Pornography and "The West Wing"

Dr Crippen has a problem with pornography.

My problem relates to the law surrounding access to pornography. When the law moves into morality, it usually makes an ass of itself. We all enjoy the extraordinary question counsel put to the jury in the Lady Chatterley trial. “Is this the sort of book you would like your servants to read”. A few years later, Judge Argyle made a fool of himself in the Oz Trial where, memorably, he branded Felix Dennis as "very much less intelligent" than the other defendants. Dr Crippen wishes he was as stupid as Dennis has turned out to be.

Dr Crippen’s experience of pornography is limited. There was that magazine that someone bought at school. That was a long time ago. Then there was that video that the medical registrar of the day brought into the doctor’s mess one evening when we were all on take-in. We ordered a Chinese, and all (about a dozen of us) sat round watching it. Grainy german couples in embarrassing nineteen seventies clothes going camping in the country; tinny and ludicrously inappropriate background music; an attempt at a story; and then very rapidly it drifted into raunchy sex, filmed in close up, and much reminiscent of a gynaecology tutorial. It was not arousing. Mary Whitehouse would say we were depraved and corrupted. The main emotion was boredom. Was it unprofessional to watch this whilst we were on-duty?

Should we all have been struck off?

If I go out and buy a “girlie” magazine from WH Smith’s, and browse through it during my mid-morning coffee, should I be struck off?

Dr Omboye Pax Harry was struck off the register for looking at pornography whilst at work.

Dr Omboye Pax Harry, from Solihull, West Midlands, had appealed against a decision of the GMC’s Fitness to Practise Panel made in March. He admitted his actions were “inappropriate and irresponsible” but argued the panel was wrong to take into account the “public interest” when deciding whether his fitness to practise had been “impaired”. The doctor admitted looking at porn on a number of occasions on two computers at a surgery in Oldbury, West Midlands, where he was employed as a full-time locum GP. (The Sun)

I would be the first to agree that it sounds tacky. But he was doing nothing illegal, and it seems to have been agreed in the court that it would not have been a problem if he had looked at it at home.

But now the GMC says doctors must be held to a higher standard. Where do we draw the line? Who sets the standards?

Doctors have been struck off for looking at pornography at home. Paedophile pornography. I have four teenage children. I am utterly opposed to paedophile pornography. It horrifies me. But I do have a problem with a law that makes it a criminal offence for me, in the privacy of my own home, to look at something that is freely and widely available. The people who make it, buy it, sell it and publish it are a different matter all together. I would lock them up.

I understand the argument that if no one looked at it, no one would make it. But it has been made. And it is available. Should it be an offence just to look at it?

Supposing you look at it accidentally? Should that be an offence? How would you be able to prove that it was accidental?

A few months ago, I had a horrifying experience.

I am a great fan of the “West Wing”. Make of that what you will, but I am. I wanted to get the final series before it was available in the UK. I saw a facility advertised on the Internet to do just that. I did not want to do anything illegal – downloading pirated videos – but this was a reputable company that charged a fee. I paid the $30 up front to join. I downloaded their software, started it running, and searched for the “West Wing” on their numerous menus. I could not find it. I could not find any TV series I recognised, nor any movies. What I did find, however, were endless lists of obviously pornographic movies, many containing words like “teen” and “co-ed”.

I wanted to remove this software from my hard disk completely, and I did not know how to do it. So I called a geeky friend in. He looked at it and asked me if I realised I had set up and authorised a “hard disk sharing programme.” The “menus” I could see were lists of films on other people’s hard disks. My own hard disk was open for “sharing”. I genuinely had no idea.
He removed the software, and did a low level format of my hard disk. It has all gone. I then had a long battle (on principle) to get my $30 back.

I was probably very close to committing a criminal offence. Entirely innocently. But how would I have proved that? Look at Operation Ore. The police are particularly targeting the professionals.

“I was trying to find an episode of the ‘West Wing’, officer.”
“Of course you were, sir.”

It is not even as plausible as researching a book.

The lawyers have created all sorts of obscure definitions for “publishing” and “storing” images on computer hard disks. The trouble is, you can do all this accidentally, almost without realising it. Anything that you look at on your computer screen is on your hard disk somewhere. And you can download this sort of stuff accidentally. A few weeks ago, I was researching something on how nurse’s uniforms have changed over the years. Naively, but innocently, I put “nurses in uniform” into GOOGLE. Nothing too offensive, but not what I was expecting.

That will be somewhere on my hard disk now. Should I do another low-level format?

Animal Hospital

In what is promising to be the biggest NHS public relations disaster since Patricia Hewitt said that “despite huge job losses and mounting financial problems, the NHS is enjoying ‘its best year ever’, Ipswich Hospital announces that it will be:

“…using equipment unused at weekends to treat pets with cancer in Saturday clinics. The hospital aims to raise £50,000 a year from the idea to help pay off debts of more than £24m.”

Out in the colonies, the American medical profession will be falling over laughing. But remember we are a nation of animal lovers. Animal hospital is a popular TV programme. As expected the RSPCA was in favour of the plan. David McDowell, its acting chief veterinary adviser, said:

“To make unused medical facilities available to improve animal welfare is an excellent idea.”

Hospital spokeswoman Jan Rowsell said the idea was among 700 put forward by staff to raise funds. She said the hospital was considering teaming up with a veterinary school. If the idea became a reality the hospital would use stringent infection control procedures.

"Everything will be covered in anti-allergy drapes and hygiene will be of the utmost importance," she said. “The radiotherapy room would be thoroughly deep cleaned after each session and the costs we would charge would include very strong, robust cleaning and infection control measures."

That is all right, then.

Jan Rowsell is Head of Communications at Ipswich Hospital. For the time being.

Ipswich Hospital

On the hospital web site, they say:

Click here if you wish to make a suggestion or praise us.

Please, do not hesitate to let them know how you feel about this. Meanwhile, Dr Crippen awaits with fear and trepidation the 699 other suggestions. Come on, Jan, don’t keep us in suspense.

How to avoid cot deaths (SIDS)

Healthy three month old babies shouldn't have to die, but they do, and I went to the funeral of one of them the other day. The infant son of a nurse I know, he was put to bed fine and normal but was dead when they went to awaken him in the morning. (Neonatologist in USA)

+++++++++++

It is difficult to think of anything more distressing that can befall a parent than a cot death. (Sudden Infant Death Syndrome : SIDS) That it could happen twice in the same family does not bear thinking about. That a mother who has had two of her children die of "cot death" or from other unexpected and unexplained causes should then be unjustly convicted of killing them defies belief, and yet that is what happened to solicitor, Sally Clark. She was sentenced to two life sentences for killing her children.

She was wrongly convicted but served three years in jail before finally establishing her innocence. She was convicted on the basis of flawed medical evidence given by Sir Roy Meadow, one of the most eminent paediatricians in the UK, and by the pathologist, Alan Williams.

During her trial, Sir Roy said:

“The probability of two natural unexplained cot deaths in the family was 73 million to one.”

The figure was later disputed by the Royal Statistical Society and other experts said that once genetic and environmental factors were taken into consideration, the odds of a second cot death in the same family were closer to 200 to one. There were other flaws in the prosecution evidence, not least the fact that the pathologist, Alan Williams, had failed to disclose key medical evidence.

Sir Roy Meadow was struck off the medical register by the GMC but the High Court has just reversed that decision.

Sir Roy Meadow

Sally Clark and her family have been devastated. Other mothers, against whom Sir Roy testified, have been released.

Sally Clark

The GMC and lawyers are arguing about the best way to find and treat expert witnesses. A fascinating medico-legal debate ensues and, in the meantime, paediatricians are convinced that it may now be impossible to convict women who are genuinely guilty of killing their children, for no doctor will dare give evidence. Roy Meadow was wrong, but should he have been struck off? His work over the years has probably saved hundreds of lives.

Parents with small babies are less concerned about abstruse legal arguments. They are, as always, looking to the medical profession for advice on how to minimise the risk of cot-deaths. The question Dr Crippen is most commonly asked as a family doctor is “in what position should a baby be put down to sleep?” The advice has changed from prone, to side, to back even within his short career. Currently, we advise putting babies on their backs and it seems that is correct.


But there are lots of other factors. Phillip Gordon, an experienced neonatologist and well known author (see above) in the USA, gives an excellent summary of the best way to reduce cot-deaths. Essential reading for all parents, and all health care professionals involved in paediatrics.

GPs told to stop teenagers having sex

Dr Crippen has barely recovered from being “told” by the Independent on Sunday that he is to examine all underweight girls for signs of eating disorders, when he receives an email from a regular reader advising him that he is now being “told” to quiz all thirteen year old children who come in with bad colds about their sex lives. Does he do this, he wonders, before or after “examining” them for eating disorders?

Now I know this reader happens to have a good sense of humour, so I know it is a leg pull and a spoof reference. So I follow it up with a smile.

13-year-old with a cold? Quiz them on their sex lives, GPs are told

By Beezy Marsh, Health Correspondent
Last Updated: 11:30pm BST 28/10/2006

Children visiting their GPs with minor ailments could be closely questioned about their sex lives as part of an attempt to cut teenage pregnancies and sexually transmitted diseases. A Government health watchdog wants doctors to target children as young as 13, even if they have not asked for family planning advice. Family doctors will be ordered to make more effort to offer contraception to sexually active young teenagers, as well as warning them of the risks of infections including chlamydia, which can harm fertility.

They will be expected to spend 15 to 20 minutes inquiring into the sex life of each teenager, even if the teenager comes in for an ailment such as a sore throat.

The measures, proposed in draft guidance by the National Institute for Clinical Excellence (Nice), were drawn up to try to stem the rising tide of sexually transmitted infections and Britain's alarming number of teenage pregnancies, which cost the taxpayer £63 million a year.
However, GPs say that they will struggle to find the time to carry out counselling, while critics say the measures will do little to stop the spread of sexual diseases or prevent schoolgirls from getting pregnant. The policy also appears to contradict the latest Government message, which urges young people to "delay" having sex.

The NICE guidance says GPs should outline contraceptive choices, including the morning-after pill and long-acting contraceptive devices such as implants and the coil. They are seen as more "reliable" because a teenager cannot forget to take them, as with the pill. However, they will offer no protection against infections. (Daily Telegraph)

I have to wipe the smile from my face. None of this sounds very NICE and yet that is where it comes from.

And this time I am not just being told. I am being ordered!

Family doctors will be ordered to make more effort to offer contraception to sexually active young teenagers...

Ordered? By whom?

And they want me to fit IUCDs to sexually active 13 year old girls? Too silly for words.

Please, please, please, please will you all go away and let me get on with my job.

Anorexia Nervosa and Bulimia : GPs to blame

British GPs are responsible for all the women in the UK who suffer from anorexia and bulimia. It is clear that the GPs are either too stupid to make the diagnosis or, if they are able to make it, they are too lazy to make it. If only they would get off their butts and examine all underweight girls for signs of eating disorders, the problems would be solved overnight.

Meanwhile, back on the Planet Earth, Dr Crippen and his colleagues are once again feeling battered. Sophie Goodchild and Marie Woolf are responsible for a long article in today’s Independent on Sunday. Like all journalists who discover a medical problem that is new to them, they assume that GPs are not aware of it either, so the first part of their mission is to “educate” those ignorant, failing GPs.

GPs told: examine all underweight girls for signs of eating disorders.

Let us look at their headline in more detail:

1. There is not much to gained from “examining” girls these girls other than the obvious finding that they are underweight; they may, if the condition is advanced, have lanugo and some breast atrophy, but they will not welcome intrusive inspection. Many will refuse such an examination and all will feel threatened by it. They are self-conscious about their bodies, and usually try to hide them. Height, weight and BMI are useful.

2. The diagnosis of eating disorders is made primarily on the history, which needs to be elicited gently and subtly, with kindness and, above all else, non-confrontationally.

3. Unless patients (by the way, Sophie and Marie, you are being sexist. Boys get it too) ASK for help about eating disorders it can be difficult to broach the subject. Most patients with eating disorders are intelligent and brilliant manipulators of medical professionals and families. Finding a way in is the challenge.

4. Anorexia and bulimia are both a problem but nowhere near as common a problem as obesity. But the media does not like fat people. They are, as we discussed, ugly and stupid. Keep eating your ice-cream, Marlon.

5. Finally, a small point. People do not tell me what to do. I am an independent professional. I listen to lots of advice and, if it pleases me, I take it. If it displeases me, I ignore it.

Having made the diagnosis of an eating disorder, what do Sophie and Marie want us to do next?

There are no secondary resources.

There is nowhere to send them.

The good Eating Disorder Centres are almost all tertiary referral units – i.e. they will not take referrals from pond-life like GPs until the patient has been through the local “unit”. Unless you go privately. Then, of course, the psychiatrists will be all over you. This is a lucrative area for Yellow-Brick Road merchants. A chronic serious condition that often does not get better and for which there is no definitive treatment. It is a cash cow. So, if you are rich and thin, then get yourself up to Harley Strasse. If you are poor, well, you will have to do your best with what your GP can offer on the NHS. Not much.

The local unit in Dr Crippen’s area is run by two of our dear friends, the nurse specialists, “backed up” by a dietician. The psychiatrists, who in any case are awful, do not get involved. The unit has a fancy name. We will call it The Little Nell Unit, though that it not its real name.

Our practice has made a policy decision to stop referring to the Little Nell Unit. Every single patient we have referred there over a four year period deteriorated. Why should this be? Because there are no psychiatrists involved. All the unit has to offer is the tyranny of the weigh scales. It does not work, girls. The Eating Disorder Nurse-Specialists follow their protocol; they weigh the patients every week and if they have not put on weight they look serious and tell them they must eat more. Brilliant! Why did I not think of that? The dietician then sees them and spends an hour telling them that there are not many calories in a half a grilled tomato and then draws their attention to higher calorie foods.

The patients like to be weighed to make sure they are not gaining weight, and they listen appreciatively to the dietician’s advice as it helps them avoid high calorie food.

Dr Crippen has a anorexic patient who is a chartered accountant in Birmingham. She read economics at the LSE. She is 28 years old. She has not had a period since she was 17 years old. Her BMI is 16, and has been between 14 and 16 for ten years. She is on the road to osteoporosis. She does have fine lanugo. She also has a fine sense of humour, and complete insight into her condition. She ran rings round the Little Nell Unit and, when I finally got her to a fancy unit at a teaching hospital, she ran rings round them too. She stopped going.

She is fascinating. She is emaciated but feels fat. “It’s distorted body image, doc, I know.” She has read all the books, including the excellent one by Janet Treasure. I said to her, “If I gave you this pill and said it would make you put four stone on, is there any amount of money that would make you take it?” Absolutely not. Not for anything. I said to her, “if I gave you this pill, and you knew it would rid you of your anorexia, would you take it?”. Absolutely! Immediately! I do not have such a pill. And then we talk about the dangers of anorexia. She knows them all. She wishes she did not have the condition. But she cannot and will not eat properly.

I see her once a month. She keeps coming, like clockwork. I am not sure what we are achieving. Support, I guess. I am obsessionally non-judgemental. We talk of the anorexia in the third person, as a shared problem, as an unwelcome guest at our consultation.

Last month, I flummoxed her. When she came, I asked her to sit in my chair. I sat in the patient’s chair. I said, “Imagine I am a 17 year old anorexic with a BMI of 14. How would you advise me?”

She thought about that for a long time. Then she laughed. She said she felt inappropriately important in my chair. That is your best one yet, she said, but I need notice. I will answer that next time.

She is stable. She is not going to die at the moment, but she will probably die younger than she should. And she will get osteoporosis. And she is unlikely to have children. She knows all that, and is frightened of it, and would do anything to avoid it. Anything, that is, except eat. I shall ask her about the article in the Independent on Sunday. She will have read it.

And now I must take my medication, for if I do not, I am going to tell Sophie and Marie to fuck off, and I do not use language like that.

The death of Dirk Ooms

Dirk Ooms (1924 - 1998)

I hesitate to bring Nurse Ratchet to the fore again. She has already attracted 210 comments. Sadly, some of them are so rabid that they reflect only upon their authors and not upon the nurse’s post. The well-meaning but worryingly superficial nature of her post was therefore missed. She said:

A patient was brought into the Medical Unit referred by a local G.P. Rushed in I should say. Properly rushed, blue light, wah-wah's - everything. Presenting complaint - Bacterial Meningitis. Well, it IS the time of year for it. Symptoms - high temperature - check. Painful neck - check. Headache - check. Difficulty swallowing...hang on. Swollen neck.Wait a minute."Excuse me sir - could I have a look at your throat? What's that I see? Inflammation? Things with pus in clinging to other red swollen things?Ever had tonsillitis? Oh you have ? And it was just like this except this is worse?" Hopefully I don't need to tell you that the patient had Quinsy, and was referred immediately, by a nurse, to the ENT doctors, who did their surgical thing and removed the pus without the need for drilling a ruddy great needle into his spine. Quinsy is indeed an emergency, but to be unable to have even done the most basic of examinations before getting all excited and calling the blue light boys....well.

In the first of the 206 comments, I said:

You don’t give the age of the patient – but in a young person, in particular, who is very ill, with a sore throat, temperature, sore neck, there is a possibility of a condition called epiglottis. As soon as that word flashes through your mind, you do NOT start poking around mouths with lollipop sticks unless there is an anaesthetist around. I don’t expect you to know that. Do read it up, dear, when you have time.

I stand by every word of that.

Epiglottitis is a life threatening illness often caused by the same bacterium that causes meningitis. It requires a high level of diagnostic acumen to spot it in the first place, and skilled, specialised multi-disciplinary treatment if the patient is to survive.

The idea of a nurse poking around with a lollipop stick makes me shiver. If epiglottitis is not managed properly, the patient will die.

Via the new NHS_SUCKS forum, I have come across a terrifying story of a patient admitted in just these circumstances. I make no comment as to the rights and wrongs of the story, but The death of Dirk Ooms: NHS mistakes and cover ups deserves to be widely read.

Whatever the merits of the case, one thing is clear. The NHS complaints procedure is a disgrace. Is it any wonder that people with a grievance so often say that “the hospital will never tell us what happened”, or that the “doctors all stick together” or that “there is always a cover-up".

Watch out, there's a homosexual about

I had quite forgotten about Dr Adrian Rogers. He is a well known, indeed eminent, family doctor down in the West Country.

I was reminded of him over at Rachel’s place. Dr Rogers was upset by a toy that he found in the grocers.

I am late into this story, already described by Rachel, and by the Devil (Corrupting the young) and probably everyone else apart from Dr Crippen. I really must order the Daily Mail because they broke it first, and then it even appeared in Boing Boing.

Tesco was selling a pole-dancing kit. The Tesco Direct site advertised the kit as follows:

Unleash the sex kitten inside...simply extend the Peekaboo pole inside the tube, slip on the sexy tunes and away you go! Soon you'll be flaunting it to the world and earning a fortune in Peekaboo Dance Dollars. The £49.97 kit comprises a chrome pole extendible to 8ft 6ins, a 'sexy dance garter' and a DVD demonstrating suggestive dance moves.

Forgive me whilst I pause to giggle. As did Mrs Crippen. As did my teenage daughters. We are probably hopelessly courrupted now.

The Daily Mail did not giggle. And Dr Adrian Rogers, a scion of Family Focus, was clearly struggling with his conscience.

Dr Adrian Rogers, of family campaigning group Family Focus is certainly in a fulminating froth. He said yesterday that the kit would "destroy children's lives.
Tesco is Britain's number one chain, this is extremely dangerous. It is an open invitation to turn the youngest children on to sexual behaviour. This will be sold to four, five and six-year olds. This is a most dangerous toy that will contribute towards destroying children's innocence. Children are being encouraged to dance round a pole which is interpreted in the adult world as a phallic symbol. It ought to be stopped, it really requires the intervention of members of Parliament. This should only be available to the most depraved people who want to corrupt their children." (Rachel)

Dr Rogers is a family doctor.

Dr Crippen remembers him very well, not for his concerns about pole-dancing kits, but for his campaign during the 1997 General Election. Which brings me to the vidoe at the top, which also makes me giggle.

Dr Rogers was the Conservative candidate for Exeter. The likeable Ben Bradshaw was the Labour candidate. Bradshaw is openly and happily gay.

Dr Rogers, sometime President of the Conservative Family Institute, conducted a sustained campaign to:

‘Stop the Pink Flag flying over Exeter’ and distributed leaflets at school-gates and Exeter FC deriding homosexuality as: “sterile, disease-ridden and God-forsaken”. (Stonewall)

The Conservative majority of over 3000 in the Exeter constituency was converted to a 11,705 Labour majority with an 11.9 per cent swing which was higher than the national average swing.

Dr Rogers did not giggle about the pole dancing kit. I fear he may not feel able to giggle about the homophobic propaganda film. So it is not yet time to relax.

Cancer immunisation for rich children

Their children will have it

Gardasil, the immunisation that can give substantial protection to your children (sons and daughters) against the HPV virus (causing this, this and this) is now available, and the first vaccine has now been administered, as reported here.

The Daily Telegraph goes on to say:

A decision to offer the vaccine to children is bound to be controversial but talks have already begun with the Department of Health, the Health Protection Agency and the National Institute for Biological Standards and Control.

Why is it controversial, Dr Crippen wonders? We all know the answer, though the Daily Telegraph is too dignified to discuss it. We need the Daily Mail for that.

Dr Crippen reported in Warts & All on the Daily Mail’s characteristic attitude to the vaccine and the more balanced and sensible approach in the Lancet:

Catching up with the rest of the world, the European Commission last week licensed the first human papillomavirus (HPV) vaccine, Gardasil, for use in children aged 9–15 years and women aged 16–26 years. The vaccine offers protection against HPV types 16 and 18, which are responsible for 70% of all cervical cancers, and types 6 and 11, which cause about 90% of cases of genital warts.

Following earlier approval by the US Food and Drug Administration of the vaccine in girls and women, the Michigan Senate passed a bill on Sept 21, ruling that all girls entering the sixth grade of school (11–12 years old) should be immunised. This is the first legislation of its kind in the USA, and a decision from which the EU member states should take heed. (The Lancet)

The USA is renowned for its conservative approach to new medication. If the US FDA have given their approval, that is good enough for me. Sad that they only recommend it for girls. How do they think girls contract the virus?

Dr Crippen’s PCT has already written round “urging” doctors NOT to prescribe the vaccine until there has been “guidance” from central government. We all know what that means. Join the queue behind herceptin, avastin, erbitux and velcade. Why should this government worry if some children contract the HPV virus? By the time the cancer shows, they will have long been out of office.

Gardasil is of course widely available for the children of the rich (try here). For the time being, however, British doctors will only be prescribing it for their own children.

The Ambulance Service and the I-Pod Quacktitioner

For twenty years my partners and I have had to use a cumbersome and outmoded system for getting an ambulance for a sick patient. It goes like this:

“Could I have an ambulance please?”
“Certainly, doc, how urgent is it?”
“Immediate blue light/within the hour/not urgent as long as it is today…please”

You will note that the third sentence requires a decision.

Thank god, this old-fashioned system has been simplified. The new, improved system is being rolled out on 27th November 2006. A colleague from the south coast has kindly sent me this.

SOUTH EAST COAST AMBULANCE SERVICE

The Horseshoe

Banstead
Surrey
SM7 2AS

Tel: 01737 353333
Fax: 01737 370868

Attention of all GP’s, PCT’s & Out of Hours Providers

Re – Standardisation of Call Handling and Response Procedures

Following the recent reconfiguration of ambulance services, the South East Coast Ambulance Service NHS Trust (SECAMB) is currently reviewing a number of policies and procedures relating to call handling and dispatch functions. This process will draw on what is considered best practice in each of the current controls and rolling this out across the SECAMB area. We are particularly keen to standardise the call handling and response procedures relating to GP and other Healthcare Professionals emergency calls. This change of policy will not affect those patients who require urgent admission i.e. pick in 1 hour plus, you should continue to dial the numbers provided at present. The Department of Health (DoH) requires all ambulance services to categorise its response to 999 / emergency calls into either immediately life threatened, serious or low acuity. The categorisation of a call will determine the level of response provided, with immediately life threatened patients receiving the highest response, which may include a Rapid Response Vehicle or Community Lay Responder as well as a conveying ambulance. In order to categorise a call, ambulance services use prioritisation software, in the SECAMB area this is standardised on a product called Advanced Medical Priority Dispatch (AMPDS). When requesting an emergency response you should dial 999 and, after the call taker has confirmed the problem with the patient, our call takers will ask if the patient is conscious and breathing. They will then ask a brief series of question which will usually take no longer than 30 seconds to categorise the call. This will not delay dispatch as a response is sent as soon as we have a location. By using the 999 system, technology allows us to have a location before speaking to a caller most of the time, so our preference is that the 999 system is used when the situation is a life threatening emergency. If the call is immediately life threatened, ambulance services are required to have a trained response with an Advisory Defibrillator (AED) on scene within 8 minutes, hence why GP’s will often find they are supported by a Rapid Response Vehicle or Lay Community Responder until an ambulance arrives. The DoH have agreed that GP’s or other Healthcare professionals with an AED who is treating a patient, will not require an ambulance based AED response and it will be sufficient only to send a conveying vehicle. In future our call handlers will ask ‘do you require the assistance of a Rapid Response Vehicle or lay responder with an AED’. Where a GP states they do not require this type of support, and confirm they have access to an AED then only a conveying ambulance will be sent to scene, the GP will be counted as carrying out the appropriate treatment for their patient until the ambulance arrives. Where an emergency call is received from a Surgery and categorised as immediately life threatened the call taker will confirm if an AED is available with someone trained to use it. They will also ask if the GP is with the patient and if a Rapid Response or Lay Responder is required. It must be noted that Rapid Response Vehicles and Lay Responders are not always available in all areas. To assist us with communicating with the surgeries it would be helpful to know which sites have an AED readily available. Could we ask that you e-mail to the following address aed@secamb.nhs.uk with surgery address and telephone number. We will then update our dispatch systems with these details, alternatively if you do not have an AED and would like help with obtaining one for your surgery then please also e-mail with contact details of someone at the surgery. We are able to provide advice, support and even training and equipment where surgeries agree to provide cover to their local community during surgery opening hours. It is intended to start requesting the additional information from 27th November, if you have any questions then please do not hesitate to contact any of the control managers at your local control room.

Yours sincerely,






Mark Bailey.
Emergency Dispatch & Call Centre Manager


Have you all got that?

Before I go and have a pint with Tom Reynolds, a few small points. What does “rolled out” mean? Does it mean “introduced”? If not, please explain. What is a “Community Lay Responder”? (Do I feel another quacktitioner approaching?) Why is New Labour so obsessed with visible process, and why does it prefer visible process to simple discretion.

Where is all this leading?

It is leading to a complete dumbing down of health care so that, eventually, skilled personnel will not be needed. Indeed, human personnel will not be needed. Decisions will not be needed. It can all be done by computer. A hand-held computer. Soon you will be able to down load your own "health care professional" on to your I-Pod. And you thought Dr Crippen was joking.


Read here about the I-Pod Quacktitioner. Think of the savings.

How about some courage?

Edinburgh Royal Infirmary

Dr A. D. Toft, an eminent Scottish Physician at Edinburgh Royal Infirmary, writes the editorial for the current edition of the Journal of the Royal College of Physicians (Edinburgh)

When you have read that, read how a typical junior hospital doctor, currently struggling through higher professional training, feels on a bad day.

This is what is happening. This is how it is, day by day. Something needs to be done.

The Crippen Diaries (Week 43)

Not quite Tannochbrae

Monday 23rd October

Just back from a few days away, and the first patient comes in to tell me he is going to Egypt for a week, and to get his blood pressure checked and one or two other things. As I routinely do, I warn him about being extra-careful of the water he drinks. Egypt is one of the worst countries for people to catch gut infections and get torrential diarrhoea.

“Oh, I know, Doctor. That’s why we go.”

I looked bemused. “I have always been constipated, doctor, and so I like to go to Egypt every year to have a good clear out.”

I think my eyes must have bulged a little. He smiled, and said, “No, really, that is why I go.”

++++++++++

Mary and David came in. Their 26 year old son was killed in a car crash three weeks ago. He was an only child. They are coping well, but they would benefit from some supportive counselling. We do not have any counsellors any more in the Health Centre. They took them away. The local psychiatric deparment’s attitude is that “bereavement is not a mental illness” and so they are not interested. Send them to CRUSE. An excellent idea, and CRUSE is an excellent organisation but, since all the counsellors were removed, and since the psychiatrists decided that bereavement was not a problem for the NHS, the local CRUSE has a three month waiting list.

Should the NHS help people with bereavement? I think it should. So I shall continue to see Mary and David for a few minutes each week for a while, but I cannot give them as much time as I would like.

++++++++++

Another little cut. Another little irritation.

The PCT has announced that it will not fund the district nurses to go round the community to give flu immunisations to elderly patients in nursing homes or housebound in their own homes. So we will have to do it. Well, the practice nurses will do it. We pay them ourselves. I do not mind that. But the district nurses are so called because they go round “the district”. But not for preventative medicine apparently. Penny wise, pound foolish - that is the modern NHS.

++++++++++


Tuesday 24th October

Roger, a 54 year old man attends with his wife. She is 49. He came to see me six weeks ago. His brother, aged 60, has just been found to have inoperable prostate cancer so, reasonably enough, he wanted a check. He did not have much in the way of symptoms. His urinary stream was not bad; he did not think he could still reach the school record, but there was not a problem. He occasionally got up at night to go for a pee, but he had done so for years.

His prostate felt soft and benign. His PSA came back at 6.3 which is raised but not dramatically. He had a biopsy. He has prostate cancer but, unlike his brother, it has not spread. We are therefore looking at curative treatment. The local urologist, who is excellent, recommended an open prostatectomy. David has been out on the internet, and wanted to explore other options. He saw another urologist who recommended a laparoscopic total prostatectomy. He saw a radiation oncologist who recommended brachytherapy.

The two surgeons offer a “complete” cure. There is a small but significant mortality rate to open prostatectomy. Laparoscopic prostatectomies are in their infancy in the UK, but the urologists who are doing them are keen to practise. Who knows what the morbidity is? The surgeons told Roger that any sort of radiotherapy brought with it a risk of rectal cancer, radiation proctitis and cystitis. The radiotherapist talked of impotence and incontinence as a risk of surgery. The open prostatectomy surgeon talked of tried and tested procedures, the laparoscopic surgeon talked of the reduced risk of laparoscopic surgery.

And so we go on.

Each specialist is selling his wares. Roger does not know what to do, so he comes to see the trusted family doctor. I do not know what the best course of action is either. And that is not because I am ignorant. No one knows. You can make good arguments for each treatment modality that has been offered. Or you can go to Paris where they are playing with lasers.

We talk about it for a while. Roger has insight. It was he who said, “You know, they are all charming, but they are all selling their wares.”

Finally, he says, “What would you do, doc?”

I tell him I would have the open prostatectomy. My reasons are that it offers the strong likelihood of a cure; it is a procedure that the local urologist has done many times; I would not want to be the material upon which surgeons learn laparoscopic techniques; yes, there is a risk of impotence and incontinence but the risk is relatively small. I also tell Roger that my opinion is personal, anecdotal, not scientific, a gut feeling, and no more than that.

Roger is going to go for the open operation. He should be fine. I worry about the influence the “family doc” has on decisions like this. I worry even more about doing PSAs on asymptomatic men of this age. The cancer was very early. Have we done Roger any favours by finding it? We probably have.

But, sometimes, ignorance is bliss.

++++++++++


Thursday 26th October

A particularly bad morning. I over-ran by nearly an hour and a half. This probably happens about once a fortnight. I am quite slow compared to my partners. My patients know this and are, for the most part, tolerant. I still find it stressful. Once I am running more than ten minutes late, I apologise. It is not my fault (well, maybe I am too slow) but I still apologise and that in itself is hard work.

1. A 26 year old rugby player who had a scrum collapse on his right ankle. He says he heard a “crunch” as he went down. He was taken to the local hospital. He waited three hours, was X-Rayed. He was told nothing was broken and was sent home. Ten days later he is still limping. He has damaged the lateral collateral ligament of his ankle. A common sporting injury. Not too bad if you are not a sportsman but it can put a professional footballer out of business. He needs physiotherapy. The NHS waiting list is 16 weeks, which means NHS phsyio is effectively unavailable. He decides to go privately.

2. A 56 year old Marks & Spencer assistant manager. She came in for an immunisation eight weeks ago. The nurse found her BP to be 160/98. She is otherwise well. Non-smoker, very little alcohol, on no medication with no family history of heart disease, strokes or BP. Her cholesterol is normal. Since seeing the nurse, she has lost 10 lbs in weight, is taking more exercise, and has stopped drinking. She has bought a BP machine and has taken her BP twice a day and put the results on an Excel graph. Her average BP is now 152/90 which by all modern criteria should be treated. In the USA it would be treated. I am not going to treat it. Yet. She is coming back after another month of “clean living”. What are we doing to these people?

3. A 73 year old who had a CABG fourteen years ago, and who has done really well. But his BP was found to be a little raised last week by the nurse. 150/88. I am going to investigate and treat this. “Not more tablets” he says. Probably.

4. A 63 year old with her 34 year old daughter who is mentally handicapped. She has been getting hiccoughs for ten minutes after every meal for the last three weeks. She is impossible to examine. She grins at me all the time. I can think of all sorts of odd things that can cause hiccoughs, and I cannot guarantee that this is nothing serious, but I doubt it is. Investigating her will be a nightmare. So we temporise with some “white medicine” and I tell mum to bring her back in two weeks if it has not gone. It probably will have. So much of general practice is like this. “Probably nothing serious…come back if it does not settle.” We get it right 999 out of a 1000. Occasionally we do not, then it is the Daily Mail.

5. A 52 year old man comes because he has itchy wrists. Itchy wrists? There is nothing to see. I tell him I have not got a clue why his wrists are itching. Then he tells me why he really came. His 26 year old daughter has schizophrenia and has just been discharged from hospital after a prolonged 14 month admission, during most of which she was on a section. Social services have found her sheltered accommodation nearby. She spends the night there, but turns up at her parent's house every morning and stays there all day chain-smoking until either mum or dad takes her home in the evening. They are a high-emotive family. A lot of families with schizophrenics are. I cannot tease our the chicken and egg. Dad cares for his daughter but cannot manage being with her for more than short periods. But he feels guilty if he turns her away. They need to have a distance between them, both physically and mentally. I have to try to give dad “permission” to do that. Not easy. He still feels guilty that he does not have her living with him permanently. I give him information from the Schizophrenia Association. They are more helpful than the local psychiatric services.

6. Trevor appears. Have not seen him for a while. He has just had a two week admission with acute pancreatitis. He is now living in temporary bed and breakfast accommodation miles outside our area. He is back on the booze big time. He wants a prescription for Tramadol, Diazepam, and oramorph. There is no discharge summary from the hospital. Social services locally do not want to know because he is outside our area. I phoned the local alcohol support services who know Trevor well. Did they sound almost gleeful when they also said Trevor was outside their area? Trevor was in tears. His girlfriend has deserted him. He has nowhere to live. No one gives a shit. He is in bed and breakfast accommodation with the flotsam and jetsom of society. He is depressed and he is drinking again. He needs residential accommodation for a minimum of six months. Every time he is taken in somewhere, he is discharged within a week or two, and the cycle starts again. Anyone interested in the way someone like Trevor bounces around the system should look at his progess this year: Week 1, Week 2, Week 6, Week 20, Week 28.

7. I am now running 50 minutes late. A man with a sore throat. He says “my company have sent me down” because I am so ill. He is not that ill. He just wants a certificate for work. I tell him he can pick one up at the reception.

8. A head cold. Whatever that is. Described graphically with the kind of language that would be more fitting from someone describing Armageddon. Nothing to find. The man is not happy that he does not get any antibiotics.

9. An elderly woman with a very unpleasant looking lesion on the angle of her jaw. This is a basal cell carcinoma and it has got some secondary eczema and infection around it. BCCs, or "rodent ulcers" are technically cancer, but they never spread, so it is not really fair to use a word like “cancer”. I treat the secondary problems and explain that it will mean a trip up to the hospital to have it removed. She is not happy. She says “can’t you just give me something for it?” I wish I could.

10. An intelligent middle aged woman who says that for the last week she has been getting a dizzy feeling that comes up from her legs when she sits down. She wonders if it could be the menopause. She never comes to the surgery. I spend some time checking her over carefully. As I expected, there is absolutely nothing to find. I have not got a clue what is causing this odd symptomatology. It is tempting to take refuge in that old coat hanger for all the ailments in the world, the menopause, but that would be intellectually dishonest. I tell her, as you do, that I do not think it is anything ominous, that it will probably settle, but to come back in a couple of weeks if it has not gone.

11. A 92 year old woman with her daughter to have her blood pressure checked. She has been on atenolol 25mg daily since long before I started, indeed since before I started at medical school, allegedly for hypertension. She is well and her BP is normal. She has come because her daughter has just read the NICE recommendations and wonders “if it is safe for mother to be on atenolol.” I can almost do this by rote now. I go through the NICE recommendations. I am not going to take mother of atenolol. It probably is not necessary. And yet it may be the supporting brick that is holding up the whole pyramid of this robust old lady. Leave well alone. She is 92. She must have got it right somewhere.

12. I am now an hour behind. A 62 year old woman who had a fall last week, was knocked out, admitted to hospital and has come out on two different tablets. The cause of the fall was an SVT according to the hospital discharge summary. She is on medication for this and is awaiting further investigations. She has brought the drug insert from both packets of medication and wants to discuss all the possible side effects. There are a lot. They have frightened her so much she has stopped taking them. We go through them slowly and methodically. She agrees to go back on the tablets. Of course it is right and proper that all patients know of all potential side effects. But sometimes I miss those little brown bottles with no inserts and no information.

13. A charming elderly man who is on half the chemist shop for ischaemic heart disease, insulin dependent diabetes, arthritis, ulcerative colitis and epilepsy. The list of drugs on the computer goes from A – Z in large case letters, and then starts on small case. We are well into the second alphabet. Today’s problem seems minor, but is not. He has an infected toe nail. He cannot reach down to deal with it himself. And his blood sugars are higher than they should be. And he is pretty sure he had a couple of mild fits last week but did not want “to bother anyone.” Every time I see this man, I want to be a house officer again and clerk him in, examine him from head to foot, rationalise his medication and start again. There is never time. So we treat the toe infection, get him in with the chiropodist, adjust his insulin and alter his epileptic medication.

14. A grumpy mother with Jimmy, a ten year old. Mother comes in looking at her watch. I apologise for running late. She says she has been waiting for an hour and a half. I am tempted to say I have been lying on the chaise-longue whilst a receptionist pops peeled grapes into my mouth, but I resist it. Jimmy has a small verruca. As soon as mum says this, I know there is going to be trouble. I look at it. It is a verruca. It is small. It is not painful. “Leave it alone, it will go away.” That will not do. The sports teacher at Jimmy’s private prep school is worried about it. I stick to my guns. Finally, mother says “do you mean I have wasted an hour and a half of my time to be told that it does not need treatment”. I am tempted to say that I have wasted five minutes of my time to tell her that it does not need treatment. Mum wants something. So I press the button on the computer and out pops the hand out on verruca treatment which confirms my advice. Mother is slightly mollified. A hand-out is obviously more impressive than Dr Crippen.

15. A baby with probable bronchiolitis. This consultation is straightforward because mother is intelligent and charming, wants my advice and seems to value it. There is no effective treatment for mild bronchiolitis and so often one has to fight the antibiotic fight. Not this time.

16. A 61 year old man enters, smiles, says “you are busy today” (the polite way of saying ‘you are running late’) sits down and takes a piece of paper out of his top pocket. I have four problems. I thought I would try to get them all sorted out today. The first two are easy; a fungal groin rash and a benign mole on his back that his wife wants checking. Fair enough. Then he says he has had painful thumbs for several months. Looking at his hands, he obviously has mild osteoarthritis, and “wear and tear” at the base of the thumbs can be surprisingly intrusive. But it is not easy to treat. We decide to “treat” it by having an X-Ray in the first instance, and a blood test to check for various things including gout. Finally, he says that for the last three months he has had to get up at night three times to pass urine. This needs a complete work up. I add a blood sugar and a PSA to the list of tests, arrange for an MSU and tell him that he will need to return next week with the results for an examination. I should really do it now, but I am flagging, I am way behind, and I cannot realistically deal with four problems for every patient.

17. A teenager with a mild exacerbation of his asthma. Relatively easy to sort out.

18. An elderly couple who I have not seen for ages. He is worried that her memory is failing. She smiles and says he is making a fuss. We have a chat, and all seems fine, then I say, as I usually do, “Do you mind if I ask you some silly questions?” She says she does not. Of we go; day, month, year, address, age, prime minister, Queen’s husband ( I used to ask for the Queen’s name, but nearly everyone gets that, so now I ask for her husband’s name: more discriminating). Poor thing, she is absolutely hopeless. And she knows it. And she is embarrassed and ashamed. Her husband’s eyes are watering. I do some basic physical checks, which are normal, and arrange all the appropriate blood and urine checks, which will be normal, and then I suggest we get her an appointment at the hospital memory clinic. They will do the more formal and detailed memory testing, and arrange a brain scan. She looks at me and asks if I think she might have Alzheimer’s. I look back at her and say that I do not know, but that there is definitely a problem with her memory and it needs checking out. She nods. Unless her dementia is treatable, and that is unlikely, how much does the label matter?

19. A 37 year old with a cardiomyopathy. He apologises for being late. He is always late. Today it does not matter as I am running even later. He has an alcohol induced cardiomyopathy. He first presented two days after New Year’s Eve about five years ago. He had been on a gargantuan alcohol binge and then suddenly become short of breath. He was in fast atrial fibrillation and heart failure. I sent him in. Since then he has stabilised. He is on a lot of medication. He claims he has “more or less” stopped drinking. This means that rather than his usual ten pints a night, he will go a week with nothing, then binge. This is arguably more dangerous than regular heavy drinking. He does not understand that. He works as hospital porter and seems to think that some medical knowledge has rubbed off on him from being around doctors. Maybe it has, but he does not take his medication properly. For the “nth” time, I try to persuade him to comply better with the advice he is given. He smiles benignly. In one ear and out the other.

20. Finally a patient with a clear cut, circumscribed medical problem with which I can deal on auto-pilot. He is 46. He has had a change in bowel habit with three or four significant rectal bleeds. He does not feel unwell and has not lost weight. His mother died of bowel cancer aged 68. There is nothing to find in his abdomen and the rectal examination is normal. Nonetheless, he needs investigation and although he does not quite meet the “two week rule” referral criteria, I make a “two week rule” referral.

Phew!

+++++++++


Friday 27th October

Our Qof partner is in hyperdrive at the moment. She only works two days a week, but is very good at chasing the pennies and, heavens, she is chasing hard this week. She keeps sending me emails “reminding” me to check up on all my patients whose eGFRs are low.

eGFRs are driving GPs towards insanity. It is all a bit technical. The GFR, the glomerular filtration rate, used to be calculated by getting the customer to collect all their urine for 24 hours in a large plastic bottle. The bottle was then taken to the hospital, and a blood test performed. From this, you can calculate how well the kidneys are functioning.

This test was not done very ofen.

Now someone has realised that you can produce a computer guesstimate of the GFR from one routine blood test. This is called the eGFR. We are now getting eGFRs on all our patients whether or not we want them. Hundreds of them. Every day. The trouble is, the eGFR really is a guessimate, and can be wildely inaccuarete.

It gets worse. People in their late eighties and nineties tend to have reduced renal function. There’s a surprise. Until last year, we could pretend we did not know it was happening. Ignorance was indeed bliss. Now the QoF partner tells me that Mrs Bloggins, aged 92, has a reduced eGFR. I am not going to pass this information on to Mrs Bloggins however much money the government is going to pay me.

However, I shall spend this evening reading up about eGFRs here.

I do not know what our QoF partner is up to. She was last seen heading towards the local cemetery with some cholesterol bottles.

++++++++++

A 22 year old student with advanced male pattern baldness. He wants to know if here is any treatment for it.

There is not.

It sounds harsh, but there it is. You can spend a lot of money at the trichologists up on Harley Strasse, and they will put you on funny diets with certain expensive Vitamin supplements which are difficult to find on the open market but do not worry, by a strange co-incidence, they just happen to have some in stock. You can have hair transplanted from the back to the front. One by one. John Cleese is supposed to have had this done. Or you can buy a rug. Like Elton John.

There is Minoxidil. This was originally introduced as a blood pressure treatment, and still is used as same. Some of the punters taking it started getting unwelcome additional hair growth. Big Pharma does not miss a trick like that. Now you can buy Minoxidil lotion and rub it into your scalp. I have one patient try it. After a week or two of sprinkling and rubbing, a scanty growth of what I would have described as “bum fluff” appeared. My patient’s wife thought it was more pubic in nature. We all agreed that the treatment was “disappointing”.

I chatted to the student. Some men who present with this sort of worry have underlying psychological problems. There were no alarm bells here. He was well balanced, but fed up.

I advised him to cut it short. I am sure that is best. There is nothing worse than a “comb over”.

(For readers using an RSS feed : this post is updated and expanded on a daily basis from Monday to Saturday)

Nurses on the treadmill

I need help. I know it sounds pompous, but I regard myself as being quite good with words. But this time, I cannot find the correct one.

I have just read an article in the Nursing Times (you will have to sign on and log in) entitled

The Bigger Picture: Skill-mix and HCAs
by Adrian O'Dowd

I am looking for the one word that captures the precise nuance of feeling I had as I read the article. I have not found it.

It seems that the nurses are getting worried about dumbing down in the NHS. Yes, really.

Adrian O’Dowd reports:

Skill mix is also changing as healthcare assistants are increasingly taking on roles normally done by nurses such as taking blood, dressing wounds, giving injections, and performing electrocardiograms (ECGs).

Glee? Schadenfreude? A bit of each, really.

Whatever the word, though, you have to laugh! Perhaps “hee hee” will do.

On a more serious note, the Nursing Times also reports that morale in the profession is getting even lower following the government's derisory pay rise. That is, of course, for nurses who have a job.

Three quarters of new qualified nurses are still searching for a permanent job months after finishing their pre-registration course, according to a snapshot survey carried out by the RCN. Some 71% new nurses said they were still searching for a band 5 job and 86% were not confident of finding a permanent position. Almost all ‘agreed’ or ‘strongly agreed’ the problem was the result of NHS job cuts and recruitment freezes. More worrying is the finding that shows 85% said they would consider re-training if the situation continued.

What is the government playing at? There is a desperate shortage of nurses. Where are they all? Working behind the counter at Marks & Spencer where Stuart Rose pays them better, looks after them better , and gives them genuine career prospects.


Come to think of it, Rose has “a reputation for turning around struggling firms”

Maybe he should take over the NHS.

Flu immunisations

It is ‘flu immunisation time again. A reader asked how GP re-imbursement works.

This year we paid £4.23 for each immunisation. This was after the substantial discount we get from the manufacturer and includes VAT at 17.5%

The PPA reimburses us £9.57 for each immunisation

On top of that, we get a total “item of service payment” of £7.51 for every immunisation we give to any patient over 65, and any patient under 65 who is in one of the government certified “at risk” categories.

£9.57 – £4.23 = £5.34
£5.34 + £7.51 = £12.85

So gross profit of £12.85 for each immunisation.

In our practice, we normally give about 2500 immunisations to patients in the fully-reimbursed categories. We have to find the time and the staff to do it. This is expensive and time consuming, but there is nonetheless a healthy profit.

Privatising Stalin

One is enough

There is much resentment amongst the British medical profession at the government’s Stalinist attempts to curtail professional autonomy. Protocols and guidelines flood out of the Department of Health. The National Institute of Clinical Excellence (with its appalling acronym) may only be advisory, but the fear is that if a doctor deviates from NICE recommendations and problems arise, the legal onus of proof may shift onto the doctor to demonstrate that he acted reasonably. NICE becomes the new Bolam. And NICE, though theoretically independent, in reality is an arm of government.

We cast a jealous eye over to the colonies. Doctors in the USA work independently and free from government interference. True, to some extent, but they have another master. The insurance companies. The insurance companies collect the premiums and pay the bills. They pay the doctor’s fees. Increasingly, they are not only telling the doctor’s how much they will earn, but they are telling them how to do their jobs.

Enter a company called Milliman.

The Milliman Care Guidelines® are a series of products that span the continuum of patient care, describing best practices for treating common conditions in a variety of care settings. Designed for ease of use, they are available in many access formats. The Care Guidelines are written by an experienced editorial staff of physicians, nurses and other healthcare professionals, and represent a compilation of best practices drawn from the current best medical evidence. The purpose of these clinical tools, which are updated on a regular basis, is to assist health care professionals in providing quality care, by reducing underuse, overuse and misuse of medical resources.

Sounds super, doesn’t it. We are all in favour of “reducing…overuse and misuse of medical resources”. Who could challenge that?

Let us look at some of the ways they are “reducing overuse” of medical resources.

1. Mastectomies may be performed on an outpatient basis
2. Congestive heart failure patients to be hospitalised up to a day
3. Twenty-four hours in hospital is standard for a vaginal birth
4. Elderly patients with cataracts should receive surgery in only one eye, as seeing with both eyes is not essential

Out-patient mastecomies? Done by the GP I daresay. Not essential for elderly patients to see with both eyes? Hmmm…try driving a car without binocular vision. This is privatised Stalinism.

What do respected American journalists say?

Pulitzer-prize winning journalists Donald Barlett and James Steele say the guidelines are used inflexibly in the US to save money and maximise profits. In their book, Critical Condition, they said: 'Rather than serving as a guide, the manuals have become the bibles for insurers to exert strong pressure on doctors and hospitals.' (Hospital Doctor)

It could only happen in the USA. Could it?

Hammersmith Hospitals NHS Trust last week began piloting the guidelines on patients with fractured neck of femur. An influential group of NHS commissioners has also shown interest in Milliman guidelines. (Hospital Doctor)

BMA private practice committee chairman Mr Derek Machin said: 'This will meet huge resistance in the UK. Milliman guidelines take no account of individual circumstances - they are the opposite of patient-centred care.'

Dr Crippen knows which way this is going.

So, if granny has not already had her cataract extractions done, you can purchase her eye-patch here. Get in quickly before the rush.

Nurse shortage boosts death rates

A light has gone on at the Royal College of nursing.

Nursing shortages are linked to an increase in patient death rates, a study of English hospitals has found. Scientists discovered mortality was 26% higher for the hospitals with the worst staffing levels compared with those with more nurses per patient. The Royal College of Nursing said the study, published in the International Journal of Nursing Studies, showed it was essential to retain nursing posts. (BBC)

Excellent.

This is progress. We now have to hope that the light shines brightly enough for Bev and Pete, her successor, to understand WHY there are not enough nurses.

1. The government is too mean. The “cheapo-cheapo productions” dumbing down of the NHS means that they will not pay for enough qualified nurses to staff the wards. Instead, they only provide auxiliaries. And just as patients suffer when nurses try to act as doctors, so they also suffer when auxiliaries try to act as nurses. The RCN supported and encouraged this process in the infamous Project 2000

2. The RCN has become arrogant and has fixated on putting its nurses on the skills escalator so that they can take over from doctors. REAL nurses are treated with contempt by their own college. There is no career structure left for those wanting to do hands-on nursing.

This was reported by Geoffrey Rivet in his excellent short History of the NHS

Too posh to wash
Hospital nursing had changed radically as patients came and went far more often and treatment was of a complexity undreamt of by the founders of the NHS. Patients were often either too sick to eat, or could feed and wash themselves. The recruitment of staff from an aggressive society where the love of one’s brother was not always evident, created a new dynamic in the wards, mitigated by nurses from gentler cultures overseas. Many nurses still delivered exemplary care, but it was distressingly clear to the elderly or their relatives that basic levels of care were often not provided. Some seemed to believe that the caring aspect of nurses' roles should be devolved to health care assistants to enable registered nurses to concentrate on treatment and technical nursing. However Beverly Malone, General Secretary of the RCN, told a press conference at the College's 2004 conference that "the argument that you are too posh to wash is ridiculous. A nurse who doesn't want to provide basic care has missed what an important part this plays in nursing. Nurses that don't want to 'wash' have missed the point of what it is to be a nurse. When bathing a patient, nurses are also assessing them, checking their breathing and emotional wellbeing."

The conscientious nurse faced massive problems. Staff shortage because it was difficult to recruit, even if the budget was there, lowered staff morale on the wards. This in turn, resulted in nurses leaving the profession for other, less stressed and better paid, jobs, a vicious circle. And the proportion of qualified nurses was falling. Could staffing levels that pushed staff beyond their limits of stamina and compassion be condoned? How could nurses who had received what was planned as a rigorous and systematic education be party to such poor quality of care? Two thirds of hospital beds are now occupied by people over 65. The Standing Nursing and Midwifery Advisory Committee, reporting in March 2001 on Caring for Older People, found major problems:

"Studies suggest that there are deficits in the core nursing skills required to meet the needs of older patients. Too many nurses see fundamental skills, such as bathing, helping patients to the toilet and assisting with feeding as tasks that can be delegated to junior or untrained staff. The emphasis on qualified staff being involved in patients’ activities of daily living may have shifted as other aspects of the nursing role, such as technical and managerial components have developed. But skilled nursing care cannot be delivered from a distance or through agents. It is a “hands-on” activity. ….. In the past, any qualified nurse would have been expected to be able to assist with activities of daily living, including the management of incontinence, nutrition and skin integrity. However, this may not now be the case. Nurses may identify these areas as requiring specialist skills. …. The rapid expansion of specialties within nursing and the developing role of the allied health professions, e.g. physiotherapy, occupational therapy and dietetics, mean that several separate professional groups are now responsible for aspects of care, such as nutrition, that were previously nursing domains. There are also a large and growing number of nursing specialties, such as tissue viability, continence and infection control, whose areas of expertise overlap with traditional nursing practice. Increasing specialisation may have had the unintended detrimental effect of de-skilling adult nurses."

The RCN knows what is going on.

Beverley herself, who uses the phrase “too posh to wash”, seems to have recognised this problem a few years ago.

What did she do?

This is where the medical profession (by which I mean doctors) despairs. Look at the RCN solution.

The Royal College of Nursing takes action

"Care Pathways" were being developed as a way of systematizing the treatment patients received, building upon the long standing nursing procedures. While few were actually available, over 2,000 care pathways were under development in over 200 NHS organizations and were predicted to be a key NHS resource for ensuring that patients were looked after along the lines specified in the National Service Frameworks. (source)

I can think of no paragraph that more accurately epitomises the activities of the modern Royal College of nursing.

“Over 2000 pathways were developed, but few were actually available”.

Quite.

Take your heads out of your arses, stop talking about “pathways”, roll up your sleeves, get down to the wards and start nursing.

If you don’t, you will loose this experienced nurse, and this one will never even finish her training.

Preparing for post-graduate medical examinations

Distance learning

Education – it’s a wonderful thing.

Dr Crippen did his fair share of exams over the years, and would not care to do any more.

In his day, of course, there was not much educational hi-tech. Sleep-inducing blue slides packed with dense yellow print. And whilst it was not quite all chalk and papyrus, distance learning meant getting in the car and driving somewhere.

Not any more.

Now we have onexamination.com, so we can sit back and do it in the comfort of our own homes, at a time of our own choosing. And onexamination.com must be an organisation of taste and discrimination as they recommend Dr Crippen.

Anyone who scratches my back…

++++++++++

Dr Crippen has just spent an entertaining fifteen minutes looking at some of the specimen questions for MRCGP preparation. I am sure doing things like this would be better than the annual appraisal game. Try your luck with these two questions, both with a urology theme. For each one, you have to chose one of four management strategies:

1. Lifestyle advice
2. Lifestyle + medication
3. Referral
4. No intervention.

1. A 43-year-old teacher comes to see you because TV presenter Richard Madeley, on the “Richard & Judy Show”, advised that every man should see his GP at once to insist on a rectal exam to have their prostate checked. Ever since seeing the programme, it occurred to him that he has been having to wait a long time before initiating micturition and has had dribbling of urine afterwards. He gets up once a night, every night to pass urine and the stream is poor. U&E, fasting glucose, PSA and urinalysis are all normal. There is slight induration of his prostate and the median sulcus is not palpable. He has no past medical history of note, but a recently retired colleague has entered the words “A born worrier” in his past medical history. He takes no prescribed medication, but a multitude of herbal “pick me ups” – none of which have names that are familiar to you. He visits an acupuncturist once a week for treatment to relieve work stress.



2. A 58yr old painter and decorator has come to see you because he has seen an article in the Sunday papers and thinks that he has prostate cancer. His wife thinks that his symptoms are “normal” for his age. He wakes once/night to pass urine and his stream is reduced. There is delay in initiation and some post micturition dribbling (from the urethra). On examination, there is a moderate soft prostate (about 25mls to be precise) and his PSA is 1.3ng/ml (<5). U&E normal. Urinalysis is normal and fasting glucose is 4.7 mmol/l. He is a non smoker with 20 units alcohol (all beer) spread over the week (he visits the local working men’s club most evenings). His medication lists voltarol prn (frozen shoulder 3/12 ago) and 1% hydrocortisone cream prn for eczema.

Dr Crippen got them both right but then he would say that, wouldn't he! How did you manage? Answers here

GPs leave elderly patients in pain

GP pain clinic

Another deeply depressing article in the papers yesterday.

GPs are ignoring elderly patients who have problems with chronic pain.

Nearly a third of the 3,000 carers surveyed by the Patient's Association said their patient's chronic pain was poorly managed. Two-thirds said their patients were less able to cope with everyday life because of the pain, and a fifth said their patients had talked of suicide. Part of the problem is a lack of awareness among GPs, says the charity.

Great.

One of the joys of my job is opening the papers every day to read articles telling me how ignorant I am, and how I neglect my patients. If there is something wrong with the health service, if the right resources are not available, then it is my fault.

Katherine Murphy from The Patients Association concluded:

"The government must take the lead on this initiative as it is clear that older people's chronic pain is still being neglected. GPs need more education on managing pain and carers and the general public should have better access to the information available on pain management solutions."

I fear another wadge of guidelines is approaching followed closely by a phalanx of community pain-nurse specialists.

Elderly people with chronic arthritis have problems with pain. Too right they do. And it may sound boring and conventional but, actually, pain-killers, NSAIDs and newer drugs such as gabapentin can be very helpful. And treating any underlying depression is essential. And physiotherapy, backed up by a detailed OT assessment, can be very helpful too.

But when you have done all that you can, you are often left with problems for which there is no easy solution. Life is not perfect. Old age does bring such problems. There is no god-given right to a carefree old age, and when problems arise that cannot be solved it does not help to scapegoat the GPs.

Dr David Bowsher of The Pain Relief Foundation said there was also a misconception by some that pain is something to be expected in old age. He said non-drug treatments, including relaxation techniques, could help relieve pain.

Great stuff David. Relaxation techniques? Which planet are you visiting from? Where can I find relaxation therapy for my patients? Perhaps it is in the same department as the “talking therapy” that the government recommends for my depressed patients.

"What we need is more community care. Patients don't necessarily need to be seen in pain clinics, but they ought to be assessed by staff from pain clinics," Dr Bowsher added. (BBC)

Very plausible, Dr Bowsher. What exactly do you mean by "community care"? And when the "staff" have "assessed" the patients, what are they going to do then? Tell me now, and I will do it and save your "staff" the trip.

Dr Crippen has just spent a few minutes on the Pain Relief Foundation website. Take a look. The main advice it gives is:

If you have a pain problem, which needs treatment you should contact your own doctor who can refer you to a pain clinic in your area.

Excellent.

So off we go to the pain clinic where, if we are lucky, we will see a doctor who will…prescribe some tablets, usually. Occasionally suggest a nerve block. They do not have access to “relaxation therapy” either. If you are unlucky and go to the pain clinic in our area, you will probably see the consultant-nurse who will come out with such gems as “I advised paracetamol on a time contingent basis.”

Katherine Murphy : she knows, you know.

So, Katherine Murphy, if you, or anyone else who is reading, can advise me of some genuine new resources that are available to help patients such as this, then I will use them. And if you can advise me of any new pharmacological strategies, then I will consider them. And if you can tell me how to get domiciliary “relaxation therapy” then I will order it.

But if, as I suspect, you have nothing to offer, then please stop this gratuitous abuse of family doctors.

The medical profession erupts

Doctors.net.uk is a popular site for British doctors. It provides an email service, some educational facilities, a few adverts, and a forum. In the forum, unseen by the general public, doctors vent their spleen.


Dr Crippen has a degree of unease about secret comments. If something is worth saying and, in particular, if you wish to criticise, it is best done in public so that those who are criticised at least have the chance to reply.

Currently on the Doctors.net.uk forum two topics amongst many are causing great controversy:

• The role of the community matron
• Pre-operative assessment of patients being done by nurses rather than doctors

If you think Dr Crippen is OTT about the “nurse-specialists” and the “nurse-practitioners” who pretend to be doctors, you ought to read the comments on Doctors.net.uk. Sadly, for copyright reasons, I cannot quote them to you.

But I can now show you exactly what is going on.

A few days ago, I highlighted a post by Nurse Ratchet, in which she criticised a doctor who sent a critically ill patient into hospital. She went on to describe how she “managed” the patient. It was not a well written post. She made a fool of herself. She did not understand the dangers of dealing with a patient in this situation and was pompous about the doctor whose management of the case was, whatever the diagnosis, unimpeachably correct.

Nurse Ratchet behaved just as Dr Crippen fears that all protocol driven, non-medically qualified nurses and other HCPs behave when they try to take over the role of doctors. Well meaning, certainly. But they do not know what they do not know, and once they are off the protocol, they founder.

Nurse Ratchet’s post was picked up by Doctors.net.uk and battalions of doctors have emerged from their normally secret forum. There are now a hundred comments under the original article. The comments are vitriolic. Amongst them, however, there are recurrent threads of rationality, particularly from some of the ENT and A&E consultants who have contributed.

The correspondence is at times strongly worded. Nonetheless, be under no illusion. It represents the fear and anger that the medical profession feels when it sees patients’ lives being put at risk by these well-meaning nurses who do not know what they are doing.

Essential reading.

Make the NHS safe for my family

Will they use the NHS?

Will David Cameron sign the petition?

I return once again to this very simple question.

Richard Solomon, of Our Petition, has already written extensively on Webcameron about the question.

And still no answer from David Cameron.

He may be hoping it is going to go away. It is not. It is being taken up all over the Internet and the silence from the Cameron camp is deafening. Odd, really, because David has already made his position clear:

Or was it just humbug? Dr Crippen would like an answer. Guido would like an answer. Tim Worstall would like an answer. Wat Tyler would like an answer. The Devil would like an answer.

There is an important principle behind Solomon’s petition. Put simply, until such time as the great and the good start using the NHS - and the state education system - neither will improve.

The “poor folk”, the ones who do not have high incomes and BUPA, have no alternative other than to use comprehensive schools and the NHS. Over the last ten years, New Labour has introduced a two-tier system of medicine and education. The “poor folk” get their medical care from HCPs and nurse-practitioners. The rich see doctors. The children of the “poor folk” are taught by “teaching assistants”, the education system’s equivalent of HCPs and nurse-practitioners. The rich send their children to Eton and St Paul's. You do not find unqualified “teaching assistants” there.

More words from David

We need a commitment from David Cameron; a commitment to say that he will forgo his private health insurance and USE the NHS.

Will Dr Crippen give such a commitment? Not bloody likely. Because at the moment, he is terrified of the idea of being critically ill and being subjected to the protocol driven medical “care” (sic) now provided on the front-line by people who have not been to medical school.

That is an open, honest and honourable position. Dr Crippen will not sign the petition.

Let David Cameron be similarly open, honest and honourable about his position. Either he signs the petition, or he makes a statement that New Labour’s NHS is not good enough or safe enough for him to use.

And if the latter, he gives us an undertaking that, during his first administration, he will put that right. He will make the NHS good enough and safe enough for him and his family.

“Making the NHS safe for my family”.

Dr Crippen does not like slogans, but that one has some appeal.

Cambridge Angry Medic

Another medical student appears on the internet. The Angry Medic is already making waves, and now takes a look at the friction between doctors and nurses.

Great stuff so far. Will he keep it up?

Spectacular surgery

Plastic surgery has been much in the news recently with face transplants.

Is there anything these guys cannot and will not do?

Take a careful look at the picture? Do you believe it? An advert for PHOTOSHOP maybe? Or spectacular surgery? Is it for real? What do you think?

Why would anyone want this done?

The answer is here. In detail. Not for the squeamish.

Nurse Ratchet and the five percent

Nurse Ratchet

An angry nurse has appeared out of nowhere.

She may have been wounded in love, maybe a passionate affair with Dr Rant which ended in tears. Who knows?

For too long now Nurse Ratchet has been reading blogs by erstwhile members of the Medical profession; and while the views and observations on the whole are to be commended, there runs a theme throughout of "Nurseism", or "Nurseogynism" - or even "Nurse-o-phobia". These self-satisfied, pompous, narcissistic fellows (I assume they are fellows?) take great pleasure in patronising nurses who have the temerity, nay the bare faced cheek to aspire to something greater than lovingly wiping an arse, mopping a piss soaked floor… (Nurse Ratchet)

All good fun, but she misses the point.

Dr Crippen is a strong supporter of nurses who do nursing. He does have this old fashioned idea that nurses went into nursing with some commitment to providing personal hands-on care for patients. Nurse Ratchet dismisses old-fashioned nursing and moves on to “something greater than lovingly wiping an arse”. (sic) This sort of attitude patronises the few real nurses who still do real nursing. More worryingly it exemplifies the “Project 2000” mentality that is destroying nursing care in the UK.

In her second post, she brands a GP who sent a critically ill patient into hospital as a “quacktitioner”. She has hit the wrong target. As I have pointed out in her comments, there are plenty of GP Quacktitioners around who deserve ridicule (some of the GPwSIs and all the putative GP surgeons) but she has hit the wrong target here.

Lots of harmless fun and banter with Nurse Ratchet and Dr Rant but we must not let this “fun and banter” disguise a serious underlying point. The example Nurse Ratchet gives eloquently demonstrates why doctors worry about HCPs being on the front line in A & E departments. They are not diagnosticians. They cannot formulate a proper differential diagnosis. Their protocol will always take them to the obvious diagnosis and, in ninety-five per cent of cases, the obvious diagnosis will be the correct diagnosis.

God help the other five percent.

Crown Immunity

"You pay the bill : we are immune"

Family doctors in the UK and any hospital doctors working in private practice have to make their own arrangements for medical negligence insurance. Junior hospital doctors and Consultants not doing private practice can rely on “Crown Immunity”. As can nurses and all other NHS employees.

“Crown Immunity”, by the way, is a sophisticated way of saying that, if there is a cock-up, the tax payer (not Her Majesty) picks up the tab.

Why do all NHS employees not have to carry professional insurance? Why should the tax-payer shoulder this burden? How much does this cost us each year?

I am grateful to Russell Brown, who pointed me at an obscure written answer to a question put in the House of Lords.

NHS: Compensation and Legal Costs

Lord Steinberg asked Her Majesty's Government:

Whether the cost to the National Health Service of £175 million for compensation and legal costs as stated by the National Health Service Litigation Authority includes all outstanding cases to the end of the past financial year. [HL7454]

The Minister of State, Department of Health (Lord Warner): The NHS Litigation Authority 2005-06 accounts report expenditure of £591,586,000 on clinical and non-clinical negligence claims in the past financial year. The accounts include a provision, as at 31 March 2006, of £8,344,980,000 for all outstanding cases including an estimate for incidents that have occurred but not been reported. (Hansard)

£591 million spent last year, and a contingent liability of £8,344 million.

Ouch!

No wonder the government does not rush to inform the tax payer of the costs of crown immunity.

Is Wat Tyler aware of this?

+++++++++

More details of the costs of Crown Immunity, and many other medical matters, can be found at the ever reliable Brown Stuff

A few short days...

I was away for a short time with limited internet access. So much seems to have happened in only a few days. Trying to catch up on medical and related news, the following in particular caught my eye.

Michael Baum, emeritus professor of surgery at University College London is one of the most respected authorities on breast cancer in the UK. He has strong and at times controversial views.

He has long felt that most of the resources spent on breast screening would be better directed towards the treatment of breast cancer.

Now a report suggests that screening is “diagnosing woman with breast cancer who would have survived without treatment, meaning they were undergoing unnecessary chemotherapy, radiotherapy or mastectomies. About a fifth of cancers picked up by screening are in the milk ducts of the breast. Some of these cancers will progress while others will not - but there is no way of predicting what will happen. This means women and doctors have to decide whether or not to risk doing nothing, or go ahead with treatment which might be unnecessary."

They also revealed a further 200 women out of every 2,000 experienced distress and anxiety because of false positives - a result that indicated a cancer was present but was later found to be wrong.


Professor Baum does not prevaricate.

"This latest evidence shifts the balance even further towards harm and away from benefits. If this report stands up, the NHS screening programme should be referred to the National Institute for health and Clinical Excellence to decide whether it should be closed down."

Controversial views, particularly during Pink October.

++++++++++

Looks like Velcade is not going to be available in the UK for patients with advanced myeloma. I had a good friend who had myeloma. He was treated with Velcade and it gave him an extra two years of quality life.

I know, I know, the experience of one of Dr Crippen’s friends is anecdote not science, but sometimes when science comes in at the door, common-sense goes out of the window. It is, of course, available in the USA. (Full story here)


++++++++++

A quarter of all autopsy results are of a “poor or unacceptable standard”. This is not news to doctors. We know that both autopsies and death certificates are often a work of fiction.


All they really say is that on balance there is nothing suspicious about the death, and then they give a best guess as to the likely cause of death. We covered this in Chopping up Granny. To do an autopsy properly requires several hours work and additional investigations such as toxicology. The current fee for an autopsy is £87.70.

You get what you pay for.

++++++++++

Children are not getting sex education soon enough in the UK. The medical profession (mostly) has been saying this for years.



Many children are sexually mature and able to procreate at 11 or 12. Sex education needs to start in primary school.

Patricia Hewitt's bowel movements.

"I've just been, thank you!"

I am grateful to an eminent headmaster, a regular NHS BLOG DOCTOR reader, who points me in the direction of the Times Educational Supplement. An excellent journal, no doubt, but not on the Crippen regular reading list.

There is however a recent TES article which is unmissable for it discusses Patricia Hewitt's bowel movements.

No, really!

As part of the publicity for “The Health Profile of England”, government PR services were primed to issue information to the Press about the lifestyle and eating habits of individual ministers. We learned that:

• Gordon Brown is often found “munching an apple or an orange” [munching an orange?]
  
  
• the Prime Minister, “before his heart trouble” used to “join Alastair Campbell . . . in an occasional chocolate binge”.
  

As expected for our Health Secretary, Patricia Hewitt, 57, apparently leads a life of exemplary healthiness...a spokesman insisted that she eats "infinitely more" than the recommended five portions of fruit and vegetables per day. She has never smoked and allows herself only the occasional glass of wine but given her busy schedule, struggles to "exercise properly with her busy schedule".

"And she does have very, very regular bowel movements".

Rate your stools

Fascinating stuff. But it gets better.

In fact, according to the Media pages in Sunday’s Observer, Hewitt’s spokesman had never referred to her bowel movements: Neil Tweedie had put this in as a (rather appropriate) joke, expecting the sub-editor to remove it. Clearly, the sub-editor thought that the remark was entirely in character and assumed it was genuine. Apparently, there is now discussion between Hewitt’s office and the Telegraph as to whether a printed retraction would make her look worse.

Patricia Hewitt denies she has a regular bowel habit? Surely not! She is between a rock and a hard place.

This is a source of great pleasure to Dr Crippen, who always thought the Secretary of State was anally retentive. Apologies for that, Patricia.

Heaven knows what the Devil and his ageing Greek friend will make of this. There is a comedy sketch here, maybe a series. All suggestions gratefully received.

++++++++++

Dr Crippen respectfully reminds his readers that he is unable to give advice about bowel actions or any other personal medical problems. As always, however, if you are worried about your stools, or the stools of a loved one, please send a specimen in a sealed container to the Department of Health, marked “for the personal attention of the Right Honourable Patricia Hewitt PC MP”

Fat people are stupid

The relentless attack on the obese continues, and is beginning to make Dr Crippen uneasy.

Britain has been declared the “fat man of Europe”. A quarter of our adults and sixteen percent of our children are now officially deemed to be obese.

I have not the slightest doubt that if all the people deemed to be “obese” were to lose weight, their general health would improve. But it is not as simple as that. There is a question of self-respect, of self-esteem. A lot of people who overeat do so not just to “fill a hole” in their stomach, but also to “fill a hole” in their lives.

The more the media batters them, the bigger the hole becomes, and that applies particularly to fat teenagers. Next stop anorexia.

There is another problem. If a quarter of the population share a certain characteristic, we have to re-consider our concept of so called "normality".

It gets worse. It seems that it is not just your physical health that may suffer. Now a piece of research has appeared which purports to show that the more weight you put on, the lower your IQ goes.

I find this hard to believe. But the media loves it and will take great delight in declaring the obese to be both ugly and stupid.

This is not going to help.

Starving hospital patients

Back to one of Dr Crippen’s greatest concern about NHS hospital care. The lack of hands-on nursing. Project 2000 made the only career pathway for nurses one that took them away from patient care and into jobs as “nurse-specialists”

Elderly patients in NHS hospitals are suffering from malnutrition.

There has been a persistent problem with patients not getting the nutrition they need while in hospital. The release of the figures, in a parliamentary written answer, follows a study by Age Concern into what it called "the scandal of malnourished older people in hospital". Nine out of 10 nurses told the charity's Hungry to be Heard survey that they did not have time to provide the elderly with the help they need at meal times. (Telegraph)

• The NHS pays for more than 300 million meals a year, spending an average of £2.65 on each.
  
  
• Hospitals are throwing away more than 37,000 untouched meals every day.
  

Meanwhile, what are all those “nurse-specialists” doing?

As Dr Crippen said in Ashamed of the NHS, we need to get our nurses back to nursing.

Government punishes Tory voters by demolishing their hospitals

Hospital in Conservative constituency

Two days ago, we were looking at government plans to save money on hospital budgets by farming out surgical operations to decentralised cheap labour such as GPs. Yet another example of dumbing down healthcare for those who do not have private medical insurance.

Ms Hewitt recently promised a £750 million cash injection to community health services declaring:

“Community hospitals have for too long been viewed as the poor relation of larger hospitals."

Then Dr Crippen discovers that the government is planning to close down large numbers of community hospitals. How can this be? If you are going to decentralise, you need the community services. What is going on? Can the cash injection be to cover the demolition costs? Surely not.

There must be another agenda. A secret agenda.

Indeed there is. The Times reveals that

“…seven times as many community hospitals have closed or are under threat in constituencies held by opposition MPs. There are 62 closed or at-risk hospitals in Conservative constituencies and 8 in Liberal Democrats seats, with 11 in Labour areas.” (The Times)

Seven times as many community hospitals have closed or are under threat in constituencies held by opposition MPs.

Oh dear. Oh dear, oh dear.

What can Dr Crippen say? He can only refer you to the ageing and as ever appallingly distasteful Mr Eugenides who describes yet another way to “dispose” of Patricia Hewitt.

Quacktitioner Alert (10)

The government is at it again.

More dumbing down. More deskilling of traditional NHS services to save a few pence.

This time, Dr Crippen is ashamed to say, it is the GPs who are jumping on the bandwagon. The plan is for them to start doing surgery. Not just the minor lumps and bumps which are well within their capabilities, but real surgery. Surgery during which the patient is anaesthetised.

You can train a GP to repair a hernia. You can train a monkey to repair a hernia. That is not the point.

The government thinks that you can take any medical speciality, divide it up into tiny parts, and allocate each part to a “heath care practitioner” or, as Dr Crippen prefers to call them, a quacktitioner. The problem is that the sum of the parts does not equal the whole. Each quacktitioner possessively holds onto his little piece of the jigsaw, but cannot see the overall picture.

Repairing hernias is easy – until something goes wrong, until there is some aberrant anatomy, until you make a mistake. A skilled surgeon has the training and the ability to cope with unexpected. A GP does not.

And what is the point of decentralising the NHS? The NHS has been a roller coaster over sixty years as each political administration changes its direction. Open or close the cottage hospitals; invest in centres of excellence one day and the next close them all. And so it goes on.

Dr Crippen hoped that GPs would fight against this. We have our own skill set. We are family doctors, not surgeons. But no, GP leaders are in favour. This, from the soon to be renamed Royal College of General Quacktitioners:

"In some areas, this will involve making sure there are GPs who are as skilled with the scalpel as they are with the stethoscope."

Clinicians, including the Royal College of General Quacktitioners, also welcomed the announcement of the pilot schemes. Professor Mayur Lakhani, chairman of the RCGQ said: "There is an untapped potential for primary care to deliver even more services for patients." (source)

Dr Crippen is checking that the family private health insurance is up to date.

In like Flint

Getting fruity with Flint

I occasionally get the feeling that some of you do not believe Dr Crippen when he talks about the Stalinist control freakery that pervades the NHS.

One of the greatest control freaks in the NHS bunker is the very lovely Caroline Flint. You may remember her from one of the Stalin awards. On your behalf and at your expense she “invested” millions of pounds of taxpayer’s money to provide a “toolkit” to enable doctors to recognise obesity. You don’t believe it? Have a look here. There was of course a “pathway”. Isn’t there always?

Dr Crippen will not be taking the path, nor using the toolkit. As I said at the time:

Dr Crippen will struggle on with the soon to be out-moded equipment he has used to diagnose obesity for the last twenty years. This is a complex photo-electric receptor apparatus which has integral bionic micro-electronic circuitry calibrated automatically to orientate and binocularly co-ordinate the three-dimensional spatial presentation of the propositus in relationship to a complex wooden matrix specially designed by skilled craftsman to admit and contain all members of the population with guaranteed confidence levels up to and including the mean and three standard deviations of the population norm.

In other words, he glances at the patient as they enter the door, and knows instantly if they are overweight.

If they are fat, he tells them to eat less. Next!

Now Caroline Flint has turned her attention to fruit. We do not eat enough. So the government is going to sponsor (i.e. the tax-payer is going to sponsor) fruit eating lessons. Those of you who do not know how to peel a banana please listen carefully.

You don’t believe this either? Nor did I. But it is true.

Overweight people should be given lessons in how to eat fruit and vegetables, a health minister said yesterday. Caroline Flint said too many Britons are refusing to eat fresh produce because they see it as "scary food". She wants supermarkets to provide in-store demonstrations on how healthier food – even apples and bananas – should be prepared and eaten. Flint admitted the government faces an uphill challenge-to persuade some people to adopt healthier lifestyles. She cited a parent at a recent seminar held by the Department of Health who said she was intimidated by "scarier foods". "What she was talking about was vegetables she had never seen in her life before. Here’s a fruit you have never seen before. What do you do with it? Do you peel it? Do you boil it? Do you chop it?" she said. Flint said the solution was to provide cookery lessons in major stores. (source)

Patronising git.

I hardly dare tell you how Dr Rant approaches it.

Flint also plans to introduce vouchers for families on low incomes which can only be exchanged for fresh produce.

Patronising git.

Those of us working in the NHS have had to put up with this sort of codswallop for ten years.

It is appalling, rude, patronising, offensive, discriminatory, Stalinist, and ignorant to assume that “the poor folk” do not know how to peel an apple.

And anyway, Dr Crippen thought they all ate cake.

Will you sign the petition, David?

I was delighted to recommend Webcameron yesterday not least, of course, because of the presence of a fascinating article published there entitled Ashamed of the NHS. Following on from that, I notice an interesting post has appeared there.

It is entitled, as headlined above, “Will you sign the petition, David”

What petition? We looked at this before.

This is not a complicated issue. It is straightforward. It asks MPs to pledge their support for the NHS by undertaking to use it. What could be simpler than that?

Our petition has a simple mission statement:

"The most effective way for ordinary citizens to ensure NHS reform will be successful is to make certain that those who are responsible for creating the public health system voluntarily agree to exclusively use the same system, without opt-out for their own medical treatment.”

So, David, will you sign?

Let’s watch Webcameron closely.

And finally, a little quiz. Who said:

"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."

Was it David Cameron or Tony Blair? The answer is here.

Webcameron and new media

When I was a small child my great grandmother, who was born in 1887, talked frequently of the major changes in “the media” that she had experienced during her life. Of course, she did not use words like “media”. But she talked of the difference that the introduction of radio made, and how much it changed family life. The advent of television changed life even more but, like many of her generation, whilst she loved radio, she hated television.

We are on the threshold of another media explosion. The internet allows anyone to express their views in blogs. There are at least forty million blogs worldwide, and thousands more appear every day.

And from blogs, we move onto Internet Television and Video. The man in the street has been enfranchised. He can express his opinion in words and now on film. Unlike the main stream media, there are no press barons, no control from above and no censorship.

The entrepreneurial Sam Roake has created Webcameron. This gives an opportunity, on a daily basis, to watch the Leader of the Opposition at work. You may or may not be a Tory supporter. That does not matter. Webcameron is not a Tory Broadsheet. It is a forum for debate, a debate that is read and watched by the leaders of the Tory Party, by the shadow cabinet and by David Cameron himself.

It is open to any one to comment. If you are a Cameron supporter, tell him. If you do not like what he is doing, tell him. This is the first time in British politics that the electorate has been given the opportunity to communicate directly with the leadership of a political party.

Sam asked Dr Crippen to write an article on changes he would like in UK health care. Have a look at “Ashamed of the NHS”.

++++++++++


If anyone wishes to comment on Ashamed of the NHS, would they kindly do so here under the article. You may need to register. It only takes a minute.

Private Eye hits the spot

Dr Crippen cannot resist recommending the current edition of Private Eye, which contains two health-care gems (and much else of course)

NHS NUMBER CRUNCHING

£340 million
Salaries of NHS medical consultants 2005 – 2006

£325 million
Salaries of NHS management consultants 2005 -2006

What can one say? If I may borrow a phrase from Crippen junior's GCSE maths, Q.E.D seems to fit the bill.

++++++++++

This leads directly onto and indeed may explain a letter in Private Eye from Daryl Bamonte:

“I was using Google to find the name of a hospital in Essex, and was directed to eBay, where I was invited to buy one.”

Surely not. So Dr Crippen put "Hospitals in Essex" into Google, and there it is.

Very New Labour.

New Labour destroys NHS dentistry

The government’s attempts to “solve” the lack of availability of NHS dental care have failed.

They forced a new, target-driven contract onto the dentists. The contract paid paltry rewards to dentists to do rushed, sub-standard amalgam bashing, and gave no incentive for sensible, preventative dentistry.

This is exactly what they did to the GPs. Our income now depends on hitting government set targets which have very little to do with genuine health care and a lot to do with the views of Patricia Hewitt’s focus groups.

The dentists are voting with their feet, an option not open to GPs. Most dentists have always had hybrid NHS/Private practices. Now they are no longer hybrid. They have left the NHS. They can now do high quality dental work. They do not have the same pressures. They do not have to report in triplicate to a hierarchy of dental commissars who demand that they retrospectively justify the need for all the work they have done. And they are earning twice as much money. Who can blame them?

More than 1,600 dentists in England quit the NHS in the first three months since a new contract was introduced, according to official figures.

NHS Information Centre statistics show the number of contracted dentists fell from 21,111 to 19,462 on 30 June. (BBC)

How is the government going to deal with this?

It is going to fall back on its favourite strategy. It is going to use the well-known "sword of truth and trusty shield of fair play".

It is going to lie.

Poor old Rosie Winterton (see Guido) got the short straw. Patricia would not sully her reputation (sic) with this.

Lester Ellman, chairman of the British Dental Association's (BDA) general dental practice committee, said: "At a time when the government are trying to increase access to NHS dentistry, the loss of any dentist to the service has an impact. "Dentists are frustrated by the target-driven approach of the new contract, which fails to allow a more preventative approach to care."

The Department of Health issued a statement on behalf of Health Minister Rosie Winterton.

It said: "NHS dentistry is expanding, with primary care trusts now commissioning more services than under the old contract."

Of course it is, Rosie

Teaching doctors to suck eggs

UK mental health services : Care in the community

There is another spectacular piece of New Labour health care fraud approaching the mentally ill.

The provision for mental illness in this country is appalling. The long-stay mental hospitals have been closed, so the schizophrenics wander the streets looking for their community care. There are no psychiatrists in the hospitals outside normal working hours. The government extols the benefit of “talking therapy” but does not provide the therapists. So patients’ expectations are raised, and then dashed. And quite often it is the GPs who are blamed for not providing the therapy. We would if we could.

The Independent on Sunday reports today:

Revealed: 50 per cent of alcoholics and drug addicts are mentally ill

More good news from the University of the Bleeding Obvious. Except this time it is not true. The proportion is higher than fifty per cent. Far higher. Trouble is, alcoholics and drug addicts are difficult to treat. The severe ones need detoxification before you can even begin to scratch the surface of what made them start drinking. There are not enough detoxification centres. There are not enough consultant psychiatrists. Worse, there are not enough psychiatrists in training. Finally, there are not enough beds in mental hospitals.

Most drunks and drug addicts who tip up at A & E departments, and a lot do, are given short shrift by the medical staff. When confronted by patients smelling of alcohol, doctors in A & E departments switch off. It is easy to criticise. But part of the reason the doctors switch off is that they have no where to treat these patients. Nowhere to send them. So, with the best will in the world, what are they supposed to do?

There is an excellent organisation called Turning Point. Turning Point is a charity. Have a look at their web-site. Why does this have to be done by a charity? Why is not the NHS doing it? There is no charitable organisation to buy Harrier Jump Jets for service in Iraq. But that is important, is it not?

SANE and Turning Point are raising awareness amongst the general public about the fact that most alcoholics and drug addicts have mental health problems. The doctors have been saying this for years and have been ignored. But now the media is forcing the government to take action.

So is it going to provide more resources? No, that would be too expensive. Instead, it has promised the general public that it is going to “educate” the medical profession.

"...doctors' surgeries and hospitals are to be given official guidance to help them to identify people abusing drugs or alcohol who are also mentally ill.

Ministers have commissioned Turning Point to produce a good practice guide for doctors and nurses to help them to identify people with the symptoms of mental illness." (Independent)

I feel another phalanx of “nurse-specialists” coming on. The “drug” and “alcohol” nurse-specialists. Their task will be to annoy doctors and experienced CPNs by teaching them how to suck eggs.

Doctors already know that most drug addicts and alcoholics have mental health problems. Give us the resources to deal with them, and we will sort it out.

But no, the government is not going to cough up for that. It will paper over yet another crack in health care with yet another nurse specialist. They have done just the same with lung cancer. The survival figures for lung cancer in the UK are appalling compared to the rest of the civilised world. So the government has appointed lung cancer “nurse specialists” to paper over that crack. What we really need is more radiation oncologists, more radiotherapy machines, more radiation physicists and more hospital facilities. We are not going to get them. So you will still die much more quickly of lung cancer in the UK, but at least you will die with a dolly-bird lung cancer nurse-specialist patting your hand.

I’m off to the pub with a Shiny Happy Person

The Crippen Diaries (Week 41)

Not quite Tannochbrae

Monday 9th October

Annual meeting with the accountant today. How are we doing? How many targets have we hit and so on.

As always, I have this lurking fascination with language. Two of the partners stop speaking ordinary English. They do not talk of the money that is going to come in for this and that, or did come in last year. They talk of “monies”. We must “look at the monies (sic) " expected in for April. Why this odd and gratuitous use of the plural I wonder? Businessmen and accountants do it a lot. Why? “Money” would do just as well and is better use of English. Odd. And the political party conference season has just past. Why do some politicians, left wingers in particular, favour dropping the definite article before using the word “conference?” As in “We will see what conference decides” rather than “We will see what the conference decides.” A grammatical eccentricity favoured in particular by Tony Benn.

But I digress. The accountant (he is a specialised medical accountant) always brings with him an anonymised list of the three hundred or so general practices he audits for comparison purposes. See how you are doing. We are well above average but nowhere near the top. The top ten practices are all earning in excess of £250,000 per full time doctor. Top of the list is a single handed GP with 6500 patients who is earning a staggering £450,000 a year. The accountant says he is more of a business man than a doctor.

++++++++++

Our oldest partner is retiring next spring. He is only 57. He has had enough. He will take a pension of approximately £30,000 a year, indexed linked, with a lump sum of approximately £90,000. Sounds a lot, but is barely a quarter of his current income. If he had been a real civil servant, it would have been two thirds. This makes me pretty fed up. We have been working together for twenty years, and the practice will be very different. I can’t afford to retire yet. I am younger, and my pension such as it is would be actuarially hammered if I went now. I could retire and do locums to supplement the pension. A lot of middle aged doctors are doing this. You can get part-time sessional employment working for the entrepreneurial single handed doctors who run their huge lists by employing both doctors who have taken early retirement, and young female doctors with children who need part-time work. It is all a bit of a rip-off, but at least doing locums you do not have to worry about QoF data and all the admin.

It’s a thought.

++++++++++

And what are the realities of QoF? Of all this obsessive, Stalinist data collection? Did you know that the government is collecting a list of all people in the country who have had significant mental health problems? It will all be secret. Of course it will. Stories that they are all going to be rounded up and moved to the Isle of Wight are much exaggerated. How would you like to be on the that list? How would a doctor who has had mental health problems feel about being on the list? How do doctors, when they have to be patients, feel about QoF in geneneral? See what happens when a psychiatrist goes to the doctor.

++++++++++


Tuesday 10th October

A lot of hot toddlers today. The first case of hand, foot and mouth disease of the year and probably the first case of bronchiolitis too. Bronchiolitis always takes a long time because parents, understandably, want active treatment, preferably antibiotics.

++++++++++


A patient in (already!) to ask why he was not given radiotherapy to his bowel before he had his bowel cancer resected. The BBC published the story only yesterday. I favour the cautious approach of Dr Rob Glynne-Jones, one of the leading UK bowel cancer oncologists. Local recurrence of bowel cancer is very rare indeed. Radiation cystitis and proctitis are two of the most awful conditions it is possible to suffer. Imagine the worst, ring-burning attack of diarrhoea you have ever had in your life. Then imagine having it six times a day and four times a night, and then imagine having it for several months. And we have not even started on the cystitis and the impotence.

+++++++++++

An angry meeting at lunchtime. We agreed to go into the Central Allocation System (CAS ) provided always that, when we refer a patient to the hospital and specify a named consultant, the patient will be seen by that named consultant. Already we have had a referral to a vascular surgeon diverted to a nurse quacktitioner, and a referral to an orthopaedic surgeon diverted to a physiotherapy quacktitioner. We have made a formal complaint and insisted that both patients are seen by the consultant to whom we referred them.

If this keeps happening, we will pull out of CAS altogether. At the moment, the only way a patient can guarantee to see a medically trained consultant (you can’t just say consultant anymore because although the layman thinks that, in a hospital context, consultant implies senior doctor, in fact there are now lots of quacktitioner consultants) is by paying to go privately.

Classic New Labour hypocrisy.

++++++++++


Thursday 12th October

An extraordinary day.

Three patients waiting at 8.00 am. I saw them. Normally, by the time you have seen three patients, the whole session is booked.

It wasn’t. Lots and lots of empty spaces. And the phone stayed silent. I did some paperwork. Checked my email. Still no more bookings. Then you start getting paranoid and thinking, maybe they have all gone off me. So you flick around the computer screens and see what everyone else is up to. They were all quiet too.

I saw nine patients rather than the usual twenty five or so. I caught up with my paperwork. I checked all the results. By twelve o’clock my desk was clear whereas usually there is a mound of paperwork to plough through and lots of dictating. And no visits.

Brilliant. This happens about half a dozen times a year. I just wish I could predict it, work out what factors come together to cause such a quiet day.

Probably just a statistically predictable quirk.

++++++++++


Friday 13th October


Friday 13th, duty doctor, and yesterday was unnaturally quiet. They were all waiting for today. There is no such thing as a free lunch in this business.

+++++++++++

A 62 year old man whose father died two months ago. He has just brought his mother to live with him. His father died of disseminated prostate cancer. Sound like the last couple of weeks were pretty rough. They were a devoted couple. His mother did everything. There was a Macmillan nurse in attendance for a while until they asked her to stop coming. They could not stand all the hand-patting and ‘deep and meaningful looks’ but the last straw was when she suggest that they got married again, or had some sort of ceremony reaffirming their marriage vows.

Not their scene. They had a fit of the giggles. The nurse stopped coming. I really liked this story. As I have said many times, dying is a bad business, and you cannot wallpaper over it with Mills & Boon fantasy.

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

And then I had to tell David, a retired maths teacher, that he has Alzheimer’s. I think he knew. Well, he certainly knew that he has dementia. He presented three months ago, with his son and daughter. He is a widower. His short term memory was startlingly bad. He performed very badly on the standard personalised Crippen mini-mental. I checked all the normal things you check. The fantasy is that you will find that they have undiagnosed myxoedema (under active thyroid gland) and “cure” them with some thyroxine. It rarely happens. He has been to the memory clinic, had detailed memory testing and scans and it is Alzheimer’s. Does it much matter what “kind” of dementia it is? There is the possibility that Aricept will help. David still has complete insight into the problem and being highly intelligent is compensating well for the time being.

David’s son said that at the clinic they ask all the patients if they want to know the results of the test. Apparently some do not. I sort of vaguely get the feeling that he would have been happier if I had not told his Dad, or at least not used the word Alzheimer’s. I believe there is no alternative but to tell patients the truth. I think that is right. Not everyone agrees.

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

Finally, all paperwork cleared. It is half-term next week, and so a few days off.



(For readers using an RSS feed : this post is updated and expanded on a daily basis from Monday to Saturday)

Warts and all

The Daily Mail has been at it again.

Europe has been dragging its heels about the introduction of Gardasil, the immunisation that can protect our teenagers against genital warts and cervical cancer.

An editorial in The Lancet says:

Catching up with the rest of the world, the European Commission last week licensed the first human papillomavirus (HPV) vaccine, Gardasil, for use in children aged 9–15 years and women aged 16–26 years. The vaccine offers protection against HPV types 16 and 18, which are responsible for 70% of all cervical cancers, and types 6 and 11, which cause about 90% of cases of genital warts.

Following earlier approval by the US Food and Drug Administration of the vaccine in girls and women, the Michigan Senate passed a bill on Sept 21, ruling that all girls entering the sixth grade of school (11–12 years old) should be immunised. This is the first legislation of its kind in the USA, and a decision from which the EU member states should take heed. (The Lancet)

How does the Daily Mail approach it?

Schoolgirls must have compulsory sex disease jabs, say doctors

God, I hate the Daily Mail. We can see the agenda here. They print the report under a provocative headline. And then, as the Devil himself observes, they lapse into the passive tense. The passive tense is the last refuge of the anonymous.

Despite claims that it encourages under-age sex, medical journal The Lancet has called for compulsory cancer jabs for schoolgirls. The jab, against what is effectively a sexually transmitted infection, is controversal because it is argued that they (sic - they can't even do grammar these days) encourage under-age sex. (Daily Mail)

We all know for whom the Daily Mail caters. Mary Whitehouse, who will be turning in her grave, poor thing. And those extraordinary nurses down in the wilds of Tennessee. They will not take sex lying down.

Fortunately, there is already a website campaigning agaist the lunatic fringe of the moral minority. Gardasil Watch says:

...a new immunization looks like it may be able to prevent these deaths, but some narrow-minded religious groups may be against the immunizations because to be most effective it should be given to children before they are sexually active. It is vitally important that people be informed that intolerance should not play a role in saving these women's lives.

I think I had better send them a copy of the Daily Mail.

In the meantime, if you want to protect your teenage daughters against this, or this and your teenage sons against this, I would get them the immunisation as soon as it becomes available.

++++++++++

A reader kindly reminds me that it is no longer necessary to buy the Daily Mail to get the headline news. Daily-Mail-o-Matic will generate all the headlines you will ever need. For free.

Dr Rant

Just discovered Dr Rant.

Where has he been hiding? Short (only a handful of posts so far) and sweet and hits the spot.

Take a look here.






Cartoon from Cartoon Monkey

What shall we do with grandad?

Dr Crippen is a fairly high-emotive doctor. This is good for most of his patients and bad for a few. It is not good for him. Two of my partners are low-emotive doctors. Don’t get me wrong. They are excellent doctors. I would happily see them if I were ill. But they are more dispassionate than I. They do not get involved as much.

Eric is a retired airline pilot. He is well into his eighties. He has a reasonable pension. Dorothy, his wife, is 78 and in good health. Which is just as well, because Eric is not, and Dorothy is his full-time carer. In Eric’s case, full-time means full-time, because Eric is demented. A full time job. They had a daughter, but she died of leukaemia when she was twenty. Eric still recognises his wife. He even recognises me. Sometimes. Last week, when I went to see him, he told me they did not need double-glazing.

As well as dementia, Eric has benign prostatic hypertrophy. So he pees a lot. Nappies at night, which he always takes off, so the bed is wet every morning. He does not wet himself during the day too often, but he pees in the wrong place. The fireplace. The plant pot. Once, the tumble drier. And he keeps falling over. He has not broken anything yet, but he will.

The NHS may be “free at the point of entry” but the door is closed for Eric. I have phoned and written to social services more times than I can remember. A rather sullen carer now comes three times a day for forty five minutes. Because Eric and Dorothy are “rich” they have to pay for the carer.

Dorothy is a proud woman. She makes sure that Eric is always smartly dressed. She takes him out for walks. Have a chat with him in the park. You probably will not realise there is a problem.

Dorothy is on her knees. Eric needs full-tim care. He cannot be left. He should be in a nursing home. I have told social services that he needs residential care. They responded by saying that they would send “someone” round to “assess” him. I said I had already “assessed” him, but that will not do. I am not “someone”. When “someone” arrived, she had a clip board and a tick-sheet. Can Eric dress himself? Yes. Tick. (Well, sort of. Sometimes his shirt is back to front and he puts both legs down one hole in his old fashioned commodious underpants). Eric can also undress himself, and frequently does, but not in appropriate places nor at appropriate times. “Someone” asked Eric lots of questions. He was on best behaviour. He accrued enough “ticks” not to qualify for residential care. My opinion is irrelevant. The only option is the private sector. “Rich” though Eric and Dorothy are, they could not sustain that for more than a few months. Well, they will have to sell the house. Dorothy will do that if necessary, but where does she live? And even then, the money will soon run out.

My low-emotive partners would tell Dorothy and Eric that they have done all they can, that the “system” can provide no more. I find it hard to do that. I keep telling Dorothy that I will try to get some more help for her. And then I shout at social services, and make critical remarks about the well-meaning, deskilled, dumbed-down “someones” with the clip chart and tick-boxes who now make the decisions.

We will soldier on until Eric breaks a leg, or Dorothy breaks her back. Then they will both be admitted to hospital and block acute medical beds until, finally, social services are forced to act.

Do not get old. Do not own your own house. Do not have a caring partner. Do not, what ever you do, tell social services that you can still make a cup of tea. As a psychiatrist describes here, "someone" regards the ability to make a cup of tea as proof positive that you do not need to be in hospital.

Meanwhile, Eric and Dorothy’s high emotive family doctor is stressed.

Again.

Compulsive gambling

When Dr Crippen was at University, he played a little poker. Not for match sticks, not for pennies but for a few pounds. And he did not do too badly.

I have not played since. Until last year. I had a look at one of the Internet gaming sites, and signed up. Within five days, I had accumulated just over two million dollars. I really was rather good at it. Sad to say, they were virtual dollars but, encouraged by my success, I went into one of the real money games with £50 worth of chips. I lost them all within the hour.

Most of the people who play are probably maths students at Oxford. Well one of them certainly is because he is a patient of mine. Last year, his winnings were in excess of £50,000. Including my £50 I dare say. He plays for several hours a day. He is good at it. Is he addicted? I do not think so. He seems to have insight.

I received an email today from someone who is addicted. He writes:

I would be interested to know how you, or GP's in general, handle a request for help from a patient who is a compulsive gambler - for information, I am a compulsive gambler. I have not had a bet for more than 3 years now, and have never mentioned a word of this to my GP, who is an excellent all round chap by the way! I have often wondered if I should tell him of my "condition"(?) or not. Would you as a GP want or need to know this at all?

Keep doing what you're doing Dr Crippen - it's greatly appreciated.

Thank you for the kind words, but I am no expert here. I have had a few patients over the years who spent too much time in the bookies, but I have only had one true gambling addict. He had lost his house, his wife, his job and his self-respect. He spent most of his benefit money on gambling rather than on food. I tried to get him some psychological help, but he did not turn up for the appointment and left the area. I do not know what happened to him.

How would I handle the next gambling addict? I would assess him for psychiatric and other psychological problems and address those. I would certainly set some time aside to see him regularly for support. I suppose I would give him the number of Gamblers Anonymous, though I have no first hand experience of them. I suspect the true gambling addict is like the true alcoholic. He cannot be helped until he seeks help, and he may need to bottom before he will seek help. Wives, girlfriends and family may prolong his problem by supporting him.

I do not have access to any specific psychiatric or psychological support in the NHS. Whatever was done would have to be done by me.

I suspect it is not a common problem. But with the internet, it is going to get commoner. The USA is trying to ban on-line gambling. It did not work with prohibition, so I would not be optimistic.


And could they be closing it down because most of the companies are British? They are not closing gambling down in Las Vegas, but then that nice Mr Soprano would not like that, would he!

The Crippen Diaries (Week 40)

Not quite Tannochbrae

Monday 2nd October


A bad start to the day.

The first patient in was Jane, accompanied by her husband David. Jane is in her seventies. She has COPD, heart failure, atrial fibrillation and rheumatoid arthritis. And she is anaemic, slightly more so than she was two months ago, the last time I checked her bloods. She is on half the chemist’s shop, including warfarin, digoxin, Tildiem and a Seretide inhaler. Her heart rate control is not wonderful. She sees the heart failure nurse specialist, the respiratory nurse specialist, the rheumatology nurse specialist and me. Each of the nurse’s clutch frantically onto their piece of the medical jigsaw but none sees the overall picture. Jane is chronically short of breath. Heart failure nurse and respiratory nurse want to increase Jane’s medication. They are arguing about highly selective beta-blockers which might improve her rate control and might improve her cardiac failure. Highly selective or not, a beta-blocker will not help her COPD though she might get away with it. I am going to check out the anaemia before I do anything else.

I hum and ha my way through her medication, check her over, have a chat and leave things alone. Jane is not much worse than she was three months ago. The big picture here, as far as I am concerned, is trying not to make things worse. And finding out why she is anaemic.

I have a real problem with beta-blockers and heart-failure. When I trained, and indeed when I was a medical registrar, beta-blockers were absolutely contraindicated in heart failure. They would make it worse. They could kill the patient. If I had put a heart failure patient on beta-blockers at that stage of my career, and the patient had died, I would have been looking at a negligence suit, and the only question would have been quantum of damages.

Now we have realised that beta-blockers are a helpful, indeed essential, treatment for heart failure. I think part of this is being macho. Using a drug that used to be regarded as potentially lethal sorts the men out from the boys. And now it is life-saving. Apparently. And so, when the cardiologists recommend the homeopathic dose of bisoprolol, I dutifully prescribe it, but it frightens me. I must learn to adapt, I suppose. But I have been practising medicine long enough to see fashions come and go. Spironalactone was routinely used in the late seventies and early eighties, then fell into disuse, and has recently been rediscovered. HRT was so fashionable until a few years ago that it became a woman’s right to have it. The universal panacea for all the ailments of middle age. Now it is prescribed almost reluctantly and with a long list of caveats. I would not be surprised if beta-blockers fall out of favour again.

I digress.

By the time had I finished with Jane, I was twenty minutes late. David said, “Would you mind doing my medication to save me coming back?”

“But you haven’t made an appointment.”

From the look on his face, David clearly thought I was being petty. So I checked his blood pressure, made sure his tests were all up to date, and duly did the prescription. Probably not with very good grace.

One appointment down and half an hour late. That meant starting every consultation for the rest of the morning with an apology.

++++++++++


Tuesday 3rd October

I was asked exactly the same question by two different patients this morning. One had been referred to our local breast surgeon directly by the mammography unit. Do you know him? Is he safe? Would you let him operate on your wife? Do you get good feedback on him.

And then the rugby player with the painful hip, which turns out not to be hip pain at all, but referred pain from a prolapsed intervertebral disc. He has been referred to the local orthopod who does backs. He had exactly the same questions.

For both patients, the answer to all four questions was an unequivocal yes. Our local breast unit is excellent, as is the orthopaedic department.

Sometimes it is not so easy. There are one or two consultants who are not so good. We do not routinely refer to them, and try to steer patients gently towards someone else. It is difficult. But we are highly educated consumers of secondary medical care, and it is part of our responsibility to refer patient to consultants in whom we have confidence. I do not think it is unethical to do this, though one ducks and weaves to try to avoid having to say, “Look, I do not have a great deal of confidence in Dr So-and-so.

This is why most GPs get shirty with patients who have been out on the internet and found their own consultant. The internet is a medical tombola. The letters after a doctor’s name may look impressive, but most doctors can bring half an alphabet of qualifications to market. A doctor’s competence is inversely proportional to the number of letters he feels the need to display after his name.

++++++++++

Sebastian is 12 years old. He is tall and athletic. He came with his father who is a local garage owner. Sebastian goes to a private day school. He is an outstanding footballer, and is on the books of a local premiership football club. We have had quite a few boys over the years who have been signed on by professional football clubs. It is a depressing business. We have yet to have one who has made it to the top. When they are told in their mid-teens that, contrary to their hopes and expectations, they have no future, they are devastated.

Sebastian has come because “he has that cough again doctor”. Dad would like some antibiotics. There is nothing to find examining Sebastian. The cough is a recurrent problem. Only in the winter. He coughs a lot at night. He coughs when he goes out of the house into the cold air. He coughs when he does exercise, and once or twice has had to stop football training because of the cough. When he was a small child he was “always getting chest infections and needing antibiotics.” And every time he gets a cold it “always goes onto his chest”. I measure his peak flow rate (PFR) which is just about at predicted level, but not as high as I would expect from someone of his height and level of fitness.

I have to handle this very carefully. There is no indication for antibiotics. I do not have a “magic pill” to get rid of the cough. I talk to Sebastian about measuring his peak flow. I would like him to do it twice a day for a while and chart it, and do it before and after exercise. I also want him to keep a “cough chart”.

“Just a minute” says dad. "My brother’s children all have those peak flow things. And they all have asthma. You are not saying that my boy has got asthma. We don’t want to go down that road.”

Asthma is a distinct possibility. Or irritable airways, if you like. But I have deliberately not used the word. It is a bogey word.

I say that I am not suggesting anything at all at the moment, but that I want to check things out further.

“I don’t think we want to go down that road” Dad repeats “He gets it every year. It’s just his cough.”

We all tend to assume that anything our children do is normal, and that all other children do it do. Children should not cough, or not for more than a few days. All children get coughs and colds, but persistent coughs need investigation. Dad agrees to take the prescription for the Peak Flow Meter, but his eyes are glazed over. I book a follow-up appointment, but I doubt he will come.

More likely, he will take Sebastian to one of the walk-in clinics and persuade someone to prescribe some Amoxicillin. Looking back through the notes, this is exactly what he did last year when one of my partners also tried to organise some peak flow monitoring.

++++++++++


Thursday 6th October

Mary is in her late forties. She came today, with her son and daughter. All three were distressed.

She came to see me just over four weeks ago. A change in bowel habit, motions a bit lose with some mucous and blood. Mother died of bowel cancer in her mid-fifties. An ominous history and examining her there was a hard, craggy lesion in her rectum which I could just tip with my finger.

Two week rule referral to the colo-rectal clininc. She was seen well within ten days, and within three weeks she had had a colonoscopy, CT scan, liver ultrasound and appropriate blood tests. No sign of any spread.

She is scheduled for surgery at the end of the month, in just over three week’s time. Mary does not want to wait for three weeks and, to be honest, nor would I. So she phoned the surgeon’s secretary and asked if she could have it done sooner if she went privately.

Did she have £5000 and, if she did, could she come in on Monday?

This is the system. I have a problem, somehow, with the surgeon offering his NHS cancer patients a fast-track if they can afford to pay. Mary cannot afford to, really. Her husband is a maintenance officer in a local factory and she is a receptionist. But the family have had a whip-round and found the money.

From the day I referred her to the surgeon, including all appropriate staging investigations, seven weeks will have passed. All government targets have been hit. It is highly unlikely that saving three weeks will make any difference to the prognosis, but who knows. All things considered that is not bad service.

I suggested to the family that I write to the surgeon to see if the operation could be expedited, and further suggested that they spend the money on sending Mary and her husband on a three week convalescence holiday in Florida

They are going to pay for the operation.

++++++++++


Friday 6th October

An interesting conversation with Jennifer. A 32 year old chartered accountant. Not married. Busy social life. She had been about a stone overweight for some years. We talked about it awhile ago. She knew where the weight came from. Excess calories. But she did not know how to cut down. I asked her how much alcohol she drank. It soon emerged that she was drinking over a bottle of wine a day. And the odd vodka. Probably three times her allowed 21 weekly units.

“I’ll cut down” she said.

“Why don’t you stop altogether for a while?”

She looked appalled. “I don’t think I could do that”.

I said that if she really could not do it, then it was essential that she did. Good servant. Bad master. All that sort of guff. Except it isn’t guff.

“Right” she said. “I am not an alcoholic. I will stop.”

And she did. She has not had a drink for nearly nine months. She has lost the stone, and a bit more. Her face no longer has that slight puffiness. She looks and feels better. I asked her if it had been difficult.

Not after the first three days. She hardly thought about it after that. But there were other unexpected difficulties. Social difficulties. It made her friends feel uncomfortable. She found the last hour of dinner parties, that hour when the well-lubricated philosophy starts, intolerable. She now leaves early. People who did not know her so well were irritating, often patronising. “Oh, well done” and then, sotto voce, “one day at a time”

And the best thing about it?

Time. Jennifer has rediscovered so much time. Nine months ago, she would start drinking wine when she arrived home, and not stop until she went to bed. The evenings passed in a pleasant, non-productive blur.

Is Jennifer an alcoholic? I don’t think so, or not in conventional terms. Will she start drinking again? She paused, and said “I don’t know.”

If you feel so much better, why on earth would you ever want to start again?

“I don’t know” she said, “but a good question. Why does anyone drink regularly?”

Why indeed.



(For readers using an RSS feed : this post is updated and expanded on a daily basis from Monday to Saturday)

Doctors on the scrap heap : sign the petition

Postgraduate medical centre

Dr Crippen is now receiving several emails a day from doctors in distress all over the country. Two arrived this morning.

The first is from one of my spies in Dundee and quotes an article in the University of Dundee's Clinical Skills Centre newsletter.

The Article is entitled,

“Oh shit, patients are dying on the wards and I can’t find a doctor.”

Er...no, it isn't. You can't say things like that in an official document.

It is called:

Hospital at Night Training Course

The Hospital at Night project aims to redefine how medical cover is provided in hospitals during the out-of-hours period. The aim being to move away from cover requirements which are defined by professional demarcation and grade and migrating towards cover defined by competency.” There will also be a need to think across the traditional boundaries and out-with the existing medical models.

Now you can say, Oh shit!

Our dear old friends, Sue and Dave, must have emigrated. And, er, excuse me but isn't "professional demarcation and grade" the best way to define and recognise "competency"? It looks like we are going to be "getting a picture of the night" in Dundee as well as at Arrowe Park Hospital.

This new week long course was developed to help experienced nurses learn how to work as Hospital at Night Practitioners (H@NPs)

Hospital at Night' is a whole hospital model, intended to improve (sic) both patient care and the working lives of clinical staff. The development of all clinical professionals by extending their traditional roles and competencies should enhance the multidisciplinary concept of care, ensure a balanced work/life ratio and enhance personal development and career opportunities within and across the NHS Tayside. The concept will also contribute towards addressing the European Working Time Directive and lessen the impact of the Junior Doctors New Deal and the Modernisation of Medical Careers.

The H@NPs will work at night in the hospital as part of a team of nursing and medical staff looking after the patients who have been admitted. Their role will include assessing patients, administering initial treatment to them, and then deciding whether or not a doctor needs to see them.

The educational approach used in the H@N practitioner's course was the cognitive apprenticeship. This recognises the need to explore and analyse using clinical experience, the knowledge skills and attitudes required to provide high quality of patient care. This approach facilitates the link up between theory and practice in relation to new learning and how it can be transferred most effectively to the workplace through reflection"

People ask me sometimes how I manage to write NHS BLOG DOCTOR. Well, frankly, these days it writes itself. As I say ever more frequently, some things are beyond satire. I can only sit back and wonder which paragraph of this sententious garbage annoys me the most.

This new week long course was developed to help experienced nurses learn how to work as Hospital at Night Practitioners

Medical students are so stupid. It takes them five years to learn how to do this kind of work. These clever nurses can do it in a week. And by week, we mean five days. Mind you, they have flip-charts and bourbon biscuits on their "skills acquisition courses". Medical students do not get pampered like that.

The H@NPs will work at night in the hospital as part of a team of nursing and medical staff looking after the patients who have been admitted.

There aren’t any doctors.

Their role will include assessing patients, administering initial treatment to them, and then deciding whether or not a doctor needs to see them.

So the quacktitioners will “assess” patient to see if they are ill enough to need a doctor. But you have to be medically trained to do that. So you will have to call a doctor to check you have got it right.

There aren’t any doctors.

What has happened to them? Where have they gone? Are they hiding? Is there a shortage of doctors? Should we train more?

No.

This is MMC. “Modernising Medical Careers.” Another slogan. Hospital at Night. Essence of Care. New Labour. It goes on and on.

There are plenty of newly trained doctors, but as they walk out of medical school, they are put on the scrap-heap. The government is happy. Why pay one doctor to do a job when you can get four quacktitioners for the same price?

Worrying new job figures...

The second email was from some distressed, unemployed, newly-qualified doctors. They are ready to work. No one will give them a job. So they are going to go abroad or change careers.

It costs £250,000 to train a doctor.

Support the doctors : sign the petition here

Please help them by signing their petition. And full details of the campaign by unemployed junior doctors can be found here.

Change of Shift 1.8

Kim, from Emergiblog, has just posted another editions of "Change of Shift". Kim is an ER Nurse from California. Have a look here at how nurses (and others) from the USA are coping with their heath service.

It is not a bed of roses in the USA either.

They don't make them like this anymore

And then spend a minute looking at some of the wonderful illustrations (and articles of course) that Kim posts regularly on Emergiblog.

Wanted : Large breasts

Have you seen these?

This story was a source of much happiness in the Crippen household tonight.

Physician heal thyself...

Luke 4:23. And he said unto them, Ye will surely say unto me this proverb, Physician, heal thyself: whatsoever we have heard done in Capernaum, do also here in thy country.

"I know of nothing more laughable than a doctor who does not die of old age" (Voltaire)

++++++++++

Doctors in general, and GPs in particular, do not have a good reputation for practising what they preach. In the “old days”, before they had become government sponsored health Nazis, doctors treated illness, they did not try to prevent it.

James Robertson Justice

Fictional older doctors, such as Sir Lancelot Spratt (the late, great James Robertson Justice) and even Dr Cameron who features in the picture at the top of the Crippen diaries, were obese. Nowadays, it seems it is not allowed. A myopic optician treats your myopia, so why should a fat doctor not advise you about your health? The journalists, and possibly the general public, seem not to like it. Kevin MD draws my attention to an article from Australia:

Fat doctors under fire

GPs are being urged to take their own advice to lead the nation's fight against obesity (The Australian)

Dr Crippen, though himself small and perfectly formed, thinks this is tosh. And anyone reading the Fat Doctor, and seeing the compassion and humanity with which she both relates to her patients and copes with her own illness, will surely agree.

There are much more disturbing data about the general physical, emotional and mental health of GPs from the Royal Australian College of General Practitioners in a report presented to them two years ago.

Emotional health
THE CONSPIRACY OF SILENCE
among Medical Practitioners
Dr Danielle Clode

This is a long document and may take a while to load, but is essential and disturbing reading for anyone interested in doctors’ health and behaviour. The following points, amongst others, emerge:

• 57 per cent of general practitioners did not have their own GP, with 12 per cent nominating themselves
  
  
• 55 per cent undertook only low levels of exercise (compared with 38 per cent of the general population)
  
  
• 64 per cent had a post-vaccination test for hepatitis B, although almost half had a needle-stick injury in the past year
  
  
• 90 per cent had self-prescribed antibiotics, 30 per cent sleeping pills, 6 per cent opiate painkillers and 3 per cent antidepressants
  
  
• 26 per cent suffered from a medical condition warranting a medical consultation but felt inhibited about consulting a doctor
  
  
• Up to 25 per cent would treat themselves or not seek treatment for conditions such as alcohol and drug abuse or excessive tiredness, and 45 per cent for insomnia or sexual difficulty
  
  
• 19 per cent of doctors reported marital disturbance
  
  
• 18 per cent emotional disorders
  
  
• 3 per cent alcohol problems
  
  
• 1 per cent drug abuse

Of course, this report applies to Australian doctors. It is therefore of no relevance to British GPs

Feeding at the trough

Where's the grub? GPs at drug dinner

We do not see drug reps.

We do not go on drug dinners, outings or other junkets. We do not accept hospitality of any sort from drug companies,

Aren’t we just the moral ones, then, eh?

Well, actually, I think we are. Remember Mrs Crippen’s Vagina?

I was appalled to see in the Times today that Big Pharma has been at it again. This time it is Merck, Sharp & Dohme (MSD) who have been inviting GPs to feed at the trough.

MSD have been providing“free” MSD nurses to monitor hypertensive patients. Provided of course that the GPs agree to prescribe Cozaar for the patients. The treatment of hypertension is big business so, as No Free Lunch has shown, best not to let research or bourgeois morality get in the way.

What a load of crooks.

The only question, in terms of moral turpitude, is who do you blame more? The drug company who fills the trough or the GPs who feed at it?

Another one bites the dust

Alastair Campbell

I am grateful, once again, to Tom Reynolds from Random Acts who was quick to spot that another medical blogger has been made an offer he cannot refuse by the NHS. Shut up or stop working seems to be about the size of it.

Dr Crippen did not exaggerate in “Gagging doctors and nurses”. We tread a fine line.

I had not come across ANGRYNHSDOCTOR and it seems I may have missed something. Look at his last two posts here. The rest has gone, but will be cached somewhere out in the wilds of GOOGLE. I am not geeky enough to find it, but if anyone can give me a pointer, I would be grateful.

And talking of Geeks, I still miss GEEK NURSE who disappeared in similar circumstances a few months ago.

Gagging Doctors & Nurses

Greetings comrades and good news from the Health Commissariat. Morale in your health service is at an all time high. Comrade doctors and nurses are in a state of perpetual happiness. I have decided, therefore, that it would not be in the best interests of democracy to allow them to express opinions in the forthcoming elections.

Meanwhile, back at the coalface, Dr Crippen soldiers on.

The NHS is a truly Stalinist organisation. Criticsim of the NHS from within is not tolerated. Remember the treatment meted out to Dr Peter Dawson, one of the most eminent radiologists in the country? When things went wrong, he dared to speak out. As fully reported in the BMJ here, his career was soon in tatters.

The government pretends that it welcomes criticism from within and indeed there is talk of a “protection officer” to make sure that whistleblowers are not penalised.

As so often with this government, it says one thing but stealthily does another.

When a general election is called, the gags go on. It is acceptable for Tony Blair and colleagues to glad-hand their way round hospitals for egregious photo-opportunities, but woe betide any doctor or nurse who stands up and gives his opinion. Dr Crippen has a copy of the gagging order that was sent by Lord Crisp, as he then was not, to every hospital chief executive in the country, before the 2005 general election.

“In particular, you will want to ensure that there are no grounds for complaint against your organisation that it has behaved partially towards candidates or parties represented in the election during this periods.”

Or, to put that in English, shut up.

Click on each page and it should enlarge so that you can read it in full.







The NHS is the largest employer in the country. It is state owned and government run. Why should the people who work within the NHS not state their opinions on how the service is being run?

One thing is for sure. They will not be able to silence the bloggers. British blogging was in its infancy during the last general election. Guido had not been invented.

It will be different next time.

A man with toothache writes...

Dear Dr Crippen

I've read your blog for several months now want to bring up a point which is dear to my heart. It concerns the NHS, or lack or it.

I work in the NHS and have done for the past 23 years.

Several years ago I had an NHS dentist. I saw him regularly albeit reluctantly, he used to do his 'stuff' and I'd leave, sometimes sore and sometimes not.

Then I moved house.

The area I moved to has few NHS dentists and none of them has vacancies for new NHS patients. I've been on four different waiting lists for several years during which I've received no dental treatment.

It started with a single filling falling out, shortly followed by another and then within six months nearly every filling in my head ended up in the bin. I rang all the NHS Dentists in the area but I was turned away. I was not registered and, in any case, they had no vacancies. Some of the dental practices didn't even bother to talk to me. As soon as I mentioned 'NHS' and 'Not Registered' they just put the phone down on me.

So off I went to see a private practice, very unhappily as I am not wealthy and I really couldn't afford another regular monthly outgoing. Suddenly all those dentists with no NHS vacancies were welcoming me with open arms. But before I could join one of their private plans all of them told me that I had to be “dentally fit” The figures quoted to get me “dentally fit” were in excess of eight hundred pounds. That sort of money is out of my league.

"Oh you can do it monthly" I was told. "Some treatment here and some treatment there, a bit at a time. Until you are fit enough to join a dental plan".

The problem is that even this would drain my bank account of all excess funds for the next couple of years. So off I went, with no real option but to wait my turn to come up on one of the NHS waiting lists.

My unfilled teeth started to break apart. Now I have several 'stumps', all sharp and painful and they frequently slash my cheeks causing pain and bleeding.

I seem now to get a lot of oral infections and ulcers, probably due to the carnage in my mouth caused by my stumps. I've had two abscesses, both of which caused me to go overdrawn and pay bank charges for the next quarter, and I still can't get NHS treatment.

Finally I rang up the PCT. They said there was no available NHS dental care. I would have to continue to wait until a place came up.

I asked what would happen if I got another abscess and I didn't have enough money to pay a dentist? She said that the only option would be to ring NHS Direct as they have a 'couple' of places which cover the whole region for emergencies. I said that that didn't sound very many and she replied "to be honest you haven't much of a chance of being seen".

One of the doctors I work with suggested I might try my GP and see if he could refer me to the 'Max Fax' department of the local hospital. I went to see him. He agreed that I needed treatment and was happy to refer me. He warned me though that the hospital might refuse to see me, which is exactly what happened. I received a letter from the consultant. It wasn't rude but it was nastily worded and basically told me to F@*# Off and see a dentist...

I now have one option left before I start pulling my own teeth out. This was also suggested to me by a doctor but was something I was, until now, reluctant to consider. That is get my GP to refer me again but this time for a full dental clearance under general anaesthetic.

So far everything I've tried has failed or been impossible for me to pursue. I'm not an old man by a long shot...I consider myself too young to have full dentures but I'm sick and tired of the pain and the infections.

Its not as if I neglect dental hygiene either, I've brushed my teeth three times a day since childhood. I don't have a sweet tooth. In fact I don't even like chocolate.

But here I am, having to consider a full dental clearance under general anaesthetic because I've not been able to get basic dental NHS treatment for the past several years.

Yours




A non patient

+++++++++

There does not seem much to say, except that this is an extreme example of a common problem. GPs are increasingly being asked by patients to treat acute dental problems. What amazes Dr Crippen is that over the last ten years, NHS dentistry has been virtually abolished by a goverment that purports to believe in health care free at the point of entry. How have they got away with it?


There are not even any Dental Nurse Specialists to fill the holes. Literally or metaphorically! Dr Crippen bets that Tony and Cherie get good dental care. Actually, thinking about it, Tony's bottom two middle teeth need some attention.

Maybe he cannot find a dentist either.