Debate : Doctors for the rich, nurse specialists for the poor
If NHS BLOG DOCTOR has one mission statement above all others, it is to fight against the dumbing down of the NHS. This dumbing down most frequently involves the over-promotion of nurses into roles for which they are ill equipped. Roles that used to be filled by doctors.
In many fields of medicine the only way to be sure of seeing a qualified doctor is to go privately. Take yourself to the “free” at the point of entry NHS and most likely you will find yourself managed by some sort of “Health Care Professional” (HCP = there is no doctor available today).
This is two-tier medicine. Only the wealthy and the “great and the good” see doctors. The riff-raff get the cheapo-cheapo productions HCP.
The nurse-specialists usually counter this argument by saying that “we are just as good as doctors”. But now a new strategy has emerged. Oddly it comes from the normally excellent, multi-authored Mental Nurse column.
They are saying that the wealthy and the great and the good are now being treated by HCPs as well. (see here). Even if this were true, and it is not, would that make it any better? Put this into educational terms. Why not let teaching assistants take over at Eton and St Paul's? Bring the education in those schools down to the level of the sink comprehensives. That would teach the toffs.
I do not agree with the article, but I did however think it was important to discuss it and so I highlighted it in this week’s BritMeds.
Private sector quacktitionersMental nurse does not like that. He accuses me of not debating seriously. And now in the BritMeds comments he has a little sulk because I took the piss from the promotional video for “Lean Health Care”
“So, nurse specialists for the NHS, doctors for the private sector. It’s great rhetoric, but is it actually true? Let’s get the bourbon biscuits out and have a look at the claim. As a bit of lazy research, I’ve picked up a copy of this week’s Nursing Standard and flicked to the jobs pages. So let’s see who’s recruiting nurse specialists and nurse practitioners. Well…....”
Mental Nurse still does not understand that private patients are referred to and seen by consultants and that NHS patients take pot luck. Look at the Lean Health video.
Funny thing.
I try to inject a thoughtful, evidence-based approach to the whole nurse specialist/practitioner debate over on Mental Nurse, and Dr Crippen's approach involves hyperbole and cheap insults...
...yet I'm the one who's apparently not clever enough to do anything other than eat bourbon biscuits.
I did take the piss from it. I said
“A man with a beard and funny teeth explains how to make the NHS quicker and cheaper. The one-stop quacktitioner service. Of course it’s cheaper.”Of course I took the piss from it. This odd chap is trying to dress up NHS cost-cutting in specious psychobabel. “Lean” health care. “Hospital at night”. “Teaching assistant”. “New Labour”.
Slogans and sound bites.
Spin.
I take back not one word. This is total toss-pottery. It is worse than that. It is fraudulent and dishonest. It is dressing up second rate medicine as something desirable.
“Lean Health Care”?
Crap.
This is fobbing off poor folk with second rate treatment. Do you think Tony Blair would see a quacktitioner if he broke his wrist?
And then mental nurse makes much of the fact that man with beard and funny teeth is an eminent doctor from the University of Warwick.
So what?
We are used to this sententious botty-wipe from the University of FormerPoly in Warwick. They specialise in it. We have already met another exponent of total toss-pottery from the very same centre of excrement:
So, come on Mental Nurse. What do you make of this bearded Telly Tubby? You seem to rate the University of Warwick and men with beards. What, precisely, is he saying? Go on, tell me. Explain it to me. And when you have done that, let us look at the over-promoted nurse specialist in the video.
As I have said before, I do not have a flair for languages so I do not speak “nurse”. Maybe you can help. Listen to Rachel Horley, Director of Learning and Support:
"The key to involvement is developing the learning capacity of everybody to recognise and realise the potential for involvement. The challenge for us is to find practical and creative ways of developing the capacity of everybody through learning and development opportunities both within formal learning and also in everyday work capacity."Please explain what this means.
Mental Nurse, I shall continue to take the piss from over-promoted NPs who are put in positions of perceived responsibility and spout crap like this. And it is crap spouters like this who are being let loose on NHS patients.
I am fervently committed to decent health care for all, and it infuriates me that people without private health insurance are at the mercy of tossers like this.
Does anyone disagree?
Labels: dumbing down, men with beards, mental nurse
73 Comments:
If I remember correctly, the University of Warwick is *not* a former poly, unlike Coventry University. It was one of the "new universities" in the 60s. And it has an excellent reputation in some subjects at least, whatever junk it may also contain.
Just one point for now. The University of Warwick is not a former poly., it's one of the 'new' 'plateglass' universities of the Sixties. The Guardian ranked it 8 in its subject table rankings in 2005, the Times, using slightly different measures, ranked in 8 this year. It's (according to RAE ratings) a top ranked research university. Etc..
sorry, anonymous, didn't see your comment.
As I say to many university applicants; would you care to explain the relevance of RAE rankings to yourself?
I don't care what Elton and Paul think. Nurse practitioners are doing great work.
the nurses are getting smarted up, the doctors dumbed down. Hooray!
The Times and Guardian rankings aren't RAE, renal. And as anonymous says, Warwick has some departments with excellent reputations.
The last time I heard the word crapulent used was by Monty Burns on the Simpsons. It doesn't mean what you think it does Dr Crippen.
Also, the UK is churning out the doctors at a great clip. The hoi polloi will be seen to by doctors.
We actually have a doctor surplus now days. Awesome!
warwick uni is significantly lower standard than cov uni (the ex lanchester poly) in many subjects, but yep warwick was never a poly, although its not in warwick rather its in the outskirts of cov in its own little time warp of failed public school boys who really should have gone somewhere else for all the money spent on their schooling
it does internestingly have close ties with coventry PCT (one of the worst PCTs in the country, dont believe me? try visiting the "nurse led" "walk in centre" which the poor folk get now that access to GPs is none existant), and cov and warwick hospital trust (staggeringly dirty and bad A & E), but hey the good prof is obviously clever enuf to avoid all that crap and spends his time in a Brummie hospital
Cov and Warwick are also masters at other aspects of "lean" health, ie patients needing trigger finger are seen by pysiotherapists rather than surgeons after GP referral, lots of money spent on diabetic centre but poor patients get fobbed off with diabetic nurses when they are clearly ill enough to need to see a consultant urgently, etc
however Warwick uni is clever enough to line up its own GPs for its staff and students as it knows better than most that GP provision in Cov is piss poor
"lean" manufacturing is as far removed from this crap health service bullshit as my drive to the shops is from buzz aldrin going to the moon
i wish wankers like this would actually study true lean manufacturing concepts rather than making it fit the spin of their rather 3rd world service
no one
If what I read on NHS Blog Doctor and other blogs is correct, as of August 1 there will be about 10,000 unemployed junior doctors who will be available to become HCPs. That should improve the image of HCPs considerably. Or does changing job title from "junior doctor" to "HCP" mean a lowering of intelligence?
I'll respond in a bit more depth later on, but as I'm a bit rushed I'll just make a couple of general points for now.
For the record, I'd just like to state that I do not believe that nurse specialists are "just as good as doctors". I think there's a reason why doctors spend so long at medical school, and I don't think nurses can or should attempt to compete with that level of expertise.
My own opinion of advanced nursing roles is I have no problem with them, provided that they are nursing roles, designed to complement a doctor rather than replace them. Basically, I'm in favour of nurse specialists as extra-skilled nurses, but not as under-skilled doctors.
Just to give an example, consider a clinical nurse specialist in, say, wound care, acting as a point of contact with regard to wound management. Wound care is an area that nurses deal with routinely - district nurses in particular tend to have a lot of expertise in wound care. One could argue that such a role is much more identifiably a nursing (rather than substitute-doctor) role than, say, a nurse practitioner diagnosing and treating minor illnesses.
One of the objections I have to the current level of debate on this issue is that at the moment there's no middle-ground argument being proposed. Nobody seems to be saying, “I think nurse specialists do a good job at a-b-c, but I don’t think they should be doing d-e-f” or, "I'm in favour of nurse specialist roles, but not of nurse practitioners". Only blanket good vs. bad statements are being made at the moment. I think there's a middle ground to this argument that could and should be explored.
teaching assatiant here, fighting the system, trying hard not to be left with a class of children.
This week I have been asked to produce art reports for some children. Recently I was left with 90 children and 3 other TA's to take a music class, and I have had to teach a newly qualified teacher long devision (the old fashion way)
3 of the ohter TA's do have better degrees than the teachers which made for an interesting huffy morning break when one of the let this infomation slip!!!!!
I agree with zarathustra regarding the role of advanced nursing, but the problem is (as far as I gather from reading this blog) that the NHS seems to be paying nurses more to do a doctor's job cheaply, rather than to pay nurses more to do a nurse's job better and more expensively.
However, I do think that Dr C has on previous occasios said that he believes in the role of advanced nursing within their capacity as nurses; community nurses for example get the thumbs-up from him (but let's not mention the 'm' word, shall we?).
You wrote to Rachel Horley in March: I've looked but I don't see the response?
You asked her to explain the quotation that you highlighted and to comment on the annual cost to the tax-payer of The NHS National Centre for Involvement.
Thanks wingnut:
A careless pseudo-neologism from me. Quite right. Crapulent does not mean what by rights it should mean
"Home > Library > Words > Webster 1913
Crap·u·lent
(-lent), Crap·u·lous , a.
[L. crapulentus, crapulosus: cf. F. crapuleux.]
Surcharged with liquor; sick from excessive indulgence in liquor; drunk; given to excesses. [R.]
+++++++
I did not know that. I shall right it in my vocabulary book and try to use it in three sentences over the next few days.
But what a pleasing word and meaning. I shall definitely be baffling people by using it in its correct sense
John
John you're wrong on the golden era of Doctor-led NHS. Consultants held the country to ransom by regulating the supply, and then mixing private and NHS patients. It was well known that if you wanted to get to the front of the NHS queue you had to pay the consultant's fee.
The current HCP-led system has delivered a significant increase in healthcare across the country. Waiting lists are largely a thing of the past.
let go John - it'll do you good
Dear John
I think that you need to be little more open minded. I grant you that the presentation isn't great and there is a fearsome ammount of awful management speak verbiage.
In case you haven't had enough of "lean thinking" which came from Toyota, there is also "six sigma" from Motorola!
I also am not convinced that the NHS has got it right in the way that it seeks to implement some of this stuff and sees it as some sort of panacea.
However there is potentially something in these management ways of working. A medium sized DGH has an annual budget of £200 million and if one is running this sort of sized “business” with public money there is an onus to do so both safely and efficiently.
There is evidence that Lean Thinking can help. For example I quote from an Australian article in the BMJ earlier this year.
http://www.bmj.com/cgi/content/full/334/7586/169
BMJ 2007;334:169 (27 January), doi:10.1136/bmj.39101.389271.1F
“Over three years, we have halved the number of serious safety events that have had to be reported to our insurers, despite a substantial increase in the numbers of patients seeking care in our hospital. At the beginning of our lean thinking journey, our hospital was struggling to contain a deficit. In the last financial year, we were several millions dollars in the black accomplished without extreme measures such as shedding staff.”
I personally do not have experience of implementing these methods but if it can reduce clinical errors and save money it is worth a look at before automatically assuming that it is all management claptrap.
And I didn’t hear the man with a beard talk about your old hobby-horse of nurse practitioners.
I am now probably irredeemably consigned in your eyes to the management dark side and to an extent you’d be right. Declared COI, I am deputy medical director of my Trust. I do this because I do feel that it is essential that doctors’ do get involved in managing and running healthcare.
All the best
Dermot O’Riordan
Dr Crippen,
Think you're generous for giving these nurse quacktioners the room on your blog. On the one hand you can't blame them for taking on these new roles and defending their existence, but they don't want to believe the "driver" for change across the NHS is money saving.
Crap service costs less. Period. The stories of utter incompetence by NPs at our hospital are terrifying. I can tell you with my hand on heart that about a dozen patients have died this year on my wards because of the over reliance on NPs and advanced nursing “specialists”.
The greatest irony is that we're short of proper nurses (maybe because they're all becoming NPs) and patients are suffering from not getting basic care on the wards.
Don't get me started on HCPs, Jesus wept.
Dr Crippen, clearly you have fallen in love with your fossilised hypothesis about NPs to the extent that you are unwilling, and dare I say it, afraid to confront the objective evidence.
By that I mean the various NP studies [however imperfect] cited time and again on this blog which suggest that Quacks are generally doing a decent job.
More importantly, perhaps, if the Quacks have been plying their 'dumbed-down' trade for well over a decade: why are there NO studies supporting the kind of accusations made by you and other docs, such as young ferret ?
Could it be that there are none - if so, why do you think that is ?
One or two of the medical students have whispered about seminal studies [in the making] that will finally and unequivocally expose the Quacks once and for all.
The data will confirm 60% error rates and gross mismanagement, in fact, they will do no nothing less than write large the Crippen-esque anecdotes that crawl out of the woodwork everytime the NP role is mentioned.
You ask about Bliars wrist, well lets assume it was a deformed colles afte mechanical fall - if I saw him I would reduce it under Biers block [with a senior squiriting in the IV prilocaine] - no big deal.
If the post-reduction position was acceptable, home in a POP and fracture clinic, having been warned that the position might shift and an operation may still be indicated.
Of course a Smiths would go straigh to ortho, an undisplaced scaphoid would be put into a scaphoid cast, while displacement through the waist or proximal pole would go straight to ortho, etc, etc.
An incidental lyitic lesion, would that get overlooked ? maybe, but that would probably because of fawning seniors desperate to kiss Tony's ass, rather than NP error - he and Hewitt recently visited our place [to see the pacs radiology system], the photo's of the politicos and the hospitals great and good did not make for comfortable viewing.
What is fun about the internet is the way you cn flit from one topic to another. Depressed by your examples of management-speak, but intrigued by "Lean Thinking", I did a quick Google scan. The Wikipedia entry was very depressing; huge amounts of jargon, signifying - well, nothing very much, except lots of middle managers pretending to be Japanese. Five minutes more browsing, including several documents relating to the NHS, and it appears that the essence of this philosophy COULD boil down to: put the patients' interests first, and eliminate waste. Not a bad idea, I would have thought - waste like endless pamphlets exhorting us to eat more fruit and hugely expensive computer systems that don't work would be a start. Unfortunately, it seems that lots of pea brained managers will just latch on to the bits about cutting costs, learn the jargon enthusiastically to murder the English language and chaos will reign as always. It ain't more money alone that is needed in the health service. Some really intelligent thinking would help. It is all beyond depressing - and as a teacher, I will wait for "Lean" to appear on our agenda any time now.
Sorry to be a pedant Dr Crippen - but should the third final paragraph read over-promoted NPs ?
Over-prompted suggests we may have been put put up to it - by NuLab presumably : )
Oh God, I'm hopeless. I need an editor. What the spell checker does not pick up....
(AND I see "right" for "write" above in my comment too...)
Quite right, over-promoted.
But ISN'T she fun?
Following on from the ponderous telly-tubby with that glorious paragraph of meaningless verbiage.
How can the government spent tax payers' money on stuff like this
JOhn
Nurses, medics, PAMs working as part of a team is A Good Thing.
Senior nurses working in an environment delivering optimal care within their capabilities is desirable.
Such nurses, delivering direct patient care, can arguably deliver better patient care in many situations than inexperienced SHOs could. This is laudable.
Such nurses can not undertake diagnostic or interventional work to the level that a trained senior doctor in that area could (since training is so different) and as such nurses replacing doctors in such an environment is disatrous. Pathology is missed. Much badness.
Collaborative work, I'm all for. Couldn't get through the day without my excellent senior nurse colleagues who I rely on far more than my junior medical staff. Replacing medics (so there is no medical presence or input perturbs me.
I am impressed by the amount of bile and vitriol on both sides! I am a medical student and have been taught by some excellent nurse practitioners, and been horrified by some dim ones as a patient and a student. Equally, I've met pompous and ill-informed doctors too. Not something to be porud of on either side, and a case of people in glass houses perhaps on both sides?
The thing that worries me most is one of the comments at the top "I don't care what Elton and Paul think. Nurse practitioners are doing great work.
the nurses are getting smarted up, the doctors dumbed down. Hooray!"
How can it be good that doctors are getting dumbed down? If you wanted to be a doctor, apply to medical school. If you wanted to do nursing, be a nurse. I can't believe it can be anything other than frustration and jealousy. My grandmother badly wanted to be a doctor, but her parents said they would only pay for a boy (her older brother) to go to medical school. She went on to be a matron and later a practice nurse, and was brilliant at it, but she felt nurses should be nurses and doctors should be doctors, despite her aspirations. Why don't we get on with doing well in what we're trained for? I make a rubbish nurse, but I hope I will make a good doctor.
re "Waiting lists are largely a thing of the past." oh how we laughed, who believes this nu labour spin? obviously not someone who has needed an operation in the last 12 months
not nu labour spin - but Bob Marshall-Andrews MP recently on any questions. No fan of Tony Blair he!
Crickey- I do like a bit of venom to start the day right; however I worry that you may run short of relatively low level insults and I heard one the other which I haven't heard for years and I pass it on.
"what a complete tool mr x is.."
It's a fantastic insult - nothing to anglo saxon, or profane but contemptuous and dismissive. I am currently using it in many of my dealings with the LEA..but not to their many faces naturally.
Shrink - in A&E ENPs are very much part of the team - why bother having consultants if ENPs or FY2s/SHOs don't need to 'consult'.
It wouldn't be the end of the world if the ENP service was quietly dropped but we have been going for a decade and radiology/ortho audits have been favourable.
My experiences simply do not tie in with the NP detrator anecdotes that get trotted out every time this issue raises its ugly head - personally, I would not be able to sleep at night if I kept missing fractures or wounds with tendon or nerve injuries, etc, etc.
I am not arguing that some NPs are not crap, although to the best of my knowledge there is no research evidence which supports the contention that NPs are crap as a population, quite the opposite, in fact.
Our consultants think ENPs are OK, and I'm sure continuity has become even more important given that FY2s/SHOs placements in A&E now rotate every four, instead of six months.
I think NPs are hear to stay [at least in the short to medium term] and as Zarathustra points out, they are even providing a service in the private sector.
I hardly think BUPA & Co will have been unduly influenced by NuLab, so I suspect NPs work for such organisations on merit, despite what Dr Crippen and others may say about them.
"In the drive to save the NHS, I'm choosing a Toyota" - from the Observer, 14 Jan 07, http://society.guardian.co.uk/comment/story/0,,1989824,00.html
the A&E charge nurse says
"You ask about Bliars wrist, well lets assume it was a deformed colles afte mechanical fall - if I saw him I would reduce it under Biers block [with a senior squiriting in the IV prilocaine] - no big deal."
You wouldn't get within a mile of Blair's wrist and well you know it.
If NPs and so on are just as qualified as Doctors then why are Doctors paid more?
If NPs and co are just as educated then why do Doctors suffer 100s of exams, spend 5 years of undergrad training and 3-7 years of post grad training?
As I mention above Matt - when Blair & Hewitt dropped in to our Trust there was an unseemly queue waiting to courtsey, or grin deferentially at a few banal remarks about a digital x-ray system.
But you are absolutely right, NuLab may appear very pro-NP, but not when it actually comes to treating one of their own.
Like Ruth Kelly and all the other hypocrites they advocate one thing for Joe Bloggs, but something quite different when it comes to themselves, or their nearest and dearest.
I have seen a few celebs though and even a famous Lord - being stuck in A&E must undermine the ability to think rationaly, I guess.
Future Doc - I don think anyone is suggesting that NPs are 'just as qualified as Doctors...' Where on earth did you get that from?!
How do you define 'educated'?
re "Waiting lists are largely a thing of the past" yes because there are now waiting lists to get on the waiting list which is published, and dirty tricks to keep the lists low such as consultants sending patients back to GP for another referal when they would have got on an treated related conditions in the past
Browns "normal birth" baby was delivered by a consultant not midwife! blair has a heart consultant sent to him from one side of london to the other on the back of a motorcycle, lots of examples of "some are more equal than others"
nu labour really are hypocrites of the highest order
future doc - actually, pay between doctors and nurse practitioners is fairly similar.
Assuming your nurse is on AfC Band 7 (which is likely in A&E), they're earning somewhere between £27-£35k (roughly). That's roughly equivalent to your senior SHO/junior reg.
What is interesting is that out of hourse (e.g. nights & weekends), nurses are actually more expensive - whilst doctors get paid a flat salary, nurses get unsocial hours payments which push their costs up a bit higher.
"I do not have a flair for languages so I do not speak “nurse”. " - wow, how incredibly patronising to a group of professionals that you profess to admire Dr C. You continue to say that it is only NP's you are after, and then spout this kind of inpleasant crap.
I am concerned about the uncharismatic bearded person's plans to 'take steps out of the xray department that don't 'add value''. Which steps would they be?. Perhaps he feels it is no longer necessary to get someone who has been trained in radiology (ie a doctor, not a nurse who has done a one day course on how to recognise a fracture - if you're lucky) to examine said xrays. I agree with Doctor Crippen, and feel that nurses are now in roles that they are not trained for. I am sure they are fine if there is a process to be followed, but I fear that when things deviate from the norm, most nurses do not have the underlying training and experience to recognise and react to this. There are several years worth of training in subjects such as anatomy, biochemistry, pharmacology etc etc in medical degrees - boring but necessary to underpin the clinical skills. My opinions about nurses lack of suitability for these enhanced roles have come from working as a vet - we seem to have a disproportionate number of nurses as clients. I know this as they tell me the second they walk in the door. On the plus side, there is no need for me to strain my brain to make a diagnosis as they will already have decided what is wrong and what treatment is required. On the minus side, the lack of underlying physiological and anatomical knowledge frequently exhibited in their bizarre diagnoses is frankly frightening. It makes me panic that one day I will be ill and seen by one of these people, without basic knowledge and who does not recognise their own limitations.
re "one day I will be ill and seen by one of these people, without basic knowledge and who does not recognise their own limitations." welcome to Coventry PCT "Walk in c
Centre"
the NHS leading the world in crap
as Dr C has said, you would get locked up if you treated dogs like this
just to elaborate on waiting lists. What Bob Marshall-Andrews said was "in 1997 the two issues that dominated constituency surgeries were access to disability benefits and NHS waiting times. Both those issues have, essentially, completely disappeared."
so its not the figures its the experience of people complaining to their old-labour MP.
And on the subject of nu-labour getting the top docs. Did they request them? Or did the NHS see fit to provide them without prompting?
I can tell you for free I know several MPs that get stacks of correspondance re real end to end waiting in the NHS
Did you know there is a large NHS hospital with a Legionaires outbreak? people ill from it? its not even in the news - because the press just know how fucking dirty and bug ridden nhs facilities are and nobody gives a shit, die from MRSA and get a free anti-smoking leaflet from a politically correct labour mandarin
Prescott got his foot problem seen straight away out of hours
The speaker and Dennis Skinner both jumped the heart surgery waiting list
If they dont know they are getting special treatment they are stupid
That warwick prof should be struck off for spouting such obvious dangerous bollocks, dont get menengitis in his area cos youll get sent home by a nurse with no clue etc
lots of people seem to get offended by politicans jumping NHS waiting lists. Are you equally offended by Consultants shoving their private patients to the top of NHS waiting lists?
Dr C really is getting desperate now. If he can’t dismiss the content of what anyone, who disagrees with him has to say by criticising their spelling, grammar or syntax he seeks to undermine them by making fun of their appearance. How low can you get. I bet his breath smells as well.
“Oi specky you smell of poo”
Is that the level of debate the good doctor has descended to?
Eee up Granville Ah don’t hold with this ere new fangled automated printing machine thingy what’s wrong with writing t’ bloody bible out bah ‘and and bah candle light like we used to in't olden days. Bloody Caxton dumbing down again, I dornt ‘old wi ‘ it.”
Zarathustra, A&E charge nurse i should hold your breath if i was you no one is listening.
It seems there is a lot of misinformation here about 'Lean'.
The principles of Lean are
- To look at things from the customers perspective (could be patient, could be another department)
- To look at all the steps along the process and to ask what adds value to the customer (in a health care setting this would be say, diagnosis and treatment) and seeking to remove all the 'bits' that don't add value (waiting for things to happen, duplication of effort, unnecessary movement of people or resources)
- Seeking to make the process 'flow'
- Only doing something when the 'customer' demands it (the concept of pull)
- persuing perfection
http://www.lean.org/WhatsLean/Principles.cfm
Some of the biggest advocates of Lean in the NHS I've met have been doctors and nurses who have realise that the things that frustrate them in their working life are all the 'wastes' in the system that prevent them delivering patient care.
Where it has been used there have been some stunning results - Flinders Hospital, Australia, Bolton Hospital in the U.K.
However, like all things it can be done badly, and there is a danger that 'lean' is diluted into some tools and techniques rather than a management philosophy (it is the latter rather than the former).
Key to lean is 'up ending' the management structure and allowing the people who work in processes to both understand them and redesign them.
I would suggest that people seek first to understand before they criticise. There's a growing amount of literature and evidence out there about lean approaches and I would encourage those of you working in the NHS to find out more. The report comissioned by the Scotish Executive on the attached page is useful
http://www2.warwick.ac.uk/newsandevents/pressreleases/NE1000000213205/
NHS manager, is the Birmingham A & E deploying 'lean' correctly?
Hi E - your wisdom has been a bit thin on the ground lately, I always look forward to your erudite observations.
You're right [as usual] I need to go and lie down in a dark room and count backwards from.... well, a very high number; the sort of figure usually offered to private plastic surgeons [miowww].
Just realised there is someone else posting on this site under the name 'NHS Manager' - I might have to think of something else - my first post was the one above about Lean.
Jayann - in answer to your question it probably isn't my place to say but I don't believe the organisation is adopting the same approach as say, Bolton, where Lean has become the way the organisation is run at all levels. I hope, however, for the sake of staff and patients they don't use Lean as a 'toolkit' as it will fail and be yet another management 'fad' that gets a bad name.
P.S I too was sceptical about Lean until I went to Bolton and saw it in practice.
social pariah, thanks for the comment. I'm not against 'Lean' (but have a couple of doubts about its applicability in medical settings).
Zarathustra,
I think there is definitely a role for nurse specialists when they are extended nursing roles.
However when these roles stray too far towards doctoring and not nursing roles then it spells big trouble.
A doctor's role is not that easy to explicity define, and this slippery grey slope has been exploited by the dumbing down process.
Unquestionably when non-medically trained staff are taking histories/examining/diagnosing/presribing and managing in an unsupervised fashion then things have gone way too far.
A & E charge nurse, have a stiff Scotch! I would buy you one but live too far away...
jayann - as the sun sinks on the yard-arm, I may be tempted :)
I have been trying to think of an answer to the conundrum you have posed on the parrallel thread [the one about who gets to decide who is sick] - that apparently innocent questions is actually the catalyst for much of the angst exhibited by those on either side of the doc-quack divide.
And by the way I still haven't come up with a sensible response to it - ahh well, back to the dark room and fluffy cushions.
http://my.telegraph.co.uk/jambon_goddard/june_2007/doctors_clean_your_filthy_hospitals_then_lecture.htm
have a laugh .
Dr Crippen
Just a quick query regarding some comments in your original post:
+++++++++++++++++++++++++
And when you have done that, let us look at the over-promoted nurse specialist in the video.
As I have said before, I do not have a flair for languages so I do not speak “nurse”. Maybe you can help. Listen to Rachel Horley, Director of Learning and Support:
+++++++++++++++++++++++++++++++
I'd agree with you that the video is a bit rubbish, but there's absolutely nothing in it to indicate that Rachel Horley is a nurse.
Unless there's something you know about her that we don't?
Utterly depressing that NHS centre of bullshit, sorry involvement
as if they give a toss about patients
this is on the same day that a petition signed by 140,000 people has been handed into no10 about AE closures in the south east
this kind of AE closure is nothing but dangerous as the AE units left do not have the capacity to deal with the workload, while the minor injuries units are not capable of taking any of the strain either
the more centres for involvement there are, the less patients are listened to
the more 'patient choice' initiatives, the less actual choice for patients
and still some of you are fooled- did you by any chance train at NHS university?
Garth, something we finally both agree on, progress ?
a & e charge nurse, of course, I haven't got an answer to my own question :) -- but yes, it is doubtless a catalyst (and I'm glad to hear it is!)
-- have a scotch a bit later?
Garth Marenghi says
"when these roles stray too far towards doctoring and not nursing roles then it spells big trouble"
This is the absolute knub of the debate. Doctors should doctor and Nurses should nurse.
What we are creating is a third tier who are too posh to nurse and better than doctors because they have protocols.
a&e charge nurse
Don't get so wound up by John's comments. He only makes them to stimulate debate.
We in the UK have the lowest number of Doctors per capita in the 1st world (and Nurses, and hospital beds, etc).
The answer seems to be to replace the doctors with nurses and reduce the number of acute hospital admissions (stupid GPs, what do they know). As for nursing care, well who cares?
The basic principle of John's arguement makes sense - forget the rhetoric.
We should unite to oppose the political scum who have got us and the British public in this position.
It's OK Matt, I'm much calmer now [a bit of jayann therapy seems to have worked wonders] - you probably won't believe this but I'm much more of a traditionalist than my blog alter-ego would have you believe.
Dr Crippen is an astute commentator and I think the vast majority of his commentators hold him in great affection, I am no different.
But I must speak as I find, so inevitably things will get heated once in a while.
Mind you I seem to recall that you have been guilty of placing an itchy finger on the trigger, once or twice ?
And long may it continue.
The thought occurs that, beneath the screeching, at least some of the people on here aren't as far apart in their viewpoints as they may seem.
Some people who claim do be "pro-nurse specialist" are only in favour of nurse specialists within certain roles and parameters. Likewise, some of those in the "anti-nurse specialist" camp don't actually seem to be opposed to ALL nurse specialists - just those who appear to stray outside their competency.
Just to reiterate my own view: I'm in favour of advanced nursing roles, but only when the intention is to produce an extra-skilled nurse rather than an under-skilled doctor. In that sense, I suspect myself and Garth Marenghi are violently agreeing.
"Mind you I seem to recall that you have been guilty of placing an itchy finger on the trigger, once or twice ? "
Moi?
John you are becoming unhealthily obsessed with NPs etc. I’m sure your time could be spent more fruitfully on more important matters like parting the waves so the chosen few can be saved!
so are "nurse led" walk in centres a good idea? or just a recognition that there is inadequate access to GPs and A & E in many areas?
name me one other first world nation to staff its walk in centres with nurses and no doctors?
Nurses are enjoying a mandate handed down by the DoH to take over much of the responsibility of doctors and undermine their authority over how patients are treated. I see it and experience the effects of this phenomenon every day, making my job significantly harder.
As a doctor, I do not believe that I am in any way intellectually superior or more worthy as a human being when compared to other healthcare professionals.
I am expected to ensure that the medical management of a patient is optimised. I can be held criminally accountable for the standard of medical care. I also believe that I am more qualified to make medical decisions. This decision is often based on some of the input gained from nursing colleagues.
However, the reality on many hospital wards is utter contempt for doctors and a complete lack of respect. Not in terms of 'I'm better than you so you should respect me' but 'I am a highly qualified professional with something to offer here'. This has noticeably worsened over the last few months now that MTAS has destroyed morale and destabilised medical training. There are many nurses that seem to have 'smelled blood'.
I have worked in Australia and there is a more level playing field socially. You EARN respect in Oz and arrogance from any professional, whether judge, doctor or cleaner, is frowned on. Are we experiencing some battle of the classes here sparked off by the accumulated snottiness of generation after generation of upper middle class GPs and consultants? My parents were both nurses and were a little uncomfortable with me becoming a doctor. They are now in their 50s and in positions of responsibility. Their mild anti-doctor feelings are surely shared by their generation of senior nurses, ex-nurse managers and politicians that now run the NHS and the New Labour government.
Also, back to NPs, many NPs and other nurses that contribute to these debates are by nature inquisitive, intelligent and obviously are prepared to debate issues. They are undoubtedly well qualified and good at what they do. But the wider context remains anti-doctor, both in provision of training, recruitment policies, politically as seen in the New Labour press and socially as witnessed in the everyday interactions between managers, nurses and doctors.
Let's get real here. It's open season on doctors and we're expected to take this from all angles and look our patients in the eye and reassure them that we'll all be 'doing our best for them' together.
Is it any wonder that doctors are done with talking?
When a doctor is no longer free to act in good faith and is controlled professionally and financially by third parties and rules and guidelines become the measure of good practice, which seems to be the case or becoming so, then I see the end of doctoring being a profession.
Once we doctors have become obedient soldiers carrying out the wishes of third parties, then I see little difference between a doctor GP and a GP nurse practitioner. The latter will work within their protocols and so shall we doctors. It's very depressing. The doctor as friend and healer, an ideal maybe, is a dying breed.
Two days ago, as a locum Gp, I saw two patients being treated by doctors for hypertension. Forced out of fear to take endless pills to drive their BPs to the latest idiotic guidelines without any buy in or understanding.on their behalf. Totally unacceptable to my way of thinking. Absolutely no 'healing' relationship here - just computer driven bullshit and it seems little interest in the patients' experience or concerns
Now if my income was dependent upon these two taking these pills how would I have behaved??
If I was concerned that I might be audited by my peers, how would I have behaved?
Unless we doctors tell the powers that be to take a running jump, which isn't going to happen , then we will be dumbed down, they will be dumbed up and the patients will be drowned in a medication guideline driven tidal wave.
I work with an independent GP nurse practitioner at the moment. She is like an old time doctor in her nature. She cares, she is interested in people, she knows her limits. She is great to work with. She knows the problems with guidelines but she is not free to act outside them. I see huge potential in someone like her. However I see that potential being dampened by the reality of her being regularly audited. Boy if we end up being audited like she is, that truly will be the end of
independent thinking doctors and the health services becoming a sausage factory.
end of rave
Read this http://kiwidocblog.blogspot.com/2007/06/blood-pressure-what-level-to-treat.html
Here is a challenge to the very basis of BP guidelines! What these authors are right! Who cares tick the boxes!!
Download the pdf file JOhn if you want some justification for doing little with that old lady with a bp of 180
I would gladly spend more of my day focussing on "patient care" rather than running around chasing my tail and trying to fit in with all the local guidelines/protocols/SOPs...why is it that once you become a ward sister, you are no longer able to do your job as a nurse? I am seriously tempted to put on a HCA uniforms some days so that people will just let me get on with my job. Problem is, there is no value placed on staying at the bedside...most jobs that are higher than a Band 5 are designed to prevent you from doing so. Yes, yes, its not all about money but lets face it, no one is going to train for three years to end up on a maximum salary of £24K (after 6 years post qualifying) with only cost of living increases to look forward to and no chance of developing professionally....how many doctors would be prepared to stay as SHOs forever eh? Quite a few of my friends have decided to stay on the wards and are now deemed to be unpromotable as they do not want to become practioners or specialists....and lets face it, each ward only needs so many sisters. Its about time that such expertise was rewarded and more ward based Band 6 jobs were available.
I'm all for "advanced " roles for nurses if it improves patient care (most of the PRHO and SHO on MAU are more than happy for us to replace venflons for IVs or to organise for a PICC line to be placed as its one less job for them to delegate back to us anyway) Same goes for wound management...we have tissue viability nurses who are excellent and are more than happy to come onto the ward, do teaching demos (and have been asked for info by doctors as well as nurses). I agree that what we want are "super nurses" not "wanna be docs"....most of the NPs I have come into contact with fall into the former and most are also highly praised by the medical staff. Obviously its a fine balance between super nurse and inadequately trained docs (not able to practice due to the competition for patients) and I must admit that over the past few months I have attended arrests where the inability of anyone (doctors or nurses) to put in a venflon has caused serious problems...in one case, two docs were arguing over who was going to do it "no you do it, no you do it" So guess I'll do it then :0)
anaru -
Ignorant non-clinical bioscientist comment here, but don't we need to know what the BP "history" of John's lady in her 80s with the BP of 184/96 is?
I had always assumed a sensible BP target would be age-adjusted...
If she has been happily getting by with a hypertensive BP for years and years undetected, and all her vascular beds are "expecting" that sort of pressure, stuffing her with BP-lowering drugs would presumably be rather likely to give her renal failure, or cause her to faint and fall down and break something. Surely...
If the BP indicated an "acute increase" that would be different.
Sorry, playing amateur doctor again. Fortunately I only do it virtually, not in real life.
Yes, that is a sensible thought, but target driven healthcare often misses the complexities of individual patients medical needs. What you say is potentially correct if a little obvious!
Dr. Crippen, do you rich GP's eat the bourbon biscuits before or after the swan?
.......arf the inquiring yank
http://www.advancedpractitioneruk.blogspot.com/
arf:
Allow me to let you in on a piece of arcane British-ery: a mere GP would not be allowed to eat swan unless he perchance were dining with Her Majesty the Queen, whose property British swans are:
http://www.garfnet.org.uk/new_mill/summer97/ah_swan.htm
It is rumoured that certain of the more exclusive Oxbridge colleges are allowed a few swans, by Royal dispensation according to the Swan Act of 1484 (there really is one), for serving at High Table at grand dinners. But one would have to be a most important personage to be invited.
By the way, there have been stories in some of our tabloid newspapers hereabouts that dastardly foreign chaps have been killing and cooking the Queen's swans:
http://www.thesun.co.uk/article/0,,2-2003302470,00.html
Calls are afoot for these blackguards and disrespecters of tradition to be dealt with most severely.
Since we have abolished the death penalty, the obvious solution is to put the offenders on a reality TV show with a mob of Sun-reading British patriots and watch them fight it out.
Sorry to be ultra pedantic, but a humble doc could also legally dine on swan at the Vintners' and Dyers' Livery Companies, which were granted their rights of ownership by the Crown in the fifteenth century and St Johns College Cambridge, as I remember from a May Ball many years ago. Goes well with quacktitioners chips; you know, the ones they wear on each shoulder. Well, you'd know these things if you lived in Kuwait!!
Thanks for the clarification, Martin. I did mention the Colleges, but didn't know about the fortunate Vintners.
Swans feature, of course, in the (Cambridge) College dinner scene in Tom Sharpe's immortal "Porterhouse Blue".
I remember a mate (PhD Cantab) and I telling one of our newer (non-English) academic colleagues prior to their first visit to Cambridge that s/he should read or watch Porterhouse Blue if s/he wanted to understand what the Oxbridge college system was about. S/he though we were taking the piss.
Some days later, at the Conference, we were all sitting on the grass in a college Quadrangle when we were approached by a wizened porter. "You'll all have to move" he says "you're sitting on the Fellows' grass". He pointed to an identical lawn the other side of the path "but you can sit on the grass over there - that's the College grass".
Our non-Cambridge familiar friend practically swallowed his/her tongue.
Put me in mind of the famous Cambridge University limerick:
"There was a young man at St John's
Who wanted to ****** the swans;
Cried the loyal Hall Porter,
"No Sir! Take my daughter!
"Them birds is reserved for the Dons!"
Attrib. Algernon Charles Swinburne, 1833 - 1907
These would be the same HCPs who ignored the text book signs of meningococcus for 3 days (wait, I should mention there was also a GP; not OUR GP, but A GP who said it was viral!), so that a member of my family could contribute to the Scottish NHS avoidable deaths stats, would they?
I was eventually told by the consultant that the member of my family was only alive because I persisted and kept forcing the HCPs to SEE the patient till our GP ensured the patient was admitted. Great message of hope, that is. He also said something about our colour not being the kind that the HCPs were used to seeing so signs, such as rashes, can be tough to interpret. I am still trying to find if he meant it in jest or if he really was outlining lack of experience with non-white patients in the Scottish NHS, or if he was saying something else about how non-whites are treated in the NHS. My money is on the inexperience bit of the possible explanation.
There is a reason why we need doctors. The nurse practitioners, who saw the patient, when the out-of-hours GP should have seen the patient, did not have any idea. Their pumping the patient with codeine for the pain easily could have contributed to the drowsiness being missed... I am still hopping mad though happy to say we did not become a statistic.
When you guys discuss 'choice' and how 'articulate' patients have better choices, you are on to something. Next time I do not want to have to depend on my persistence though...
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