, because she was admitted to hospital in February with acute pancreatitis and again in early April. On the second admission, her amylase was 8000. Pancreatitis is a dangerous condition, particularly in the elderly. It is also extremely painful. Gladys is getting pancreatitis because of a simple plumbing problem. The stones need removal. They can be removed by laparoscope as a day case. She has been on the “urgent” waiting list now for ten weeks.

Gladys asked to exercise her “right” under the much vaunted “choose and book” system to be referred to another hospital. The general public thinks that “choose and book” will solve this sort of problem. Could I refer Gladys to another hospital? Absolutely. Will it speed things up? Absolutely not. All the hospitals have similar surgical waiting lists and she cannot even get on their waiting lists until she has got to the top of the waiting list for an outpatient appointment with the new surgeon. "Choosing and booking" for Gladys will take longer.

Of course, she could always sell her house and go privately. If she does that, the very same surgeon who she is waiting to see on the NHS will operate on her next week.

And it took me four months to get the ultrasound.

Reported today in the Times today is the usual story of the “man with the brain tumour who saw a succession of incompetent doctors all of whom failed to make the correct diagnosis.” The media always report it like this. The story is almost generic. It is possible that the GPs, casualty officers and neurologists who saw him were all incompetent. It is likely that, as is so often the case, the brain tumour was undiagnosable in the early stages. The twist on this story, which stops it being the usual generic example, is that the patient’s work-mates had “a whip round” and bought him a private brain scan. Like Gladys, this man had no easy access to the radiology department. (Full story here)

Access to the X-Ray departments is free at the point of entry but the patient may not live to see the door opened.

It gets worse. The £20 billion the government has spent on new technology to speed up appointments has actually delayed them. Full story here.

That £20 billion could have been spent on funding a modern treatment for prostate cancer that is available in all civilised countries. Except one. Full story here.

The government is raising expectations and training the patient to believe that everything is available immediately. It is not. When patients cannot get what they need, they come to their doctor. They may complain. They may moan. Usually they are fairly accepting. They see through the governement lies. Some, like Gladys, are frightened. Family doctors have to spend an increasing number of consultations explaining why that which needs to be done cannot be done.

Grand Rounds 2:37

This weeks edition of Grand Rounds is hosted and selected by Dimitry Kruglyak from the Medical Blog Network.

This is the best of the week’s medical and other blogging from around the world. Take a look here.

Dimitry was interviewed for Medscape by Nick Genes of Blogborygmi.

"Just as Web-logs have expanded openness and participation in journalism and software, Kruglyak hopes that his network of bloggers helps to spur the transformation of the healthcare industry. He's an ambitious -- and at times polarizing -- figure in the medical blogging community, but he's moving forward and may just change the way people think about medicine."

Read the full interview here.

The Crimbleshank Choice

The New Labour NHS Spine

I took my car in for a routine service last week.

When I went to pick it up, one of the technicians came out to see me. They do not have mechanics any more. They are technicians. Mechanic-specialists I daresay. He told me that the camshaft crimbleshank needed replacing. Or something like that. He offered me a choice of crimbleshanks from any one of five different suppliers in the county. He said it is the company policy now to offer all their customers a choice. I do not know much about crimbleshanks and so I asked the technician which one he would recommend. He said the one from the supplier round the corner was as good as any. But he had to document on the computer that I had been offered a choice.

He sighed. Company policy. We have this new computer system. It cost £60,000, so it is policy to use it.

The NHS new computer system for crimbleshanks cost more than £6 billion.

When Dr Crippen started in General Practice, he could refer his patients to any hospital in the United Kingdom. He referred 95% of his patients to the two local DGHs both within ten miles of the practice. The other 5% went to a variety of hospitals. Some to Birmingham, a handful to London and one or two further a field.

GPs are educated consumers of secondary care. We are fortunate to have two excellent DGHs close by. We know who, within those hospitals, are the good consultants. Most patients did not ask for a choice. They relied on our expertise to select the right specialist. A few said they preferred hospital “A” over hospital “B” usually for reasons founded more in emotion (Mother died in hospital “A” so we do not like going there) than in common sense. They were easy to accommodate. We sent a very small number further a field, almost always because we, as the referring GP, wanted to tap into a highly specialist field of expertise not available locally.

When the Thatcher government introduced fundholding the freedom of choice for the referring GP was wrapped up in bureaucracy. But it was worth it. Under fundholding, the money followed that patient. Now it became important for hospitals to attract work from well-organised fundholding practices such as ours. The care our patients received improved.

New Labour does not like professional freedom. New Labour does not like “choice”. When New Labour came to power in 1997, one of the first things they did was abolish fundholding. Not only did they abolish fundholding, which was relatively new, but they also abolished freedom of choice of referral which we had had since the inception of the health service. We were compelled to send all our referrals to the local hospitals. We could not avoid the areas of lesser expertise. The hospitals no longer had to compete for our custom and the standard of service declined.

Now, in an act of brazen hypocrisy, they are telling the electorate that they are introducing choice into the NHS with the new “Choose and Book” system. Choice is nothing new. They are only giving back what they took away. Actually, they are not even doing that, because the image of “choice” is an illusion.

GPs will toe the line because they are going to be paid huge financial bonuses for offering patients a “choice” of five prescribed hospitals. The overwhelming majority of patients do not want or need this choice, any more than Dr Crippen needs a choice of crimbleshanks. They can and do say straightaway, “Well, what do you recommend, doctor”. And we recommend the best local specialist, as we would always have done. But the GPs do not have real choice of referrals because we are stuck with the five pre-selected hospitals.

Humbug.

It gets worse. The “Choose and Book” computer system is going to record all the medical details of the referrals and this information will be available for all on “The Spine”. (Read all about "The Spine" here)

So not only will you have to carry an identity card; not only will it carry the details of your latest Viagra prescription; now it will detail which hospital treated you for that attack of gonorrhoea about which you were trying to forget.

The NHS Crimbleshank Choice has cost you, the taxpayer, £6 billion pounds.

Fighting for your life in North Yorkshire

The Friarage Hospital : Northallerton

Dr Crippen has had a tip off from Yorkshire.

Doctors at the Friarage Hospital (full details here) , are fighting for the lives of local people.

The county town of North Yorkshire, and the seat of North Yorkshire County Council, the largest local authority in the country outside London, is Northallerton. Northallerton is served by the Friarage Hospital, and the Friarage Hospital is in trouble. Financial trouble.

This is not urban hospital planning. North Yorkshire is a large rural area. The two local air ambulance services, the Great North and the Yorkshire, are used locally and land at the Friarage.

North Yorkshire Moors

Just up the road (the A1) there is a Three Star Hospital in Darlington. It is not altogether logical to have two hospitals so close together. Nonetheless, at a public meeting in Richmond (full details here), the following commitment was made:

“It is important that the service at the Friarage is maintained and given fair consideration and not compromised. Though a rural area, Richmond gets a lot of visitors which amounts to a lot of people who need healthcare.”

Jill Moulton is the director of planning at South Tees Hospitals NHS Trust. She was asked why we should support a one star trust when there is a three star trust at Darlington? She replied:

“The one star rating was due to a specific failure on access targets. Star ratings are not an accurate indicator of the clinical quality of a hospital. Patients will have more choice of hospitals and where they are treated in future.”

Controversial stuff, Jill. Dr Crippen agrees that the star rating system is nonesense (as discussed here in Three Star Scams) but Jill has taken the New Labour shilling and she is off message. I hope Patricia does not notice what she has said. (Full details of the Department of Health Star system here.)

Whatever the realities of the matter, you would have to forgive the majority of the general public for assuming that three star status was an indicator of clinical quality. And being able to “access” a hospital would seem a reasonable prerequisite for good clinical care. Apparently not. A "discussion" document, originating from the PCT, is currently circulating between the PCT and the hospital planners entitled:

“Commissioning Effective, Efficient and Necessary Care Pathways”

Oh! Dear! I feel an attack of New Labour jargon coming on.

Cynics like Dr Crippen would first ask, “What does the word ‘pathways’ lend to that title”? Does it mean anything? Secondly, having read the document, they would ask why the document is not entitled “Saving money by cutting medical services” because that is what it is really about. I should be used to it by now. It is New Labour speak. New Labour does not use words like “cost cutting” or “reduction of services”.

In order to make the Friarage financially viable Jill (who is not herself medically qualified), her colleagues and the PCT are discussing the following “effective, efficient and necessary care pathways” (sic):

The following patients are “deemed” not to need admission from Accident & Emergency Department. (Lovely word, “deemed”. What does it mean? Why not omit if from the sentence? Why not just say “the following patients do not need admission…? But I digress.)

• those with an upper limb fracture
• those with back disorders
• those with a “pelvis lower limb fracture (whatever that may be)
• those with “complex elderly musculoskeletal” problems
• those with fractures of the pubic rami
  

The following patients are “deemed” (that word again) to be “unlikely” to need admission:

• Poisoning
• Angina
• arrhythmia or “other chest pain”
• those with asthma.

This is new Labour bureaucracy at its best. We need to save some money. A hospital in the middle of the North Yorkshire Moors is expensive. So the Planning Directorate, run by someone who is not medically qualified, and the PCT will tell the doctors how to do their job. In particular, it will tell them who should and should not be admitted to hospital. Please help Dr Crippen. How is this “Commissioning Effective, Efficient and Necessary Care Pathways”. Is this not in fact closing pathways to patients with a pre-determined list of illnesses? Illnesses that people who have been to medical school would say could be very serious. Have any of these people ever seen an old lady in severe pain having fallen and fractured her pelvis?

The following draft letter, from the medical staff at the Friarage, has been leaked to NHS BLOG DOCTOR. I print it in its entirety:



24 May 2006

Mrs J Moulton
Director of Planning
South Tees Hospitals NHS Trust
James Cook University Hospital

Dear Jill

Proposed commissioning arrangements, North Yorkshire & York PCT

I would like to respond to the discussion documents which have been circulated in relation to NY & Y’s proposals for reducing the commissioning of secondary care services. Whilst some of their proposals, contained in their document: “Commissioning Effective, Efficient and Necessary Care Pathways” are eminently sensible, others appear seriously divorced from reality and have considerable potential to damage patient care. My particular concerns are as follows:

• P4 & 5: patients deemed not to need admission from A & E include those with an upper limb fracture, those with back disorders, those with a “pelvis lower limb fracture (whatever that may be) and those with “complex elderly musculoskeletal” problems. Later on p5 the statement is made that people with fractures of the pubic rami generally do not need admission. These are sweeping statements, which take no account of the age or general frailty of the patients, nor of their level of social support. To suggest that elderly patients who have a humeral fracture or a pubic ramus fracture and who can’t look after themselves can all be cared for in community settings is completely unrealistic.

• P5: patients deemed unlikely to need admission include those with collapse, those with poisoning, angina, arrhythmia or “other chest pain” and those with asthma. Once again, these statements are far too sweeping: it would be a brave casualty officer who would send someone home if they had a history of having taken a quantity of antidepressants or paracetamol; to discharge someone from A & E after an overdose is very much the exception, not the rule. The same could be said of most of the other conditions on this list. Clearly, whoever wrote this section of the document does not have an up-to-date knowledge of acute medicine.

• P17: the proposals relating to diabetes are generally sensible, although the category of patients who should be referred to secondary care needs to include not only those patients who are already pregnant but also those who are planning a pregnancy.

• P31: the statement that follow-up should be provided “by exception only” flies in the face of established practice in the care of large numbers of people with chronic diseases, including diabetes, asthma, COPD, inflammatory bowel disease, arthritis ad a large number of other conditions. Whilst there is, of course, scope for some flexibility around follow-up in chronic disease, it is crucial that we continue to provide a clinically appropriate service to those people who need it, including people with complications of diabetes or who have multiple and complex health problems related to diabetes. I also find it extraordinary that the PCT should expect to receive a copy of every letter which goes from secondary to primary care in connection with the management of people with chronic disease – do they really want to be buried in paper?

• P31: the statement that the PCT will not pay for nurse-led follow-up as these services can be provided in primary care is bizarre and is also insulting to specialist nurses in diabetes, respiratory medicine and a variety of other specialties. There is abundant evidence that specialist nurses provide an effective, and cost-effective, service and that they allow patients to be cared for in their own homes and to avoid hospital admission.

I would be very grateful if you could include these observations in your discussions with the NY & Y PCT.


Yours sincerely



On behalf of the medical staff of the Friarage Hospital


++++++++++++

This is an extraordinarily temperate letter. If these changes come in, what the PCT, the bureaucrats, Jill Moulton and her planners will really be doing is re-defining the definition of hospital. Hospitals used to be a place to go to if your were seriously ill. Not any more.

How does this fit in with the original mission statement:

“It is important that the service at the Friarage is maintained and given fair consideration and not compromised. Though a rural area, Richmond gets a lot of visitors which amounts to a lot of people who need healthcare.”

Do not let granny fracture her pelvis in Northallerton. Do not have an asthma attack in Northallerton. Do not have angina in Northallerton.

The only “pathway” you will have is out on the street.

+++++++++++++

Dr Crippen may have been too hard on Jill Moulton, the Director of Planning. It seems she is the ham in the sandwich between the PCT and the hospital doctors. A local doctor writes:

"Jill Moulton is actually one of the good guys. Her response was in no way agreeing with the principles of the PCT proposals but we are in a bit of a bind here. If the PCT decide not to commission something then we can do little about it or else we do work for no payment and then get stung by the SHA for not being in balance."

Poor old Jill.

But doctors should not be pressurised like this. To quote from the venerable Wat Tyler:

"And it's obvious to anyone who's experienced a typical NHS hospital recently that patients have slipped down the priority list...as have the staff. The only people who have clout are the Commissars."

The Crippen Diaries (Week 22)

Not quite Tannochbrae

Tuesday 30th May


After the May Monday Bank Holiday, it is a short week, and being school half-term it should be a quiet one too. First a call from the coroner’s officer. An elderly lady collapsed in the local dry-cleaners on Saturday and could not be resuscitated. Was this an expected death, had I seen her recently and would I be able to issue a death certificate? The answer to all three questions was “no”. I had seen her three weeks ago about a minor problem but I was not expecting her to die.

When an elderly person dies, family doctors are often put under pressure to produce a death certificate. It saves the family the stress of a post-mortem. There is no way I can do this certificate, and it amazes me that after Shipman we are still subjected to these pressures. Routine post-mortems on elderly people who die suddenly frequently do not reveal a definite cause of death. The pathologist will put down one of the usual bland statements about myocardial degeneration, or some such plausible expression, but it is all a bit of a fudge.

++++++++++

I have a fourteen month toddler who has been presenting regularly over the last two weeks with recurrent high temperatures. He is often a bit listless, but there has never been anything specific to find. You need to exclude a urine infection. I have two normal urine specimens off him so that diagnosis is now unlikely but still not impossible. I sent him into hospital last week. He was kept in for two days under observation. Nothing was found. He was send home on Co-amoxiclav with a diagnosis of “probably viral infection”. Mum wants to know why a viral infection was treated with antibiotics. Beats me. And he is no better. The temperatures continue. He does not seem parituclarly ill, but his mother is worried about him and so is his doctor.

++++++++++


Thursday 1st June

Julie, a teenage girl, is brought in by an apologetic mother. She is singing in a choir at the Albert Hall in a few weeks in a concert organised by the BBC. As part of the requirements, the BBC insist that Julie has a medical certificate stating that she is fit to perform. Presumably this is to cover them if she drops dead during the performance. Someone can sue me rather than them.

It happens all the time. No one will take responsibility for anything anymore. Certificates to join the gym, to go on holiday, to go parachuting, scuba diving, bungee jumping…the list seems endless.

This sort of attitude disenfranchises parental rights and duties. The parents should be allowed to make this judgement. They would be the first to express concern if Julie had any illness likely to make it dangerous for her to go to the Albert Hall.

Julie has no medical history. I rarely see her. She may have undiagnosed congenital heart disease, early leukaemia, cystic fibrosis, epilepsy, a brain tumour, a grumbling appendix, Asperger’s syndrome or tuberculosis. So might I. So might you. The only way I can express a sensible opinion as to Julie’s fitness is by doing an extensive and detailed medical examination, running some blood tests and getting a CXR. And even then, you cannot prove a negative. All the normal tests in the world will not stop you dropping dead if your time has come.

The NHS, rightly, does not cover work like this and the costs would be several hundred pounds. The parents could not afford it, and the BBC will not pay.

So I scrawl on a piece of paper something along the lines of “I know of no reason why Julie should not perform at the Albert Hall.”

This “certificate” means nothing.

Mother thinks this is nonsense and so do I. Julie will perform at the Albert Hall. Let us all hope that she does not have open pulmonary TB.

+++++++++

A 74 year old comes in for his biannual check. He had a CABG done four years ago. Since then, he has got himself remarkably fit. He is lean and active. He is on BP medication and a statin. His cholesterol is 3.9, his BP is 126/78 and he takes regular exercise. He should live to be a hundred. But he has a problem. He is going to California for two weeks next month, and he cannot find satisfactory travel insurance. The insurance companies are terrified of hospital bills from the USA. I do not blame them. He is a “cardiac patient” and they are quoting premiums of over £300 for two weeks cover. It seems extortionate to me. Actuarially I would have a flutter on him. I think he is good for another 25 years. But the insurance companies do not look at individual cases or individual fitness. They just load the premium on the basis of the history.

++++++++++

A letter from the local chiropodist asking me to see a patient with a fungal nail infection. That is all straightforward. Except for one thing. The local chiropodist has now turned into a podiatrist. What does this mean? Is it similar to the way that the dentists have started calling themselves “doctor”? Do they think “podiatrist” sounds grander than “chiropodist”? It says here that they are the same.

Is this pretentious guff, or is Dr Crippen being cynical again?

+++++++++++



Friday 2nd June

Duty doctor today, so I have to pick up all the unsolved problems that will not keep until Monday. Friday is the worst day to be duty doctor. Many problems can wait over night, but not three days. And on Fridays in the summer, a lot of people want to “tidy up” elderly relatives for the weekend.

Ethel is 82, frail and has been having “dizzy attacks and funny turns” for ten years. These have been extensively and appropriately investigated. No underlying serious pathology has been found, and the “dizzy attacks” continue once or twice a week. Ethel’s daughter is going to Greece for a fortnight. Ethel worries when her daughter is away and, predictably enough, has another “funny turn”. So she calls her daughter who calls me. She would like mother “checked over.” Just in case. And would you mind calling on her at home as we live five miles away and we are busy packing.

++++++++++

Amongst all the routine appointments, the extra appointments, the urgent telephone calls, the visit to Ethel and others there were the events surrounding the prescription for hormone replacement therapy. Events in a way so dull and trivial that I hesitate to describe them. And yet, they epitomise the stresses and strains of general practice, the impossibility of responding immediately to all demands, and the reason why so many patients are critical of the “appalling” service that GPs provide.

It is just after ten o’clock. Two hours into the surgery. Doing quite well. Only ten minutes behind. The senior receptionist nips in with her “don’t shoot me I am only the messenger” look on. Mr Jones is at reception. He is demanding an urgent prescription for his wife and “will not leave until he gets it.” The prescription is for her regular supply of HRT.

This is not medication upon which the patient’s life hangs. Far from it. I tell the receptionist that I am not doing this in the middle of the surgery, but I will look at it at the end. The receptionist is relieved. Although she will have to go back to an angry Mr Jones, she has already told him that the doctors do not issue prescriptions on demand in the middle of surgery. If I had done the prescription, and we once had a partner who did this sort of thing, it undermines the reception staff by giving the message to the patient that the receptionists are awkward and obstructive and if only you can get through to the nice doctor, everything will be sorted out. In any case, it is not appropriate to keep patients with booked appointments waiting whilst you write out prescriptions. We put time aside for that later in the day.

Halfway through the next consultation, a message flashes on the screen saying “Mr Jones will be back at 12.30 and expects his wife’s prescription to be ready. He says this prescription was requested three days ago and should have been done then.”

I finish the morning surgery at 12.25. Already another message has flashed on the screen saying Mr Jones is back. First things first. I go for a pee. Sorry. Four and a half hours with two cups of coffee. No choice. On return, I get Mrs Jones up on the computer. I have not met her. She “belongs” to one of my partners who is away today. She is 53. She has been on HRT for 5 years. She is on a no-bleed, continuous combined preparation. She is a non-smoker. Her last cholesterol was 5.9 and her blood pressure was 128/78. She has been called for the routine mammogram screening program but did not turn up for the appointment. She has no first degree relative with breast cancer, but an elderly aunt died of it some years ago. She has not been seen at the practice for over a year.

I hate the word policy. Our practice policy is that we do not issue repeat prescriptions for HRT. We insist on seeing the patients twice a year and, if all is well, we will give them six months supply. There is no magic about the period of six months. Nine would probably do. Three would be too short a period, a year too long. But, yes, it is an arbitrary line. We see some patients ourselves and the practice nurses see some of them in the Well-Women clinics. Appointments are available from 7.45 a.m. through until 6.00 p.m. on four nights, and 7.30 p.m. on one night.

Mrs Jones needs a BP check. We need to know what her plans are on mammography. If she wants to decline to have it, that is fine, but I need to document that that is her informed decisions. We need to talk about her slightly raised cholesterol. Basically, I need to do my job.

Looking at the notes, my partner has issued the last two prescriptions for HRT after difficult telephone conversations with Mrs Jones who has always been “too busy” to come in for a check. The letter requesting the prescription this time was seen by my partner on Wednesday and she has marked it “NO. This time she must come for BP etc.”

When do you draw the line? When do you dig your heels in? My partner has already issued a year’s supply without seeing her.

I call Mr Jones in at 12.45. He is not happy. He ostentatiously looks at his watch as he sits down. I explain politely that I am not prepared to do the prescription until Mrs Jones has been seen for a check. He is angry. Very angry.

“My wife is a company director. She is too busy for this sort of thing.”

I am too busy for this sort of thing too. I start at 7.45 am in the morning four days a week, and I do the late night commuter surgery on Tuesday to try to help people like Mrs Jones. It is not good medicine to prescribe HRT to a patient who is not being monitored properly. From the medico-legal point of view, if I issue this prescription, and Mrs Jones has a stroke next week, what shall I say to her lawyers?

I have no appointments left. Nonetheless, I offer to see her after the surgery at 6.45 pm. That is no good. She has a meeting. I offer an appointment for 7.45 am on Monday morning. That is no good either. She is going down to London.

Mr Jones says “I am not leaving without the prescription.”

When he finally realises that this statement is inaccurate he tells me that we are “the worst organised practice he has ever come across” and “you can never get a bloody appointment here” and storms out. He means that you can never get an appointment at a time convenient to Mrs Jones.

He will tell all his friends locally how awkward and difficult we are, and what a dreadful “service” we provide.

++++++++++

And so on with the rest of the day.

Labour MPs will not commit to using the NHS

Between a rock and a hard place

Time for Dr Crippen to re-visit “Our Petition”.

You may remember we discussed this a few weeks ago here. Dr Crippen has always said that our schools and our hospitals will never improve until the great and the good start using them. The idea behind Our Petition is simple and simply brilliant.

Let us ask the great and the good to sign a petition committing themselves to use the NHS. What could be easier than that?

It is perhaps not surprising that many Tory MPs are reluctant to sign. We mentioned here that David Davies, the MP for Monmouth, 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!"

Oh! Dear. A bit off message. Not quite what the boy David had in mind.

In his King's Funds Speech of 4 January 2006, David Cameron said:

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

But who is he to decide what Tory Party policy should be? Still, he is in excellent company.

"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)

That’s all agreed then. We do not want to "affront" our beliefs.

Dr Crippen’s patients, who are still waiting for the cardiac surgery that the Prime Minister had last year, feel affronted. And many of his patients with demanding and stressful jobs which have caused ulcers would have been affronted had they known that the same Tony Blair, when Leader of the Opposition, crept into the Chelsea & Westminster Hospital to have an endoscopy carried out by a leading English gastroenterologist. All on the NHS? Of course it was.

So let us get the MPs to put their money where their mouths are. Or where their leaders’ mouths are.

For the Labour Party, surely it is straightforward. All their MPs will sign without hesitation. They are proud of what they have done to the NHS. Indeed, the Rt Hon Patricia Hewitt, our worthy Secretary of State, has told us that the NHS is having its best year ever.

Have they all signed? I am afraid not. They are between a rock and a hard place. They do not want to sign but cannot say why. So most of them are ignoring it and hoping it will go away. It is not going to go away.

To date, only a miserable 7% of the Labour MPs have agreed to sign. Proportionally they are behind the Lib Dems. Full details of the MPs who have signed here.

Keen though he is on the NHS, Dr Crippen will keep paying for private health insurance for himself and his family until such time as the NHS is safe for all potentially serious conditions.

What, I wonder, will the Labour MPs give as their reason for not signing the petition?

What would Patricia say?

What would Guido say?