The Crippen Diaries Archive (2006)

Not quite Tannochbrae

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NHS West Midlands Workforce Deanery - Professor Steve Field on MTAS

NHS West Midlands Workforce Deanery

Modernising Medical Careers – Medical Training and Application Service (MTAS)

A briefing note

The Workforce Deanery fully supports Modernising Medical Careers and the philosophy behind the MTAS system and welcomes the national review process to get the system to work effectively for the good of junior doctors, SHA staff, the Service and patients.

Modernising Medical Careers & PMETB

• Modernising Medical Careers is an overdue reform of medical education. It has its origins in Calman’s reforms of specialist training (1995) and to Donaldson’s later review of SHO training.

• MMC’s introduction is coupled with the establishment of the new independent regulator for postgraduate medical training - Postgraduate Medical Education& Training Board (PMETB). PMETB’s role is to set the standards for training programmes.

• Both MMC and PMETB are perceived by the medical royal colleges as being agents of the DH.

• Both MMC and PMETB have challenged the central role that the colleges had in postgraduate medical training. The colleges are also threatened by the increasing role of deaneries in the delivery and QA of training programmes.

• The BMA has opposed the shortened training programmes and selection system.

• The overseas doctors issue has polarised opinion – on one hand the feeling is that we need to protect the increasing number of UK graduates, on the other a desire to support the many thousands of overseas doctors who have come to this country – far in excess of the programmes that were available or will be available in the future – the eligibility of overseas doctors is a complex issue and the subject of recent judicial reviews and court action.

• But MMC is live has already successfully delivered new 2-year Foundation Programmes across the UK – specialty training begins in August 2007.

• MMC/PMETB together will raise standards and help produce the types of specialists and GPs that we need for the service and more efficiently.

Entry points to training programmes and the number of programmes

• The number of entry points to GP and specialty training programmes available this August in WM and across the UK is the largest ever.

• We have not reduced any specialty posts in any hospital in WM because we have promised to work with CEOs to ensure the service is not compromised.

• The next problem is how to reduce the number of surgery and anaesthesia SHO posts while not adversely affecting the service and move their funding to create training programmes in specialties that the service needs e.g GP or acute medicine (In WM this means reducing surgery in year one from 120+ to 36 (the same in year 2 and 3).

• We are planning for the changes to begin in 2008 and have set up a joint delivery board with our CEOs in the West Midlands, chaired by Peter Blythin

Selection & interviews

• The old system for recruitment required often hundreds of applications to individual hospitals and deaneries for SHO and GP / specialty training posts – it was highly inefficient for the candidates and for the service.

• GP selection has been under development since 2000 – it is centralised and run through an office in the WM deanery – it’s highly successful and has had no problems so far (though there is concern re functionality of the MTAS computer).

• There have been significant problems with the MTAS computer system – see below.

• There are problems with the short listing system – the design of the questions did not discriminate enough between candidates – this is one of the major concerns of our surgeons.

• We have had more applicants than we expected (12,700 in the WM – we planned for 8000) .

• Increasing numbers of doctors from the Europe and overseas have applied for our training programmes - the problem is how to address the competing demands of the increasing numbers of UK graduates with the demands of overseas doctors – there will be unemployment of doctors because the number of programmes available across the UK (19000) is less that applicants (33000) – it was always like this because of the large numbers of EC and overseas doctors trying to get into the UK – this should have been sorted by the DH / Home Office but there continues to be problems with the eligibility rules for overseas doctors / HSMPS – fraught with legal issues.

• Despite the problems with short listing and the IT system, the feedback from our interviewers has been excellent. The interviews processes were designed with our consultants’ input – there were many excellent candidates – the interviews continue at the deanery.

• The DH review will add more pressure on the staff – we anticipate the need to bring in some temporary / transitional staff and are preparing a project plan.

• Unlike most deaneries, our additional costs are very low because of the use of the research park accommodation – we did not need to book expensive hotels or football stadia. We did not appear in the Sunday Telegraph hit list!

Applicants and Interviews in the West Midlands – the story so far

• 12,758 applicants to the West Midlands.

• 1568 WM candidates and 115 Defence candidates have been interviewed so far
• 3387 WM candidates have been called to interview (156 Defence).

• 10 our General Surgeons refused to interview Surgery ST3 candidates on the morning of their interview.

• They voted and took action – one military surgeon and one administrator from UHB abstained.

• Over 81 trainees were affected – all candidates were sent home after being spoken to by those consultant surgeons - some had travelled from overseas (one from Australia, one from New Zealand).

• The surgeons issued a press statement and appeared on television. Note that the emails on the Drs Net UK and Telegraph discussion for a have all supported their stand. Many of our consultants have questioned their action particularly after seen how well the interviews have gone.

• On no occasion have the surgeons criticised the deanery except for stating that due to the MTAS problems we were not able to long-list before short listing for the interviews (they are correct for surgery). This resulted in a few ineligible candidates appearing for interview. Their anger is directed at MTAS; the computer problems and the short listing forms which they feel failed to discriminate between candidates at the ST3 level.

• I would agree with many of their complaints but not their action which was wrong and many feel their actions are unprofessional.

• The only interviews that we have failed to complete so far in the West Midlands are Surgery ST3 (our cardiothoracic surgery STC has postponed their interviews but have not refused).

• We are working with them to rearrange the interviews for the ST3 cohort that was affected by their walk out. Some of the rebel surgeons did attend to interview for surgery at ST2 level last week.

• There have also been a number of consultants who have raised similar concerns. Some have written to the press and the SoS. A few individuals refused to interview in anaesthesia and other specialties but the vast majority continued with their interviews.

• Interviews are going well and according to time table

Implications of the Review

There are major implications for staffing, both medical and administrative. For junior doctors : ST1 - will need to review all non short listed applicants. ST2 – face to face interviews with a trained medical advisor for all applicants not short-listed. ST3/4 – all first and second choice for the West Midlands guaranteed an interview. This will mean circa 10,000 reviews for the West Midlands.

NB See appendix A for more detail

Steve Field

March 18^th March 2006

Appendix A

Below is the text of what we submitted to the DH Review and more detail about the MTAS problems

NHS West Midlands Workforce Deanery

Modernising Medical Careers – MTAS

Dear Keith,

I promised to send you an update and some thoughts re the process to date for use at the Review Group.

Following the walk out of 12 of our General Surgical colleagues, we have spent a lot of time reflecting on our own deanery processes and the MTAS system generally. I have met with the surgeons concerned and debated their concerns. While I disapprove of their action, they did raise similar concerns to those raised by deanery staff.

As you know, I presented our concerns at the last meeting of the Modernising Medical Careers Programme Board and would have also shared concerns at the UK Modernising Medical Careers Strategy Group if it had not been abandoned due to the fire / bomb scare. I have also listened to the concerns of the BMA and others when I chaired the UK Modernising Medical Careers Advisory Board, but I did not share my thoughts openly at that meeting.

The workforce deanery fully supports Modernising Medical Careers and the philosophy behind the MTAS system and wishes to be part of the review process to get the system to work effectively for the good of our junior doctors, our staff, the service and our patients.

Update

The only interviews that we have failed to complete so far are Surgery ST3 and one person who was short listed for academic rheumatology has yet to be interviewed. You will be well aware that the surgical problem has featured across the national press this week. I know that the group have forwarded comments and concerns to the review group. We are planning to interview again for Surgery ST3 in 2 weeks pending news re whether the President of the RCS has gained agreement (or not) for all those with MRCS to be interviewed – I have sought clarification from the Modernising Medical Careers Team.

One academic group selecting Walport doctors for rheumatology have refused to interview because someone they feel should have been short listed (having looked at the academic forms) didn’t make it through the first stage. I am dealing with that problem.

There have also been a number of consultants in other specialties who have raised similar concerns but have continued with their interviews. The cardiothoracic surgery STC has postponed their interviews and awaits a national announcement from your review group.

An e-mail has been distributed to all STC Chairs within the West Midlands by three STC Chairs seeking support for an immediate suspension of round one. I have spoken to the authors, one of which was one of the surgeons. There has been a flurry of phone calls and emails from consultants that I have dealt with personally over the last 5 days – the concerns generally reflect those of our surgical colleagues.

Most interview panels and STCs have proceeded but we have lost a handful of consultants who have refused to interview.

Better news

We are beginning to get feedback from many interview panels that despite their concerns, they are able to select some excellent candidates from those interviewed. The mood is lifting in the consultants who have seen the interview process in action. There is nothing but praise for the deanery staff.

MTAS

As a workforce deanery we have major concerns about the MTAS process that we have been involved in during round 1.

Having been involved in developing the GP selection system and having run the original MDAP process for foundation training for three years up to 2006, we are well aware of the advantages and the problems of electronic systems and are up to date on HR selection issues.

The timetable for delivery was tight but became impossible because of the delayed functionality of the MTAS system and its many glitches.

My staff, like those of other deaneries, worked very late each night and over the weekends in order to try and meet what was an impossible deadline. We had 12,700 approx applications – we had expected about 8000. Luckily we had fantastic support from the multiprofessional deanery admin and specialist staff.

We remain very concerned that the change to the London UofA created an apparent 10 day delay in functionality which produced further problems down stream. The closing date for short listing should have been delayed further and not announced just before the weekend – this together with added pressure from some DH staff to deliver caused undue pressure, forced staff to work 12 hour days over the weekend and put the deanery at increasing risk of error. EWTD!! We could not practice what we preach to our junior doctors. I cannot and will not expect my staff to work under such conditions for round 2.

Some suggestions

While we have lessons to learn re our internal deanery systems, I will address the national issues below.

We must all work hard to regain the confidence of our juniors and seniors. A unified communications strategy is essential. Any changes must be communicated as soon as possible. A regular flow of information is necessary to keep our consultants and juniors on board. Deans have an important role to play in this. Information on applications per specialty, competition ratios, numbers of interviews and success rates must be made available quickly; regular updates are essential. Our CEOs must be kept informed so that they can make plans for their consultants to be released from service in good time.

The access to the system for overseas doctors must be clarified as a matter of urgency.

We support the national review of MTAS round one and the need to learn lessons before embarking on a new round two.

We have debated the situation at length and believe that we should proceed with the round one interviews but we must make changes for round two. We do not believe that interviewing all applicants for round one is feasible. We do not believe that it would be supported by the service. If that decision is made then David Nicholson would need to add his weight to the decision and work with SHA CEOs to ensure that consultants were freed up for the deaneries.

We believe that the MTAS system is the way forward. But, it is essential that the MTAS electronic system is refined and the bugs / glitches sorted out. The E system for long listing and short listing must be reviewed and streamlined. The short listing criteria need reviewing e.g. more marks for academic excellence, more discriminatory questions and better instructions to help assessors give marks is essential.

We believe that the GP system of a factual MCQ followed by multi station selection is the way forward for all specialties. The GP system was developed over a 6 year period and works well. We acknowledge, however, that it is too late to develop and validate MCQ tests for the specialties. We must concentrate, therefore, on short listing and the interview process.

The new timetable must be realistic and allow time to change the short listing forms and develop the interview process in partnership with deans, the royal colleges and deans. The timetable must allow adequate preparation time and most importantly, rest for deanery staff – this is a safety issue not just for the staff but also for the candidates, in order to reduce the potential for error. All deans want to provide an excellent service; therefore, deans be supported and must be involved in reviewing progress throughout and must have a veto on delivery dates free from any external pressure.

I trust these comments and suggestions will be helpful to the review group.

Best Wishes

Professor Steve Field

Head of Workforce and Regional Postgraduate Dean

NHS West Midlands Workforce Deanery

8^th March 2007

Some detailed MTAS issues from the West Midlands

I asked my deputy to collate the problems encountered with MTAS 2 weeks ago (we are now collating the issues in more detail but I add to this paper Alan’s original complaints for information – more will be available soon)

As you know, I presented these concerns to the Modernising Medical Careers Programme Board – these are his words:

Long listing

• We were led to believe that the long-listing flags would highlight specific areas of the application form requiring attention so that staff could investigate that area. In MTAS when a flag shows the staff have to go through all 15 pages of the application entry criteria looking for the relevant area. This adds a considerable time to the process which on average is approximately 15 – 20 minutes each application. We were aware that the vast majority of the applications would be submitted in the last couple of days (Friday 2^nd, Sat 3^rd and Sun 4th Feb) thus making it impossible to long-list before short-listing commenced. Attempts to access MTAS in order to long-list were very slow during the period leading up to the closing date. The long-listing/shot-listing guidance was also issued very late.
• The first opportunity our staff had of seeing the Entry Criteria screens was on 22^nd Jan – the day applications opened to candidates.
• Due to the time that it took to undertake long-listing most candidates will be allowed to progress though to short-listing. (This is the only complaint that our surgeons appear to have with the West Midlands part of the process)

Short-listing

• Staff started the process of identifying applications for each of the specialties/levels first thing on Monday 5^th Feb. A decision had already been made that the West Midlands would not use the electronic short-listing process as we had concerns that this part of MTAS would not be ready. We gained this function on the Friday.
• In order to be in a position to service the pre-organised short-listing panels a decision was made to start printing off applications, which at that stage did not include the applicants reference number. They then had the laborious task of double checking the screens and writing the reference on the top of the applications. At approximately 4.30pm on Monday 5^th Feb a reference number started to appear on applications although the specialty and level was still not present.
• The printing of a batch list summarising the applications was difficult as applications were sometimes missing from the print.
• It was not possible to count the number of applications either for each specialty, level or total number of applications received for the whole Unit of application.
• Short list forms – we had several cases of data loss when we tried to use the computer – but either way the white-space questions were not written with an understanding that most of the doctors would look so similar – i.e. 5 years of medical school and 2 – 3 years of foundation / SHO and the academic questions could have offered marks for Masters degrees etc. Someone who was coached could gain lots of marks and be a poorer candidate who was honest and factual. Plagiarism software was absent.

Post Upload

• All posts had to be individually added to MTAS as there was no bulk upload facility. This resulted in double data entry from our own spreadsheets and resulted in approximately 10 days additional data entry each from 3 people. This was available for Foundation selection.
• The computer was extremely slow on a number of occasions which often lasted some hours.

Scoring

• The National Short-listing Scoring Indicators cannot be used by short-listing panel members as they do not have an area for the applicant number to be added or for the panel member to add comments and their signature. A whole series of additional score-sheets have had to be produced for each specialty and level.

Applicant “Choose & Book”

• Functionality was very late arriving – this seems to be a general problem with Methods.

Training

• There has been no national training on MTAS looking specifically at the ST module – this is due to the modules not being available until the day of launch. Training had to be done in a piece-meal fashion with staff as and when elements of MTAS become available.

Bugs on MTAS

• There are numerous bugs identified such as:
• GP questions appearing on the CMT long-listing sections
• Application “sign off” by applicants not being mandatory
• Employment history start dates not being mandatory – making it impossible to gauge the length of an applicants experience.
• The Plagiarism Finder did not work
• Countless problems with data loss – we lost over 1300 applications on the day before the closing date and had many separate episodes of data loss – candidates also appeared on the screen unannounced during the short listing period! – As a consequence, the staff have no confidence in the system.

Dr Crippen elsewhere

Labour's NHS is a real tonic for the Tories
Nick Cohen
Sunday December 31, 2006

An excellent article by Nick Cohen in today's Sunday Observer, describing the way that some Labour MPs are so incensed by failing healthcare that they are out on the picket lines protesting against their own government's NHS cuts.

The article quotes Dr Crippen on the money that has been wasted on GP's recent pay increases

The BritMeds 2006 (6)

Thinking of going to medical school? Worried about the interview? This is how it should be done.




Healthcare does not stop for Xmas. What is it really like for the staff:

“I’ve worked every Christmas day for the last ten years on a variety of wards and enjoyed every single one. I did miss one but I was technically unemployed for 5 days. This post will be a sort of amalgamation of my blurred and confused memories.”
Is it that bad?

And yet, is it easy to access healthcare out of hours? What would you do if your baby was choking? NHS Direct spoilt the Welch Family Christmas

The ambulance service has ground to a halt because poor old Tom Reynolds is on crutches – and using bad language.

The top jobs in the NHS are sinecures. You do not get sacked for incompetence. You go on gardening leave. Five months after job-share CEOs Sue Osborn and Susan Williams were suspended from the National Patient Safety Agency (NPSA) over their managerial record, they are still on leave at public expense. National Patient Safety Agency (NPSA) annual cost of £34 million, it could provide no figures for exactly how many patients had died as a result of medical blunders.

It is different at the bottom end. The other day, Dr Crippen said:

“I think the pay rates at the top end of the NHS are poor. Whether or not you agree with that, I do not think anyone will dispute that the pay rates at the bottom end are disgraceful. How do you retain such a huge work force when you are paying them not much above the basic minimum wage, when many of them are living in poverty?”

Not all agree, but is the DK arguing that nurses are overpaid?

Dr Grumble shares Dr Crippen’s hatred of gypsies.

“I’ve discovered some of the most informed, considerate and knowledgeable people in the US. I’ve also discovered some of the most frightening, genuinely ignorant people in the US.”

Kevin Leitch looks at “autism extremists”.


In “The day I nearly died”, Fang describes what really winds him up about the NHS

The US takes another look at the UK in "The wonders of socialised medicine".

Secondhand smoke writes that NHS is approaching Medical Discrimination

Ozzy Osbourne discusses how he was terrified by wife Sharon's cancer diagnosis

The NHS is now moving away from rationing by treatment queues on the basis of clinical need towards rationing on lifestyle.

In the UK: MORE than 20 children and teenagers are being treated in hospital every day for alcohol-related illnesses, including mental disorders, poisoning and liver disease, according to newly released official data.

Thousands of overseas doctors have been approved to work in the UK without passing English-language tests. 15,952 doctors had gained their qualifications from other European countries, but were not required to demonstrate English proficiency ...

Dr Rant is “reconfiguring bullshit”.

Fined For Being Too Fast - UK punishes hospital because it didn't make patients wait

On line gambling is just part of another new addiction reports Gamblog.co.uk

Nip/fuct has “undergone some major life re-shuffles (none of which have involved gambling thankfully) and (is now) settled.”

Emily gets to her post-natal check. Her piles are as bad as ever.

The Register reports on Frankenstein’s cure for ageing.

Gizmodo reports that “First Take-Home HIV Test Available in Blighty”

John Prescott, the deputy prime minister, has Xmas lunch in hospital

Dramatic Change To Physicians' Working Methods To Benefit Patients, UK

Take a look at “Samantha’s Story” - an online journal of her fight against the childhood cancer called Neuroblastoma.

I am 16 and my son toby keeps getting coldsores and when i take him to the doctor the treat me like i dont know nothing about babys because im 16 but that does not stop me from being a mother and amother knows their own child! DONT THEY!

And now a story that has been blown up out of all proportion and is being used by the gutter press to incite religious hatred. Take a look. Are you happy with the coverage? First, this from the so called "Democracy Front Line blog":

Some Muslims are undermining the battle to rid Britain’s hospitals of killer infections by refusing to wash their hands when visiting sick relatives. It prevents people bringing in more infections. But some Muslims refuse to use the hand cleansers on religious grounds because they contain alcohol.

In fact, Moslem religious leaders have said there is no problem about using these hand cleansers, but that is not going to stop the gutter press printing inflammatory headlines like: "More Muslim Insanity from the UK" from "Yet another Conservative Right Wing Blog".** The “soar away sizzling” Sun is not going to be left behind and nor is "The Conservative Voice." **

I suppose it is the inevitable price we pay for press freedom, but it makes me sick. Incidentally, if you do NOT find it offensive, try the "Jewish Test." Re-write it all, and every time you see the word "Moslem" change it to "Jew" or "Jewish". So it becomes "More Jewish Insanity from the UK". You see? It IS offensive.

More news on Labour hypocrisy on health care cuts

Thoughts from Baghdad reveals there is a shortage of doctors. How is the UK helping?

Are British patients more stoical than the French?

Finally, New Labour is trying to deny health care to…to…

Get them young

++++++++++

Please send your recommendations for next week’s BritMeds to: thebritmedsATnhsblogdoc.wanadoo.co.uk


++++++++++

Finally, and most importantly, a Happy New Year to all.


** I have been asked to point out that both the "Conservative" sites quoted above are American, and are nothing to do with the UK Conservative Party.

Change of Shift 1.14

" I'm one of the many twentysomethings out there trying to make something of herself. I have a bachelor of music degree in piano performance from Penn State University (main campus) and a bachelor of science in nursing degree that I got through an accelerated second-degree program.

I'm currently working towards obtaining my master's degree in nursing to become a pediatric nurse practitioner.

Despite the years since I last performed as a concert pianist in public becoming greater in number, I still have an enormous passion for music, and I love to share that with everyone. My absolute favorite activity is playing the piano and singing."

Neonursechic is editing this week's edition of Change of Shift. Take a look here - and keep your speakers on to listen to the excellent music she has chosen.

The Crippen Diaries (Week 52)

Not quite Tannochbrae

Thursday 28th December

When I was a child, Christmas holidays lasted for two days, and if those days happened to be on a Saturday and Sunday, there were no holidays in lieu. And New Year’s Day was not a bank holiday at all. Over the years, the two holidays have grown longer, and gradually merged. The UK now grinds to a halt at lunchtime on Christmas Eve and does not restart until 2nd January. When I worked in the USA there was no sign of a similar process there. I remember being surprised – and pleased – to find shops open on Christmas afternoon. But that was a few years ago. Things may have changed now.

So, unlike the rest of the country, back to work today and, as always, it was infuriating. Not because it was busy. On the contrary, in terms of numbers, it was reasonably quiet. That is what is so infuriating. Minor illnesses, aches and pains, bad colds and so on may be an inconvenience, but they are not inconvenient enough for people to take time off from going to the sales for yet more shopping, or staying in bed with their hangovers. They will be back next Tuesday when, suddenly, their minor illness will once again assume significance and warrant a day off work.

++++++++++


Friday 29th December

The final working day of the year, and it is still very quiet. Very little traffic on the roads. We have three doctors on holiday but we did not employ any locum cover as we predicted, correctly, that it would not be necessary. It will all change next Tuesday, when everyone goes back to work.

Patrick came in early in the morning. We have met him several times before, most recently last month. He is desperate for help and was close to tears. The psychiatric services are still playing pass the parcel. They keep having meetings to decide what they should do, but they never reach a conclusion and these meetings do not involve me or Patrick. Lots of “process”, lots of multi-disciplinary meetings, lots of cups of coffee, lots of jammie dodgers, lots of letters, no action. It is so very new Labour.

“Patrick does not meet the criteria for a service from the Community Forensic Team. The case has been closed to the SCATS team.”

Great.

Patrick spent Christmas Eve with his girlfriend. She got very drunk. Again. Patrick does not drink, but still lost his temper with her when she became verbally abusive. He bit her finger. She called the police. They took Patrick away and locked him up. He is already on police bail. This time they are charging him with common assault. The police are far more sympathetic to Patrick than the psychiatric services. They released him early on Christmas morning and drove him home in a squad car. The hospital would never do that.


++++++++++

An irritating 22 year old secretary. She walked in, sat down and said, “I just want a letter to see a dermatologist.” I asked her why and she said “to get something done about this on my finger.” I looked at her finger. There was a small wart, about 3mm in diameter at the edge of the nail of the third finger on her right hand. I asked her if it was painful. She looked exasperated, glanced at her watch, and said it was not, but she wanted to see “someone”.

I smiled politely and said I would write a letter to “someone” immediately. After she left, I did just that. I picked the busiest dermatologist, making the referral “named consultant only” and classifying it as “routine”. She will wait a very long time to get exactly the same treatment that I would have given her today had she let me do my job.

++++++++++

I was running late by the end of the day. The final patient was an elderly lady. She came in with a carrier bag. There was nothing wrong with her. She had made the appointment to bring me a bottle of Glenfiddich. This sort of thing is always touching but, like most doctors, it makes me feel slightly uncomfortable. She thanked me profusely for all the care I had given her during the year. In fact, I have seen her but once in twelve months when she had impacted ear wax.

++++++++++

Happy New Year

The Good Wife's Guide

As the head of a large family I have for some years been trying to explain to Mrs C. how she should best fulfil her duties as a good wife:

• Have dinner ready. Plan ahead, even the night before, to have a delicious meal ready on time for his return. This is a way of letting him know that you have be thinking about him and are concerned about his needs. Most men are hungry when they get home and the prospect of a good meal is part of the warm welcome needed.
  
  
• Prepare yourself. Take 15 minutes to rest so you'll be refreshed when he arrives. Touch up your make-up, put a ribbon in your hair and be fresh-looking. He has just been with a lot of work-weary people.
  
  
• Be a little gay and a little more interesting for him. His boring day may need a lift and one of your duties is to provide it.
  
  
• Clear away the clutter. Make one last trip through the main part of the house just before your husband arrives. Run a dustcloth over the tables.
  
  
• During the cooler months of the year you should prepare and light a fire for him to unwind by. Your husband will feel he has reached a haven of rest and order, and it will give you a lift too. After all, catering to his comfort will provide you with immense personal satisfaction.
  
  
• Minimize all noise. At the time of his arrival, eliminate all noise of the washer, dryer or vacuum. Encourage the children to be quiet.
  
  
• Be happy to see him.
  
  
• Greet him with a warm smile and show sincerity in your desire to please him.
• Listen to him. You may have a dozen important things to tell him, but the moment of his arrival is not the time. Let him talk first - remember, his topics of conversation are more important than yours.
  
  
• Don't greet him with complaints and problems.
  
  
• Don't complain if he's late for dinner or even if he stays out all night. Count this as minor compared to what he might have gone through at work.
  
  
• Make him comfortable. Have him lean back in a comfortable chair or lie him down in the bedroom. Have a cool or warm drink ready for him.
  
  
• Arrange his pillow and offer to take off his shoes. Speak in a low, soothing and pleasant voice.
  
  
• Don't ask him questions about his actions or question his judgment or integrity. Remember, he is the master of the house and as such will always exercise his will with fairness and truthfulness. You have no right to question him.
  
  
• A good wife always knows her place.
  
  (The Good Wife's Guide)

It must be said that Mrs Crippen has not been as compliant with the guidelines as I would have liked. Indeed, she regards her job as a breast radiologist as just as important as mine and has gone so far as to delegate some of her wifely duties to a cleaner.

Science does not stand still.

There have been many advances over the fifty years since the Good Wife's Guide was written. The role of the wife is much better understood. And now, in what will surely be the greatest scientific discovery of the 21st Century, we learn that housework prevents breast cancer.

Women who exercise by doing the housework can reduce their risk of breast cancer, a study suggests. The research on more than 200,000 women from nine European countries found doing household chores was far more cancer protective than playing sport.

Dusting, mopping and vacuuming was also better than having a physical job.

The women in the Cancer Research UK-funded study spent an average of 16 to 17 hours a week cooking, cleaning and doing the washing. Out of all of the activities, only housework significantly reduced the risk of both pre- and post-menopausal women getting the disease. Housework cut breast cancer risk by 30% among the pre-menopausal women and 20% among the post-menopausal women. (BBC)

What more can Dr Crippen say? "Dusting, mopping and vacuuming..." is better than having a physical job. I suggested to Mrs C. over breakfast this morning that, in her own best interests, we should let our cleaner go. Her reaction was both illogical and vulgar.

Sometimes it is very difficult to explain rational science to women.

97 year old man survives heroic cardiac surgery

Elderly man survives surgery

I am grateful to the ever reliable Kevin MD for drawing my attention to a medical news story that is extraordinarily touching and yet raises profound ethical questions.

An aneurysm of the thoracic aorta is potentially lethal. It is surgically difficult to repair. The operation may take 8 – 12 hours and has a high morbidity and mortality rate.


No surgeon in his right mind would be prepared to undertake such surgery on a man of 97 and even if he was so prepared he might not be able to find an anaesthetist.

And yet, that is exactly what happened in the USA - but only after long discussions by the hospital ethics committee and a lot of pressure from the patient’s family.

What makes this story extraordinary (and many of the doctors amongst you will have recognised him from the picture) was that the patient was Dr. Michael E. DeBakey, one of the greatest cardiac surgeons of the 20th Century, and the surgeon who devised the operation he now needed.

Dr. DeBakey as a younger man…devised the operation to repair such torn aortas, a condition virtually always fatal. The operation has been performed at least 10,000 times around the world and is among the most demanding for surgeons and patients.

Over the past 60 years, Dr. DeBakey has changed the way heart surgery is performed. He was one of the first to perform coronary bypass operations. He trained generations of surgeons at the Baylor College of Medicine; operated on more than 60,000 patients; and in 1996 was summoned to Moscow by Boris Yeltsin, then the president of Russia, to aid in his quintuple heart bypass operation.

Now Dr. DeBakey is making history in a different way — as a patient. He was released from Methodist Hospital in Houston in September and is back at work. At 98, he is the oldest survivor of his own operation, proving that a healthy man of his age could endure it.

A wonderful, happy outcome.

There is no other country on earth where this surgery would have been attempted on a 97 year old, and probably no other country on earth where a 97 year old would have survived the surgery.

Should it have been done? The cost of the operation was over $1 million. Would it have been done on any other patient? Will it be offered to all men of this age?

Difficult questions. For doctors, one of the most fascinating aspects of the story is the coureageous and stoical way that Dr DeBakey both self-diagnosed and managed his condition in its early stages.

Full report from the New York Times.

Cruel and unnatural punishment

Justices of the Supreme Court of Georgia

Charles Wooderidge was a trooper in the Queen’s Royal Horse Guards. He was convicted of murdering his wife, and hanged on 7th July 1896. His crime and execution would have been long forgotten, had one of his fellow inmates not written a poem about the few short weeks leading up to his exeuction.

I never saw a man who looked
With such a wistful eye
Upon that little tent of blue
Which prisoners call the sky,
And at every drifting cloud that went
With sails of silver by.

I walked, with other souls in pain,
Within another ring,
And was wondering if the man had done
A great or little thing,
When a voice behind me whispered low,
'That fellow’s got to swing.'

The poem was, of course, The Ballad of Reading Gaol, and the fellow inmate was Oscar Wilde.

My mind turns, once again, to the horror of cruel and unnatural punishment as I look at the front page of this morning’s Times. A large picture of Saddam Hussein with the heading “Dead in 30 days.”

There is a quote from an unnamed White House spokesman who greets the decision with undisguised enthusiasm. Meanwhile, in Florida, the President's brother, Jeb Bush, has put judicial killing “on hold”. There are 374 prisoners on death row in Florida, waiting to be killed. The last killing was botched so they are not going to do any more until they are sure they can get it right. A few more weeks respite.

Six weeks our guardsman walked the yard,
In the suit of shabby grey:
His cricket cap was on his head,
And his step seemed light and gay,
But I never saw a man who looked
So wistfully at the day.

I never saw a man who looked
With such a wistful eye
Upon that little tent of blue
Which prisoners call the sky,
And at every wandering cloud that trailed
Its ravelled fleeces by.

He did not wring his hands, as do
Those witless men who dare
To try to rear the changeling Hope
In the cave of black Despair:
He only looked upon the sun,
And drank the morning air.

He did not wring his hands nor weep,
Nor did he peek or pine,
But he drank the air as though it held
Some healthful anodyne;
With open mouth he drank the sun
As though it had been wine!

You may think that lethal injection is a humane way to kill a criminal. I struggle with the concept of humanity in this context and, as Dr Grumble so eloquently points out, there is an inherent obscenity in attempting to sanitise the procedure by medicalising it. No self-respecting doctor or nurse will take part in judicial killings, and so there is not the expertise to do it properly. Killing by lethal injection has led to a catalogue of disasters. It is the most macabre example of the dumbing down of medical expertise; of allowing amateurs into territory where professionals will not tread.

How can one characterise the years on death row, waiting for the inevitable? Back to Victorian England, and Reading goal:

He does not rise in piteous haste
To put on convict-clothes,
While some coarse-mouthed Doctor gloats,
and notes
Each new and nerve-twitched pose,
Fingering a watch whose little ticks
Are like horrible hammer-blows.

He does not know that sickening thirst
That sands one's throat, before
The hangman with his gardener's gloves
Slips through the padded door,
And binds one with three leathern thongs,
That the throat may thirst no more.

He does not bend his head to hear
The Burial Office read,
Nor, while the terror of his soul
Tells him he is not dead,
Cross his own coffin, as he moves
Into the hideous shed.

Lord Alfred "Bosie" Douglas & Oscar Wilde

Oscar Wilde was in jail, not for murder, but for acts of “gross indecency” or, as the Marquis of Queensberry (the father of Wilde’s sometime partner Lord Alfred “Bosie” Douglas) put it, for “posing as a sodomite.” He was sentenced to two year's hard labour. Even Victorian England was disturbed by the cruelty of the sentence.

“Why does not the Crown prosecute every boy at a public or private school or half the men in the Universities?" this in reference to the presumed pederastic proclivities of English upperclassmen." (Source)

It could never happen now, a century later. The “offence” of consensual sodomy has long disappeared in the United Kingdom. It has not, however, disappeared in the United States. Generalow Wilson has just been sentenced to ten years in jail, without parole, and ordered to be put on the sex offenders’ register for the rest of this life for:

aggravated child molestation involving an act of sodomy

What exactly was his crime?

Genarlow had oral sex with a girl well known to him during a party "sleep-over". The girl performed a similar act on other teenage boys in the room. The oral sex was consensual but that does not matter, for Generalow was seventeen at the time and the girl was fifteen. That makes it a criminal offence and in Georgia, in this context, oral sex is regarded as more serious than penetrative vaginal sex. In the Oval Office it might not be sex at all but, down in Georgia, it is sodomy. Even though the girl happily performed the sexual act on him, and on other boys. The whole episode was videod. Pursuant to the version of the aggravated child molestation statute then in effect, Wilson was sentenced to ten years imprisonment without possibility of parole.**

Unless the executive takes action, and there is a pardon, this intelligent young teenage boy, who has no criminal record, is going to stay in jail for ten years and, what to him is worse, be labelled as a child molester for the rest of his life.

There are complex issues here, not least the question of race (the girl was white, and the boys were black) but nowhere has it been suggested that this was anything other than consensual sexual activity by teenagers after a party and sleep-over. And now one of those teenagers is in jail.

How would Oscar Wilde describe it?:

This too I know - and wise it were
If each could know the same -
That every prison that men build
Is built with bricks of shame,
And bound with bars lest Christ should see
How men their brothers maim.

The vilest deeds like poison weeds,
Bloom well in prison-air;
It is only what is good in Man
That wastes and withers there:
Pale Anguish keeps the heavy gate,
And the Warder is Despair.

For they starve the little frightened child
Till it weeps both night and day:
And they scourge the weak, and flog the fool,
And gibe the old and grey,
And some grow mad, and all grow bad,
And none a word may say

For Man's grim Justice goes its way,
And will not swerve aside:
It slays the weak, it slays the strong,
It has a deadly stride:
With iron heel it slays the strong,
The monstrous parricide!

If you would like to express your support, the Genarlow Wilson support site can be found here.

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**This article has been edited and expanded as a result of several comments and emails pointing out that the criminal charges did not result from a simple boyfriend/girlfriend relationship.

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For the few who may not have read “The Ballad of Reading Gaol”, the full poem may be found here.

The BritMeds 2006 (5)

Put on the karaoke, with apologies to Sir Bob, it’s NHS Band Aid.

'What would happen if the Virgin Mary came to Bethlehem today?'

In all this time, there were no vitamins handed out, no ultrasound scans, no detection of congenital abnormalities. Imagine that the NHS had simply packed up and stopped one day and did not reopen for 12 weeks, and you get a sense of the scale of the medical disaster.

A worrying report from “Dare to Dream” :

Today six million American children have been diagnosed with a serious mental disorders, a number that has tripled since the early 1990's. What is going on?

What is Tony Blair really like? Is it sincerity or humbug? Does he listen? This article on his approach to the NHS sums it up. Do you laugh or cry?

The Gremlins provide seasonal help for a children’s hospice

Dr Crippen said compared working in the NHS to working in McDonalds. DrNick observes that McDonalds gives a better deal.

Cambridge Angry Medic is branching out.

If you believe this, you will believe anything. A study compared male students and discovered that those who were tall and handsome tended to become surgeons.

Dr Grumble looks at rich, lazy and out for the money GPs. Is it as simple as that?

It seems we have too many nurses. In July the NHS announced a clampdown on overseas nurse recruitment, which was swiftly follwed by a Home Office announcement to take General Nurses off the official skills shortage occupations list from 14 August.

The average Briton will drink a surprisingly large amount over the holiday: 18 pints of beer, three bottles of wine, one bottle of spirits and four glasses of fortified wine. That comes out to 137 units of alcohol in a little over a week. Oh dear

A small matter, but this is no way to treat a child. The NHS should be ashamed.

For whatever reason, another medical blogger perishes.

The bonuses being paid this year to bankers at Goldman Sachs and other City investment banks will seem obscene to many. Correspondents on the letters page of the Daily Telegraph - not normally a hotbed of insurrection - were suggesting that the excesses might be a prelude to revolution. It is galling for nurses, firefighters, teachers and scientists to see their contribution valued so meanly compared with financiers, who do not obviously add one jot to the good of humanity.

Jealousy or fair comment?

Wiltshire ambulance staff poised to strike and start blogging

Holy Freakin' Nuts! Why people with a Peanut Allergy annoy me.

Depressing news from Alcoholics Anonymous

An American view of the NHS here:

Take England, for example, where the National Health Service is sometimes considered a model for the United States. Access to treatment often depends on whom you know, not what you have. A recent London Observer article, "Ex-NHS advisor slams cancer lottery," noted that, "The trust has refused the (prostate cancer) treatment to 11 out of the 12 men who have asked for it since April 2005."

The person who did get treatment is quoted as saying, "Because I was articulate and well-informed and also, I suspect, because I had connections with the Department of Health, I got the right to my treatment."

“The only complete protection against HIV is safe sex and any decision to circumcise should be made by the owner of the foreskin when he is able to give informed consent,” says David Smith, who is General Manager of NORM-UK, a UK based foreskin health charity.

Whose foreskin is it anyway?

Christmas approaches and “Every 14 minutes, someone in the UK kills him or herself, and depression is one of the main causes behind these suicides.”


Lets sack some ambulance men, that will save some money.

See Dr Rant’s “difficult decisions” NHS hit parade.

Tony looks at the Commericalism of Stress…and Christmas

A little good news. The medical profession can sleep easy knowing more than nine in ten of the British adult population still says it trusts doctors to tell the truth, as it has during the past few years.

Pink News reports that George Michael is helping UK nurses.

A superbug that has killed at least 60 people in the last four years could be linked to milk and meat from British farms, warn experts.

Two thirds of UK doctors feel that financial balance in the National Health Service (NHS) is unachievable.

Finally, this is one of the fringe benefits of working for the Elf Service.

And a happy Christmas to all.

Choose your rations

As we approach the end of the year, it is interesting to compare the approach to healthcare in the UK and the USA. It is common to hear Americans dismiss so called “socialised medicine” in a few sentences.

America spends a much greater proportion of its wealth on health care, and when you get good health care in the USA, you are getting the best the world has to offer. And yet,

"...I have been treated in hospitals in both the US and the UK. There was no comparison in the quality of care, facilities, medical technology, promptness, and follow-up - the US was far superior. However, I had insurance. So from my standpoint, privatisation is useful and beneficial. If I was one of the 40 million other Americans who did not have insurance, then I would definitely think otherwise." (BBC)

So what happens if you do not have insurance in the USA or, more commonly, you have some but not enough insurance?

The number-one question people ask us is, "What possessed you to move to Mexico?" The number-one answer we give is that we simply could no longer afford to live in America, so we found a country where we could, and moved there.
We found ourselves in a position not unlike many Americans: A major illness strikes, unexpectedly, and though insured and with incomes, the cost of funding the illness simply becomes too much. It becomes, essentially, impossible. We were not alone.

It turns out that more than 50% of bankruptcies filed in 2001 were medically related and were filed by middle-class homeowners who not only had an income but also health insurance. The prevailing myth that most bankruptcies are due to credit card debt is not true. Less than 1% of filed bankruptcies are due to credit card debt.

Researchers found that, in those surveyed, 1.9 to 2.2 million U.S. residents filed a “medical bankruptcy”. The average person filing for bankruptcy during the 2001 period spent $13,460 on co-payments, deductibles, and uncovered services even though they had private insurance.

"Our study is frightening. Unless you're Bill Gates, you're just one serious illness away from bankruptcy. (source)

It would be easy to look critically at this from the security of our so called “free at the point of entry” healthcare “for all” National Health Service.

In the UK, people do not go bankrupt for lack of medical care. They die.

Whatever the problems in the USA, there is a degree of transparency. Access to healthcare there is limited by the size of your wallet. There may be no UK style Stalinist government health care policies, but there are the insurance companies who increasingly are not only telling the US doctors how much they will earn, but what they may or may not do. This is not very nice.

In the UK, healthcare becomes nicer everyday. For the appallingly named NICE, set up in 1999 to rationalise healthcare, is in fact rationing it. And NICE is an arm of government, and does what it is told. So we get medical care predicated by the whim of focus groups. Healthcare that will garner votes. Tackling obesity. Funding nicotine chewing gum for smokers. Refusing Velcade for myeloma sufferers. There are not enough votes from myeloma.

Addressing these questions requires a clear understanding of the purpose of the NHS (something that is hardly clear at present), and a notion of health that transcends patients’ fantasies about magical medical solutions. In this difficult area we need values that are based on more than economic utilitarianism and that recognise how disease entails a more complex world of relationships: with ourselves, with society and with Nature. There may then be some hope of protecting patients and the NHS from the medicalisation of societal and cultural problems: a trend that threatens to overwhelm health care systems. Finding answers will be difficult for the very reasons that MacIntyre enunciates, but we must try, or accept that medicine will choke on its own trivial non-solutions for enormous problems. (BMJ)

While NICE gave the impression that its decisions were evidence based, this was only partly true. In October 2001 government decided that NHS organisations should be compelled to implement the recommendations of NICE. Authorities existing allocations would have to cover the cost, so they would have to decide which services to cut to fund the NICE recommendations. (NHS History)

As Wat Tyler points out in Sex, Violence and Health Care:

The really scary thing about healthcare is that, even though it's already the world's largest industry, it's now growing at about twice the rate of world GDP. What that means is that in less than a century it will account for the whole shebang. Which means there will be no cash for anything else.

Healthcare is being rationed in every country in the world. All you have to decide is how you want it to be done.

A message from Patricia

The infection control nurse specialist has been doing her rounds.

Every doctor in my part of the world has just received one of the above.

It’s glossy.

It’s laminated.

I do not suppose it costs much to laminate a piece of paper, but costs mount if you send it to every doctor and nurse in the country.

Now, I accept that there is a need to improve hygiene, and we could all do to pay more attention to the Semmelweis message.

We all need to be reminded to wash our hands, but do we need to be told how to wash them? And is “germs” a good word? What is a “germ”? And should we not use a bactericidal hand wash rather than soap?

This is how the NHS is run these days.

A chip on the shoulder

The discussion under the three articles, on the dangers of nurse-practitioners, on the cost savings of using nurses to fill roles traditionally occupied by doctors, and the shoddy way that modern medical students are treated rages on.

If the comments on NHS BLOG DOCTOR are representative, it is clear that many people have little respect for doctors and feel it is reasonable and appropriate that they should be supplanted by nurses and others who are not medically qualified.

Nurses and other non-medically qualified health care workers – physiotherapists, podiatrists, EMTS, you name it - are increasingly being used to teach medical students. When Dr Crippen was a medical student, he spent a little time with workers such as these so that he could form an overview of what they did. There was no question of being taught by them. Meeting mifwifes for the first time was one of my enduringly unpleasant memories of medical school. So many of them had chips of their shoulder; for so many of them their mission in life was to show that they were “better” than doctors; and so many of them treated medical students disrespectfully.

Can you imagine trainee airline pilots being taught by baggage handlers and check-in staff? Too silly for words.

From the emails Dr Crippen gets from medical students all over the UK, the situation is now much worse, and it is not just the midwives.

In Canada, they are going to take action to stop it. This report from a leading medical school:

"…there were red flags raised about a four-week obstetrical rotation in one hospital where there wasn't always a doctor on site to assist students, although a supervisor was on call. This often happened in the past but standards have changed. The survey team also interviewed several students who reported being berated on the job by other health-care professionals..."

Do not be surprised if medical students leave medicine for other careers.

Does the general public understand what is going on in medical training at present? I print a selection of comments from the last few days:

I think all health professionals should learn from each and most of all the patients. Otherwise we will have this continued crap that one profession is more intellectual than the other nonsense being perpetuated for years...as has been the case. of course there are some core knowledge and skills that all professionals in health care should have and there will be some specific technical knowledge and skills that may be professional specific ..this is the expanding area in health care. Hence the debate about doctors and NPs in these pages. Protectionism is alive.

Does he feel the same about baggage handlers and pilots, I wonder?

Doctors in the top percentile? No way. Maybe back in the 50's before the advent of computers. Medicine is a course for rote learners with no creativity. Diagnostic doctors will be replaced by nurses taking tests ordered by computers in the near future. Read “The end of medicine” by Mr Kessler.

Oh dear, I fear that may be right.

Obviously it’s not just the money but the way in which we are treated. I start work as an F1 doctor next august. Our application process for jobs means we have to say we're willing to work anywhere in the country, for an unknown wage, unknown hours and not sure whether we get free accommodation chucked in.

There can’t be many professions where people who have worked hard and trained for 6 years are given such little information about what job they are doing. Signing a blank contract allowing them to fill in the details is worrying, it feels more and more that we are an expendable asset to the NHS and not people. But i guess it goes with the vocation.

How would you persuade this young doctor to stay in medicine?

I discussed the issue of medical professionals being the top 1% with a couple of consultant friends of mine. I was astounded that this is what students entering medicine are told at university...how shocking. Reminds of a discussion I had with a social work trainee who was adamant that only social workers can advocate on a patient’s behalf...this is what they were being told at colleges etc. Is it any wonder there is so much inter-professional misunderstanding and rivalry. And some of the bizarre comments made in these pages.

Looking at the entry requirements for medical school the entrants are in the top 1%. The same is not true for ancillary medical jobs.

My question is directed respectfully to the doctors in this room. Does it worry you that so many morons are admitted into medical school these days? Will the quality of care be vitiated?

Time to go home!


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Any comments under the original article here, please.

Cheapo-cheapo productions

In a different age, I was a big fan of John Sebastian - Lovin' Spoonful, and so on. I was reminded of him today when I came rather late to a controversy that has been raging on Doctors.net.uk for just over a year. The controversy was started by an article in the BMJ by Ghislaine Young, who styles herself as "a nurse practitioner working in a large general practice in West Yorkshire, where I am a salaried partner."

I cannot print any of the numerous comments on Doctors.net.uk. Even more sadly, I cannot print the whole article from the BMJ as it has not yet been released from copyright. It is available by subscription from here.

I will print one short paragraph.

"My job as a nursing practitioner in general practice and an extended nurse prescriber means that I work alongside the GPs and offer patients an alternative healthcare practitioner to consult. I improve access to medical services and am authorised to order all sorts of investigations, including radiography, and can refer patients for consultant opinion or even admit them as acute patients to hospital if need be. This all sounds like a traditional medical role, but we nurse practitioners are more than this: we inhabit a nursing ethos of which the essence is the therapeutic relationship. This allows us to connect with our patients and to understand their experience of their illness and to respond to their needs. Our critics say we are being mini-doctors, but actually we are maxi-nurses, and this is not mere semantics: the difference is important. There is much research evidence to show that in comparison with doctors we deliver safe and effective health care, but with a difference: patients often prefer consulting nurses because of our communication skills and because our approach centres on the whole patient."

Ghislaine Young, nurse practitioner in general practice
Shipley, Bradford ghislaine.young@bradford.nhs.uk

There has, as you would expect, been a lengthy response in the BMJ from doctors, and also from some of the nurses who are still proud to be nurses. This is all in the public domain here.

A small point, Ghislaine. There is no such thing as a "salaried partner." It is a legal oxymoron. Either your “partners” are kidding you, or you are kidding us.

“This all sounds like a traditional medical role, but we nurse practitioners are more than this: we inhabit a nursing ethos of which the essence is the therapeutic relationship. This allows us to connect with our patients and to understand their experience of their illness and to respond to their needs.”

OK, right. Sounds good. I forget what it was I trained to do.

“…in comparison with doctors we deliver safe and effective health care, but with a difference: patients often prefer consulting nurses because of our communication skills and because our approach centres on the whole patient.”

I used to be annoyed by all this. Now I am past caring. The government is right behind you Ghislaine, because you are cheap. You will win. Slowly but surely, people with medical training will disappear from the NHS. And very soon, like the dentists, you girls will start putting "Dr" in front of your name.

The medical profession is angry and disbelieving but vent their spleen in private.

What do the patients think?

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Golly gosh, I have had an email from Ghislaine herself. She says:

Dear Dr Crippen

Maybe if the argument has been raging on Doctors' Net for a whole year it is time you moved on and looked at the situation in a more open minded and accurate way!

Nurses and doctors go together like peas and carrots! More importantly patients need us to work in active cooperation not competition. Educating nurses to undertake some of the roles previously the doctors' domain, frees doctors up to treat patients of a different complexity who need their specific skills and time. There is more than enough work for all of us, and medicine and nursing has always been a symbiotic relationship.I have the highest regard for my medical colleagues and have been very fortunate in having such a great team to work with. But maybe this is far more widespread that the "doctors' netters" would have us believe? The majority of my NP colleagues have the whole hearted support of the doctors they work with, and NPs work successfully as part of a multi-disciplinary team whether in primary or secondary care, complementing but not replacing the doctors. The outcome is I believe win for patients , win for doctors and win for nurses!

I really hope that 2007 will allow nurses and doctors to reconcile any differences they may have and to remember that nurses need doctors but also doctors need their nursing colleagues in order to deliver safe and effective health care for the benefit of patients!

Ghislaine Young

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I will let everyone make up their own mind about this letter, but for one question. In what way have I been inaccurate?

Looking after NHS health care workers

A talented family

I learnt something from a reader earlier this week which made me giggle. I had written an article (Pay peanuts, get monkeys) on pay rates in the NHS. I think the pay rates at the top end of the NHS are poor. Whether or not you agree with that, I do not think anyone will dispute that the pay rates at the bottom end are disgraceful.

How do you retain such a huge work force when you are paying them not much above the basic minimum wage, when many of them are living in poverty?

How long before such a work force starts to organise, starts to complain? Is it any surprise that, all over the country, this is happening?:

“Workers in the NHS are paid low wages. The NHS does not pay overtime rates even when employees work very long hours. Pressure to keep profits high and wage costs low results in understaffing, so staff have to work harder and faster. As a consequence, accidents (particularly burns) are common. The majority of employees are people who have few job options and so are forced to accept this exploitation, and they're compelled to 'smile' too! Not surprisingly staff turnover in the NHS is high….”
(Source 1*)

Which leads to this:

ARE YOU SICK OF LOW WAGES?
Would you prefer a decent pay rise, guaranteed hours, overtime pay and an end to humiliating "performance reviews"?
ARE YOU SICK OF SEEING PEOPLE INJURED?
Even the the NHS admit that burns, slips and falls etc are BIG problems.
ARE YOU SICK OF BEING BOSSED AROUND?
Do you want RIGHTS, and freedom from being constantly watched and treated like being in the Army? Do you want an end to harassment and unfair dismissals?
ARE YOU SICK OF POOR WORKING CONDITIONS?
Do you want relief from continual pressures to work hard, to 'hustle', to cut corners with safety procedures? Do you want decent breaks, and to smile when YOU feel like it?
ARE YOU SICK OF the NHS?
Are you fed up with all the crawling to bigwigs from Head Office, and the company's inane propaganda?
DO YOU WANT TO DO SOMETHING ABOUT IT?
(Source 2**)

How has the NHS dealt with this potential problem? It has hired Camel Flatley at £180,0000 a year as the CEO of NHS Professionals. Carmel’s cousin is Michael Flatley, of Riverdance fame. That is a wholly gratuitous piece of information but it pleased me. More to the point Carmel has for many years been responsible:

“…for the recruitment, retention and career development of a transient workforce of over 55,000.”

Excellent. Just what the NHS needed. And where did she get this experience which so equipped her for managing the largest healthcare workforce in Europe? Why, at McDonald’s. Really. I am not making this up. With the Department of Health it is not necessary to make things up.

Carmel Flatley (Chief Executive)
Carmel Flatley is American, and has lived in England for over 20 years. Her career background is in Human Resources, most of her experience being with the MacDonalds Corporation. She rose from being a personnel officer in the organisation in the early 1980s, appointed in 1998 as Senior Vice President, Chief Human Resources and Training Officer. In this post she was responsible for the recruitment, retention and career development of a transient workforce of over 55,000. She left MacDonalds earlier this year, having decided to seek a career transition to a new area. Carmel Flatley is 46. (DoH biography)

Brilliant. Just what we needed.

As Wat Tyler points out in Leadership : Spot the difference, private sector companies rarely have CEOs who do not have many years experience of their own industry.

HSBC is Britain's second most valuable company, employing 284,000 staff. It is led by Sir John Bond who joined the company in 1961, at the age of 21; he started as a clerk and worked his way to the top.

Tesco is Britain's most successful retailer, employing 335,000 staff. It is led by Sir Terry Leahy who joined the company in 1979, at the age of 23; he started as a marketing executive and worked his way to the top.

The NHS is Britain's dysfunctional health service, employing "approximately 1.3 million staff" when last officially sighted (in 2004). It is "led" by CPO Commissar Hewitt, who joined ten months ago; she started as...er, the boss. Although she did have all this highly relevant experience:

1971-73: Press and PR with Age Concern
1973-83: Womens Rights officer and then General Secretary for National Council for Civil Liberties
1983-1992: Press Secretary to Neil Kinnock; also helped set up Institute for Public Policy Research, Tony Blair's favourite thinktank
1993-97: Anderson Consulting (yeah-but-no-but-yeah-but-definitely-not-the-bit-of-Arthur-Anderson
-that-had-to-be-shut-down-because-it-cooked-the-books-at-Enron-
honestly-anyone-would-think-the-whole-barrel-was-rotten-anyway-
they-probably-only-gave-her-a-job-because-of-her-Labour-contacts-
so-she-wouldn't-have-had-nuffink-to-do-wiv-any-of-that-anyway-so-shuttup)

On second thoughts, maybe Dr Crippen is being unfair. Maybe years of experience of fast-food service at McDonalds IS the best training for the modern NHS.

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Dr Crippen's admits to artistic licence in making "slight" alterations to the two quotes above. The correct quotes can be found in their natural "fast food" habitat here:

Source 1*
Source 2**

Breast cancer screening : mammography

More controversy about mammography is approaching.

In the UK, the national screening programme starts for women aged 50. Lots of reasons for that, not least that screening (as opposed to diagnostic) mammograms are not as easy to read in the pre-menopausal breast.

The Lancet (The Lancet 2006; 368:2053-2060) has recently reported on a trial of the value of screening women from the age of forty, and concluded:

Interpretation
Although the reduction in breast-cancer mortality observed in this trial is not significant, it is consistent with results of other trials of mammography alone in this age-group. Future decisions on screening policy should be informed by further follow-up from this trial and should take account of possible costs and harms as well as benefits.

This conclusion has not been greeted with enthusiasm in the USA. Kevin MD reports “Mammograms before age 50: Will the NHS use a recent Lancet study as a tool to deny screening? Hopefully not!"

A "tool to deny"?

An emotive statement, not science. This is a research document which is trying to establish whether such screening would be of value. He refers to an eminent New York physician who is similarly unimpressed :

Mammograms in Women under 50 - The Lancet Study Reviewed

Her conclusion is as follows:

“…this study adds little to our understanding of the role of today's mammograms in women under age 50 as practiced in the United States. For my patients, I will continue to recommend mammograms every 1-2 years beginning at age 40, and annually at age 50 and above. I advise women with dense breasts to have digital mammograms and ultrasound in addition to mammography, especially if there is a family history of breast cancer.

Hopefully, the data from this latest Lancet study will not be used by the NHS to continue to deny this same screening to women in the UK.” (my italiacs)

Again, another emotive statement which confuses "screening" mammograms and "diagnostic" mammograms, and also confuses the difference between screening the whole population, and the surveillance of high risk women. High risk women need to be in a separate survellance programme such as the ones run by the Christie Hospital in Manchester, and the Royal Marsden in London.

Screening ALL women from the age of forty is not the current USA recommendation**, and it is not the UK recommendation. Screening should be done according to science not whim. Screening for diseases is only valid if done on the basis of scientifically designed programmes.It should not be done unnecessarily.Mammography involves subjecting breast tissue to radiation. In a litigious society, unnecessary tests which subject the patients to the dangers of radiation could give rise to a law suit.

Someone is about to say, “Ah yes, but they are better at this sort of thing in America. They have more resources, the standard of medicine is higher.”

They certainly have more resources, but there is no evidence to suggest that the Americans are “better” at breast screening than the British.

There is another consideration. The psychological effect on women. Having a mammogram is stressful. It is uncomfortable. A lot of non-cancerous pathology is unearthed, and women are stressed even further whilst they await the outcome of investigations. This is a particular problem in the USA where mammograms tend to be over-reported. Mind you, they would probably be similarly over-reported in this country if British breast radiologists had the American legal profession peering through their keyhole.

The JAMA compared breast screening outcomes in the USA and UK:

Conclusions
Recall and negative open surgical biopsy rates are twice as high in US settings than in the United Kingdom but cancer detection rates are similar. Efforts to improve US mammographic screening should target lowering the recall rate without reducing the cancer detection rate. (Full JAMA article here)

In other words, American women are subjected to twice the stress as their British counterparts, and all to no avail.

** or is it? See the comments

The Crippen Diaries (Week 51)

Not quite Tannochbrae

Monday 18th December


Next a charming paramedic who had hurt his knee playing rugby over the weekend. We did the knee, then turned to gossiping about the NHS and soon enough, as one does, we got into the “what is the most ridiculous thing you have ever been called for” conversation.

A common call out for paramedics now is toothache. Can you imagine? People get toothache and dial 999. The unit cost of an ambulance call-out is £500.

It might be cheaper to pay NHS dentists properly.

++++++++++


Tuesday 19th December

There are a lot of bad colds around at the moment and so, once again, we entrench for the annual antibiotic fight.

Even after all these years, I remain staggered at the way a proportion of patients react when they realise you are not going to prescribe antibiotics. They seem to see it as a deliberate act of cruelty.

All the usual vocabulary is trotted out. A “head cold” (as opposed to?); can I have something to “throw it off”?; I am “not a tablet person, but…”; noses stream, sinuses throb, coughs hack, and so it goes on.

And then an interesting one. A 48 year old plummer, David. We do not see much of David. He sat down and said “I think I may have a headache”.

What exactly does this mean? Is it different from “I have a headache”. I asked David that very question. He looked mystified and said, “I do not get headaches.” I smiled. David did not.

We danced around these philosophically challenging symptoms and, in the absence of any physical signs or red-light symptoms, agreed on some simple analgesia and a review in a couple of days. I have asked him to come back because I do not really understand what is going on so, as always in those circumstances, I safety net.

++++++++++

A letter came in with a brief but perfectly reasonable clinical summary of a patient's admission with a heart attack. The computer letter is in the usual form. However, under the heading “Consultant”, rather than giving the name of the consultant it says “The Cardiology Team.”

Oh dear, oh dear, oh dear. Such a small point you may think. But this is the cloak of anonymity. It is the dilution of clinical responsibility. It is the empowerment of the lesser clinical mortals such as the nurse-specialists.

There is a trend now to anonymise doctors, to airbrush them out of the painting. As a GP I like to know which consultant is responsible for my patient. Often I wish to locate a particular doctor in a particular hospital. I still have this quaint feeling that the doctors are the most important people in the hospital, that without the doctors there would not be a hospital. Silly, I know, but that is how I feel.

The chief executive and administrators are always easy to find. The PALS system (as we know call the “complaints department”) even easier. But where are the doctors? How do you find them?

Take a look at these websites. Find the name of two consultants working in different specialities in each hospital. See how long it takes you. One, two, three, four, five and six.

+++++++++++


Friday 21st December

Robin is 73 and has osteoarthritis. He has had two hip replacements which helped enormously, but we cannot replace his lumbar spine which has been troublesome for several years. He takes regular pain killers and diclofenac which is a non-steroidal anti-inflammatory. Or he used to.

He came today for several things including a blood pressure check. I asked him if his prescriptions were up to date. He smiled broadly and said he stopped the diclofenac six weeks ago and that he had never felt better. He could see that I looked mystified.

“I bought this, doc” he said, brandishing a shiny copper bracelet. Lots of people with arthritis wear copper bracelets. This is of course therapeutic nonsense. I know this because I am a doctor.

Robin said his bracelet was special. On the inside of each end of the open bracelet were three small magnets. This makes all the difference. According to Robin. This is of course therapeutic nonsense. I know this because I am a doctor.

Robin left, smiling and happy, without another prescription for diclofenac.

++++++++++

I had to go out in the middle of the morning surgery to see a patient who had died. She was 78 and had cancer, and it was an expected death. She had been wonderfully cared for at home by her family, with nursing support.

I had known her for twenty years. I said all the things one says, talked the family through the paperwork, and went back to the surgery. She is to be cremated and so I had to fill in a death certificate and a cremation form, and find an independent doctor from another practice to do the second part of the cremation form.

We all do this. It is routine. I suppose. But as I get older, I find it harder. Death never comes at a good time, but three days before Christmas is particularly bad.

+++++++++++


Friday 22nd December

If Christmas Eve is on a normal working day, we normally have a moderately busy morning and the, round about lunch-time, it goes quiet. Illness is put on hold for the festive season. Very quiet. The ultimate Poet’s Day of the year. This year, in a way there are three Christmas Eves, and it did not go quiet at lunch time. Busy all day.

Lots of bad colds and mild viral illnesses, all wrapped up in seasonal good cheer. Preventative medicine is much desired at this time of year. “I wouldn’t normally have bothered to come with a cold, but as it is Christmas…”

Proximity to Christmas Day does not alter the fact that there is not much treatment for bad colds, but at least everyone was cheerful about it.

Pay peanuts, get monkeys

Still in work

The Taxpayers’ Alliance has recently published a document that they call The Public Sector Rich list.

Public Sector Rich List
This note presents a list of the 170 most highly paid people in the public sector – people earning above £150,000 a year in government departments, quangos, other public bodies and public corporations.

click to enlarge

The 12 most highly paid people in the NHS earn an average of £183,000 each. By comparison, the starting salary for a nurse is around £19,000.

There is a clear innuendo here. These “fat-cat” NHS executives are all overpaid. Just look, everyone, some of them are earning ten times more than the average newly qualified nurse.

The Taxpayers’ Alliance has but one mission statement. Reduce taxes. Reduce taxes and never mind the consequences. The clear implication here is that these salaries are far too high, and are thus a waste of taxpayers’ money.

This is nonesense. Since the demise of the Red Army, the NHS is the largest employer in Europe. It supplies health care to every man, woman and child in the country. It is therefore more important to Britain than any one of the Footsie 100 companies.

Take a look at the pay rates of the chief executives of these leading British Companies. If you put a nought on the end of the NHS executive salaries, you still would not be close to the earnings of, for example, Stuart Rose, the chief executive of Marks & Spencer’s. He earns more than a hundred times the salary of one of his junior sales assistants.

Marks & Spencer’s is thriving. Over the last two years it has been turned round. Marks & Spencer executives earn salaries that dwarf NHS salaries. They bring excellence to the company. They generate wealth and employment for the country.

There is another big difference between the NHS and private sector. If the private sector executives do not deliver, they are sacked. The NHS does not sack people. It moves them sideways.

Why is Nigel Crisp still on the payroll? He failed. Why was he not sacked?

The Taxpayers’ Alliance has got it wrong. The NHS salaries are, in context, paltry and thus attract unimaginative journeymen who value job security above success. A leading economic commentator recently said:

“Is it me or are the mandarins going to the dogs? Back in the days of Sir Humphrey, surely the top brass used to be Oxbridge double-firsts, smooth as silk, and answering tricky questions with Latin aphorisms. Yes I realise they also used to fly us into mountainside regularly, but at least the cabin announcements were polished and reassuring. The new CEO of the NHS- the largest employer in the Western Hemisphere... I'm sorry, no offence... but he comes across as a senior clerk from a local building society somewhere up North. And the lady who runs NHS Professionals... umm how should we put this... possibly used to work at Nails4U in Basildon.”

The solution?

Pay salaries so high – and that means several million a year – to the top NHS executives that you attract the cream of British businessmen. Give them the autonomy to do the job by freeing them from all the Stalinist bureaucracy, and pay them huge (several more million) bonuses when they deliver.

And if the do not deliver?

Sack them.

Another medical blogger perishes...

You cannot burn blogs.

It is hard to remove blogs from the internet. They are usually cached somewhere. But a lot can be done to empty the caches and it seems that, in the case of HospitalPhoenix, it has been done.

HospitalPhoenix has disappeared without trace.

An articulate, witty experienced middle-grade hospital doctor. An articulate, witty experienced middle-grade hospital doctor who was abruptly sacked a couple of weeks age. An articulate, witty experienced middle-grade hospital doctor who wrote about his experiences.

He was probably too expensive. He has probably been replaced by a nurse-specialist.

I hope it is a technical glitch, but I fear it is not. I fear he has been made an offer he cannot refuse, an offer upon which his career will depend.

This is the modern NHS. This is Blair’s Britain. CCTV. Identity cards. The Spine.

Big brother is watching. We must all behave ourselves.

R.I.P. HospitalPhoenix

The BritMeds 2006 (4)

An even bigger crop of nominations. The most exciting new find for me was “Suspect Paki” but I am going to leave him until the end.

The Tax Payer’s Alliance has just published the PUBLIC sector rich list. We are not talking Richard Branson and Stuart Rose here, we are talking of government employees. Jot down on a piece of paper your guess as to the identity of the ten best paid NHS workers, and guesstimate their salaries. Pay peanuts, get monkeys - or is it a king’s ransom? You decide when you look here.

Could a brain tumour give you psychic powers, or was this immigrant just trying to get free treatment on the NHS?

This look at British GPs spoilt Dr Crippen’s breakfast:

Try and get one on a call out. They hardly have to diagnose anything themselves. Everything is wait, wait, wait, then test, test, test and then wait, wait, wait again usually followed by die, die, die. And yet their dough goes through the roof.

What’s that old joke?:

“Doctor, how soon after the baby is born may we resume intercourse?"
"As soon as you like, but a gentleman waits until the placenta has been delivered.”

Sex during and after pregnancy? Like “shagging a space hopper.” A frank and frankly hilarious discussion from Emily who says that “by the time the six-week milestone after birth arrived, I was gagging for it. Despite extreme tiredness, we were at it constantly. I was consumed by raging hormones, which left me insatiable.”

Space hopper or not, Tiny Tim tries to persuade us that size does not matter, whilst an elderly Greek gentleman asks if hitting his head with an iron bar will improve his flagging libido.

Staying with matters sexual, Puddlejumper, an excellent bipolar blogger (wonderful illustrations) who only went to the doctor during depressive episodes, asks “…have I told you the story of how I slept with my husband’s boss and thought the three of us could all live happily ever after?”

And whilst we are on sex, it seem the Scots are missing their post-coital cigarette. Maybe this will help.

It’s important that men take an equal part in childcare. Googa Baby reports on the introduction of Breastpumps for Men. You don’t believe me? Well, have a look here, because they have filmed it. Really.

Talking of sucking, the NHS Sucks Forum only started a few weeks ago, and goes from strength to strength. Perhaps not surprising when it is run by the formidable Craig Walsh. Look at what he says about the last hotel he visited.

It is not just smoking that should be banned in theatres and cinemas. There are many other foul habits as well.

Onto more serious matters. Nurses for reform is a new blog written by Helen. She says,

“NFR believes it is no longer acceptable for nurses to sign up to careers in public sector healthcare only to find they are unable to access the resources and autonomy they need to do their work. It rejects bland egalitarianism in favour of contestability. And it believes in people - not politics.”

Dr Crippen is not good at languages. A little French maybe, but he does not speak “nurse”. Can anyone translate that into English for me?

Which leads straight onto the finest summary of New Labour’s NHS that Dr Crippen has ever read.

You may be glad that Lord Warner is going, but Gordon is still after even more of your pension.

Obesity could bankrupt UK health system. The Atkins diet may be dangerous, but would you rather do this to our children?

News that cannabis chocolate helped a UK patient hits the USA

“THE rationing of expensive drugs on the NHS was brought into sharp focus yesterday when a young girl won her battle for treatment, while hundreds of other patients lost out.”

A surrealistic discussion about whether illness is ‘real’, or just a symptom of “wrong thinking”. The wickedness of denial.

And thank goodness for the NHS… says another American now living in the UK

Let’s deskill the psychiatrists. Whilst the doctors are tucked up in bed or on the dole, the NP are trying to do their jobs.

The Furry Monkey has found that her lymphoma has turned her into a bed banana.

A little encouragement last week, and Tragedy Towers – Life at NHS DIRECT is back in action

I can’t remember a better NHS than the one we had now, I don’t remember the NHS being a ‘national treasure’, or ‘the envy of the world’. This is mainly because I’m 25.

The governemnt’s advice on boozing may be modified.

A Doctor’s scream. Lucy Chapman, the pseudonymous doctor, writes another harrowing article, this time in the New Statesman.

Dr Adrian Mackie’s excellent spoof of Modernising Medical Careers is available from Dr Rant in Do Not Pass Go.

Would you want to work with a fascist? Tom asks if the NHS should employ workers who are members of the BNP?

Do you have a large number of younger brothers and sisters? Then you have an increased risk of developing a brain tumour. Sexist or not, there are anatomical differences between the male and female brain

Gill tells us about “The real free (healthy) health service."

Do the Bahamas count for the BritMeds? Are they still part of the Empire? Who knows, but WeblogBahamas is taking a look at the NHS from afar.

More dumbing down. It is all the rage.

“Our PEC became increasingly populated by PAMs (professions allied to medicine) which in my view weakened it. The final straw was when I sent around a spoof email suggesting clergymen be on the PEC and got two serious replies from GP colleagues.”

Get this. The cash-strapped NHS spends £330,000 on improving blue logo Official figures reveal that the bill for protecting and promoting the 'NHS identity' has more than doubled in the last four years - reaching almost £334,000 last year. The money would have paid for 75 extra hip replacements - or the salaries of 15 nurses. Download the "new improved NHS logo" from here. It is "free". One for Wat Tyler. Surprised he missed it.

"In a sane world, all you'd need to tell the hospital staff is your name and address and they'd pull up your details on screen. In fact, we've become so used to that from every other organization on the planet that it just seems absurdly archaic for it not to happen. Not only have the NHS not entered the Computer Age, but they're not even comfortable yet in the Getting-stuff-out-of-a-filing-cabinet Age." Amazing. Not everyone is against The Spine then.

A sad story of another failure by the medical profession:

“It’s just as well this is all in my mind, girl, because otherwise, this is unbearable”.

Psychosomartyr watches her mother die of MUS.

Finally, definitely Dr Crippen’s pick of the week.

A few days ago I said that I would be frightened if I, or a member of my family, had to me admitted as an emergency to an NHS hospital. A wonderful new (to me) writer,

Suspect Paki (100% Londoner. 100% Muslim. Deal with it.)

was admitted to St Mary’s with diabetic ketoacidois. Dear God, what have we done to the NHS.

++++++++++

Any reader wanting to look at a round-up of non-medical blogs should cast a quick eye over Tim Worstall's weekly Britblogs.

++++++++++

Please send your recommendations for next week’s BritMeds to: thebritmedsATnhsblogdoc.wanadoo.co.uk

The Dangers of Nurse Practitioners : the GMC "acts"

Don't get ill here

A couple of weeks ago, in “Cheapo-cheapo productions” I printed an excerpt from a BMJ article by Ghislaine Young, one of the leading nurse “practitioners” in the country. In the article, she said, inter alia:

“...this all sounds like a traditional medical role, but we nurse practitioners are more than this: we inhabit a nursing ethos of which the essence is the therapeutic relationship. This allows us to connect with our patients and to understand their experience of their illness and to respond to their needs.

…in comparison with doctors we deliver safe and effective health care, but with a difference: patients often prefer consulting nurses because of our communication skills and because our approach centres on the whole patient.”

The debate has continued, and so I have put the original article back on the front page, just below this.

Much reference has been made to the flagship of NHS cheapo-cheapo productions, namely the Canary Wharf Walk-in centre:

“With its spacious reception, plush seats and large plasma screen, the Canary Wharf walk-in centre couldn't be more different from the usual NHS surgery. The centre is a flagship in the Government scheme to improve access to GP services. They are run by nurse practitioners, with the promise of providing fast and convenient access to all NHS services. There are already 80 across the country with plans for at least 16 more - seven of these clinics, including the Canary Wharf centre in London Docklands, are managed by private companies on behalf of the NHS."

It all sounds most impressive, but...

there are serious concerns about the working arrangements at some of these walk-in centres, with patients' lives being put at risk. Indeed, two doctors and a nurse recently left the Canary Wharf centre, concerned that patient safety was being compromised.” Daily Mail.

One of these doctors was Anila Reddy, an experienced doctor who has post-graduate training in family medicine and paediatrics. He resigned from Canary Wharf because he was concerned by the standard of care being provided by these NPs for babies and small children. Dr Reddy said:

“At first, we were told the nurses could not see babies or children but later that rule suddenly changed, and I wasn't told why. I felt particularly unhappy that children and babies were being assessed by nurses who had never worked on children's wards, let alone been registered as specialist children's nurses."

But it was when Dr Reddy assessed the work of the nurses that he became really concerned.

"Part of my job was to carry out an inspection of the work at the centre. This involved reviewing patient notes and following up how they were managed by the nurses. I quickly began to pick up mistakes.

A young woman came in with a lump in her armpit. Standard practice would be to examine her breasts for lumps because she could have early signs of breast cancer. Yet I discovered she had no breast examination and was sent home. I found out about it, phoned the patient who told me she had noticed some breast changes. I advised her to see her GP straight away.

'The audit also picked up a patient who had not been able to walk due to a glass injury but had been sent home without a foot X-ray. And another patient had his anti-depressant medication stopped suddenly, which is dangerous.

Later, I discovered a 17-year-old girl had come in drowsy, admitting she had taken an overdose. She said she had taken just four tablets containing paracetamol - a drug which can cause permanent liver damage. Although she said she'd swallowed just four tablets, you cannot take at face value the word of someone who's overdosed. She should have gone to casualty and been seen by a psychiatrist, yet a nurse had just sent her home.

In all these cases, doctors had to follow up the patients and deal with the mistakes - as far as possible. But it was worrying because the system only allowed checks on 17 in every 400 patients seen. I began to wonder what else was being missed."

Dr Reddy has joined the discussion under Cheapo-cheapo productions and in particular has reproduced his correspondence with the GMC, to whom he made a formal complaint. (see all the correspondence here)

What is the GMC going to do about it. Please read the correspondence in full, but the Jane O' Brien, the head of the Standards & Ethics committee of the GMC concludes her reply by saying:

Specifically you were asking what the GMC would expect a GP to do if asked to provide supervision for nurses under arrangements which the GP considered would compromise patient safety. We have made clear in Good Medical Practice that:

"If you have good reason to think that patient safety is or may be seriously compromised by inadequate premises, equipment, or other resources, policies or systems, you should put the matter right if that is possible. In all other cases you should draw the matter to the attention of your employing or contracting body. If they do not take adequate action, you should take independent advice on how to take the matter further. You must record your concerns and the steps you have taken to try to resolve them." - GMP, paragraph 6, November 2006 edition.

In the circumstances of the WICs, this would mean taking steps to provide or arrange additional training for the nursing staff and raising your concerns with those responsible for managing the centre.

I am copying this e-mail to Sir Graeme Catto and Mr Richard Dale, and Sarah Thewlis.

I hope that this is helpful in explaining the GMC’s views and the scope of our role.


Jane O’Brien
Head, Standards & Ethics
e-mail: jobrien@gmc-uk.org
telephone: 020 7189 5417

Maybe Sir Graeme Catto, Mr Richard Dale, and Sarah Thewlis at the GMC will take action. But Dr Crippen is not holding his breath. Jane O’Brien’s letter suggests that the complaint is noted but nothing will be done. In fact, Jane O’Brien suggests that Dr Reddy should personally take responsibility for training these nurses.

Ghislaine Young has replied to Dr Reddy and, to be fair to her, says:

“However I do welcome the opportunity to say that where I agree with Dr Reddy and others is that the NMC is currently failing in its mandate to protect the public and that the sooner we regulate the NP role the better for all concerned.”

We all agree with that, as far as it goes.

But lots of words and no action. We will have to wait until a few children die of undiagnosed meningitis; until a few brain tumours are missed; until there have been enough mistakes made by these untrained amateurs for the Red Top newspapers to take an interest. We shall have to wait for the general public finally to realise that their much beloved “angels” are not doctors and cannot function safely as doctors.

This debate rages – and I do mean rages – in private on doctors.net.uk. It is time it was out in the public arena and it is time that the numerous people who write in saying “Oh, you doctors are being so mean to the nurses” realise that doctors are fighting to protect the public from dangerous, under-trained incompetence brought to market by plausible and well-meaning amateurs.

Comments under the original article here please.

Looking after medical students

Group portrait of fifth year medical students 1893

It used to be different.

When Dr Crippen was a medical student (second from left, seated) – OK it was not yesterday, but it was not that long ago – the student body as a whole was a happy and optimistic lot. I cannot personally remember a single student who left of his or her own volition, nor a single newly qualified doctor who left medicine altogether. One or two went abroad, but the overwhelming majority stayed in the UK.

Higher medical training was a little chaotic; it was not well structured. The hours were long, too long, and the pay was poor. But given a reasonable amount of ability, and a capacity for hard work, no door was closed, and no career option was impossible. Above all else, there were no doctors on the dole.

Rose-tinted glasses? Possibly. Am I turning into a curmudgeonly old fart? Probably.

But something is going wrong. Badly wrong.

Today I received an email from a medical student still in the early days of his training. I could not imagine a medical student feeling the need to write such a letter in my time.

I thought I'd offer my opinion on what my thoughts are about entering the NHS - I'm only a second year pre-clinical student so I have yet to even see a patient!

When I applied to medical school in September '03, I knew that it was going to be tough, both getting in and staying in. What I also (perhaps naively) thought was that I'd come out of it at the end with a job waiting for me and a structured career path with job security and decent training all the way. I'm sure I speak for a lot of medical students when I say that when we see what is happening to the NHS we get demoralised and we start to question whether it's actually worth it.

We study things that might not be that interesting, that we find hard, and it's becoming hard to stay motivated. A lot of us want to move abroad when we qualify - not because the money is better or we prefer the weather in Australia but just because we can't see ourselves fitting into the NHS and getting the necessary standard of training to get competent when we graduate in a few years' time.

I'm in a class of 190 people - all of whom are incredibly intelligent, caring people, and the NHS is going to lose so many of them unless it sorts itself out.

Cheers, and please keep writing.

Pete

Something needs to be done.

The Crippen Diaries (Week 50)

Not quite Tannochbrae

Tuesday 12th December

The first patient who came in was a middle aged, smartly dressed man. He needed a BP check and some advice about immunisations for a forthcoming holiday. When he took his jacket off, he has the most appalling body odour. He lifted up his arm for me to put on the BP cuff. It was quite awful. As is usually the case – I assume – the patient is completely oblivious to the problem. After he left, I opened the window and sprayed the air-freshener and, even though I was running late, I did some paper work for five minutes. It is embarrassing to say to the subsequent patient that “the smell is not me” and so one tries to let it clear.

One of the little joys of the job!

+++++++++++

The local community pharmacist is pushing us very hard (again) to change all the patients on atorovastatin to simvastatin. The latter is much cheaper but has more side effects. We have refused to let her do this without prior discussion with the patients. I am suggesting it to the patients. The frightening thing is that most patients do not ask why, they just say, “Whatever you think is best.” I think on balance that atorovastain is probably better, though I am not sure. I doubt the cost differential is justified. I am therefore being honest. I say “This is a cost issue. Simvastatin is much cheaper.” Some mind. Some do not.

It is very difficult.

++++++++++


Thursday 14th December

Got up. Felt dreadful. Headache, hot. Had shower, got dressed, had orange juice, coffee, two paracetamol and threw up. Got undressed and went back to bed.

Took the day off. This is the third time this has happened.

Pathetic, really. Not very good at being ill.

++++++++++


Friday15th December

Back to work, not quite firing on four cylinders, and a duty day.

+++++++++++

John is 59. His mother died of bowel cancer when she was 63, and John’s older brother has just been diagnosed with the same condition. John has no symptoms and is, as far as he knows, in good health. Reasonably enough, he wants to know if he should be screened. He should. No argument about that. He said he has private health insurance. Unfortunately, private health insurance does not pay for screening tests in asymptomatic patients. So I referred him to the colorectal clinic, warning him that he would have to wait a few weeks.

I had a letter today. Because of pressure of work, there is now a delay for screening colonoscopies. That delay is two years.

John is too worried to wait that long, so he is going to pay for it out of his own pocket. I do not blame him. Unfortunately, the government does not have a “target” for screening colonoscopies so they go to the back of the queue.

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

Lots of children with temperatures. Lots of parents with thermometers. They take the readings, the numbers are frightening, and so they phone the doctor. Whether or not the children are unwell. Sometimes they are. Sometimes they are not.

When my four children were small, we used to take their temperature, and the numbers used to frighten us too. So we threw the thermometer away. We do not have one in the house, and have not had one for years.

I suggested to a couple of parents today that they should do the same. They thought I was kidding.

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

The day finishes with one of those deeply depressing visits to one of the local nursing homes. Joe is in his late seventies. He is utterly demented, and has been for as long as I have known him. He is frail and more or less permanently bed ridden. Over the last forty eight hours he has stopped eating, and they are having difficulty persuading him to drink. And his chest is bubbly. He has not been seen by a doctor for several weeks. No reason for him to have been. The nursing home have called because they think he is going to die over the next day or two, and so they want a doctor to see him.

Yes, of course, to see if anything can be done, but that is not the main reason. The main reason for the call is paper work or, more correctly, the avoidance of paper work. If someone dies unexpectedly and they have not seen a doctor recently it means phone calls, discussions with the coroner’s officer, delay in removing the body and more distress for the family.

Joe has a caring family. And when I arrive his son and grand-daughter are there. They know the score and they do not expect, nor do they want, any heroics. I still feel the need to “clerk” a patient. It is too deep in my hardware to remove now. I feel the need to “take a history” and to conduct a thorough examination. It was what I was trained to do. It is not appropriate here, but they did not teach me that at medical school. So I feel uneasy.

Joe is not going into hospital for drips and physio and X-Rays and there is nothing I can do. A cursory examination of his chest, which is indeed bubbly, some amoxicillin syrup (why?), a long chat with the son and granddaughter and home.

And if Joe dies over the weekend, I will be able to do the paperwork, which is important.

But it’s a strange job sometimes.

Pissing into the tent

"It's probably better to have him inside the tent pissing out, than outside the tent pissing in." Lyndon B. Johnson

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It is always easy to criticise the status quo and to be destructive rather than constructive. I am aware that over the last year many of the Dr Crippen articles have been highly critical of the government’s management of the NHS.

In 1997, I voted for Tony Blair. I really believed he would improve health care (and education). I expected taxes to increase and was ready for that. On a personal level, I am earning more money now than I was in 1997, and I am earning that money by a great deal of hard work as I, and many of my colleagues, are hitting all the government targets.

We have done what was asked.

And yet, for all that, the medical profession is demoralised. Older doctors are counting the days to retirement. Younger doctors are on the dole, many considering leaving the country. The wards are denuded of trained nurses, and the ones that remain are at their wit's end.

Not a day goes by at work without several complaints about poor care from the hospitals. Some of the complaints are minor. Many are not. See Martin's story, last week. I am genuinely frightened as to what would happen if I, or a member of my family, had an acute serious illness requiring hospital admission. For all the health care problems that existed in 1997, and there were lots, the NHS was by and large delivering for acute illness.

The government is now so desperate about failing health care that it has resorted to lying. I am not talking about political spin, nuance, media-management and all the normal strategies one expects from politicians of any party. I am talking about bare-faced, brazen dishonesty.

The Minister of Health, whilst sacking nurses and closing hospitals, talks of the NHS having its “best year ever.”

The Prime Minister lies to the the House of Commons when he states that the the NHS is the "pride of the country".

After years of cutbacks under the Tories the NHS was getting better under Labour. (BBC )

I hold no brief for the Tory management of the NHS, but in 1997 I was not frightened about the prospects of hospital admission. But whatever the Tories may or may not have done, that was ten years ago. Tony Blair has had ten years to get it right, ten years to make improvements, and he has failed. Margaret Thatcher is long gone. Whatever your views on her, she is not responsible for what the NHS has become.

If you do not have the staff, you cannot provide the care.

Joint RCOG/RCM Statement
Senior obstetricians and midwives are needed to avoid future tragedies in NHS maternity services.

The recent Healthcare Commission investigation into the safety of the maternity unit at Northwick Park identified lack of clinical leadership in the Labour Ward from consultant obstetricians and senior midwives at the trust. This lack of supervision in the labour ward led to the diminished quality of care and poor management.

It is acknowledged that inadequate training and supervision of clinical staff, and the employment of temporary staff are likely to occur when there are insufficient supervision by experienced obstetricians and midwives to ensure a minimum standard of care. (Full report)

Let us now flesh out that statement with a patient’s experience:

The pain was so unbearable I begged for drugs, so Andrew went searching for the midwife. He was told she was "on a break". When she reappeared 10 minutes later, she refused to give me pethidine, but agreed to gas and air, which was useless but at least stopped me howling. The pain was relentless and I felt as though I might black out – I kept waiting for it to pass as a contraction does, but there was no respite.

Twice more he approached her, pleading for help. Twice she categorically refused to give me an epidural, claiming I wasn't even in labour, and, again, didn't lift the sheet. Had she done so, she would have seen that I had dilated from one to 10 centimetres in just over an hour and a half – a process that naturally takes place over 12-14 hours in first-time mothers – and that the baby was crowning and the sheets beneath me were soaked in blood.

Later, after the babies birth, the midwife continues to do as she pleases:

She was holding a bottle of milk. I implored her not to feed my daughter, but she ignored me, and proceeded to push the teat into my baby's mouth as tears streamed down my face. I returned to the ward shortly before midnight and held my precious baby all night. After two days, and barely able to walk, I asked to be discharged as the filthy bathrooms and rude staff had become too awful to endure any longer. (Full story in the Daily Telegraph here.)

Hard cases make bad law. Just an anecdote, you may say. You cannot generalise on one experience. The trouble is, family doctors around the country are hearing stories like this all the time.

Back to the Daily Telegraph, where a junior hospital doctor, still in training, describes what is really going on.

"I sit in the lecture hall and stare at the presentation being flashed up. Photographs of smiley faces projected on to the screen look down at me, benignly. Key words appear in bright colours. The lecturer drones on. Fewer doctors, he explains, will be employed by the trust this time next year. He smiles. This, he concludes, will improve patient care. Now he's saying something about delivering a modernised and focused career structure. Streamlining. Flagships. Supporting real patient choice."

"Hospital closures will save lives, says Blair"

"War is Peace. Freedom is Slavery. Ignorance is Strength". Jobs aren't lost; instead services are "streamlined" and "restructured".

Resources are "redistributed" and "modernised" rather than reduced; and valuable services are improved by being axed. Bad things are renamed and rebranded as being good; their "benefits" repeated again and again in the hope that we will begin to believe it. (Full story in the Daily Telegraph here)

Theirs is a shiny, happy world of smiling faces, looking down benignly while the NHS is slowly destroyed."

This is “getting a picture of the night with Sue and Dave”; this is the “essence of nursing care”. This is why Dr Crippen has been pissing into the tent. This is why doctors and nurses are demoralised.

Desperation in the NHS bunker

Lord Warner

They are getting desperate in the NHS bunker.

Lord Warner, the junior health minister, has resigned. A spokesman for Tony Blair strongly denied any suggestion that the minister's departure was connected to the troubled (sic) National Health Service IT project which he was overseeing.

“Troubled?”

Even in the pantheon of Blair euphemisms, “troubled” is still an extraordinary word to describe the wastage of £60 billion of taxpayers money.

"His decision to retire has absolutely nothing to do with that at all," the spokesman said. (The Guardian)

Of course not. Blair has never let minor considerations like complete incompetence influence such decisions.

So why has he been sacked?

Maybe the Prime Minister does not like his spectacles.

British doctors will join Dr Crippen in wishing Lord Warner a long and happy retirement. Let us hope he has a good pension and does not end up in the Brown Stuff.

Murder victims

Ipswich

I am having a real problem with the media at the moment.

The main-stream media, of course, not the blogosphere. There is yet another serial killer rampaging around in the Ipswich area. It seems likely that he has claimed five victims so far, and it is hard to believe that there will not be more.

Like the so called Yorkshire Ripper before him, his victims are young females who are working as prostitutes.

The fact that the victims are prostitutes has to be reported, but it is not the main story. The main story is that there is a serial killer on the loose. The continual emphasis on the life style of the victims is demeaning but, more worryingly, is seen by some as mitigating the offence.

It is, I know, difficult to achieve a balance here. The media must report fairly and accurately and the police have a duty to warn other young woman working as prostitutes that there are even more dangers than usual.

It may be difficult to draw lines but it is not difficult to decide on which side of the line press coverage falls.

The foreign press, which is giving the case wide coverage, is frequently on the wrong side of the line. Take the Washington Post.

Race against time in UK prostitute murder hunt

What does the use of the word “prostitute” lend to this headline other than seedy sensationalism? Why not substitute “young women” or even “vulnerable young women”? Or just omit it all together.

If these women were all chartered accountants or shop assistants or train drivers, would such a fuss be made about their occupation? I think not.

We are moving into deeply sexist territory. How close are we to saying that prostitutes deserve to be murdered, or that women who get drunk, or wear fashionable clothes deserve to get raped? The boundaries between risk, foolishness and 'just desserts' become blurred.

I was much more impressed this morning by the coverage in The Times. Yes, the article mentions what these girls were doing to earn a living, but the headline is about “victims” and the journalists have taken the time to find out about the people behind the headlines. And get some information from family and friends. For, whatever they do in the evening, these girls do have parents and children, family and friends.

"…she was my beautiful niece, she was loved by all our family. I just can’t understand why some evil person would want to hurt her and her friend. I hope the police catch whoever did this soon."

"Tania, we were grew up together at Gusford in the same class for 6 years... I'll always remember the countless laughs we had ... "

"I knew Tania when we were younger, and we had some good times. I remember making up dances with her and one memory that will always stay was .. . setting up a tent in her back garden one summer to stay in overnight. She was a beautiful girl, very smiley and wouldn't hurt anyone."

"Gemma was truly a special and beautiful person inside and out. She will be missed by everyone who knew her. She brought a lot of joy and happiness to my life which I will never forget, ever. My love goes out to her family in this time of pain and heartache. xx"

"I taught Gemma at high school. She was a very normal, very ordinary girl with lots of friends — who was a very special daughter to her family. We can now only pray that justice will be done. This has been shocking news for all of us: but let us not forget that it is also a very personal, very private and tragic loss for her family. My heartfelt condolences to them all. "

That’s better.

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I have always enjoyed Matthew Parris's writing; possibly because I usually agree with him! He is one of the few remaining positive reasons left for staying loyal to The Times. I was glad to see today (14th December) that once again we are in agreement.


The Ipswich murders: they were women, weren't they?
Matthew Parris


Prostitute is a noun and a useful descriptive term, but is it the right word to use in a headline reporting the death of a woman? “Another prostitute murdered” — yes, she was murdered and she was a prostitute, but she was a woman first, a woman of whom you could have said so many things if you had known her, only one of which was that she worked as a prostitute.

I am not advocating euphemism. Woolly words such as “sex worker” will soon attract the same opprobrium as the terms they replace, and lose their wool. Nor am I suggesting we hide what those women in Suffolk did for a living. It is central to the case, it is what has linked the murders, and in a grisly way it fascinates. Any report should be unsparing and the language honest.

But in the headline, in the opening sentence, couldn’t we at least start by calling a victim what she mainly was: a woman? Some words seem to push a person away, to make them other than us. We ignore our common humanity when in the very naming of a person we launch straight into a descriptive term drawing attention to difference and inviting shame. (The Times)

Medical research at its best

I am grateful to a reader who has sent me detailed information about scientific research into Celadrin which we discussed in "A cure for arthritis?" below.

The main research paper is here:

Journal of Strength and Conditioning Research, 2005, 19(2), 475–480

and is written by the following splendid men and women.

WILLIAM J. KRAEMER,1 NICHOLAS A. RATAMESS,2 CARL M. MARESH,1 JEFFREY A. ANDERSON,1 JEFF S. VOLEK,1 DAVID P. TIBERIO,1 MICHAEL E. JOYCE,1 BARRY N. MESSINGER,1 DUNCAN N. FRENCH,1 MATTHEW J. SHARMAN,1 MARTYN R. RUBIN,1 ANA L. GO´ MEZ,1 RICARDO SILVESTRE,1 AND ROBERT L. HESSLINK JR3

1Human Performance Laboratory, Department of Kinesiology and Department of Physiology and Neurobiology and School of Medicine, University of Connecticut, Storrs, Connecticut 06269; 2Department of Health and Exercise Science, The College of New Jersey, Ewing, New Jersey 08628; 3Imagenetix, Inc., San Diego, California 92128.

Our data provide further support for the use of a topical cream consisting of a blend of cetylated fatty acids and menthol in the treatment of individuals with arthritis of the knee, elbow, and wrist. In the present investigation, we reported significant improvements in stair-climbing ability, ‘‘up-and-go’’ performance, balance, and range of motion; reductions in pain in individuals with knee OA; significant improvements in dynamic and isometric local muscular endurance; and a reduction in pain in individuals with severe pain in the elbow and wrist. The changes were similar to what we had previously noted. In addition, the use of such topical treatments may allow individuals to better exercise, thereby helping them improve their health and fitness. Strength and conditioning professionals who work with such populations may find that it enhances workout capabilities.

Excellent. I take it all back. This cream is clearly wonderful. I am going to rush out now, buy some and rub it on grandma.

But, just a minute, what is that small print at the end of the article?

Acknowledgments
This study was supported in part by a grant from Imagenetix, Inc., San Diego, CA. Coauthor Dr. Robert Hesslink Jr is a research consultant for Imagenetix, Inc

Dr Crippen has never heard of Imagenetix Inc. Who are they, I wonder? An arthritis research charity, maybe?

Here is their website. They say they are leaders in Bioceutical Innovation. And what is their main product? It is

Celadrin®- Imagenetix’s Lead Natural Based Product

Ha ha ha ha ha ha ha ha ha ha ha!

And those of you familiar with Mrs Crippen's Vagina said I was cynical.


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Comments under the original article please, here

A Cure for Arthritis?

Douglas and Phyllis are an elderly couple who both suffer from moderately severe osteoarthritis. Their pain is moderately well controlled, but these days there is an expectation that all people are entitled to be permanently pain free. Douglas and Phyllis are not pain free.

Their niece has drawn their attention to a new drug that cures arthritis. They wonder if I have heard of it.

Introducing Celadrex, a new Arthritis Pain relief cream using the all-natural proprietary ingredient Celadrin. Why suffer stiff joints or chronic arthritis pain when one topical application of Celadrex works within 30 minutes? Enjoy everything life has to offer without the pain and hassle. Click a link below for more information on how Celadrex works for you.

Pain free in the UK

Pain free in the USA

Shit. How did I miss this? Look at that happy young family in the UK. Look at that young, good looking American father and daughter. They do not have arthritis or, if they did, it is now cured.

I cannot prescribe Celadrex, because the prescribing authorities have not heard the good news yet either. And gosh, its name is so similar to Celebrex, that drug that really did help arthritis but turned out to cause an increased risk of cardiac problems. I wonder if that similarity is a co-incidence? Perhaps I am being too cynical. But never mind all that. Douglas and Phyllis can pay out £35.98 a month, and their arthritis will be cured. And then they can gambol through the forest with their family, or take a trip to San Fancisco.

That is how Douglas and Phyllis see it.

It is not true. The advert does not say it can cure arthritis. It strongly suggests it can make arthritis pain free even though the academic paper it quotes does not say that.

Celadrex may be the best new drug in the world. But I have not heard of it. And I cannot find any hard evidence to justify the claims made in the advert.

"While this is a promising body of research, it is far from definitive. Current advertising claims for cetylated fatty acids go far beyond the existing evidence." (source)

All this is beyond Douglas and Phyllis. They are not naïve. They are not stupid. But, like may people, particularly older ones, they have a degree of trust in the written word.

Can you blame them?

Grand Rounds 3 (12)

Anxiety, Addiction and Depression Treatments is the public voice of Treatment Online.

Here we strive to report and comment on the most important news in medication, treatment, psychotherapy, clinical research and other areas of mental health. We chose the title Anxiety, Addiction and Depression Treatments to represent the broad range of topics that peak our interest. Beside new issues in bipolar disorder, PTSD or drug addiction you will also find pertinent discussions on parenting, healthy eating, therapy strategies and all manners of health care, especially as they relate to mental health.

This week, Anxiety, Addiction and Depression Treatments is hosting Grand Rounds, the pick of the week’s medical blogging from around the world. Take a look here.

Sacking the workers

The Rt Hon Patricia Hewitt

"I'll tell you what happens with impossible promises. You start with a far-fetched series of resolutions, and these are then pickled into a rigid dogma, a code, and you go through the years sticking to that, misplaced, outdated, irrelevant to the real needs, and you end in the grotesque chaos of a Labour government, a Labour government, closing hospitals, sacking doctors and scuttling round the country handing out redundancy notices to its own health care workers. I tell you - and you'll listen - you can't play politics with people's jobs and people's homes and people's services." (adapted from the Leader of the Labour Party, Neil Kinnock, 1985)

The NHS is moving into the world of make-believe.

The government is to tell the NHS in England it must achieve a £250m surplus next year. (BBC)

This is nonsense. The NHS is a state owned monopoly providing a service with no front-end charge. The service may be deemed to be efficient or inefficient but the concept of profit and loss is illusory. The “profit and loss” game can only be played in terms of arbitrary budgets set by the government. We spend less of our GDP on health care than the USA and many European countries. So the quality of care is poorer.

For British health care, “profit and loss” is a straw man.

The government has moved into bunker mentality. Sir Nigel was blamed and sacked. The GPs are blamed for earning too much money. The hospital doctors are blamed for laziness and for earning too much money. The nurse are…well, even this government would not dare blame the nurses, but it is still sacking them. The hospitals are being closed. Doctors are on the dole and leaving the country.

I cannot improve on this excellent analysis from Burning our Money:

"A nightmare from Alice in Wonderland" is how one hospital finance director describes the orders from the DoH Bunker. And no amount of screaming into field telephones by the Commissar and her senior clerk can alter the grim reality of life on the frontline.

All along the line, treatments are being postponed; training scrapped, elderly male and female patients forced to bed-share, and God knows what other low-budget medieval practices reintroduced.

Because the money's run out. Finito."

Essential reading. Look at it now.

The NHS ended the last financial year £512m in deficit, but Health Secretary Patricia Hewitt has pledged to balance the books this year. And she will keep closing hospitals and sacking health workers until she has crossed the arbitrary profit line that she has drawn in the sand.

It is Derek Hatton all over again.

The BritMeds 2006 (3)

Even more nominations this week. First of all, seasons greetings from the most important doctor in the UK. Then, once again, it is back to Gordon Brown, the Lying Tosser who has just introduced another £2.2 billion of additional taxes. At the same time, HospitalPhoenix reveals that the medical research budget is being cut.

NHS DIRECT has found a new way to cut the cost of advising patients. Oh dear!

Whistle blowers in the NHS live dangerously. This site names the names.

The publishers were complimentary about this patient’s breast cancer journal, but said that she “needed a hook to sell it, like being a celebrity.” She is not Kylie Minogue, so she went back to the drawing board and rewrote the journal as a series of haiku. Brilliant. [I have already had a lot of emails about the haiku. They have now been published. £4 plus postage. Email Anna at madick@supanet.com]

“Will Labour's policies kill or cure the NHS? A recurring feature of NHS policy making is the apparent failure to appreciate that system reforms have unintended consequences. Policy documents are filled with statements about desirable outcomes, but it would be more useful to consider the likely consequences, however undesirable they might appear”

I am increasingly fascinated by Adrenalin Rush – an unusual and captivating writer.

How does NICE respond to ME and how do ME sufferers respond to NICE? You need to know. You may not like it, but you need to know.

Sophie had ME. She died. Read her story here.

How did this go on for so long before it got to the GMC?

Tales from Tragedy Towers – Life at NHS DIRECT. I hope this guy keeps writing.

The prize for the most sexist post of the week goes here. And on that topic, Dr Crippen’s mates at the Centre for Nursing Advocacy picked up on last week’s BritMed post on the appalling article in The Sun.

Look half way down the page here to find that doctors who do not wash their hands kill more people than drunk drivers.

It is not easy being a junior hospital doctor. Taking exams is stressful, but not as stressful as meeting the putative in-laws.

A student nurse is depressed when she comes across more nurses who are too posh to wash.

The clever ones out there will know all about Devic’s Disease. The rest of you should ask Gayle.

Trixie says the smokers have funded the NHS for sixty years and now bemoans the fact that from next year the only safe place to smoke will be in prison.

“Forgive me if my typing is not so accurate today: I am combining writing this post with smoking a delightful cigarette. In the office. I felt that I had better make the most of it before that malevolent witch Patsy Hewitt makes it illegal to do so.”

Doctors beware of people like Trixie. It cost this anaesthetist a lot of money when he told a patient to stop smoking.

Oddly enough, some British doctors lead normal lives. Well, nearly normal.

Meanwhile, Cancergiggles, “an idiot’s guide to accepting and living with, laughing at and dying from cancer” has got Irritable Bastard Syndrome.

A worrying report from the “cock-up” book about a GP who forgot to measure blood pressure.

Dr Pete Davies puts another side of the confidentiality arguments. He suggests medical confidentiality is a sham.

We need a new concept to replace confidentiality. It is not even an entirely good concept. There are evil people who have confessed all to their priests but who have not apologised or made reparation of any sort to their victims. Should we really praise the priest’s confidentiality when we know that others could benefit from knowing what they know or that harm could be prevented if the priest broke confidentiality? Medicine sits at the hub of an information network and as doctors we are now as much information handlers as practitioners and we need to be conscious and careful about what bits of information we send out along which spoke. But can we please stop pretending that we are “confidential”?

Have a look at Lee’s experience of healthcare in Scotland. You can say it is a bit of a rant. You can say it is one sided. But once you have read it, are you proud of the NHS?

A Mental Health nurse struggles with bronchiolitis.

I’ve decided that I am going to stop making predictions about when Evan will be able to come home. Nearly every post I’ve made about his hospital admission I’ve written something like “he might be home tomorrow” and each time it’s been proved wrong. That’s not to say he’s not continuing to get better however, because he is. He doesn’t need the oxygen at all now when he’s awake; but he still struggles to keep his saturation levels up while he’s asleep so technically he’s still on it. He has to be breathing completely independently for 24 hours before he can leave.

A GP's receptionist is suffering:

I hate people who are rude for no reason. This probably stems from being on the receiving end of some really rude people when I worked at a doctor's surgery. The thing that annoyed me the most about them was that they'd treat receptionists (and sometimes nurses) like they were the scum of the earth… a GP receptionist is suffering.

A Scottish MP claims:

Patients complaining of mild depression were increasingly being prescribed anti-depressants, rather than being made aware that "unhappiness is part of the spectrum of human experience, not a medical condition. Inappropriate prescription of medicines by GPs is of particular concern." Some doctors had prescribed anti-depressants on a grand scale, many of them linked with high rates of suicide.

The following from Carmello, yet another EMT. Are they ALL going to start blogging?

I’ve been reading back what I’ve written over the past few days and in a way I’m disgusted. I’ve been rude, obnoxious and generally a wanker. I know I said earlier that this was the end of the subject but its still been playing on my mind quite a bit. Even my Missus said I was being “big-headed”. I was. I know I’ve pissed a fair few people off about this, I would like to properly apologise. Carmello

A medical student on a surgical firm tells the consultant that he is hoping to be a psychiatrist. Nothing much changed there then. And a psychiatrist is fed up with young physicians being rude to her.

Into the lion’s den.

A management consultant who specialises in the NHS has been reading the Britmeds, and asks if he can play too. How much an hour, I wonder?

“I'm an approachable Organisation Development and Change Management consultant who always trys to bring enthusiasm, creativity and purpose to my work”

The proceedings of the Public Accounts Committee are hardly mainstream viewing, but worth a visit when they are analysing the NHS. Labour MP, Sadiq Kahn is becoming more and more disenchanted. "Can you imagine," he asked, "how depressed some of us are, who not long ago argued for putting up taxes to fund the NHS?"

And who is running the NHS?

“Is it me or are the mandarins going to the dogs? Back in the days of Sir Humphry, surely the top brass used to be Oxbridge double-firsts, smooth as silk, and answering tricky questions with Latin aphorisms. Yes I realise they also used to fly us into mountainside regularly, but at least the cabin announcements were polished and reassuring. The new CEO of the NHS- the largest employer in the Western Hemisphere... I'm sorry, no offence... but he comes across as a senior clerk from a local building society somewhere up North. And the lady who runs NHS Professionals... umm how should we put this... possibly used to work at Nails4U in Basildon.”

Full report on the horrors here.

Maybe you need your direct line to Tony Blair, asking him not to privatise the NHS.

Are you in the MDU or the MPS. Are you English, Irish or Scottish? Some very odd goings on for Irish members of the MDU. Very worrying.

What constitutes asthma in a toddler? The patient is confused. So is the asthma nurse but then there is a breath of fresh air.

“The National Health Service isn't, in general, the best provider of treatment for any transgender conditions. There are still too many providers of Health Services who genuinely believe that Transsexuality is a life choice rather than a condition that we are born with”. Full report here.

A US citizen from Chicago checks in with a British GP for his first experience of UK medicine. How did he get on?

Over in the colonies meanwhile, a Brit checks in for some American health care. How did he get on?:

"You'll be happy to know that some things are the same on both sides of the Atlantic so I waited around quite a bit. The main difference was them talking about payment before I had seen a doctor. Obviously at home with the NHS you just go straight into the hospital, but here it is $500 to see the doctor in hospital…"

More trouble in Scotland. Scottish Area Health Boards - not a place of transparency or fairness as patients made to fight for treatment.

How ever much trouble there is, New Labour plods on. People moan about GPs salaries but did you know that the NHS has just blown another £800m on management consultants, redundancies, and slipshod budgeting? Why does no one moan about that?

A mother struggles with the Maudsley approach to anorexia nervosa.

The Government is not just after your private health records for “The Spine”. It is after your children too. Light Blue Touchpaper. It plans to link up most of the public-sector databases that contain information on children.

Alcoholics get poor care in the UK. The social workers seem to be running the agenda. A consultant physician grumbles because he is not allowed to do his job.

A bipolar patient writes:

There is a line between me and the human race
A line so thin I can see right through it
And yet so thick we shall never touch

Back in her archives, a patient explains how to deal with cancer, and how to deal with doctors.

A Moslem GP trainee writes:

If somehow we can collectively highlight the major deficiencies in certain reports and attitudes against Muslims, perhaps things can change and people will realise that we're not all fundamental, face covering bombers!

The Big Opt Out is a whole site dedicated to protecting patient confidentiality. It is all there. Essential reading.

Finally, It is a dangerous time of year for elderly patients with COPD. Support the campaign for CPAP for Santa Claus.

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Any reader wanting to look at a round-up of non-medical blogs should cast a quick eye over Tim Worstall's weekly Britblogs.

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Please send your recommendations for next week’s BritMeds to: thebritmedsATnhsblogdoc.wanadoo.co.uk

Casino Royale

For some light relief on a Saturday, I though I would mention in more detail something that I commented briefly upon in the diary at the end of the week.

My children took me to see Casino Royale a few days ago. I have not been to the cinema to see a James Bond film for years. No time for them at all. The last good one, as far as I am concerned, was “From Russia with love”. Come back Rosa Klebb. All is forgiven.

I thought Casino Royale was brilliant. A “rattling good yarn.” The last half hour was reminiscent of Victor Borge and his teasing false endings but I did not mind. I could have watched it for hours.

One thing baffled me. The film's classification as 12a. In the UK, 12a means that anyone may see it, but children under twelve must be accompanied by an adult. As I said in the diary, I am not a fan of censorship and would not have a problem if films were not censored at all, but if we are going to censor them, or give guidance, how can a film the shows a naked man sitting in a chair with a hole in it having his scrotum beaten by a sadist with a knotted rope be deemed suitable for an eight year old?

Probably, as a Dutch reader points out, because there was no sex in it. Not even a nipple as I recall. Well, that’s a sexist remark, we saw the Bond nipples. Does that count?

I regard the “18” classification as particularly stupid. A seventeen year old could arrange a baby-sitter for her two children, drive her car to the cinema and then be told she is too young to see the film.

I let my children watch anything they want. They seem to self-censor themselves pretty well. Not all parents agree. I remember one mother dropping off her 15 year old daughter saying, “Rosie is not to watch an “18” film unless it is of “exceptional merit.”

What does that mean?

I really do not mind sex of any sort in a film as long as it is not violent or abusive, but I worry about gratuitous violence. The first twenty minutes of Casino Royale was non-stop gratuitous violence, but sanitised, so I suppose that is acceptable. But I must not impose MY boundaries, whatever they may be, on others and I try not to.

I wonder what criteria Rosie’s mother uses to deem an “18” film as being of “exceptional merit”?

The Crippen Diaries (Week 49)

Not quite Tannochbrae

Monday 27th November

First patient in was Jack, an incredibly anxious 14 year old boy with his even more anxious 42 year old mother. Over the weekend, Jack noticed a lump under his right nipple. It is about a centimetre in diameter and slightly tender.

This is pre-pubertal mastitis. It is common. It is entirely benign. Unfortunately, despite the fact that it is common, there does not seem to be much public awareness of it.

This consultation was made very difficult because mother has not heard of pre-pubertal mastitis, and is currently being treated for breast cancer.

I had to reassure Jack and his mother that it was not cancer, re-assure both of them that it would go away and, most of all, address Jack’s biggest fear, that he was (as he put it) “not about to grow boobies”.

++++++++++

A charming 58 year old man presented at the end of last week to one of my partners complaining of excessive thirst. The blood tests came in this morning. He is not diabetic as was feared. Surprisingly, he is in chronic renal failure, with raised sodium, creatinine, and urea, and an eGFR of 23. All these tests, when they happen to have been done for other reasons six months ago, were normal. He denies any problem passing urine. His BP was up a bit, but he felt entirely well apart from the thirst. Examining him he had a huge, huge distended bladder. One of the largest I have ever felt. It is probably a prostate problem stopping the urine getting out of the bladder, putting back pressure on the kidneys and causing the renal problems. He also has a history of heart disease.

All a bit technical but he needed admission. In view of the deranged chemistry, and the history of cardiac problems, I phoned the medical SHO rather than the urology SHO. This was a mistake on my part. But I had a bad experience once (well, the patient had a bad experience) with a patient with similar problems who went up to Casualty. They catheterised him and sent him home. He had to be readmitted the next day with serious renal problems.

The patient and his wife were with me. I spoke to the medical SHO. He was rude and snotty and spoke poor English. I was subjected to a medical viva. Did I know what the potassium was? I did. Did I know the difference between acute and chronic renal failure? I do. Did I know that the fact that his PSA is normal is irrelevant? It is not irrelevant, though not crucial to immediate management. The viva went on and on. The patients were looking embarrassed. Eventually I interrupted and told him that I was not negotiating an admission, I was phoning as a courtesy about a patient who I was sending in whatever he thought.

Hospital doctors sometimes complain that GPs send patients in without phoning first. I do not. My partners do not. But many of my colleagues do, because they are not prepared to be subjected to a medical interrogation by a junior and less experienced colleague.

++++++++++


Tuesday 5th December

Martin is 22 and in his final year at University studying civil engineering. He has ulcerative colitis, which was diagnosed three years ago, but has been quiescent on a small dose of Asacol. Until last week when he presented with a flare up. He did not look or feel particularly ill, but he had been having bloody diarrhoea seven or more times a day, and once or twice at night. I started him on some Prednisolone. When I reviewed him two days later, he was worse, not better. He looked pale and ill, and so I sent him in.

And then a sorry tale. He was kept waiting in A & E for ages. He saw various nurses, but the doctor did not arrived for four hours. The doctor increased his prednisolone and said he could go home. Martin said he felt too unwell to go home. After a few more hours in A & E, by which time it was eleven at night, he was admitted. Having bloody diarrhoea is not much fun. Having bloody diarrhoea in an A & E department, where there are not enough lavatories is less enjoyable. Having bloody diarrhoea on the ward was even worse. A nightmare. The toilets were filthy. There was urine all over the floor in one of them. Martin told the nurses. “Not our job, we will get the cleaners on to it tomorrow.”

During the course of the night, Martin developed severe abdominal pain. He told the nurse who told another nurse who said she would get the doctor. Five hours later – yes, five hours – the orthopaedic house officer arrived. Bone doctor or not, he was coherent and sensible, and provided some analgesia and put Martin on a drip.

Martin was in for two weeks, during which time he saw a doctor on four occasions. A different doctor each time. The final doctor was the consultant, who discharged him.

He is improving. The high dose steroids are working. He is home, feeling dreadful, but relieved to be out of the hospital.

He told me this morning that he would rather die than go back in. It was the urine on the floor of the lavatory that really got to him. He said he had seen cleaner public conveniences in parks. If he gets ill again he is going to go to another hospital.

It is deeply depressing.

++++++++++

I had a senior medical student, Toby, with me today.

In the old days, when we had the more experienced medical students, we would sit them in for a day, and then let them loose with a half a dozen (pre-warned and consented) patients and see how they got on.

Now it is very structured. They come from the medical school with a protocol of what we are to provide. This time the brief was for the student to assess a pregnant woman at home, and then report back to me on the state of her pregnancy, the impact it was having on her family life, how she was managing at home and so on and so forth.

This took a total of two hours, including travelling to and from the patient’s house. Toby did the job brilliantly. I had deliberately picked a patient with some social and other problems, and he picked up on all of them.

But it was pre-arranged, pre-determined, non-threatening, and non-challenging. I do not think it is the best way to do it. The big challenge of general practice is that you do not know what is coming through the door next. Yes, like any other job, much of what does come through is routine but occasionally and without warning, something quite extraordinary will present

The trick is to be awake when it does.

++++++++++


Thursday 7th December

A particularly frustrating day.

I had a letter about Patrick this morning. You will recall him from here. I have been trying to get him assessed by a Consultant Forensic Psychiatrist. Not because I do not know what the problem is. I do. And I know that there is no easy solution. I know also that there is a grave risk that Patrick will one day murder someone. So he should see the psychiatrist. Medicine must not only be done, it must be seen to be done.

I am being stonewalled. The PCT has refused to fund an out-of-area referral to an experienced forensic psychiatrist, but has given me the name of a local doctor who sees patients in this area with forensic problems.

Today I have had a response. From the local “Community Forensic Service”, whatever that means. It certainly does not seem to encompass Patrick seeing someone who is medically qualified. The letter is signed not by a doctor but by a “Community Nurse” and an “Approved Social Worker.”

Let me quote, verbatim, their conclusion.

“Patrick does not meet the criteria for a service from the Community Forensic Team. The case has been closed to the SCATS team.”

On what grounds to they reach that conclucsion. Earlier on in the letter, the nurse and the social worker say, and again I quote verbatim (hence the odd grammar in places):

“The multi-agency professionals had expressed concerns of the significant high risk presented by Patrick based on his assaulting behaviour against his partner. He has very poor impulse control and despite having access to many different interventions provided by the Probation service, SCATS and others, Patrick continues with his assaulting behaviours. The Police reported that they had dealt with 30 crimes reports this year. In the past he has been alleged to have punched, kicked, thrown objects, attempted to strangle his partner. We believe that Patrick will one day cause serious harm to his partner due to his poor impulse control.”

I want this man to see a Consultant Forensic Psychiatrist. I do not think that is unreasonable. So today I have again written to the PCT asking for funding to refer him to one out of the area. And I have written to the community nurse and the approved social worker asking them what a patient has to do to meet the “criteria for a service from the Community Forensic Team”.

++++++++++

Two weeks ago, I arranged for Betty, an elderly lady, to be admitted to the local hospice for respite care. She has a lot of medical problems, in particularly leukaemia, heart failure and early dementia. She is not in imminent danger of dying, but Tom, her husband and the main carer, is on his knees. A week in the hospice is ideal, but brings with it one problem. The week comes to an end, and she has to come home. That will be on Monday, and I have been worrying about it, as has Tom. He cannot afford a private nursing home, there are no NHS nursing home beds and hospital would be inappropriate even if they would admit her, which they would not.

And then, today, I had a very upbeat phone call from one of the hospice nurse-specialists saying they were referring Betty to the “LCP”. She thought this would be enormously helpful.

I had one of those moments that doctors often have when they meet something new. Do you nod wisely and pretend you know all about it, or do you admit ignorance. I swallowed my pride and took the latter course. This made the nurse-specialist very happy. She explained that the LCP was the Liverpool Care Pathway.

Tom does not want Betty to go to Liverpool, that is for sure, but I presumed from the referral that there would be a local branch.

The Liverpool Care Pathway for the dying patient (LCP) was developed to transfer the hospice model of care into other care settings. It is a multiprofessional document that provides an evidence-based framework for the dying phase. It provides guidance on the different aspects of care required including comfort measures, anticipatory prescribing of medication, and discontinuation of inappropriate interventions. Additionally, psychological and spiritual care and family support is included.

Oh dear.

The LCP is a key recommendation in the NICE guidelines for supportive and palliative care. It is an NHS Beacon project.

A Beacon project. Oh dear, oh dear.

"the care of the dying must improve to the level of the best" The National Cancer plan September 2000

I go along with that.

"Better care for the dying should become a touchstone for success in modernising the NHS" Sir Nigel Crisp

Hasn’t Sir Nigel been sacked?

If you want to join the LCP:

We strongly recommend that you:
• set up a steering group or working party
• link directly with your modernisation teams
• have the project integrated with your local Specialist Palliative Care Service and Palliative Care Cancer Network Group
• ensure that the LCP Implementer/Facilitator continues to achieve learning outcomes via the LCP Advanced Study Day

Steering groups, working parties, modernisation teams, implementers and facilitators…Oh! Joy.

Betty and Tom are in the commuity, so I looked particularly at

“Care of the dying pathway (LCP) Community”

as seen here. It runs to seventeen pages, so it is a long pathway. This must be a voyage, not a journey. Take a look at it yourself.

Instructions for use:

1. All goals are in heavy typeface. Interventions, which act as prompts to support the goals, are in normal type.

2. The palliative care guidelines are printed on the pages at the end of the pathway. Please make reference as necessary.

3. If you have any problems regarding the pathway contact the Palliative Care Team. Practitioners are free to exercise their own professional judgement, however, any alteration to the practice identified within this LCP must be noted as a variance on the sheet at the back of the pathway.

Criteria for use of the LCP

All possible reversible causes for current condition have been considered:
The multi-professional team has agreed that the patient is dying, and two of the following may apply: -

The patient is bedbound 􀂆 Semi-comatose 􀂆
Only able to take sips of fluids 􀂆 No longer able to take tablets

It is full of wonderful advice, but too long to print in full. There is a five page tick-sheet protocol which includes:

Psychological/Insight support

Family/other

Goal: Family/other are prepared for the patient’s
imminent death with the aim of achieving peace of mind
and acceptance
• Check understanding of nominated family/others / younger
adults / children
• Check understanding of other family/others not present at
initial assessment
• Ensure recognition that patient is dying & of the measures
taken to maintain comfort
• Chaplaincy Team support offered
Religious/Spiritual support
Goal: Appropriate religious/spiritual support has been
given
• Patient/other may be anxious for self/others
• Support of Chaplaincy Team may be helpful
• Consider cultural needs

If I had to fill this form in, tick all the boxes, note all the variances every time I have to care for a dying patient, I would not have time left to see the patient. And please, please tell me how you achieve peace of mind about the imminent death of a close family member.

You read through this document and you feel mean criticising it.

It is the Vera Lynne of terminal care. The media will love it. It is the modern Project 2000 approach to nursing care. Do not worry about the patient. Follow the protocol and tick the boxes. It epitomises the New Labour approach to a health care problem. Cover up the abscence of resources with a protocol laden glossy brochure.

The hospice have referred Betty to the Liverpool Care Pathway. And they will visit once a day for a few minutes, tick all the boxes and phone me to say that Tom is tired. And Tom will continue to wipe Betty’s arse, and wash her soiled shitty underwear. The one thing that would help, and the one thing that the NHS cannot provide, and one of the many things that Macmillan nurses do not do, is hands on nursing care.

As long as all the boxes are ticked though, the outcome will be deemed to be successful.

+++++++++++


Friday 8th November

One of those rare, unpredictable quiet days. No doctors on holiday. Possibly everyone is Christmas shopping. We all had gaps. Catch up time. Some QoF work. And some gossip. Wonderful!

++++++++++

I saw five patients today who are on statins, and they all had questions about safety, and memory loss and the "new statin" that has turned out to be dangerous. I worry about this more and more. I ask myself, how much do I REALLY know about the efficacy and safety of these drugs? I am merely the victim of the latest reseach paper.

Pfizer’s next big drug for heart disease (torcetrapib which was slated to replace Lipitor) has bombed in trials, causing sufficient deaths that the trials have been ended early and development has been stopped. This is obviously dreadful news for Pfizer, and I assume that the stock will be well done on Monday. But that’s how the pharma business is supposed to work—big bets on new blockbusters may not pan out, but others will do so. (Matthew Holt)

Statins are big business. Very big business.

An academic colleague in the Southern Hemisphere sends me regular updates on the dangers of statins. He draws my attention to this:

Frank Cooper - author of "Cholesterol and the French Paradox".

France is a nation of 62,000,000 people who have been eating foods high in saturated fats and cholesterol for a long time, and yet they enjoy very low levels of heart disease. Frank will explain how the French eat 3 times as much fat and cholesterol as Americans yet have 1/3 the deaths from heart attacks. (Source)

Popular medicine, maybe. But can someone explain it to me? Then I can explain it to my patients.

+++++++++

Since it was so quiet, apropos of nothing, I took my four children to see Casino Royale last night. Loved it. As did they. Rattling good yarn. But one thing baffled me. The film’s classification. In the UK, it is a 12a. That means that anyone may see it, but children under twelve must be accompanied by an adult. I am not a fan of censorship and would not have a problem if films were not censored at all, but if we are going to censor them, or give guidance, how can a film the shows a naked man sitting in a chair with a hole in it having his scrotum beaten by a sadist with a knotted rope be deemed suitable for an eight year old?


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

The Abortion Charade - and the Joffe Bill

If you trawl through medical records dating back to the early seventies, when David Steel’s Abortion Act was in its infancy, you find much medical cud-chewing about whether it was appropriate to perform abortions on young girls. There were even psychiatric referrals made to ascertain if the “continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the…mental health of the patient." A lot of doctors put a lot of thought into whether it was legally appropriate to sign the form.

At much the same time, Mr Crippen, then a law student, was having tutorials with, to name names, a young law tutor called John Finnis. The Finnis position on the Abortion Act was straightforward. “Gentleman, this legalises abortion on demand.”

How we argued.

Take a look at the Abortion Act Form that two doctors must sign to autorise an abortion.

Click to enlarge

This form is now stamped and signed without thought, without analysis, and without hesitation. The simple fact is that, statistically, it is safer to have an abortion that it is to carry a baby to term. So that is the end of the argument, and John Finnis is now an internationally eminent Professor of Law.

Professor John Finnis

David Steel is a wise man and may quietly have realised what he was unleashing. The Parliament that enacted his bill did not. Nor did the medical profession. And nor, most certainly, did the general public.

Now there is a move to remove the requirement that two doctors should sign the form. It is even suggested that nurses should be allowed to sign. Dr Crippen has no problem with this. I dislike abortions, but I dislike the alternative more. Given that we do have abortion on demand, why bother to go through this charade of pretending that we do not; of pretending that only some “particularly deserving” women should be allowed to have an abortion?

We have discussed abortion, and Roe v Wade, on many occasions. The point I would like to make today could perhaps be best summarised as “the thin edge of the wedge”. I make the point in reference to the Joffe Bill.

Read it in its entirety if you have time.

So many precautions, so many conditions, so many safeguards. A law tutor’s dream. You can run rings round it. You can postulate an endless number of situations which circumvent the intention of the Bill or, frankly, turn it into burlesque.

Burlesque or not, there is a danger. Pass legislation like this and, within a few years, when the furore has died down, you will have licensed wholesale euthanasia on demand. Just like the Abortion Act. And a large number of patients with cancer will be terrified to go near a doctor in case s/he decides that they are at the end of the road. Which, apart from the many moral considerations, is why I believe that no doctor should have anything to do with euthanasia.

If assisted euthanasia is to be allowed, that assistance must not be provided by the medical profession. The Joffe Bill purports to provide guidance, a protocol even; so maybe this is ideal territory for a nurse-specialist.

The “euthanasia nurse specialist.” The mind boggles.

There's a hole in my bucket, dear Liza, dear Liza...

“Choice is now a reality in the NHS. Patients have new rights over their own healthcare. These rights will allow patients to choose services which best meet their individual needs and preferences.” (Commissar Patricia Hewitt said here)

Dr Crippen has on several occasions (see The Crimbleshank Choice) mentioned the brazen fraud of the “Choose and Book” (CAB) System. Remember, until 1997 Dr Crippen could refer his patients to any hospital in the country. This freedom was removed by New Labour.

More recently we have seen the “introduction” of “choice”. It is only giving back a tiny bit of all that was taken away nearly ten years ago, but Patricia Hewitt is hoping you will forget that. GPs have been given a financial incentive to offer patients a choice of up to four hospitals. The freedom is largely illusory as the four hospitals are pre-selected by the PCT, and CAB does not apply to all speciaities and in particular not to the specialities where we would most like some choice, such as psychiatry.

Suppose Dr Crippen has an elderly patient who needs a hip replacement. Before CAB, he would have written to the orthopaedic consultant of his choice. The hospital had a duty to respond and in due course the patient would have been sent an appointment. That no longer happens. Because there is now a “choice” of hospitals, the duty of care has been diluted. If a hospital is under pressure (and they all are) they now deem it reasonable to suggest to the GP that he tries another hospital first.

Dr Crippen has just referred a patient to the local orthopaedic department. She received the standard letter which requires patients to call the appointments office, give their personal details and a password, and then an appointment is allocated. It did not happen. The patient phoned the hospital but was told that “the hospital is allocated a certain number of appointments in a twelve week period, and when they are all gone you have to be referred to somewhere else. There are no appointments left at present. Please go back to your doctor to be referred to another hospital".

Does CAB cater for patients whose requests for appointments are rejected? Of course it does. There is a system. A system that is so simple that it has been reduced to a one page protocol. Or is it a pathway?

Click to enlarge

Do not worry if you have difficulty reading the protocol. Legibility does not aid comprehension. So, when we have interpreted and understood the protocol, and tried again, and still failed, off we go to the second choice hospital. They probably have their own protocol too. If they have exceeded their twelve week allowance, we go to the third hospital. Then the fourth. And if they are full, I suppose we go back to the beginning. “There’s a hole in my bucket, dear Liza, dear Liza…”

Dr Crippen would ask you in particular to note the first sentence at the top of the protocol.

When a Service Provider rejects a referral, ‘clinical responsibility’ is retained by the referring practice.

In other words, when the patient is fobbed off, when he comes up against another stealth barrier to health care, when “free entry” to the NHS does not exist, it is the GP’s fault.

Diary Archive 2008

What do you want to do when you grow up...

January (1) More on schizophrenia
January (2) Unstable angina and protocols
January (3) Tucking shirts into underpants, Benefit scams
January (4) DCFS, Chairman Mao and certificates
January (5) Super specialists and silly letters

The Prime Minister is listening

It is good to know that we can speak directly to the Prime Minister via the E-petition web-site .

An interesting petition has just been started, a petition that is worth signing.

After all the extra money that has been given to the NHS over the last few years, why are hospitals closing and jobs being cut? The Prime Minister admitted it is happening at Question Time last week. So we are petitioning the Prime Minister to save the NHS - it's services and staff - as he promised to in 1997.

We the undersigned petition the Prime Minister to Save the NHS. Reduce unnecessary bureaucracy, stop the closures and keep all nurses, doctors and midwives threatened with redundancy.

Dr Crippen supports that. As, I should think, does most of the population.

The second year

Today marks the start of NHS BLOG DOCTOR’s second year.

I posted the first article on 4th December 2005 expecting very little. I put the first hit counter on three days later, and since then 376,275 readers have visited. I think Site Metre may exaggerate a little, but everyone else uses it, so it is the most useful yardstick.

It has been an extraordinary year. One to two hours a day, most days. Strangely addictive, and rewarding. I have learnt a lot, argued a lot, had some tantrums and some great laughs. It is wonderfully de-stressing.

I have made a lot of friends and maybe an enemy or two. Always remember that though Dr Crippen was born out of frustration he remains totally committed to the ethic of the NHS – not the “free at the point of entry” nonsense, but the concept of a decent standard of health care for all, independent of means.

It saddens me that that no longer exists. All we have is a government that pretends it exists.

Do I have a “favourite” article? I am not sure. Schizophrenia is probably the one that means the most to me. The photograph in this article is the one that made me laugh the most. Sorry girls.

Thank you to all who have taken the time to visit, to read and, most of all, to comment.

Happy New Year.

Grand Rounds, Volume 3, Number 11

Emily DeVoto, Ph.D., is an independent health care consultant, epidemiologist, and journalism groupie. She is exploring ways to promote, via the Internet, the use of evidence to improve health care and health journalism. Suggestions and co-conspirators always welcome.

Emily is this week’s editor of Grand Rounds

Protect the Airway tells a compelling story about saving a cancer patient from an overdose of pain meds, and rising above judgment to give her the care she needed in while treating her like a human being. It marries in well with Dr Crippen's post on "Cancer makes you mad".

This, and many other articles, from this week's pick of medical blogs from around the world.

Taste and discrimination

Dr. Manny Alvarez, Health News Managing Editor, Foxnews.com

A short note to mention Fox News in the USA and, in particular, Dr Manny Alvarez who says:

Today we begin a new series, introducing some of the most useful and informative health-related weblogs. Here's a sampling of 10 health blogs to start you on your path to learning more about taking care of your health.

Clearly a physician of taste and discrimination. Thank you, Dr Alvarez.

We want information, information, information...

Dr Crippen, and many other medical writers, have been warning patients for over a year of the dangers of the government insistence that all private medical records should be on the government central computer, eerily known as "The Spine".

Doctors are now being asked to supply the names and addresses of patients who have “genuine” reasons for not wishing their records to be stored on the government’s centralised computer. These recalcitrant trouble-makers will then be rounded up and taken to a secret location in North Wales for “retraining”.

Do not be silly, Dr Crippen. This is not Stalinist Russia. This will not happen. For, you see, there are no genuine reasons. The medical commissars want...

...the names and addresses of objectors in order to write to them to tell them that their request would not be granted because their reasons were not "genuine".

Probably not worth the cost of the stamp, then.

Patients will be ignored over privacy of records
Beezy Marsh, Health Correspondent, Sunday Telegraph
Last Updated: 1:33am GMT 04/12/2006

The Government is to reject the objections of any patients who do not want their medical records on its new centralised computer system, The Sunday Telegraph has learnt. Doctors and experts on computer privacy warned that the Department of Health is prepared to ride roughshod over patients' wishes, despite concerns that by doing so it may breach privacy safeguards in the Data Protection Act and the Human Rights Act.

More than 60 per cent of GPs fear that the £20 million NHS computerisation project, which has been beset by difficulties and is over budget, will be vulnerable to hackers, meaning that sensitive details on up to 50 million patients could be leaked

Yesterday, it became clear that Sir Liam wanted the names and addresses of objectors in order to write to them to tell them that their request would not be granted because their reasons were not "genuine". (Telegraph)

This is the most extraordinary invasion of privacy, of personal freedom that Dr Crippen has ever encountered outside a Nazi or Stalinist regime. Leaving aside all the schoolboy hackers who will access your records, do you really want the police to know your private medical history? Do you want the civil service to know it?

You caught gonorrhoea twenty years ago when you were a student. When you were a teenager you were ambivalent about your sexuality and had some psychotherapy. You were a bed-wetter until you were thirteen. You are having treatment for impotence. You have anal warts. You went to Bangkok as a sex tourist and caught an STD and your partner does not know about it. Tony Blair knows though but do not worry, he will not tell.

It is all on your medical records.

Do you really want Tony Blair to be able to access all this?

Or is Dr Crippen being paraonoid again. Re-assure me. Tell me that this information, though on a central computer, will be secure. Convince me that the government will not be able to access it if they deem it necessary.

The BritMeds 2006 (2)

An even larger crop of recommendations for this week’s BritMeds, so let’s get straight in with some controversy. Who is the bigger shit? Guido or Gordon? Cystic Fibrosis is much in the news.

The chancellor's family must now make the emotional journey that so many of us have made before him. It's not an easy road, but it does bring its own rewards. (The Guardian)

Guido makes an appallingly unpleasant suggestion about Gordon Brown already pursuing the “rewards”. Do you believe it? Dr Crippen does, but he is a cynic.

On a lighter note, please listen to this. Concentrate. There will be, as Tom Lehrer might have said, a short test on it in ten minutes.

After reading this in The “soar-away, sizzling” Sun, Dr Crippen is thinking of signing up with the Center for Nursing Advocacy.

The Immigration and Nationality Directorate meets the Royal Manchester Children’s Hospital. You can feel both proud and ashamed of your country when you read of an immigrant father’s desperate struggle to get treatment for his daughter’s leukaemia. Kezia's Story should be read from beginning (How it all started) to the end. And Dr Crippen wants everyone who reads it to leave a message of support. Let’s see how many we can get.

Tim Worstall finds that Patricia “has got a little list” – and it sounds like they’d “none of them be missed.” Tell your GP that you do not want your medical details put on the government computer and you may find some Polonium 210 in your Weetabix.

Dr Crippen is worried about Emily and her new baby. Emily reports she has already "felt the claw of the health visitor.” What can she mean?

Judging by their language, I begin to suspect that Dr Rant is related to the DK. Dr Rant says Lord Warner is talking shite. It is said Shakespeare used 170,00 words in his writing and that at least a tenth of these had never been used before. The DK uses and re-uses about thirty words, all off them unprintable, to describe the GP contract.

The most depressing thing about the Government PR attempt to denigrate GPs by accusing them of dishonesty is that people believe the propaganda, as seen by this report in the Guardian from Helene Mullholand. We can't win. And Helene, the reason that many GPs are taking early retirement is nothing to do with money. It is to do with low morale. It is to do with being criticised by the government and the press, day in and day out, for doing work that we were asked to do. It grinds you down.

And to borrow one of DKs thirty words, what the fuck are we doing to our young doctors in this country? WHAT ARE WE DOING? Spend eleven years training, five of those years being paid peanuts, and then the NHS dispenses with you at short notice, without warning. It has just happened to HospitalPhoenix. Take a look. Can anyone give a good reason why he should stay in medicine in the UK?

Dr Crippen has to increase his medication when he reads of a theatre luvvie trying to get a ventolin inhaler from a hospital. The triage nurse divides patients into “major, minors and trivial beyond belief”

The blame culture is in full swing. A young girl dies tragically of an epileptic attack. Let’s blame the ambulance service this time. Makes a change from blaming the doctors.

Pharmagossip likens Big Pharma to a dinosaur. Hmm. Dinosaurs were not rich, and Big Pharma is not about to die out.

How vigorously should we treat a frail ninety year old patient? Dr Crippen does not have any answers either.

Wat Tyler says:

The arts establishment are congratulating themselves that attendances to art galleries and museums have increased by 30 million since admission charges were abolished five years ago. Well, what do you know- you make something free at the point of use, and more people use it. What's that supposed to prove?

Is there a lesson for the NHS?

How many GPs know what an MUR is? It is the Medicine Use Review. Oh! That! You know, those flimsy bits of paper that many GPs file unread in the green receptacle under the desk. Should we take more notice? The person who compiles them thinks so.

What is happening to medical training in the country? Junior hospital doctors are not getting enough experience on the wards and now, would you believe it, they are being encouraged to have a three month break in a monastry.

Merys has only just started at medical school but is already writing “You know you have been at university too long when…..”

Battling anorexia is similar in many ways to battling other diseases...there are losses and their are gains...even when something looks licked, it can resurface and wreak havoc.

Dear God, Left brain/right brain reports:

A Bronx man overwhelmed by what he called the ‘burden’ of his 12-year-old son’s autism killed the boy Wednesday morning by slashing his throat….(Full story here)

We all slag of NHS administrators, don’t we. They are a soft target. They have to defend the status quo. And they have to reapply for their own jobs. Not much fun in that.

A greedy doctor looking for job satisfaction AND life satisfaction is worrying about gambling addiction.

Do not worry. Dr Crippen has not let the spammers in, but would you like some:

“Fast formula Horny Goat Weed Tablets”

As marketed by the once respectable Dr Gillian McKeith. Black Triangle reports that she is in trouble. Dear oh dear, Gillian!

A man with a corneal transplant tries to battle his way through the NHS bureaucracy.

From Russia with rohypnol. Why are the social workers on my CMHT so bloody weird, asks Spiritof76. He is such a dear.

And then a medical student is too fat to have an ultrasound.

When asked "Have we lost Faith?” , who replied, "Most certainly not ; but we have transferred it from God to the General Medical Council." Find out here.

Is this the funniest medical blog in the UK? Written by Suman, an anaesthetist? He sure knows how to cut through the crap of nursing bureaucracy.

I've just been to see an ENT patient on the ward:
"Can't you take him to ITU?" said his doctor. "We can't look after him here; the nurses can't see him from their desk."
Sadly, she was entirely serious. I moved the desk. Problem solved.

I hardly dare mention his story about Midget Porn.

EMT called to little old lady who has had a fall.

We got her onto our trolley and took her out to the ambulance, where we did all the usual checks. The alarm bells started ringing when we took her pulse. It was 31. They were ringing loudly by the time we took her BP, which was very low…my crewmate took bloods and started a bag of fluid to try to raise her blood pressure, and gave her a drug to speed up her heart rate. It only raised the pulse by 10 beats per minute, so we "blued" her in. (full story)

Hmmmm. a fluid load for complete heart block. And I wonder what the drug was. And the diagnosis.

Asthma is an ever increasing problem. Now it seems we may be able to cure it by eating hookworms. Honestly.

And finally, two lots of good news.

Out in the colonies, Dr Dork is alive and well and lurking around the blogosphere. Let us hope he soon puts virtual pen to virtual paper.

Back at home, SHP has reappeared:

"So Lazarus arises, a little embarassed to find her blogging holiday has caused so much concern. Thank you for the comments, e-mails, and queries as to my whereabouts on blogs and doctors.net.uk. I am alive, hurrah.

A little time was needed away from the blog. Away from a written reminder of how much I hate about my work. Life has needed some serious contending with recently, and blogging has not been at the top of my To Do list. I have not, contrary to appearances, been depressed. I thought I might be heading that way for a while. I still might be; it can be very difficult to tell until you actually get there. But for now, I am not clinically depressed. What I have been is utterly miserable. Utterly miserable is what a lot of people mistake for depression, but they are not the same thing. God, I should know."

"I am not clinically depressed. What I have been is utterly miserable." There is a big difference, as I argued only yesterday.

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Any reader wanting to look at a round-up of non-medical blogs should cast a quick eye over Tim Worstall's weekly Britblogs.

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Please send your recommendations for next week’s BritMeds to: thebritmedsATnhsblogdoc.wanadoo.co.uk

Cancer makes you mad

More sententious crap has just arrived from the hospice movement.

Now do not get Dr Crippen wrong. The care of the dying patient is one of the most important jobs in medicine, and the late, great Dame Cicely Saunders was one of the giants of 20th Century medicine.

“You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but to live until you die.”
(Dame Cicely Saunders)

I cannot improve on that.

I put my views in the post on "Stealing death from life” :

The medical side of terminal care, or palliative care as we are supposed to call it now, is not difficult. It is no more difficult than learning to wash your hands before and after examining pregnant women, or before operating on patients. Ignatz Semmelweis devoted most of his life to trying to persuade his gynaecological colleagues to wash their hands. Lister’s work on the prevention of operative sepsis also took years.

Dame Cicely Saunders devoted her life to teaching doctors how to care for the terminally ill. The traditional approach to pain and symptomatic treatment in the dying, as in anyone else, was to use painkillers as a reward for pain. They were not to be given until the patient had suffered for a length of time sufficient to earn the pain relief. Nurses would judge how long that time was, as midwives and some nurses still do. Wait until you are in hospital and need a paracetamol for your headache!

So, pain and symptomatic relief for the terminally ill should be given pre-emptively before the pain and the symptoms come on, and should be given in whatever dose is necessary to relieve the pain and the symptoms.

Now that we know, it is obvious, as is the idea of washing your hands before examining a pregnant woman. Dame Cicely Saunders and Ignatz Semmelweis devoted their lives to such matters. Simple stuff. Like the invention of the wheel. Wish I had thought of it.

The hospice “movement” (why is it a “movement”?) grew up in the sixties. The medical side of the treatment of the dying has been taught to medical students for over a generation. In particular most (not all) GPs are experienced providers of such care. The care is not so good in hospitals where dying patients, particular those who do not have a cancer label on the end of their beds, are often ignored. Long past the point of active treatment but too ill to go home they are parked at the end of the ward with the dense strokes and other bed blockers. Doctors on ward rounds walk by, averting their eyes.

These patients should be in a hospice.

Patients who have no family and live alone need a hospice. If the patient’s family cannot cope they need a hospice. And, it has to be said, if the patient’s GP cannot or will not cope, they need a hospice.

But subject to the availability of a GP who is experienced in the care of the dying, the best place to be is at home. At home with your family. That is how most people feel. They support the hospices but not for themselves. Hospices are for other people. Think about it. Where would you like to be?

The media will not have it. The hospice “movement” is buttressed by a media feeding frenzy. The general public likes to buy into hospices and Macmillan nurses not because they know much about them but because they are frightened of cancer. Supporting hospices is a form of subliminal critical illness insurance.

Just as birth has been removed from life, from the home, now death is being removed from life. Sweep it under the carpet. Tuck granny away in the hospice. It is so much less stressful. If, as and when (and please God it does not) the Joffe Patient Killing Bill, sorry, sorry, the “Assisted Dying Bill” is enacted, the hospices will turn into abattoirs. The patients’ “voyage” through their illness will be no more than a short trip. Wait till Gordon Brown gets on to this one.

What has annoyed Dr Crippen today about the hospices?

They have decided that people with cancer are mad. If they meant mad as in “angry” then I would agree. But they do not. They mean mad as in “mad”.

Patients in hospices in the UK and the Republic of Ireland may not be receiving the psychiatric care they need, a study has suggested.

Let us look at this article in more detail.

An estimated 10% of terminally ill cancer patients - who make up the majority of those in hospices - are likely to benefit from psychiatric or psychological treatment. (source)

Agreed. I do not have an exact figure, but this is probably right. 10% of Welsh architects are also likely to benefit from psychological treatment. This is meaningless.

But researchers, based at the Institute of Psychiatry, say improving the care available is particularly important with the possibility of an Assisted Dying Bill. If such a bill did become law, it would increase the need for a reliable assessment of the psychiatric health of the terminally ill, they say.

What does this imply? No euthanasia if you are potty. If you are terminally ill and want the doctor to kill you, that will only be possible if you are not depressed. If your terminal illness is so severe and unpleasant that it has made you depressed then, sorry, death is not an option. We will keep you alive as long as possible. And anyway, if we are in the business of killing sick patients, why do we not kill depressives? Chronic persistent depression, which does not respond to treatment, is far worse than cancer. Why do these poor people have to kill themselves without help?

NHS watchdog NICE says all palliative care services should provide a range of psychiatric help, from basic support from all staff to specialised services for those who need them. The researchers say the study shows there is a clear gap between what NICE recommends and the reality in hospices.

The paragraph would be improved by removing the final “the” in the last sentence and putting the full stop after the word “reality”.

This has made be very cross. I have looked after a very large number of dying patients. Having cancer, or being terminally ill, does not ipso facto cause depression or any other form of madness. Terminally ill patients do not need to have a routine psychiatric assessment and it is patronising and offensive to suggest they do. Macmillan Nurses do not understand this.

The phone goes. Its the Macmillan nurse with some amateur pharmacology:

“He is very down, doctor, do you think he would benefit from an antidepressant.”

Of course he is bloody well “down”. He is about to depart from life. He is about to leave his wife and children. Forever. He knows this. He is not just down. He is seriously pissed off. Dying is an unpleasant business. Best avoided. But, if you have to do it, do not expect it to be “fun” or a clap-happy "learning experience”. It is an absolute bugger and no one, not even Dame Cicely herself, can change that.

Do patients with cancer suffer from severe depression? Of course they do. Occasionally. And when they do, they need help, and support and possibly medication. But this is a rare occurrence. Patients with ingrowing toe nails get depression too, but you are not going to attach a psychiatrist to every chiropody clinic. Are you?

If this trend continues, we will end up imposing a psychiatrist on every patient with cancer. Unnecessary, patronising and offensive.

I hate all the specious psychobabble in which we clothe death and cancer. I hate the battlefield analogies. She “fought” her cancer and “beat” it. Take a look here at all the media battlefield codswallop surrounding Kylie Minogue.

People do not “fight” cancer they “have” it. People are not “dying of cancer” they are living with it and getting on with their lives as long as they possibly can. One of the worst things that patients with cancer have to suffer is the reaction of other people. The averted eyes. The hushed tones.

“Isn’t she brave”.

No, she is not brave. She is just getting on as best she can and trying to live her life as normally as possible. So will you PLEASE look her in the face and stop talking in that odd, inappropriately quiet voice?

And do not ever say to her, “Have you seen the psychiatrist yet?”

The Fat Doctor Changes Shift

The Fat Doctor is one of my absolute favourite American blogs.

Hard to find a more compassionate doctor. She copes with her job as a family doc, her weight, and her own serious medical illness. She is not going to let a minor thing like a stroke interfere with looking after her new baby.

I just got over a stroke. Age 37, physician, mother, wife, friend, daughter, stroke victim. Stroke survivor as they say. This run-in with mortality changed me. Better? Worse? Can't tell yet, but I'm different. I've read about other people who come close to meeting their maker and they now marvel at every blade of grass, savor every tasty morsel. I, on the other hand, am really, really pissed off. (Having a stroke)

This week she has taken responsibility for Change of Shift, so take a look, but make sure that you dip into a selection of the Fat Doctor’s own posts as well.