The Crippen Diaries 2007 (Week 22)

Not quite Emergency Ward 10

Tuesday 29th May

It is school half-term at the moment, a lot of people are away on holiday, and so it is reasonably quiet. There does not seem to be much pollen around so we are not even getting many hay fever sufferers. Life is still stressful as the Crippen household is in the middle of GCSEs and AS levels. I have no doubt that all these examinations, like the NHS, have been dumbed down. When I was at school, few pupils achieved ten “A” grades, or the equivalent. Nowadays, some do. The exams are less discriminating but expectations are higher and so the stress levels for the candidates are unchanged.

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And so the first patient is a sixteen year old girl who has tonsillitis and who is right in the middle of her GCSEs. I start her on penicillin without even considering the “is it viral, lets get a swab” conundrum and then mother says she wants a letter for the examiners. It is actually half term this week, so she does not have an exam for a few days by which time she will be better. “But its going to affect her revision, isn’t it doctor” says Mum.

So I agree to do a letter saying that she has been ill during an important revision period. Do these letters we provide for the examiners make any difference? I hope they do not. My cynical daughter tells me that there is a point’s tariff for illness and bereavement during exams ranging from “mild viral illness” and going up through “death of pet”, “death of grandmother”, “death of sibling” all the way to “death of parent.” ****

I hope this is not true either.

The half of the class who is not ill have “tracking disorders” (whatever those are) or “mild” dyslexia. I always giggle at middle class dyslexia. Why is it always “mild”?

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The “choose and book” system started a couple or weeks ago. The older partners are being characteristically stubborn and difficult about it. We can still insist on using the “old” system by specifying “named consultant only” on the referral. I prefer that. Most of my patients prefer that. Some say they do not mind a generic referral to “Dear colleague” but they do not realise that the putting their hand into a medical tombola out of which they may well draw one of the poor consultants or, even worse, a “health care professional”.

Admin is now fighting back. Referrals going through “choose and book” are being dealt with more quickly. “Named consultant only” referrals are going by second class post. I shall stick to my guns. It is worth waiting to see a decent consultant rather than being shunted into a nurse run clinic, and if anything is really urgent, I can short circuit the whole system by making a Two Week Rule referral.

I hate it. The consultants I know mostly hate it too. All the personal relationship has gone out of the system. The salutation “Dear colleague” has a “right-on”, “we are all equal” politically-correct feel, but it is merely the New Labour version of “Dear Comrade”

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**** I lead too innocent and sheltered a life. The ever cynical Mr Eugenides has referred me to this. Un-be-lievable!!

The Crippen teenagers, meanwhile, have downed tools and are doing some sums. The unexpected demise of two goldfish and a hamster might make that A* attainable and if not, well, grandma is coming for tea...

Dear Oh! Dear.

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Thursday 31st May

I saw two patients this morning, both of whom have been discharged from hospital out-patients, and both of whom are seeing community nurse specialists for further care. For one patient it has worked brilliantly. For the other it has been a disaster. Well, I exaggerate a little. Disaster is too strong a word but, for the second patient, the management has been well-meaningly incompetent in a way that makes doctors giggle.

Charlotte is eight years old and has severe eczema. Alice is nearly eighty years old and has end-stage heart failure, or nearly end-stage. The only thing that would save her would be a heart transplant, and she is not going to get that. So she potters around her warden controlled ground-floor flat, getting short of breath on minimal exercise. Eating needs time, and going to the lavatory is a real challenge.

I referred Charlotte to the dermatologist because her parents were not coping with her eczema and had asked to “see a specialist”. I had already given (lent, but it never came back) them David Atherton’s excellent book on Childhood Eczema (if you have a child with eczema you must read this book) but they had not taken it in and were still floundering in a world of quackery related goat's milk, egg allergy, fear of steroids, inability to understand the necessity for moisturisers…all the usual things.

Severe eczema is a nightmare, particularly for young children. We do not have a specialised paediatric dermatologist in my area. The dermatologist did all the appropriate investigations for allergy, none of which were helpful. And then he gave Charlotte’s parents a talk about the “appropriate” use of steroids, the “appropriate” use of moisturisers” and it went in one ear and out the other. They came away bitterly disappointed that they did not get a “magic answer”. So off to the eczema nurse specialist, who has been wonderful. She has managed to divert them from goat's milk and exclusion diets, she has done wet wraps, and she has convinced them that moisturisers are the mainstay of treatment. The household stress levels have come down, and that alone may have improved the eczema.

Alice came today because the cardiac nurse specialist has been playing with her stethoscope and has told Alice that she has a chest infection and that she needs some “strong antibiotics”. If you want to make a doctor giggle (or scowl if he is having a bad day) start talking to him about “strong antibiotics”. Alice does not have a chest infection, but does have impressive heart failure. She is on ACE and beta blockers and diuretics and so I fiddle around with the doses a little and have a chat with her. She is relieved to hear she does not need antibiotics because the last time she had some, they caused diarrhoea.

There is documentary evidence that cardiac nurse specialists keep patients out of hospital, and that is a good thing. So why do they make me giggle? Because they are so earnest, and so well meaning, but their superficial level of knowledge of complex medicine is risible. They help the patients because they visit them frequently and ask them how they are. They act as the patient's "mate" and that is helpful. But if there is a medical problem, they try to dealt with it themselves before they inform the doctor. That causes more problems than it solves.

Patients sometimes do not call the doctor when they need to. Nurse-specialists do not either. They need to confine their role to being the patient’s “mate”.

In the old days, when I started as a family doctor, we had an appropriate number of district nurses. They were not nurse specialists in the new sense. They did not have fancy titles. But they were very experienced at assessing patients. Not with a stethoscope and Mickey-Mouse knowledge typified by hilarious references to “eliciting the hepato-jugular reflex.” (It is not a reflex). With experience tempered by knowledge of their boundaries.

When the district nurses called and said, “can you see Alice, she is not right at the moment” we trusted their judgment. When the patients were ill, the district nurses called for help. The nurse specialist does not do that. She gets out her stethoscope.

Nowadays, there are not enough district nurses. They do not have the time to do the regular community visiting they used to do.

Ask GPs what resources they would most like to improve care of elderly patients in the community and they would say more district nurses. But no one asked us, did they?

Which is silly, because however the nurses are structured, whatever titles they have, ultimately we are still in charge of, and take responsibility for, community care.

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Friday 1st June

A very busy duty day.

I stopped counting the number of phone calls when it exceeded forty. One was from an embarrassed house officer at the local hospital.

Ten days ago we admitted George, an elderly man with COPD. He was not responding to treatment at home. He needed drips, and nebulisers, and steroids and antibiotics. He was picking up in hospital when without warning he passed some blood in his urine. Respiratory physicians do not understand this sort of thing, so they called in the urology registrar. He did a rectal examination and told the medical houseman that George needed to have a cystoscopy urgently to exclude cancer of the bladder.

So far so good.

Then the urology registrar told the houseman to “phone the GP and get him to do a two week rule referral to us in the clinic so that we can assess him and get a cystoscopy”.

Unfortunately for the houseman, it was Dr Crippen who took the call. “But why don’t you do the cystoscopy whilst he is in hospital” I asked. It doesn’t work like that, she said. “Well, why doesn’t the urology registrar book him into the clinic himself?” It doesn’t work like that either, she said. “Well, why does the urology registrar not have the courtesy to phone me himself to discuss the case?”

He is too busy.

You probably do not believe this. It is true. Every word of it. This is the modern NHS. This is the “internal economy”, introduced by Thatcher, and swathed in Blair's bureaucracy.

"He is too busy" was not the right thing to say to me whilst I was idly passing time lying on the Health Centre chaise longue with Britney Spears popping peeled grapes into my mouth. I told the houseman that I thought the urology registrar was an idle, discourteous pillock, that I was not his secretary, and that I would not have anything to do with this except that I would be monitoring what happened to George. And I told that houseman that if George did not get his cystoscopy on an appropriate time scale I would leave no stone unturned to make sure that copies of the complaint, mentioning the urology registrar's name, went to the hospital chief executive and every consultant urologist in the Northern Hemisphere. Then he would be able to put the experience on his MTAS form under the “mistakes I have learned from” section.

The houseman giggled. She phoned back two hours later and said that the urology registrar had said he would sort it out

Idle, unimaginative sod. It is sad. Sometimes we are all shouting at each other. It should not be like this, but that is what the NHS has become.

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It has been a bad “nurse specialist” week (see above) and being the duty doctor on Friday is the time of the week when you find the community specialist quacktitioners at their absolute worst.

Community nurse specialist quacktitioners will happily meddle with patient treatment from Monday morning until Friday lunchtime but then, come Friday afternoon, it is “clear the desk for the weekend” time.

This afternoon it was the Macmillan nurse quacktitioner. She left a phone message saying that she had asked the District Nurses to go in to Bill, an elderly male patient, to give him an enema as he had abdominal discomfort and had not opended his bowels for three days. Would I “leave out” a prescription for some phosphate enemas.

No, I bloody well would not.

Why, you might ask, did the Macmillan nurse quacktitioner not give Bill an enema herself? Good question. Macmillan nurses do not do nursing. They do not like to get their hands dirty.

I went round to see Bill. When I arrived, he said “Oh, I was expecting a female. Are you a nurse?” I said I was the doctor, and Bill said, “That’s odd, the doctor was here this morning and said she would send the nurse in to give me an enema.” Bill thinks that Macmillan nurse quacktitioner is a doctor. “Did she examine your abdomen?” I asked. Oh no, she just said that as I was uncomfortable and had not opened my bowels properly I should have an enema to relieve the discomfort.

So I got Bill upstairs on the bed and examined him. He had a large abdominal mass coming out of the pelvis, stony dull to percussion. As I palpated it, he said he needed to pass urine. He went off to the lavatory. I could hear but not see him. He passed perhaps a hundred mls or so. He came back. There was urine all down his trousers. He was embarrassed. “Its been happening for a while, doc”.

I did a rectal examination. He was not impacted. There were a lot of soft faeces.

Bill was in acute on chronic urinary retention. I do not know how long he had been like that. He needed catheterising. I sent him into hospital.

This is why these bloody quacktitioners drive us bonkers. Macmillan nurse quacktitioners are far too grand to do rectal examinations and give enemas themselves. Their role is to tell other people how to do their jobs.

It is incompetence, negligent incompetence, to give an elderly man an enema without examining him. Macmillan nurse quacktitioner had been sitting on Bill for three days. If she had not been involved, Bill would have called the doctor three days earlier, and we might have been able to sort him out without a hospital admission.

But you can’t criticise Macmillan nurses. The media love them. The general public love them. They are the perceived armour that will protect you from cancer. Sadly, in many cases, they are the barrier that will prevent you from getting proper medical care.

Mesothelioma: asbestos in hospital - a scandal emerges

Would you consider that advising workers not to inhale blue asbestos is a reasonable way of protecting their health, and preventing ill-health? This sign was attached to the boilerhouse of a National Health Service hospital in Britain, and the photo was taken in the early 1980's. With attitudes such as those illustrated by the photo, it is no surprise that hundreds of workers are sadly still dying every year from mesothelioma caused by occupational exposure to asbestos several years previously, and the number is set to continue rising, before it eventually falls. (source)

Does anyone have any evidence, tales, anecdotes or even just rumours of hospital workers contracting asbestos related illnesses? If so, please let us know.

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Following on from yesterday’s article about the risks of asbestosis related diseases contracted from walking through the tunnels underneath Guy’s Hospital, it is clear that this problem is not confined to Guy’s.

In his excellent and moving article in The Times, Dr Andrew Lawson described how he was diagnosed as suffering from a pleural mesothelioma. Take a look at My surreal slide - doctor to patient if you have not already done so.

Doctors are not normally considered to be an “at risk” profession, but Andrew raises the question of whether he was at risk whilst at Guy's. If he was, he will not be alone. There are many more of us, including Dr Crippen.

I thought that my piece might generate some interest. From my recollection the longest tunnels were from the Spit/Boland house down to the medical school, new guys house , and Hunt's House also to the exit outside the east of the Tower to avoid the wind tunnel. I have spoken to a UCH trained dentist who has a meso and recently a malignant pericardial effusion.

The prognosis for this disease is grim, screening ineffectual (not cost effective) and treatment varies. I have no doubt that there will be other cases. Andrew Lawson

And then he goes on to say:

"There has been one case at UCH/Middlsex which was settled out of court and two others are pending in London . I would be most interested to hear of any anecdotes or any other cases."

It seems UCH/Middlsex, The London , Barts, The Westminster and the old Charing Cross may have had a lot of asbestos

Andrew Lawson

All information, particularly from anyone who worked at UCH/Middlesex, The London, Barts, The Westminster and the old Charing Cross, gratefully received.

It is ironic, but scandalous, that whilst Professor Tom Treasure and his colleagues were sitting in the out patient departments of famous London Teaching hospitals, medical students and others walking through the underground tunnels to get to those clinics were put at risk of contracting the very disease that Professor Treasure was trying to treat.

Finest doctors in the world under threat

Guy's Hospital

Bloody hell.

Here is one to concentrate the minds of the finest doctors in World.

There was an article in the Sunday Times this week by Dr Andrew Lawson, a 48 year old hospital consultant in Berkshire. Andrew has recently been diagnosed as having a mesothelioma.

Mesothelioma is a malignant tumour of lining tissues which can appear in a variety of places but is most commonly found in the pleura, which are the lining tissues of the lungs. Mesothelioma is usually related to the ingestion of blue asbestos.

A survey conducted by the Health and Safety Executive indicated that in the UK the highest risk of asbestos related lung disease arises from insulation work. In one group studied more than 10% of men died of mesothelioma. Epidemiologic work by Professor Peto has shown that in the first few years of the 21st century we can continue to expect a rise in the number of new cases of mesothelioma in Great Britain. mesotheliome is a horrible cancer of the lining of the lung (usually), with a very long latency period (it can manifest itself 40 years after asbestos exposure or even longer). (source)

One of the leading mesothelioma experts is Professor Tom Treasure of Guy’s Hospital.

Professor Tom Treasure of Guy's Hospital

The peak of the epidemic is expected in 2015 to 2020 when the death rate is likely to be 2,000 per year in the UK.

The epidemic in the United States has probably peaked because of earlier awareness and action on asbestos imports,” he added. “Many countries are seeing the rising tide of an epidemic, and all doctors need to know how to recognize and diagnose this disease and what treatments are available. (Tom Treasure)

America has taken the lead here. So who is particularly at risk in the UK? Pipe laggers. Electricans. Dockers. But not doctors. Unless they trained at Guy’s Hospital which has a maze of subterranean passages linking the medical school to the dining area to parts of the hospital and even, heaven forbid, to the nursing home.

Guy’s medical students all walked miles down these corridors. All the corridors contain pipes, and all the pipes are lagged. Are they lagged with asbestos? Who knows? It was never mentioned to the medical students and we would have been told. Wouldn't we?

Andrew Lawson says:

Mesothelioma – me? Aside from the traditional sense of being invincible, common among healthcare workers, this diagnosis has come from way out in left field. I am a 48-year-old doctor, not the traditional dockworker or lagger – no disrespect to those patient groups intended.

Asbestos – from where? It seems that there may have been a lot of asbestos in the tunnels at Guy’s hospital where I spent six years training. One wonders how many of my contemporaries will get the same disease? Everybody – students, nurses doctors and porters – used the tunnels. (My surreal slide - doctor to patient)

Bloody hell.

But is there any hard evidence that Guy’s Hospital has or had an asbestos problem? I did a Google search. Not easy as any mention of mesothelioma on Google opens a flood gate of ambulance chasing American lawyers. But amongst the legal vultures, I found a traditional British Company.

Guy's Hospital Tower

"On 4 occasions we have worked in Guys Tower for a demolition company undertaking asbestos removals." Messrs Flintshaw & Co

Bloody hell.

That Tower was built and opened whilst I was a medical student there.

Bloody hell.

Funding the NHS

Who needs midwives? Anyone can deliver babies.

Tip of the Iceberg

Regular NHS BLOG DOCTOR readers will not have been surprised by the headlines in today’s newspapers complaining that untrained “health care professionals” have been working as midwives.

It is happening throughout the NHS, in all specialties. The midwifery scandal is but the tip of a large iceberg.

The NHS is being deliberately dumbed down by a government intent on saving money on the wage bill. The monkey is always cheaper than the organ-grinder. The nurse is cheaper than the doctor. The auxiliary is cheaper than the nurse. The cleaner is cheaper than the auxiliary.

A culture is now developing that makes the use of the word “doctor” old-fashioned, elitist and politically incorrect. Soon words like “nurse” and “midwife” will disappear as well, to be replaced by the ubiquitous “health care professional”.

The Spaghetti Harvest : autism, mercury & quackery

There may be a few ancient readers who remember the famous Richard Dimbleby Panorma report about the effects of the mild 1957 winter on the Swiss Spaghetti harvest. Last week, a reader recommended a well-known Canadian Blog of the same name. I do not know if Jennifer, of Spaghetti Harvest, watches Panorama but I am sure she is not sufficiently ancient to have seen it in 1957.

She did however write an article expressing her worries about immunisations and, I am afraid, gave space to some of the old chestnuts (mercury and autism for example) that drive the medical profession to distraction.

How does one deal with views that are so out of kilter with sense and science that most of us associate them with the loony tune brigade? A few months ago we had a long debate with Anthony Cox of the much respected Black Triangle about whether it is appropriate even to discuss the views of the British National Party. I think they should be discussed for, repugnant though most of their policies are, I do not think that ignoring them will make them go away.

The following appears in Spaghetti Harvest:

What I found alarming was the fact that our kids are being injected with stuff that hasn’t been subjected to any long term studies. And I’m not just referring to the actual virus (which, in some cases have been genetically altered…. frankenvirus!!!), but the preservatives and other chemicals or altered DNA floating around in the shots. In fact, this generation of children really are the “long term” subjects.

Babies have underdeveloped immune systems, yet we bombard them with viruses and potential neurotoxins. They have a weak blood brain barrier and we go expose them to mercury which destroys neurons (mad hatter syndrome anyone? Take a look at the symptoms of autism and mercury poisoning…I’m not sure how people can ignore all those Autism awareness groups). (Full article here)

There is no doubt in my mind that this is loony tunes science and maybe we should best tuck it away somewhere and try to forget about it. Trouble is, Jennifer is not a lunatic. She is a University graduate with qualifications in Anthropology and Psychology. Some wag will say that such qualifications are no guarantee of sanity, and I guess that might be true, but I think we have to give her the benefit of the doubt! Seriously, though, whatever our views may be on Spaghetti Harvests, Swiss or Canadian, Jennifer’s views are widely shared by a lot of intelligent young mothers who have understandable anxieties about immunistaion programmes.

Rarely a week goes by without me being asked about these issues by parents who, rightly and properly, want explanations, not glib and dismissive remarks about "loony tunes". It is customary to blame Andrew Wakefield for the immunisation uptake problems in the UK and he must take a share of that blame. But the biggest culprit is the Government and the Chief Medical Officer. There was far too much of the "Do as I say, I know best" approach rather than rational explanation. Exactly the same happened over pertussis immunisations a generation ago, and Andrew Wakefield was not around then.

We should, I guess, start with scientific research and there is no better article than this from the American Journal of Pediatrics. On the medical blogosphere, the best starting points for a rational analysis of Autism Quackery are LeftBrain/Right Brain and Respectful Insolence

Mother died after eight GPs failed to spot septicaemia

The stark headline in The Times, with the photograph of the unfortunate Penny Campbell holding her young son, is enough to put the fear of God into anyone feeling unwell during the evening and at weekends.

The headline should have read,

“Mother died after a consultant surgeon and eight GPs failed to spot septicemia”

but that would have confused the issue. The current media and government mission statement is to slag off overpaid, lazy GPs. And indeed that is exactly the mission that is being pursued in The Times today:

Failings in out of hours GP care will claim more victims

And some commentators on NHS BLOG DOCTOR seem to feel the same:

Dr C - why didn't EIGHT DOCTORS, highly intelligent, trained individuals spot this woman's problem? She DIED. EIGHT DOCTORS! Why?

The answer is in the question. If eight highly intelligent, trained individuals fail to make a diagnosis, then it is likely that the diagnosis was difficult - or even impossible - to make.

Penny Campbell’s partner said:

"If Tesco can open till midnight every night, why can’t our GPs open till midnight every night?"

If we are to discuss this tragedy rationally, we need to ignore the emotional statements and tabloid headlines and start with the report of the independent investigation, and then we need to consider some facts about the difficulty in diagnosing rare and unexpected conditions, such as septicaemia occurring after the injection of haemorrhoids.

The report is available in full here.

The facts can be summarised thus. Penny Campbell had her piles injected. The next day she felt unwell. She called the private consultant surgeon who did the injection who advised that her symptoms were nothing to do with the minor operation, and that she should consult her GP. Penny Campbell consulted eight different GPs over the next few days, none of whom realised that she was suffering from septicemia. She then took herself to hospital. On arrival she was lucid and coherent but over the next few hours she deteriorated rapidly and died.

No comment is made in the report about the Consultant Surgeon. Six of the eight GPs were held to have provided an acceptable standard of care. Of the other two GPs, one was held to have fallen short of an acceptable standard of care. It was not possible to make a judgment about the other one. The report is critical of the failure of Camidoc, the out of hours organisation for which all the doctors worked, to store and share clinical data on patients. Each doctor did not have the details of the previous consultations and so had to start afresh with the patient. A great part of the report is about the failure of Camidoc to hold a timely investigation into Penny Campbell’s death. This is an important issue, but not relevant to the care that Penny Campbell received.

The greatest challenge that GPs face is that they see illnesses so early in their evolution that it is impossible to make a definitive diagnosis. And so we “safety-net”. I see dozens of children a week with temperatures and not much else. Even though the child is giggly and happy, and running round the consulting room, he still could be in the early stages of meningococcal septicaemia. (See How to miss meningitis) And so, in each and every case, my standard formula is

"This does not seem to be anything too serious; see how it goes. If there is any change, or you are worried, please get back in touch.”

One of the criteria for admitting a child to hospital is parental concern. If I saw a hot child for the first time who had consulted doctors seven times in the previous three days, I would admit them to hospital. I cannot give an exact rule of thumb, but I would probably admit a child who had consulted three times.

The report puts enormous emphasis on the fact that Camidoc did not provide the eight doctors with details of the previous consultations. I think – personal opinion approaching – that this is irrelevant. Yes, that data should have been available, but most experienced doctors would not have looked at it until they had made their own assessment.

Whenever patients start a consultation by saying, “I saw Dr X and Dr Y last week, and they said I have….” I immediately stop them. I do not want to know that Dr X “thought I might have an irritable bowel…” I want to hear about the abdominal pains in the patient’s own words. It would emerge during the consultation that the patient had seen a succession of doctors and that in itself would be a significant part of the history.

Great emphasis has been put on the failures of “stop-gap” medicine. The sort of medicine practised at night and weekends by all doctors, both in the community and in hospital. The clinical question becomes not “what is wrong with this patient” but “whatever is wrong with this patient, can it safely wait until tomorrow morning, or Monday morning, until normal services are available.”

We all do it, all the time. The resources are no longer available to do anything else. Ten years ago, if I saw a ill frail elderly patient on a Friday afternoon, I would make a medical decision about hospital admission. Now I have to factor in the lack of experienced doctors on site at the weekend, and the fourteen hours she will spend on a trolley in the “medical assessment unit” which is the part of the casualty department which has been curtained off to get round the four hour rule. (see Tony Blair's Scams) That is the reality of the NHS. Far better to send her in on Monday morning - if we can get through the weekend.

"If Tesco can open till midnight every night, why can’t our GPs open till midnight every night?"

Why just until midnight? Why are GPs not open all night? Why are hospitals not doing operations twenty-four hours a day?

The answer is straightforward. There are not enough doctors, nurses and attendant ancillary staff to provide 24/7 medicine. The single biggest cost of the NHS is the wage bill. If you want 24/7 medicine, you would have to triple that bill. The government is not doing that. It is doing the opposite. It has reduced hospital medical staffing at nights and weekends (see "Hospital at Night - doctors on the scrap heap" and “getting a picture of the night") and it has reduced out of hours medical staffing in the community. You may think that is wrong. You may think that doctors are lazy, and have been let off the hook. I will save that argument for another day. But, rightly or wrongly, that is what the government has done, and it is breathtaking to hear Gordon Brown, the Prime Minister elect, talk of the last ten years of the NHS as though someone else has been responsible for it.

“We need more access to doctors,” Gordon Brown noted in response to a report yesterday on Miss Campbell’s death. He is right, despite the cruel and avoidable irony that some 15,000 young doctors, each trained at the cost of £250,000 of taxpayers’ money, will be without appropriate jobs in August as a result of the disastrous switch to a computerised appointments system. (The Times)

Penny Campbell’s death was a tragedy. But the fact that a consultant surgeon and eight GPs did not diagnose her impending septicemia does not, on a res ipsa loquitur basis, mean there was negligence.It is more indicative of the difficulty in diagnosing early septicemia.

This difficulty is, of course, ignored by the media. Indeed it is buried in some characteristically dishonest journalist double-speak which implies that GPs were not available to see Penny Campbell:

The root cause of the NHS’s dangerously patchy service at nights and weekends is an opt-out clause in GPs’ new contract making out-of-hours work optional in return for giving up £6,000 a year in earnings. For doctors being offered, in the same contract, a 23 per cent increase in average overall earnings, this has proved an attractive option; nine out of of ten have opted out, passing responsibility for out-of-hours cover to primary care trusts ill-equipped to cope. (The Times)

It is absolutely correct that the Government offered GPs the chance to opt out of night work. It was a monumental mis-judgment. But that was the government did. It thought it could save some money by providing the night cover itself. It had, however, underestimated the amount of work involved, and the attendant costs. Enter NHS Redirect. But, in context, this is a red herring. There has been no allegation that Penny Campbell could not access medical advice, or access a GP.

The issue is to what extent the nine doctors who were involved were at fault.

I say nine doctors for, if fault is to be allocated, the consultant surgeon who was first contacted should take a share of it. She performed a minor operation – privately I suspect – and shortly afterwards the patient became unwell. Why did she not see her?

As regards the eight GPs, the main criticism I would make of them is not strictly clinical. It was their failure to react to the number of consultations requested by this intelligent and articulate patient. For this reason alone, she should have been sent in to hospital earlier.

But such an admission may have made no difference.

If the first GP who saw her had sent her into hospital, she would have been assessed by an inexperienced casualty officer who most likely would have concluded “viral illness, if you are no better after Easter, see your GP”

The BritMeds 2007 (21)

It has been a very bad week for doctors, so let's start with some light relief:



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And on this topic, from Iain Dale:

About a week ago I asked you for your nominations for the most incompetent Labour Minister of the last ten years. You duly obliged and here is the poll I promised. Please vote for the THREE Ministers you consider to have been the most incompetent.

Doctors should feel under no obligation to vote for Patricia

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A perfect day…

With morale within hospitals hitting rock bottom, and Patricia Hewitt remaining in post, all be it, for now.... I thought I'd write about the future and 'The Perfect Day Exercise' to lighten the tone.

Perhaps we all need some help like this

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Looking at the government incompetence behind the death of Penny Campbell

Last year, Tyler attended the Public Accounts Committee meeting where the DoH mandarins were grilled about the whole thing (see PAC Report and evidence transcript here). As we noted at the time, it was frankly scary. The Chairman described the mandarins as being "underwhelming", and we were shocked that they were so far out of their depth.

But even more shocking was the DoH's inability to define what the OOH service was actually meant to be doing. And remember, this was a full two years after the new GPs contract was introduced in 2004. Even by the abysmal standards of government, the muddle and confusion was appalling

A tragedy waiting to happen

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The GMC goes to the devil

It's ironic that if Stalin were a medic then the GMC would not be able to strike him off the medical register, however they would be able to dish out brutal punishment to a petrified doctor who was simply following Stalin's orders. This is the world of the brave new NHS.

Judge Charles Harris raged: "It is like a totalitarian regime: anybody who criticises it is said to be mentally ill - what used to happen in Russia."

This comment related to the case of an NHS whistle blower who the GMC tried to smear as mentally ill and incompetent, before investigating the very serious concerns raised.

The DK

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Someone has cloned Polly Toynbee

The same old rag that brought us Polly Toynbee, has now rolled another clone off their production line and she is called Jo Revill. I found it hard to spot the difference between Toynbee's praise of Blair's NHS legacy in the BMJ and Revill's similar piece in the Observer.

The Ferret Fancier

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Statistical abuse

I noticed this little piece that paints doctors as being dangerous because they are 'more lethal' than gun owners. This is argued because in Sweden one is 7500 times more likely to be killed by a doctor than by a gun owner.

What marvellous logic

++++++++++

Women in medicine is one thing, but women in cars....

Did you know that car batteries are quite likely to develop faults after about five years or so?

Good enough mum

+++++++

More dangers of medical protocols

This is what happens when the involuntary side of the brain takes over something that you do in the same way repeatedly, like driving. It may also account for why some medical errors are made, when we have fixed protocols for everything and IA takes over from the conscious checking mechanism. It’s also more likely to happen (to both parties) when 2 people are following a protocol which requires them both to check it, as they both involuntarily assume that the other person has done whatever it is they are supposed to check.

Mens sana – A dangerous trick of the mind

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

It is nice for GPs to be appreciated

We're paying for a bunch of over-privileged , overpaid, self-regulated lazy monkeys to, basically, prescribe paracetamol for any condition. Perhaps if we, the tax paying public, had direct control of how our money was spent then we would have doctors that would actually deliver a service when we paid for it. We need a framework for independent regulation that actually works and sides with the patient and second real, genuine performance related pay not fake targets. Perhaps some jail time too?

Dr Grumble reports on the public perception of GPs

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Lack of discipline

I almost never do this sort of thing. I am very reluctant to apply discipline because of fear that I may be attacked in some way (physically, verbally or by complaint), or that I may have misunderstood and am being cruel.

A fortunate man

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

The lunatic fringe of science

I never know if the best way to deal with loony-tunes science is to ignore it completely, or to try destroy it with rational argument. The sad fact of the matter is that some apparently articulate people hold these views.

Take a look at Spaghetti Harvest

+++++++++++

Sex change doctor

The UK's best-known expert on transsexualism was today found guilty of serious professional misconduct for rushing five patients into sex-changing treatments

Guardian Unlimited

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Abortion fundamentalists

In my humble opinion banning abortion and refusing to refer women for abortion are steps back to medieval times when irrational dogma trumped sensible reasoned debate. It is not a doctor's job to dictate morals to patients, we must respect the autonomy of patients and treat them with respect. These fundamentalists who feel they have the right to make big brother decisions for their patients without their consent are acting unethically and illegally in doing so, they should be ashamed.

The Humble Ferret

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

Are GPs being nibbled to death by ducks?

One frequently recurring theme was that most of them felt that their professional autonomy was being eroded. Some of the GPs and family physicians mentioned that they spent a disproportionate amount of time on the telephone, justifying prescribing decisions to pharmacists and HMOs

The loss of autonomy

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

My oh my oh myopia

There has to be a medical or psychological explanation for art these days. Jane Austen's characters were autistic, Oedipus had an Oedipus complex - actually, I made that one up - and now, according to the BBC, Impressionist painters were Impressionist because they couldn't see properly.

The Iconocast

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

Another visit to our dear friend, Professor Joseph Chikelue Obi, who continues his fight to abolish the GMC

" Professor Obi would like to make it most abundantly clear that he has never , ever , (ever) , gone out of his ethical way to make Graeme Robertson Dawson Catto publicly look like an Epitomal Regulatory Buffoon ; as it very sadly seems that the Formerly Eminent Sir Catto woefully appears to be perfectly capable of doing that by himself ".

Abolish the GMC

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

Who gives “the orders” to doctors…..

Doctors have been ordered to follow a "traffic light" system of signs to prevent them missing cases of meningitis and other serious illnesses.

As reported in the People’s Medical Journal (PMJ)

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

Sometimes the NHS still delivers…

On the 20th May last year we left our home in Africa and headed to the UK – a very sick Kezia and the rest of us would enter a life with leukaemia the next day. The story of our certain escape from Kezia`s death is recounted here.Next week, Tuesday, will be the end of the first year of treatment, passing from visits to the hospital 2-3 times a week to 2-3 times a month.

A leukaemia birthday

+++++++++++

Here we go again…

I rang NHS Direct, who decided that I was suffering from anxiety. This was indeed true as I was feeling anxious because I had a slightly dazed feeling and a headache and a numbness of the side of my face and tingling in my right arm….

The Cartoon Blog

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

The Scotsman picks up on the “freebirthers” debate

"Birthing uses the same hormones as lovemaking -- so why would you want anyone poking and prodding you, observing you and putting you under a spotlight?," said Veronika Robinson, an Australian based in Britain who sees growing interest in freebirth among readers of international magazine, "The Mother".

Full story

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

A medical student battles with OSCEs

Arrrgh, so I guess I should actually say how things went in the OSCE.

Overall, I am quite disappointed in my performance. I could have done miles better. I don't know why. I knew my stuff, inside out, but it's totally different when you're in a room doing it in front of the examiner.

Blunt trauma

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

How I gave up on the UK

It wasn’t meant to end like this - I didn’t really want to go abroad. When I qualified I was a Believer in the NHS. I believed it worked, I believed it was the system I wanted to work in. I thought there was job security. My IFA said I’d never be unemployed and advised me to take on a large mortgage. Everyone said that there would be plenty of jobs.

FtM Doctor

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

Getting Here - An Approximate Guide to How I Became a UK Registered Nurse

It’s not all bad

+++++++++++

Dr Rant sorts out the BMA…

What the BMA needs is one member, one vote. Until then the BMA cannot claim to be democratic, or to reflect the views of the membership at large. Dr Rant has long argued, on DNUK and elsewhere, that only external pressure can bring about democratic change in the BMA. That external pressure may finally be here in the form of RemedyUK.

A Democratic BMA?

+++++++

Anything for a good education

A GP gave a false address to education chiefs to help his lover's child get into a good school, a disciplinary hearing was told.
He also failed to mention he was having a relationship with the youngster's mother at the time….

Full report here

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

Samizdata quote of the day

He [Michael Moore] travels to London to show off the beauty and brilliance of the British National Health Service. He talks to an unstressed doctor who has a four bedroom house in Greenwich and a £100,000 salary from the NHS. He films empty waiting rooms and happy, care-free health workers. He even talks to Tony Benn about how this wonderful marvel came into existence in 1948………..

Is he right?

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

Do the manufacturers of breastmilk substitutes undermine breastfeeding?

The aim was to raise awareness of the practices Nestlé continues to use in attempts at undermining breastfeeding and increasing sales of breastmilk substitutes. It is Nestlé’s stated aim to grow its infant nutrition business year-on-year – though it does claim that it promotes breastfeeding in the process.

Boycott Nestlé - protect infants

++++++++

The second security breach

Remember the second security breach unearthed by NHS BLOG DOCTOR which allowed candidates to view each other’s applications?

It seems it is a generic problem:

The personal data of millions of visa applicants can be easily unearthed online - simply by randomly altering a URL.

That's according to a report by IT discussion blog DaniWeb.

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

Drugs, GP’s,The NHS and making money out of illness

Apparently £100million worth of drugs gets returned unused to the NHS.

Stuff them up the hill backwards

++++++++++

What makes Dr Crippen think this is a putative nurse-specialist looking at the Penny Campbell tragedy?

By the way, I am writing about this topic without a great deal of knowledge, it not being my area of specialism (if I currently have one) so am happy for any information which tells me that my opinion is wide of the mark on this one!

Life in the NHS

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

The MTAS/MMC week

It is all there at Remedy UK

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

The Devil and MTAS

Hewitt shows her true colours

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

Dr Crippen has just discover Beau Bo D’Or – a great illustrator

Take a look at his picture of Patricia

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

Et tu, BMA?

The BMA’s in house mag reports on the RemedyUK court case. Oddly, not much mention of the BMA’s disgraceful role.

BMJ "blog"

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

Cutting Edge

The President of the Royal College of Surgeons, Bernard Ribiero, has withdrawn from ongoing discussions about the selection of junior doctors. His actions may be a little late for some people, but it is indeed better late than never. He was pretty damning in his comments:

Full report from the Ferret
+++++++++++++

Gobshite

From Dr Rant

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

Dr Grumble looks at the judicial review


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

And finally, Patsy applies a sticking plaster…

Patricia Hewitt, the Health Secretary, promised 200 extra training posts for young doctors yesterday as she attempted to recover lost ground over the crisis in medical training.

The Times

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


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

The BritMeds will now be published on Saturday morning, so please let me have your recommendations by Friday evening latest.

Quacktitioner Alert (14)

First, some definitions:

Atavistic: relating to or displaying the kind of behaviour that seems to be a product of impulses long since suppressed by society’s rules

Health Care Professional: I am sorry, there is no doctor available.

HCP: Have you Considered Private healthcare?

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Dr Crippen firmly believes that we are witnessing the destruction of the National Health Service.

My use of the term “NHS” is atavistic. I am referring to the system that existed when I trained. A system in which people who were ill, or thought they might be ill, had this impulse to see a doctor. That system has long since been suppressed by NHS rules. The doctors have all gone. The government will not admit that though. They have invented a new and better professional. The "health care" professional. Anyone can be an HCP. There is only one prerequisite. You must not have been to medical school.

After all, there is nothing special about being a doctor. Anyone can do the job and, these days, anyone does. You do not need to have been to medical school. All you need is the ability to read a protocol. Actually, you do not even need to be able to read if you can understand a pretty coloured diagram; or recognise a picture of a commonplace object.

What do you see in the picture?

You thought it was a traffic light, didn't you? But you are wrong. It is a consultant paediatrician. It just looks like a traffic light.

NICE has just published the idiots guide to paediatrics. When your child is sick, you no longer need to see a doctor. You see a traffic light and an HCP. The HCP will advise you which colour the traffic light is showing. That will tell you how ill your child is. If you read the document below, you may be able to decide which colour the traffic light is showing yourself. It is easy. Anyone can do it. Unless you are colour blind.

click to download into MS Word

This document contains a government certified, comprehensive course in methods used in the NHS to assess sick children. I did my usual frequency of significant words analysis on it:

Total Words: 7353
"Doctor": 1
"Nurse": 3
"Health Care Professional": 56

So there you have it. Think about it. Over seven thousand words on the NHS medical care of sick children, and the word "doctor" is used once.

"Feverish illness is very common in young children, with between 20 and 40% of parents reporting such an illness each year. As a result, fever is probably the commonest reason for a child to be taken to the doctor."

That is it. That is the first and last you are going to see of a doctor in this document.

• one doctor
• three nurses
• fifty six "HCPs".

That is what New Labour has done to the NHS.

I have read it through. It is all good stuff. It empowers the butcher, the baker, the candlestick maker, the nurse practitioner, the paramedic, the ambulance driver, the ward receptionist, Bill Brewer, Jan Stewer, Peter Gurney, Peter Davy, Dan'l Whiddon, Harry Hawke, Old Uncle Tom Cobley and all to work as NHS paediatricians.

I would expect a junior medical student, in his first week on the wards, to have read it and to have understood it.

I would then test the student on it and, when he scored full marks in the test, I would start letting him see sick children under the supervision of an experienced doctor. After three or four years of doing that, I would let him take some demanding exams and, if he passed them, I would let him call himself a very junior doctor, and then I would let him work under supervision in the hospital, seeing sick children on his own, but reporting back to a more experienced doctor. After another three or four years of that, by which time he will have seen hundreds of sick children, I will let him do some more exams and, if he passes them, I will let him go and work in the community as a trainee general practitioner for a year, once again under supervision. He can then sit another post-graduate exam and, if he passes it, I will let him loose as a GP. Alternatively, if he wishes, I will let him stay in hospital for a few more years, see another few hundred sick children, sit some specialised exams and, if he passes them, allow him to call himself a paediatrician.

Atavistic old farts like me used to have a short phrase to sum up this process. We used to call it “training to be a doctor.”

In the old days, when I was approached by keen, enthusiastic teenagers who wanted to go to medical school, I would wax eloquent about training to be a doctor. I told them all about the joys of medical school, about the hard but rewarding work done in those long years in hospital and general practice, and about the pride and satisfaction one felt when finally the life long goal of being a senior and respected doctor was achieved.

Nowadays, I just say “fuck off and buy a traffic light.”

Triumphant Hewitt turns vindictive

Paying Patricia's legal bills

I am grateful to Aphra Behn for drawing my attention to this.

What leaves a particularly nasty taste in the mouth is that the lawyers for the Secretary of State have applied for costs against Remedy, and have made it clear that Ms Hewitt was directly involved in that decision. The judge was very unhappy about this, and suggested in the strongest possible terms that Counsel for the Secretary of State might like to ask his client to reconsider. Counsel indicated that reconsideration was not an option. Reluctantly, the judge awarded costs. (See Vindictive Bitch)

That is beyond believe. It is difficult to think of a more ungracious, foolish and vindictive course of action. And politically inept.

Where does Hewitt think that Remedy UK gets its finances from? A PFI initiative? No. The funds they have, such as they are, come from the pockets of the junior hospital doctors. And some of them are unemployed.

+++++++++

The judgment in full may be downloaded from here

I have read through it quickly. Whatever the law maybe, it is clear where the judge's sympathies lay.

I quote one paragraph in which the judge gives one of his reasons ofr finding in favour of the Secretary of State:

124. Second, it is an application opposed not simply by the Secretary of State but also by the BMA, the doctors’ recognised trade union, which itself took part in and agrees with the decision the claimant seeks to quash. The BMA represents many doctors who would be affected by the quashing of this decision.

The Chairman of BMA has just been driven out of office precisely because he does not represent his member.

Did the BMA consult its members on this? Both Mrs C and I are members. We were not consulted and if we had been we would have supported RemedyUK

The BMA is a disgrace.

MTAS Round 1 was legal - but disastrous

Legally watertight

Round 1 of MTAS is legally watertight. Remedy UK may have lost the legal action, possibly on a technicality, but morally it has won.

Let us not forget why it was fighting, and what it was fighting against. A few months ago NHS BLOG DOCTOR found “the Templeton email” which was available here for all to read on the website of the Royal College of Obstetricians and Gynaecologists.

Shortly after I published the email it disappeared from the site. The email was sent to Carol Black. The Carol Black who, with the now dismissed and discredited James Johnson, last week wrote a letter to The Times.

I reprint that email again, in full:

From: Anne Martin
Sent: 01 March 2007 19:13
To: 'Carol Black'
Cc: Sabaratnam Arulkumaran; Diana Garrett (E-mail)
Subject: MTAS - FROM PROFESSOR ALLAN TEMPLETON
Importance: High
Sensitivity: Confidential
Dear Carol

We have had much representation about MTAS in the last few days. I think we must have had 50 e-mails or so, we have asked our Deanery College Advisers for their views and most have reported problems. I enclose four representative, unsolicited e-mails, two from Fellows with knowledge of the shortlisting process and in addition an e-mail from the Chair of our Trainees Committee and one from two trainees in UCH. These are all representative of many e-mails we have received.

The main issues emerging are:-

1. That most Deaneries have been overwhelmed by the shortlisting process to the extent that selection on merit has been a fairly blunt process.

2. The completed forms have been particularly difficult to assess and score and seem incapable of allowing the identification of the more able doctors. Also they fail to identify UK graduates, which we all thought was the major purpose of MMC.

3. We are getting reports from almost all the Deaneries of able doctors keen to do Obstetrics and Gynaecology simply not being shortlisted, much to their surprise, and to the surprise of their supervisors. This is a particular concern in our specialty. As you know we need to do all we can to encourage UK graduates to take up O&G.

4. We are becoming aware that there are many distraught young graduates out there unclear as to their future.

Our suggestion is that we try and recover the situation, to some extent at least in the second
round. We used to run a National Selection process, prior to MMC and we would like to put this in place, with the agreement of MMC prior to April. Meantime we are encouraging all those who have not been shortlisted to take advice, reapply for the second round and we will be giving them all the help and support we can.

As you know Arul will be attending the Academy in my place and is now well versed in the
issues and will be pleased to speak to the problems.



Allan

Professor Allan Templeton
President
Royal College of Obstetricians and Gynaecologists
27 Sussex Place
Regent's Park
London NW1 4RG

Direct Tel No: 020 7772 6228
Facsimile No: 020 7224 9550
E-mail: president@rcog.org.uk

The email caused a furore because of the implications of the statement

“Also they fail to identify UK graduates, which we all thought was the major purpose of MMC.”

But consider the other salient points:

• Deaneries overwhelmed
  
  
• selection on merit has become a “blunt instrument”
  
  
• incapable of the allowing the identification of the more able doctors
  
  
• able doctors keen to do Obstetrics and Gynaecology simply not being shortlisted, much to their surprise, and to the surprise of their supervisors.
  
  
• there are many distraught young graduates out thereunclear as to their future.

The BMA failed to take action. That is why RemedyUK was formed. This is what it was fighting against.

Round 1 of MTAS may be legal but, as Mr Justice Goldring said, it is still “disastrous”.

Victory for Patricaia Hewitt : RemedyUK concedes defeat

Junior doctors have lost their High Court battle to invalidate their NHS job application process.

Pressure group Remedy UK had challenged the legitimacy of a new computerised application system, calling for medics to be re-interviewed for posts.

Mr Justice Goldring said the premature introduction of the new system has had disastrous consequences - and although the legal challenge has failed many junior doctors have "an entirely justifiable sense of grievance".

He added individual medics might still have good grounds for appeal under employment law. (BBC)

The medical establishment in general and the BMA in particular had not supported the junior hospital doctors. As a direct result of that lack of support, the Chairman of the BMA was forced out of office.

However strong the feelings, however great the injustice, RemedyUK has lost. The first round of interviews stand. The damage that has been done will not now be undone. The ruined careers will stay ruined. This is a Pyrrhic victory. Doctors will now be leaving medicine, or leaving the country. Either way, their talents and expertise will be forever lost to the country that trained them.

This is a sad day for doctors and the NHS and, indeed, anyone who believes in fairness and merit in the workplace. Although the judge has recognised that the products of a botched computerised selection system were inherently unfair, he has felt powerless to act against this unfairness. We are bitterly disappointed as his judgement admits that the careers and lives of thousands of talented doctors in this country will be wasted unnecessarily, and there is nothing that can legally be done to stop it.

After an unnecessarily chaotic changeover in August many of our most excellent doctors, some involved in cutting edge medical research will be needlessly forced out of a medical career in this country.

RemedyUK came into being as a group of doctors worried about the future of our profession and that of the NHS. We have sought out and listened to the concerns of colleagues and acted upon them. Our guiding principle has been to achieve a fair and equitable outcome for doctors. (Full statement from RemedyUK here)

Dr Crippen awaits with horror the sickeningly sanctimonious statement that, even now, Patricia Hewitt’s apparatchiks will be drafting. And soon, the government will be taking on the nurses:

The Royal College of Nursing voted overwhelmingly yesterday to take industrial action over pay throughout the NHS if the government does not back down within a month to rescind a decision to postpone part of this year's award. (source)

It will not take many more Government "victories" over already demoralised healthcare workers for the NHS to be destroyed.

Picking the right cancer

Neil Kinnock

Nearly twenty five years ago, Neil Kinnock, in a fine piece of political rhetoric, warned the country of the dangers of a Thatcher government:

I warn you not to fall ill
I warn you not to get old.

The problems set in with the Thaterchite introduction of a faux market economy within the NHS. But the process has continued over the last ten years. It is estimated that 16% of NHS costs are swalled up by the internal billing processes.

Another depressing lung cancer day. I am having a spate of them.

Shirley is 71, a retired shop keeper. With her husband she ran a local village store/sub-post office. She has smoked 20 cigarettes a day since she was a teenager and it was no surprise when she presented with a particularly irritating cough with some blood in her sputum.

A chest XRay showed some ominous hilar enlargement. I made a TWR referral to the local chest clinic and within twenty eight days of coming to see me she had been through the whole process. CT guided biopsy of the tumour, CT scan of brain, MDT meeting, tissue diagnosis, all done. Cannot fault that. Excellent service and in fairness it should be said that this kind of service is better now than it was ten years ago.

Shirley has a non-small cell lung cancer. The CT scan showed a small probable cerebral secondary. The prognosis is appalling. Shirley knows that. She has always known the risk of smoking and is pretty philosophical about it. She continues to smoke and, with a twinkle in her eye, challenges me to tell her to stop.

She is well at the moment. She has just completed a course of cranial radiotherapy with no ill effects.

The conclusion from the MDT meeting is “refer for palliative care” which is chest physician code for “get of my patch, there is nothing more we can do.”

I spent a long time with Shirley today. “They are very pleased with me at the hospital. They do not need to see me again.”

Oh. Have they not made you a follow-up appointment? I glanced at the last letter from the hospital. It was sent after her lung biopsy.

It concludes :

Follow up : None
“Please refer back if she should become ill.”

"Ill"? Honestly, that is what it says. The second line is written by an inexperienced houseman. "Ill" as in ‘apart from the lung cancer and the brain secondaries’ I suppose.

“Alice, my “co-ordinator” says I can phone her if I have any problems.”

Alice is the lung-cancer nurse-specialist.

Patients used to be followed up by doctors. Now they have “co-ordinators”. “Co-ordinators” are not medically qualified.

Shirley and I talk about the next few months. “I’ve made my will” she says, and laughs. She thinks she might like to be admitted to the local Hospice when the time comes. She does not think her husband will cope. “But don’t rub it in my face, doc, I still have things to do.”

I will arrange the Hospice admission, and shortly I will arrange for one of the Hospice nurses to see her.

But not just yet.

She is going to Lanzarote in two weeks time, and her grand-daughter is being christened next month. She wants to do some living before she thinks about dying.

I reduce her dexamethasone slightly. She is not on anything else at the moment. I make her a follow up appointment for two weeks time, and suggest I see her at regular intervals. I fill in a DS1500 so that she can have a bit of extra money from Tony Blair. It will help. You do not get rich from running sub-post offices.

Shirley goes. I think about the similar patient I have with lung cancer (A tale of two cancers) who is rich, and so is being regularly followed up by a consultant oncologist, and is getting Tarceva. Will Tarceva extend his life? I do not know. Probably not, but that is not the point, is it?

No one gives a shit about elderly NHS patients with lung cancer

Take a look at this Medscape article (you may have to register – anyone can, and it only takes a minute)

Management of the Elderly Patient With Advanced Nonsmall Cell Lung Cancer

Posted 03/27/2006
K. A. Cheong; K. Chrystal; P. G. Harper
It concludes:

The elderly have a long history of undertreatment and non-inclusion in clinical trials with regard to cancer. Elderly-specific studies demonstrate that chemotherapy provides both a survival and quality-of-life benefit in advanced NSCLC.

Elderly patients comprise nearly half of all patients with advanced NSCLC. Prognosis despite the availability of several active chemotherapeutic agents remains less than 12 months. A culture of undertreatment due to perceived frailty and therapeutic nihilism persists despite mounting evidence to the contrary. Evidence is limited by a reluctance to enrol the elderly in clinical trials, and, despite recognition of this inequity for nearly a decade, enrolment remains poor.

You can read that article in the comfort of your own homes. I have to look after the patients. Shirley is not pushy. She does not read medical articles. She has not asked about Tarceva. She has probably never heard of it. She has not asked why women with lung cancer do not get the same attention as women with breast cancer.

Breast cancer is trendy. Lung cancer isn’t. It is important to pick the right cancer, and lung cancer is not the right one.

The Crippen Diaries 2007 (21)

Not quite Emergency Ward 10

Monday 21st May

David and I are conspiring to avoid treating his blood pressure. He is 51 years old, symptomatically fit, but went for one of these wretched “business man’s medicals” that big companies think are a “good thing”. Private health insurance companies make a fortune out of doing a raft of unnecessary investigations on asymptomatic adults.

They found that David’s blood pressure was 168/94 and advised him he needed treatment. His parents are alive and well, his older brother is alive and well, he does not smoke, and he takes a lot of exercise. He was about half a stone overweight, he drank slightly more than the recommended number of units (about 30 a week) and he hated seeing doctors.

So, after the company medical, he stepped up the exercise, lost a few pounds, bought a blood pressure machine and a few weeks ago presented me with an Excel graphical analysis of his BP over a month. The average reading had come down. It was 150/90 which is still in the treatment range.

He does not want to go on medication, and I don’t blame him. In the USA they would put him on medication. If I insisted he had medication he would take it, but I am not like that.

He has done his research. He knows about “numbers needed to treat”. He asked me how many 51 year olds like him, with his blood pressure, I would have to treat to prevent one stroke or one heart attack. I do not know. A lot. But I do not have a precise figure.

And so David is going off for another couple of months for more exercise, more BP monitoring and less alcohol.

+++++++++++

The question can you cure diabetes question came up again. I am not talking about Type 1 Insulin dependant diabetes, but Type 2. Maturity onset diabetes.

A patient who is seriously overweight develops Type 2 Diabetes. He changes his life-style, loses a huge amount of weight, and all tests go back to normal. A year later, all tests are still normal. He is on no medication.

Does he still have diabetes?

Technically not, though he may certainly have a greater than average propensity to it. The question came up again today with a patient who needed an insurance form completing.

Is he diabetic? I am not sure.

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


Tuesday 23rd May

Pharmacists must be the most overqualified and under-utilised professionals in the county. The days of the apothecary using his pestle and mortar have long gone. The modern pharmacist’s job is mind numbing. Counting tablets, checking prescriptions and sticking on labels.

We had a meeting with one of the local chain store pharmacists. They are now paid £25 a head for conducting comprehensive medication reviews which are then sent to the GP. Several pages of press-through-flimsy which are filed unread or, often, torn up and thrown away. The pharmacists is paid for doing 600 of these a year. Once he reaches 600, he stops.

This is classical New Labour tosh. Like Tony Blair’s target of 50% of students going to University. Why50%? Why not 40% or 60%?

Most of the medication reviews the pharmacists do are a waste of time. It is mostly intelligent middle class patents who agree to go through the process and, like women going for antenatal care, the ones who need it most are the ones least likely to attend.

But sometimes the pharmacist picks up a real problem and, by intervening, averts a disaster. So why do we not have a system whereby the pharmacist only alerts us to the problems? This would save a lot of time, a lot of paperwork and probably the odd life.

If I get one red form a month from the pharmacist, I will read it and take action. If I get three or four a day, after I have read the first few dozen, and found they are all a routine statement of the obvious, I lose the will to live.

The pharmacist wholehearted agreed but it is out of his hands. That is not the system. His bosses say he must get 600 reviews done a year. No less and certainly no more.

This is not about healthcare. This is about maximising income from the NHS.

Changing from Haloscan to Blogger comments

NHS BLOG DOCTOR has used Haloscan comments from the beginning, and there is much I like about the service they provide.

But, sadly, there have been problems.

All too often Haloscan crashes when you try to publish a comment.

Worst of all, NHS BLOG DOCTOR is attracting an irritating amount of spam. There are too many comments to make moderation feasible and, sadly, there is no effective spam filter on Haloscan.

So BLOGGER COMMENTS is now enabled as well as Haloscan and, after an interval, Haloscan will be removed.

Please switch to Blogger comments

Dr Crippen’s HTML skills are improving, but he was unable to make this change himself. He therefore enlisted professional expertise.

NHS BLOG DOCTOR recommends that fellow bloggers who wish to adapt, improve, redesign or start again, or anyone needing a professionally designed website should consult:

The Professionals

Biased BBC - they are at it again

I just watched the Newsnight programme on morale in the NHS.

A left wing journo from the Observer (JoRevill)

Andrew Lansley.

And representing the doctors, representing me, James Johnson.

Excuse me, I just sacked the bugger. And yet he was styled as representing the BMA and the fact that he had just been turfed out of office was not mentioned.

I give up.

Supporting the nurses

Affable Iain Dale who, with the exception of his appalling taste in ties, can do little wrong in the world of blogging, is supporting Noreena Hertz who has spent the last 2-3 months touring football clubs trying to get as many players as possible to give a day's pay to the May Day for Nurses campaign.

I hate it.

Not the kindness and generosity behind the scheme, but the need for the scheme to exist at all.

There is a nursing shortage looming: over 100,000 nurses will retire within the next 10 years, yet the government is cutting the numbers of new recruits. This despite the fact that our population is ageing and we will need more, not less, nurses in the future. By 2011 we will already be 14,000 nurses short. This will risk patients’ lives. Wards with the lowest nurse-to-patient ratios see one in four more deaths than wards with the highest ratios.

Student nurses have a very raw deal. They are on average 29 years old (forget your image of a 20 year-old Bacardi drinking nightclub-going girl) and over half have either children or long-term sick or disabled relatives that they care for in addition to studying. A quarter are having to quit their studies, mainly because of financial pressure.

Nurses are seriously undervalued. It is absurd that in Birmingham some of the men who paint white lines in the middle of the road earn two and a half times more than some nurses. Even compared to other professional public sector workers, nurses fare the worst. A mid-career nurse will earn over a third less than a secondary school teacher at the same stage in his or her career.

Over a quarter of nurses are forced to take two or more additional jobs just to be able to continue nursing. We should not continue to exploit the kindness of nurses by forcing them to work several jobs just so that they can look after us when we are at our lowest ebb. (Mayday for Nurses)

Why do we not just pay them properly?

Madness. Utter madness. What are we doing?

Cut the crap, Sam

British Medical Association

All BMA members have this evening received the following email. I print it in full for the benefit of all, including doctors who are not members.

Dear Dr Crippen

Monday 21 May 2007

As the elected leaders of the medical profession within the BMA, we have been and remain determined to represent and lead doctors through the considerable difficulties and pressures facing us. It is vital that we show how a united and determined profession can and should take the lead in resolving the shocking mess which is this government’s health care policy.

In particular, it is crucial that we continue to find practical solutions to the debacle of MTAS. The overriding aim of this task must be to ensure that junior doctors' careers and lives are not damaged any further; to protect them and patients, now and for the future.

We have already secured the independent review of MMC and the MTAS process. We can not and will not stop there. There is much to do to rebuild professional and patient confidence in the training of our doctors.

We demand that the government now deliver:

• A guarantee that no junior doctor will be unemployed as a result of MTAS
• Substantial resources to ensure that junior doctors who have not been successful in securing a training post for 1 August are not disadvantaged
• A robust, fair and transparent CV-based process for round 2
• Increased flexibility in the early years of training
• A lifeline for doctors who don’t get into training posts
• A new group, led by doctors, to design the future of medical training

We will keep you fully informed of developments. Together we can seize the initiative, divided we can deliver nothing.

Sam Everington, Deputy Chairman of BMA
Jo Hilborne, Chairman of Junior Doctors Committee
Jonathan Fielden, Chairman of Central Consultants and Specialists Committee
Hamish Meldrum, Chairman of General Practitioners Committee
Emily Rigby, Chair of Medical Students Committee
Mohib Khan, Chairman of Staff and Associate Specialists Committee
Michael Rees, Chairman of Medical Academic Staff Committee

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

The dishonesty is breathtaking:

"...we have been and remain determined to represent and lead doctors through the considerable difficulties and pressures facing us."

Why, then, did the doctors need to take to the street and demonstrate? Why then did the doctors form Remedy UK?

• The statement is too reminiscent of Patricia Hewitt.
• There is no apology.
• There is no recognition or acceptance of the BMA’s previous failure to take action to support the junior hospital doctors.
• There is no mention of the judicial review of MTAS.
• There is no mention of the BMA’s failure to support the junior doctors during that judicial review - Jo Hilbourne in particular has some explaining to do
• There is no explanation for James Johnson’s unacceptable behaviour
• There is no mention of Remedy UK, the organisation that, more than anyone else, currently speaks for the junior hospital doctors.

The only comfort I take from this email is the presence of Sam Everington at the top of the list of names. Sam has over many years lead the fight against institutionalised racism in the NHS.

Dr Sam Everington

He has a reputation for plain speaking.

So Dr Crippen says this to Dr Everington:

Cut the crap, Sam.

Make the necessary apologies.

Acknowledge the work done by RemedyUK and get them on board.

Not in our name, Mr Johnson....

BMA Council Meeting

It is customary these days, when writing medical articles, to declare any possible conflicts of interest.

I should say now, therefore, that I am a member of the British Medical Association as is Mrs C. We are both “senior” doctors and therefore neither MTAS nor MMC has directly affected us.

We pay our BMA subscriptions by direct debit. I have just looked up the cost here and note we are currently paying £567 a year. If you are a tad idle like the Crippens, once a standing order is signed, you tend to forget about it.

We have both been members since we were medical students. We have stayed members because we like to get the BMJ, because we have this vague, atavistic feeling that we “ought” to be members and, most of all, because of inertia.

Until this year, the activities of the BMA have not impacted on our personal or professional lives. The BMA does not speak for us. It does not represent us and, whatever the public may think, it is not our trade union. In this, we are no different to the majority of doctors.

The BMA has now let the medical profession down. It has failed our hospital doctors. It has not taken the trouble to understand the plight they are in and, most recently, has sided with the government and “the establishment” in the judicial review.

James Johnson and Carol Black signed their now notorious letter to The Times. As a direct result of that letter, James Johnson has had to resign. But, and despite what I said yesterday about him being a man of honour and integrity, it is clear he still does not understand. He now has the nerve, the gall, the confounded cheek to criticise RemedyUK.

Mr Johnson said at least a third of the BMA's council was against him, although not the leaders of the individual craft committees. "But I think they are all incredibly nervous about the effect the Remedy situation is having on the BMA," he said.

James Johnson : critical of Remedy UK

He said that Remedy UK was "very good at whipping up anger but they have no solution at all ... There are 30,000 doctors who need jobs and it is our job to get as many as possible into them as quickly as possible". (The Guardian)

Had it not been for the supine inactivity of Mr Johnson and the rest of the establishment “old brigade” at the BMA and in the Royal Colleges, the MTAS debacle might well have been avoided. Had it not been for the sterling work of RemedyUK the full horrors of MTAS might still be with us. We know Johnson is out of touch but now he adds insult to injury. Even as he clears his desk, he is making defamatory remarks about junior doctor's leaders.

Yes, there is a lot still to be done. Some of those 30,000 doctors have already left the country for Australia, New Zealand and Canada. There needs to be an immediate government initiative, supported by the profession, to make sure that the doctors who remain are looked after. This is fertile ground, dare I say it, for Gordon Brown to make an immediate impression.

And what of the BMA?

Dr Grumble for one, and many others, have already resigned. However, the demise of the BMA will not help British doctors, junior or senior. And what do those “rabble rousers” from Remedy UK, of whom James Johnson is still so critical, have to say? Are they trying to destroy the BMA?

Not a bit of it.

Dr Shaw of Remedy UK said: "The bottom line is that a lot of people don't think the BMA have been tremendously representative in their views." But he added: "It is in no one's interest to have a weak BMA."

So what action should we, the silent majority of BMA members, take? The Drs Crippen wish to remain in BMA, but are no longer prepared to do this on the basis of a direct debit.

Not in our name, Mr Johnson...

We have therefore sent the following letter to the BMA. Others may care to follow:

Subscription Department
British Medical Association
BMA House
Tavistock Square
London WC1H 9JP


Dear Sirs

We write to inform you that we have both just cancelled our direct debit payments for membership of the BMA. We have taken this action as a result of the BMA’s failure to support the junior hospital doctors during their recent problems with MTAS and specifically as a result of the letter in The Times co-signed by your Chairman, Mr James Johnson.

We hope to continue to remain members of the BMA but will now be paying our subscription on an annual basis. Our continuing support will be dependent upon your taking appropriate, decisive and unequivocal action to support the junior hospital doctors.

Yours faithfully






Dr & Mrs J Crippen


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

"I am Spartacus"

A robust defense of Freedom of Speech from Tim Worstall - and a worrying undercurrent of the dangers of criticising the government.

And what did happen to all those claiming to be Spartacus?

Remedy UK fights on : BMA chairman resigns

RemedyUK knew that it was taking on the Department of Health and Patricia Hewitt. What RemedyUK did not know as it went to court was that it was also going to have to take on the medical establishment in the form of the BMA

The BMA is regarded by the general public as the “doctor’s trades union.”

It is nothing of the sort. It purports “to be the robust voice of doctors” but, sadly, it is hopelessly out of touch.

The majority of doctors who are members of the BMA joined on cheap terms as students so that they could receive the British Medical Journal (BMJ) which is owned by the BMA. Once you set up a standing order, you tend not to cancel it. They continued their membership over the years out of inertia.

The recent letter in The Times, which I reproduce in full, caused a furore:

Sir, We understand the deep concerns of Morris Brown and his colleagues but cannot support their proposals (letter, May 14).

The Review Group examined all the options available to remedy the failings of MTAS. They concluded that withdrawal from the process was simply not an option.

We accept that the Review Group’s recommendations, while falling short of the expectations of many doctors, do offer the best available solution. The solutions favoured by Professor Brown would mean writing off interviews that have already taken place and risking either posts not being filled, or shunting doctors to nontraining posts. We agree that a better system is needed, but believe that it should be achieved through argument and negotiation, not action that could risk harming patients, the NHS or our colleagues.

Doctors who only obtained one interview in the first round will, if unsuccessful, have further interviews in the second round.

We restate our support for the Chief Medical Officer and his role in improving junior doctors’ training. He pioneered the principles underlying the reform programme. Serious though they have been, it would be a far-reaching shame if those principles were obscured by recent problems with the online application system.

The mood of our institutions is not one of resignation. We are clear that our responsibility is to ensure that the underlying principles for modernising medical careers are properly met. It is vital that the profession is united to lead a way out of this crisis, and on all issues related to the future development of training. We are also actively designing a better process for future years.

CAROL BLACK, Chairman, Academy of Medical Royal Colleges
JAMES JOHNSON Chairman, Council, British Medical Association

This letter is a disgrace. The fact that it was signed by James Johnson, the Chairman of the BMA would suggest to the general public that it was written on behalf of the medical profession, that it represented the views of a majority of doctors.

Nothing could be further from the truth.

“The BMA are so ‘popular’ now that it is rumoured that approaching one THOUSAND members have resigned since it became apparent that the BMA was betraying their members by siding with the DoH against RemedyUK." (source)

The MTAS debacle has caused enormous distress to thousands of young hospital doctors, and put their careers in jeopardy. The BMA was neither been helpful nor supportive. The doctors therefore set up their own organisation, REMEDYUK.

Remedy UK is currently appearing in the High Court seeking a judicial review of MTAS. The BMA is there and represented as an “interested party”. You would have thought the BMA would have supported and assisted the junior doctors. It was not to be. The BMA has its own agenda.

Overall, the behavior of BMA has been unforgivable. It has failed to support the hospital doctors. Moreover, it has acted acted without the consent of its members and misrepresented their views.

James Johnson has now resigned. This statement has been released by the BMA:

Mr James Johnson is resigning as Chairman of Council , the British Medical Association ( BMA ) announced today (Sunday 20 May 2007)

Mr Johnson, a vascular surgeon in the North West of England has been Chairman for almost four years. Confirming his resignation Mr Johnson said : “ I had intended not to seek re-election for a fifth and final year of office at elections in June. My early resignation has been precipitated by unhappiness within the Association over a letter I sent to The Times last week, which I wrote with Dame Carol Black, Chairman of the Academy of Medical Royal Colleges, and without consulting my senior BMA colleagues. “

Dr David Pickersgill, Treasurer of the BMA said : “The letter referred to the current problems over the Government’s mishandling of the appointment system for junior doctors, known as MTAS. While it reflected the Association’s agreed position of working towards a pragmatic solution for this year, its tone failed to reflect the anger being currently expressed by members of the Association, particularly junior doctors .It was felt to be insufficiently sensitive and has led to a loss of confidence in the chairman.

“ Mr Johnson has served his profession with distinction for almost 40 years.”

“The BMA continues to be the robust voice of doctors, with renewed determination to engage with its grass roots. We remain resolved over the next days and weeks to get junior doctors’ training right – for their sakes and those of their patients. “

The BMA will now consider the process for electing a new chairman and the interim arrangements which need to be put in place.

Mr Johnson said: "I have worked with the BMA since my first attendance as a medical student in 1969. Since then, I have led both the junior doctors and the consultants, before becoming Chairman of Council. It has been a tremendous privilege to serve my colleagues through the BMA. I have enjoyed it all enormously. I give my heartfelt thanks to all the staff of the BMA, and wish my successor and the Association well. "

The third from last paragraph is going to cause outrage at RemedyUK:

“The BMA continues to be the robust voice of doctors, with renewed determination to engage with its grass roots. We remain resolved over the next days and weeks to get junior doctors’ training right – for their sakes and those of their patients.“

James Johnson is respected throughout the profession. It is sad that some one who has given such sterling service to the BMA over many years should have to resign. But he is an honorable man, a man of integrity. He made a grievous error and has therefore tendered his resignation.

It is characteristic of the man that he felt it appropriate to resign, and equally characteristic of Patricia Hewitt that she clings to office.

"Dumbing down" the nursing profession

Nurses are to be replaced by robots. No, really, it is not April Fool’s Day. It is going to happen in a hospital near you. Soon.

Nurses, those caring people who have pulled many a patient back from the brink with their expertise, brow-wiping and tender words, are likely to be replaced soon by yards of wiring, transistors, hydraulics, a motherboard and light-emitting diodes. Enter the Robo-nurse. (Independent)

As we report today, a medication-dispensing machine is coming soon to a ward near you. Robot nurses to take your temperature and blood pressure cannot be far behind. Makes sense, though, does it not? (Leader in Independent)

And the girls and boys at Dr Crippen's favourite website, the wonderful Center for Nurse Advocacy are going to love this one. In the USA they have flirtatious robo-nurses.

Sexy robo-nurse

Pearl flirts with old men. But women like her too. Her wide eyes and smiling lips lend her face an expression that hovers between vacuous gaiety and humble servility. But don’t let the vacant look fool you. Pearl is one sharp cookie. (The Mature Market)

The Salt Lake Tribune tells us that

Robot 'Nurse' Puts a Human Face on Elderly Health Care

er...as opposed to what real nurses used to do?

But no sooner have robo-nurses, flirtatious or not, been introduced than already the boffins are working on robo-nurse specialists.

Robo-nurse specialist

Robo-nurse specialist does not flirt. She does not do hands on nursing. Robo-nurse specialist keeps doctors under surveillance to ensure that they are sticking to their protocols.

There is no escape.

Quacktitioner Alert (13)

In the BritMeds below, I refer to an article by a student mental health nurse who is training to be a quacktitioner and so, predictably enough, does not agree with the views held by many doctors about the role of nurse-quacktitioners in the NHS.

The article deserves consideration for it demonstrates better than Dr Rant or I can demonstrate, the lack of insight that nurses, particularly putative nurse specialists, have about the boundaries of their knowledge and the real role of doctors.

Hang the nurse specialists

Let’s talk about a hot topic that has strong opinions in the medical/health blogosphere: nurse specialists.

The current array of advanced nursing roles - clinical nurse specialists, nurse practitioners, consultant nurses - are a frequent target of Dr Crippen aka NHS Blog Doctor. He accuses them of replacing doctors, of “dumbing down” healthcare, of taking nurses away from patient care, pretty much of being representative of just about everything that’s wrong with the NHS.

Not quite. Replacing doctors and “dumbing down” most certainly. Taking nurses away from patient care, most certainly. But I do not suggest that it is the nurse specialists who are representative of all the ills of the NHS. It is the “dumbing down” that it is the problem. I am equally critical of GPs who rename themselves as GPsWIs and fart-arse around as ersatz consultants, leaving their own patients in the hands of the under-skilled nurse practitioners.

The managerial incompetence and profligate waste of money, and the multitudinous problems in the NHS, have nothing to do with nurse specialists and I have never suggested that they do. The nurses who remain in nursing caring for patients, and would I guess have to be called “nurse nurse specialists”, are the bedrock of the NHS. There is no better example of these than the district nurses. "Nurse nurse specialists" are undervalued, underpaid and abused.

His opinion matters, because he’s the most popular British medical blogger out there. His castigation of the “nurse quacktitioners” has been echoed by other blogging doctors, such as Shiny Happy Person and Dr Rant.

No, you are wrong. Both SHP and the Dr Rant team are independent and strong minded professionals who reach their own conclusions. The fact that we broadly agree does not mean we are echoing each other.

So, nurse specialists and nurse practitioners. They’re useless, they’re destroying the NHS and all doctors hate their guts. Right?

Wrong. They are not useless. They are not single handedly destroying the NHS, and doctors do not hate them. Most of them are well meaning, but have been overpromoted into positions in which they are out of their depth. They flounder around with their clip boards and protocols making tits of themselves.

I refer frequently to my old friends Sue and Dave, though we have not met them for a while. Regular readers will remember that Sue and Dave produced a document explaining how NHS hospitals would be better run at night by nurses rather than doctors. Pause a while to re-read the most delicious piece of bureaucratic botty-wipe that they produced in "Getting a picture of night with Sue and Dave"

Nurse specialists are not medically trained and cannot replace people who are. Those people are called doctors.

You don’t currently see all that many of these roles in psychiatry (though there seems to be an increasing amount of nurse therapists delivering CBT interventions) so I took advantage of a sojourn over to the world of “proper” medicine and nursing to find out more.

Well, you have CPNs who are nurse specialists with autonomous roles that complement doctors. They are very helpful. They are not psychiatrists, and do not pretend to be. However, what we do have in mental health now is the CMHT which is composed of a collection of people, most of whom are not even trained nurses never mind trained doctors and are destroying British psychiatric care. They are cheap though.

On the ward where I’m currently placed, we have a number of patients with a diagnosis of epilepsy. The local epilepsy unit was holding an open day, so I decided to ask if I could pop over to their open day and increase my epilepsy knowledge. The ward manager readily agreed, asking me to “grab any leaflets that they’re giving out, in case they’ll be any use for us on the ward.”

So, I head over to the epilepsy unit. I grab leaflets, I scrounge free tea and biscuits, I go “oooh” at the technological wonders of the EEG (what can I say? I’m a techno-geek, and you don’t get to see much fancy technology in psychiatry. An X-Box for the ward is about as hi-tech as we get). A consultant neurologist is giving a talk on the subject of “living with epilepsy”, so I decide to sit in on his talk.

During the talk, we see a video dramatisation of a consultation between a patient with epilepsy and the consultant neurologist. At one point in the video, the consultation tells the patient, “I can see you’ve got a lot of ongoing concerns, so I’m going to book you in for an appointment with the nurse specialist.” Aha! Nurse specialists! Useless amateurs, the lot of them! Though I can’t help noticing that in the video he doesn’t appear to be seething and gritting his teeth as he says it. Maybe he’s just not a very good actor.

So sweet, and so naïve. Like all putative nurse-specialists, you think that a short lecture with a pot of tea and a plate of Bourbon biscuits can make a silk purse out of a sow’s ear. Or a doctor out of a nurse.

During the question-and-answer session, I ask him, “I noticed that you referred the patient to a nurse specialist. Could you tell us more about how the workload is divided between the doctor and the nurse specialist? Who does what?”

“Well”, he replies, “The nurse specialists add value to our service by providing an extra level of continuity. They give advice and counsel the patients about their concerns to do with epilepsy. They answer phone and e-mail queries. Increasingly they prescribe - not in terms of starting people on new medications, but things like adjusting the doses up and down. When delegating tasks to a nurse specialist, I take account of their level of skills and experience. For example, we’re lucky in that we have a nurse specialist who’s worked here for 15 years. Obviously you just can’t buy 15 years of experience in epilepsy, and she’s very knowledgable on the subject. If she were to leave and be replaced by someone starting from scratch, then obviously that person wouldn’t have the same skills and I wouldn’t delegate the same tasks. The nurses don’t do things like diagnosing epilepsy or starting new treatments - I do that.”

What’s your point, mental nurse?

This poor neurologist no longer has experienced junior hospital doctors on his firm and so has to make use of nursy. She has been around for a few years and he is prepared to let her alter the dose of drugs. By the way, that IS prescribing. And he takes responsibility for what she does. And note, she has been there for a mere 15 years but in that time has not learnt how to diagnose epilepsy.

She is not clever enough to do that. She has not been to medical school. She was probably not clever enough to do that either.

Have some more Bourbon biscuits.

Well, that actually sounds rather sensible, to be honest. It also provides a good repost to Dr Crippen’s argument that all the nurse specialists should be sent back to the wards to do bedside care, because that’s where their skills lie.

Crap.

It is helpful for the neurologist to have nursy around to pat the pateint's hand and fiddle with the dose of drugs, but she is only there because she is cheaper than the doctors who used to be there. She is of value in terms of providing general support for the patient but currently, when patients are dying of bed sores and starving to death due to lack of nursing care, yes, she would be better back on the wards doing some nursing.

I’m not trying to deny that good quality bedside nursing care is vital and is a skilled role, but if you have a nurse who has spent 15 years working and training in epilepsy, then it strikes me as nonsensical to suggest that she should get out of the epilepsy clinic and go pick up a bedpan.

Agreed. She should never have done the 15 years pretending to be a doctor in the first place. Think of all the bedpans she could have emptied in that time.

After the talk, I’m scrounging more tea and biscuits, and I bump into the neurologist. He asks me if I’d had an appointment with a nurse specialist and that was why I was asking.

Heavens, more tea and biscuits; you must have turned into a senior nurse specialist by now.

No, I’m a student nurse,” I reply. “I was just curious as to what her role was.”

“Well,” he says, “We definitely need more nurse specialists, especially in primary care. Because continuity of care is currently lacking, and the nurse specialists provide that continuity.”

Crap. The continuity of care in the community is provided by the family doctors. Remember us? We are the ones who went to medical school and are trained in diagnosis and prescribing. These peripatetic nurse specialists wandering around the community are an absolute liability.

Then he wanders off to mingle some more, while I suddenly develop mental images of Dr Crippen, Dr Rant et al collectively developing an acute case of Exploding Spleen Syndrome at his words.

Yes, we will. Because we see the standard of UK medicine going down the tubes as people with neither the training nor the intelligence take over jobs that need to be done by doctors. And still are done by doctors in the private sector

While we’re on the subject of nurse specialists, mind if I lay to bed a certain myth that I keep hearing repeated on medical blogs. Time and again, I come across people (usually doctors) commenting that “nurse specialists are cheapo doctors for the NHS. That’s why you don’t get them in the private sector.” Dr Crippen has repeated this myth.

Nurse specialists are not “cheap doctors”. They are just cheap.

“The NHS lung cancer patient gets his hand patted by the “lung cancer nurse specialist. The private patient gets Tarceva.…The poor folk can be educated in the comprehensive schools by teaching assistants, and have their health needs catered for by nurse-practitioners and health-care assistants. The rich will continue to pay for public schools and for medical advice from doctors." (Dr Crippen)

Simply untrue. For the record, nurse specialists are not just found in the NHS. The private sector uses them too. This can be found out easily by simply picking up a copy of the Nursing Standard or Nursing Times and turning to the jobs section. If you can’t find a copy, just google the words “nurse specialist bupa” and see what you get.

You really don’t get it, do you. There is and always has been a role for nurses to work with doctors in the care of patients. The Breast Care nurses are a classical example. They work under the supervision of oncologists and provide an excellent service to patients. But they are not a substitute for doctors and are not used as such.

The same in not the case with lung cancer in the UK which is still badly managed, often by chest physicians who have no interest in lung cancer and quickly hand the patients over to the lung cancer nurse specialists. The hand patting may be plausible but the patients die more quickly than they would in Europe and the USA. But then in Europe and the USA, the patients see oncologists not nurses.

My patients die without Tarceva; sometimes without radiotherapy because there is not enough kit, and sometimes without even the benefit of seeing an oncologist. Until such time as there are enough oncologists, enough linear accelerators and enough Tarceva, you can stick your lung cancer nurse specialists up your arse.

The moral of the tale is this: blogs like Dr Crippen’s might be popular, but at the end of they day they’re still just one man’s opinion, and not necessarily an informed opinion at that.

The moral of the tale is that my blog does of course express my opinion and no one else's.

You are perfectly entitled to disagree, but do not call me uninformed. Remember, whilst you are sitting drinking your tea and eating your Bourbon biscuits, I am out in the real world, looking after my lung cancer patients who die sooner than they should because of second rate care provided by second rate people in a second rate service.

It is stressful taking responsibility for patients dying more quickly than they would if they were rich. (see A Tale of Two Cancers) Dying because their care has been delegated to nurse-specialists. I would not expect you to understand that. You are a nurse, and a student nurse at that. I suspect from your tone that you may one day be a nurse-specialist yourself.

Have another Bourbon biscuit.

The BritMeds 2007 (20)

We should treat our doctors like gods
By Andrew O'Hagan

Let us stop talking about British health institutions as if they were something to be ashamed of - undermining them, short-changing them - and railing against our health workers as if they were behaving shamefully, and let us begin to invest a little feeling and a little belief in what they are and what they could be.

A work of genius

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

Patricia Hewitt is a crooked, dishonest, scheming, unprincipled, oleaginous, incompetent, transparently ambitious, devious, calculating, wily, underhand, Machiavellian, corrupt, amoral, deceitful, unethical, insincere, unscrupulous, inept bungling slime ball.

You think I am exaggerating?

Read this delicious story about Hewitt, unearthed by the ever reliable Mr Eugenides.

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

Wasting money on medication?

The BBC and the Guardian have both run a story about £100m worth of drugs being wasted each year by patients. I'm shocked. Shocked that it's only £100m per year. The real figure is going to be far higher. I have returned medicines collected every couple of months by a contractor. They normally take away seven or eight sackfuls of drugs - thousands of pounds worth. As an example, I have had two boxes of Casodex (at £240 per box), two seretide 250/25 inhalers (£75 each) and 30 diamorphine ampoules returned recently. Once something has left the pharmacy it can't be reused. There are two reasons for this. Firstly I don't know how it has been stored, and secondly I have already claimed payment for the drugs…..

The UK Commuity Pharmacist shows it is even worst than you thougt.

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

A memo to Gordon Brown:

If you could change 5 things about how the NHS is led and managed what would they be? An American reader emailed this question to me yesterday and I've been mulling it over this evening, during a train journey to Edinburgh.

The Changing NHS

++++++++++

Closing down maternity units

A hospital administrator (poacher turned gamekeeper – she used to be a nurse) seems to argue that maternity units are not safe if they are not backed up by paediatric units. So, if you have no paediatric unity, you must closed the maternity unit.

But, just a minute, who closed the paediatric units?

Let's not jump to conclusions…

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

The cost of medical care for a hamster

How much should GPs get paid compared with, say, vets? They plainly get less - or so Dr Grumble thinks. Dr Grumble knows quite a few GPs and he has been in their homes. Mostly they are very modest. He knows where his vet lives (Mrs Grumble once had 22 pets to care for). He has not been in the vet's house. It's up a very long drive and there are big electric gates at the end. There's usually building work going on there - new swimming pools, that sort of thing. It's very grand….

Dr Grumble compares GPs and Vets

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

GPs prescribe too much Prozac

There is no help for us, except our GPs.

Since I called that health visitor for help all those weeks ago the only person to have shown concern is my GP. The health visitor hasn’t rung back to check on Zach’s welfare or me. It makes me wonder what the hell health visitors are for? That’s a lot of salary for a weekly weighing machine.

Emily tells the other side of the story in Prozac Nation

+++++++++++

Big Pharma rules, OK?

The cost of drugs has been rising at about 7% every year compared with the rest of the costs of the NHS at about 3%. Big pharma has the NHS over a barrel and spend a great deal of time selling its wares through talking to patient groups, doctors and the media. Headlines such as 'NHS refuses to treat alzheimers patients' are a clear example - perhaps it is because the new drug is unproven, unreliable, ineffective , and therefore pointless.

Green the Health Service

+++++++++++

Hang the nurse specialists

The Mental nurse (specialist?) comes out fighting

The moral of the tale is this: blogs like Dr Crippen’s might be popular, but at the end of they day they’re still just one man’s opinion, and not necessarily an informed opinion at that.

Quite right too.

See The Mental nurse and the Dr Crippen reply here

+++++++++++

Truly righteous indignation from an angry medical student sitting exams

Firstly - I wrote about Monday's exam here, since then, it has come to light that that some students at one of the base hospitals were given 35 extra sample questions at a revision session for their base hospital. Of these 35 questions, 12 appeared in the real exam.

Full story here

+++++++++++

Trotting up Everest with Tony Plant

Tony’s Happenstance blog had always been a source of “good things” but has been silent recently. And no wonder. Someone just spotted him on Everest.

Click on the photo, Tony Plant (Happystance) is the chap in front, on the left hand side, wearing the Buff beanie.

He looks happy and healthy enough. Apparently, Trek K made it to Base Camp in a new record time. Excellent news because the last that I heard, Tony was 1 of only 3 people out of the 16 who had *not been 'visited by the monkey' which I gather is a local colloquialism for a nasty GI infection - the scourge of many treks.

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

Closing hospitals

Under current reconfiguration plans City Hospital, the most central general acute hospital in Britain's second biggest city faces losing inpatient beds for emergency general and trauma surgery and for children.

Supporting City Hospital

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Words failed Dr Crippen when he read this article by some batty old coote. Can someone help?

A healthy attitude to politics

Patricia Hewitt is an intelligent, clear-thinking, diligent minister with an an aversion to social oiliness - she is far from incompetent.

“In praise of Patricia”

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Too much sex

The NHS is failing to ensure all non-emergency hospital patients are kept in single-sex accommodation, the government has admitted. Campaigners say mixed-sex accommodation denies patients the chance of treatment with "privacy, respect and dignity".

Socialized medicine

+++++++++++

I was NOT being witty

NHS Blog Doctor has been doing an energetic job publicising the MTAS débacle. He wittily goes on to suggest that the Nationalised Health Service should have a fee at the point of use…..

Purple Scorpion

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More lies, lies, lies from the BBC….

The BBC Cancer Week news special is really getting on my nerves. Every day they spew forth more smoke and mirrors rubbish for English consumption.

Waking Hereward

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A breast specialist looks at Patricia Hewitt's boobs

Time was when anyone with a vibrator up their rectum would have their x-rays shown around the doctors mess - with the marvels of PACS and the NHS IT system the images can be shared with the whole world. Let all hope it's not Patricia biggest boob.

Dr Ray

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Dangerous bugs are on the rise

…blood-sucking creatures move north. So how can we protect ourselves?

Kate Craven

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It’s not just MTAS that leaks like a sieve

The medical testing arm of pharmaceutical giant Roche has exposed the personal and medical details of UK customers on its website. The firm has admitted the security breach but has not explained how it happened. Customers who had registered their details with Roche Diagnostics received the first edition of an email newsletter on Wednesday which included a link via which they could update their personal details. Users who clicked on that link were directed to a Roche website which displayed the details of someone else.

The Register

++++++++++

And it is not just MTAS and Big Pharma that leaks like a sieve

30,000 disabled people had sensitive personal information including bank account details stolen last September, Liberal Democrat research has revealed.

Recipients of Independent Living Funds and civil servants working on the scheme had personal information including their names, addresses, National Insurance numbers and bank account details stolen when a van was broken into last year.

Public Technology

+++++++++++

Famous blogger prints picture of injured patient

A courageous post from Random Acts of Reality

Tom Reynolds

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Rant and Crippen are in trouble…

Some of the more notorious sites such as the tasteless Dr Rant have, I regret to inform you, been less than generous in their assessment of yourself and your predecessors in the Department of Health. By pointing out deficiencies in the NHS I believe these sites are subversive and serve to increase patient anxiety. It may be that these sites seek to drive patients to the private sector by circulating tales of patients being treated by unqualified quacktitioners on MRSA infested NHS wards and in support of this I would point you to the large number of advertisements for private care on the disgraceful Dr Crippen Blogsite.

A new voice

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Discrimination

Two lesbians who lost their nursing jobs have won what is described as a record amount in a sexuality discrimination case in the UK.

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NHS fails cancer patients

Cancer patients are being systematically let down by the radiotherapy services in England, a damning government report concludes. Lengthy waits and huge variations in service from place to place mean that tens of thousands of patients every year are receiving substandard service, reducing their chances of survival. The report to ministers from a top-level committee, whose broad conclusions were first revealed in The Times last month, calls for urgent action. "Unless action is taken without delay, the Government will lose the opportunity to save lives, and services in this country will fall further behind those of other comparable countries" the National Radiotherapy Advisory Group says.

Socialized medicine

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

Transform????

The latest web technology has the potential to disrupt the NHS status quo - but it could transform our experience of healthcare

Paul Hodgkin and James Munro

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Medical student needs help

If any of you doctor types out there have any useful advice or tips for me, please please please leave a comment! That also includes any 4th/5th/final years who have been through the thing before.

Of short white coats

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A lament for the Fat Doctor

It was with great sadness and a sense of irritation on her behalf, that I discovered yesterday that the Fat Doctor blog is no more. Some wicked person had found it, printed the whole thing out and shown it to her boss…….

Life in the NHS

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

Older people are often denied medical treatment because of age discrimination.

Obesity and the Salt conection

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Spring cleaning the NHS

ANGRY doctors ambushed health secretary Patricia Hewitt amid allegations their hospital was specially cleaned for her visit.

Full story here

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Even the rich and famous need ambulances…

It was Saturday night, and my friend A and I were off to a party somewhere in the midsts of the West Sector, in one of those places that I’m not convinced really exists. I should have known it was a bad idea. It was a very decadent party, with a outdoor jacuzzi, a chocolate fountain

Newnaw in West London


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Whistleblowing in the wind?

A new hotline for those who suspect malpractice in medical research has not been universally welcomed.

Science Misconduct

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

The MMC/MTAS week

still she clings on to office

The final update from RemedyUK on:

Patricia Hewitt v the doctors

RemedyUK

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A detailed analysis of the mess left behind now that MTAS has gone. The problems are only just beginning.

An excellent article from Dr Grumble

Unfinished business

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

The now famous HACK cartoon for RemedyUK

Take a look here

+++++++++++

As always, the Ferret Fancier has an excellent selection of articles:

Doctors, nurses and other NHS workers are quitting the NHS in their droves. Some are emigrating and others are switching careers. These highly skilled workers did not come cheap either, each doctor cost over two hundred thousand pounds to train.

The "flexible" labour market

This letter in the Times by Carol Black and James Johnson has created a storm of controversy with hundreds of doctors writing to voice their disagreement. It must be noted that Carol Black was directly appointed by Patricia Hewitt to her role, and that the DoH is refusing to release information concerning how she has been briefed to carry out this role. James Johnson is the beleaguered BMA boss who seems intent on siding with the government in just about everything.

Bite My Arse - the BMA

Either way, there does come a point where appeasement is no longer an option. That point was passed long ago, the malignant quango PMETB has been used by the government as a tool to force through their cynical policies.

Appeasement is rife

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


The Save Bedford Hospital site says:

See you in court

a junior doctor’s view


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Nail hit on head shock horror

MTAS: Ditched. Hewitt: Still on £255,000 a year.

SJHoward

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Patricia Hewitt in the Dock

Dr Michelle Tempest


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The DK discovers the real culpril behind MTAS.

Given this mind-boggling catalogue of incompetence, laziness, and stupidity we really should be looking for someone to blame. So who should that be? Let's look to PMQs to enlighten us, shall we?

Mr Hague said his question had been about junior doctors. He asked who was responsible in government for the "fiasco" of the online recruitment system.

After a pause, Mr Prescott said….

You will not believe the answer. All at the Devil’s Kitchen

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The risks of the MTAS whistle blowers being prosecuted.

Will bloggers get the blame for DoH mess?
Criminal charges for who?

Tim Worstall

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And from Dr Rant…

This piece was written by Dr Clive Peedell, whom Dr Rant greatly admires. His words have appeared here several times in the past. It was originally posted on DNUK, and provides the evidence that shows MTAS was used a research project for Professor Fiona Patterson to help validate her ideas for selection of doctors into higher training.

This is a scandal.

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MTAS canned

"She added that intensive security checks had been made of the website and the MTAS computer system, allowing it to reopen partially. A report was being sent to the police and Miss Hewitt admitted that "criminal offences may have been committed".

Indeed, criminal offences may have been committed. In fact, I'd say it's very much an odds on certainty. So we have the (I believe a reference to Kafka is obligatory here) situation whereby a grossly incompetent, almost certainly law breaking, computer system is online but anyone who checks that it is indeed lawbreaking and/or incompetently put together is guilty of an offense.

More from Tim

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And the cost of the MTAS fiasco?

Let’s start at £6 million…..

Burning our money

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

The BritMeds will now be published on Saturday morning, so please let me have your recommendations by Friday evening latest.

Closing maternity units

"We favour free-birthing"

The debate about home births and hospital births rages on, now spiced up by the intervention of the American “free birthers” who come from the land of obstetric insanity. The recent article is still alive with comments and contributions.

Dr Crippen feels sure that it is only a matter of time before a child sustaining physical or mental damage as a result of the mother’s dangerously eccentric views on obstetric care is given a legal right to sue his mother for damages. And the "free birthers" will be amonst the first to receive the writs.

Meanwhile, Hewitt is closing maternity units throughout the UK and telling mothers to be that they are to have the right to choose a home birth.

They also have the right to choose a sink comprehensive school rather pay for their children to have the elitist private education that wealthy left-wing “socialists” like Diane Abbott buy for their children. Diane campaigns for better education for black children in London but her son went to the City of London School, current fees £3816 a term.

So many maternity units are being closed that soon home births will not just be an option. They will be the only option. To get decent care mothers may well have to go privately. If you are a socialist and against private medicine, I am sure Diane will advise on matters of conscience.

Even the choice of units for closure is crooked. Hewitt tries not close hospitals in Labour marginal constituencies.

Currently, 43 maternity units are under threat of being downgraded or closed, or have been closed.

• 26 (60 per cent) are operated by providers which finished the 2005-06 financial year in deficit.
  
  
• 29 (67 per cent) are situated in Parliamentary constituencies held by opposition MPs (Conservative, Liberal Democrat and Independent).

When you are trying to make up you mind about the wisdom and safety of home-births, read through the comments under the article “Going it alone : the “free-birthers”.

Dr Crippen would not let some of these commentators supervise a chicken laying an egg at home.

You can make up your own minds.

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Comments under the original article here

Going it alone : the "free birthers"

Laura Shanley : Bornfree

I have only ever seen one post-partum haemorrhage.

I was a medical student at the time. I was observing a normal delivery in a "low-risk" fit young women in her late twenties. Second baby. First baby born two years previously with no problems. The baby was born without difficulty, without an episiotomy, without even much of a tear. The midwife was waiting for the delivery of the placenta which was not coming. She was doing gentle controlled cord traction. There was a sudden gush of blood. The mother said, “Oh dear, I feel strange” and asked her husband to take the baby. I glanced down at the “business end” to see a sudden torrential flow of blood. There were two midwives present. Both were excellent. I was dispatched to get the registrar, who was next door. I returned with him to find that the mother had lost consciousness. This was a London teaching hospital. Within a matter of minutes there were two experienced obstetric registrars and an anaesthetic senior register in attendance. I was once again dispatched to get the emergency supplies of blood. I have no idea how many units of blood were transfused. By the time the patient was in theatres the consultant had arrived. I stood at the back. I can remember seeing the sweat on the consultant’s surgical cap. It was the first time I had seen a surgeon, and a good surgeon at that, seriously stressed.

The mother survived and walked out of hospital in good health. I have not the slightest doubt that if this had been a home delivery, the mother would have died. I fear that in a “modern” understaffed maternity unit where there are not enough midwives, never mind enough doctors, that the mother would probably die.

It made a lasting impression on me. I have never seen the like of it since. But from that moment onwards I was resolute in my determination not to have any truck with home deliveries.

Today, I am quoted in the Guardian in an article entitled "Going it Alone":

The controversial NHS doctor who writes an award-winning blog under the pseudonym "Dr Crippen" has proposed that at some future point women will be sued by their (damaged) offspring for having had a home birth (let alone an unattended one).

I suspect it will happen. And why should it not? Does a mother not owe a duty of care to her baby? Should a mother not take reasonable care to protect the baby when she gives birth? And if she does not take reasonable care – and the standard should be objective not subjective – why should a baby who has sustained avoidable brain damage due to the mother's negligence not take action against his mother? This is well within Lord Atkin's neighbour principle:

You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbour. Who, then, in law, is my neighbour? The answer seems to be — persons who are so closely and directly affected by my act that I ought reasonably to have them in contemplation as being so affected when I am directing my mind to the acts or omissions that are called in question. (Donoghue v Stevenson)

Going it Alone states:

“…the government is planning to introduce new - and prohibitively expensive - insurance requirements for independent midwives who currently provide private backup to women who have found it difficult to arrange an attended home birth on the NHS."

This is, with respect to the author, misleading. The government is not racking up insurance premiums, it is merely insisting – and rightly so – that midwives attending home deliveries should be properly insured. Midwives working within the NHS who attend and supervise home deliveries are properly insured. They are properly trained too.

There are however some midwives who do not approve of NHS obstetric care and chose to work “independently.” There is no insurance company in the country that will insure them. This is a business decision, not an emotional one. Independent midwives are a liability. They do not understand that giving birth is the most dangerous thing that most woman will do during their life.

Not only do the Independent Midwives not understand the danger, they think they are infallible. Annie Francis, spokeswoman for the Independent Midwives’ Association said:

“Most clients understand you can’t insure against things going wrong during childbirth, only against negligence, and negligence is not really an issue for us”

Negligence is “not really an issue for us.” Breathtaking! Read here what happened to an independent midwife who did get into trouble.

Going it Alone is not just about home births conducted by midwives, independent or otherwise. It is about a new fashion that is gaining popularity in the USA. The fashion for “freebirth”. No doctors. No midwives. Do it yourself.

Although rare in the UK, there is a growing online community of freebirthers or "UC-ers" (unassisted childbirthers) in the US who are celebrating "the primacy of autonomous birth". Laura Shanley, 49, from Boulder, Colorado, author of Unassisted Childbirth (Greenwood Press) and veteran of five unassisted births, believes that "women are the true experts of birth. Birth is sexual and spiritual, magical and miraculous", she says, "but not when it's managed, controlled and manipulated by the medical establishment." Her website motto? "If you want the job done right, do it yourself."

Dr Crippen believes that a baby sustaining injury during a deliberate “freebirth” should indeed have a legal remedy against his mother. And I would go further. If a baby were to die of an avoidable cause due to and during a “freebirth”, the mother should be prosecuted for manslaughter.

The baby does not have a choice and must be protected.


++++++++++


Guardian article "Going it Alone"

The Crippen Diaries 2007 (20)

Not quite Emergency Ward 10

Monday 14th May

Stress at home this week as we start the first day of AS levels and GCSEs.

A glass of orange juice and a brief look at The Times. GPs are front page news again. This time we are accused of filling up the customers with Prozac, inappropriately and unnecessarily. Well, that is the implication anyway.

Paul Farmer, chief executive of Mind, said:

“Doctors are guilty of a knee-jerk reaction in prescribing pills, which are commonly long-term prescriptions and have well-known issues with side-effects. The mindset of GPs will have to change so that they consider counselling and other forms of therapy as a frontline treatment.” (The Times)

That’s great, Paul. We will send everyone for counselling, for “Talking Therapy”, and then for an all expenses paid holiday in the Caribbean. We are as likely to get the latter as the former. My practice no longer has routine access to therapists, they were taken away. Government cuts, don’t you know. We have poor psychiatric services generally and a CMHT staffed by amateurs many of whom do not know what they are doing.

Add on to that the increasing public expectation that there should be a “pill” for everything ever increasing consumer demand for Prozac, and you have a receipe for disaster.

It is not just GPs. Hospital doctors dole out SSRIs with gay abandon too, and many nurse specialists think that anyone with an upset – particular a bereavement – should be on medication.

Far too much of this junk is prescribed. My practice, for what it’s worth, is one of the lowest prescribers of the stuff in the county. We try to avoid it. Easy to say. You may not believe me. Suit yourself.

Driving into work, I listen to the Radio 4 Today programme. Hamish whats-his-name from the BMA is being given a hard time by Naughtie. Same old stuff. GPs are idle, are providing a lousy service and are ripping of the NHS. Time they did some work to justify there obscenely high salaries.

I arrive at the Health Centre. One of the receptionists hands me a copy of the PMJ. She does this to annoy me. She knows my views on it.

Brown to tackle £100,000 a year GPs over pay and hours

Gordon Brown is heading for a showdown with family doctors over their six-figure salaries. He will tell them to bring back proper out-of-hours care or effectively take a pay cut. GPs will be ordered to see patients in the evenings and at weekends to justify their bumper salaries - which have risen to an average of more than £100,000 in the last few years. A source close to Mr Brown insisted the GPs' contract would not be 'torn up'. Instead, he said, the existing deal would be modified to divert money away from those who do not provide out-of-hours care towards those who do.

I suppose I should try not to get angry about statements in the PMJ.

“GPs will be ordered…” “bumper salaries…” “the GPs’ contract would be…modified to divert money away from those who do not provide “out-of-hours” care towards those who do.”

So, a quarter of the QoF money will be taken away and given back to the GPs who start doing out of hours work again. Gordon may be in for a surprise. Providing an out of hours’ emergency service is one thing. Providing a walk in service for people who want their athlete’s foot treated on Sunday afternoon is quite another.

Brown needs a rabble-rousing soft target, and it seems we have got the job. The misconceptions abound and will be perpetuated. It is the same nonsense as the criticisms of the consultants who are now portrayed as doing less work for more money. I cannot be bothered to argue any more. Even some of the junior hospital doctors, who you would think would know better, seem to be jumping on the bandwagon.

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

The first patient is David, a 78 year old with prostate cancer. He had radical radiotherapy and currently his PSA is less than two. So far, so good. However, he has residual radiation cystitis and proctitis and so spends most of his life in and out of the lavatory. He also has ischaemic heart disease and COPD. The angina is well under control, but his exercise tolerance is poor because he is short of breath. His medication needs careful juggling and frequent review. Try taking diuretics when you have radiation cystitis. David is frightened by prostate cancer. He knows it can go to the bones. His staging bone scan was negative but he is particularly frightened of bone cancer because his wife died last year of myeloma, which affected her bones.
So, apart from all his physical ailments, David is bereaved. He is thoroughly fed up. To make matters worse, he has just had a letter from DVLA in Swansea which encloses a complicated form asking a variety of questions about his illnesses. If he loses his driving licence he will have real difficulties, so he wants me to help him fill in the form.

Clearly a small dose of Prozac will sort him out.

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Tuesday 15th May

The first patient limped in and was grumpy. He had strained his back lifting a heavy tea-chest into his van. He saw one of my partners three days ago, the day after the injury. From the notes he had been properly assessed and given both appropriate advice and appropriate analgesia.

He was not worse, but he was no better. I had nothing to offer. He just needed more time, which is what I told him. And no, I was not “going to give him something else”. I did not have anything else to give him.

Expectations are too high.

+++++++++++

I spend a long time with a 22 year old girl who came in with bronchitis. She has mild asthma. Her peak flow was fine, she was taking her inhalers but unfortunately she was also taking between 20 and 30 cigarettes a day. Some smokers are not receptive to advice. She was. We discussed various psychological strategies. She decided to use nicotine chewing gum rather than patches. I think the gum is vastly superior but it is still only a crutch, an adjunct. You have to want to stop. I arranged to see her again next month.

When she had gone I filled in the new Government QoF smoking template. Lots of reasonable bits of data, like how many cigarettes a day, and then finally a question as to whether I had “referred her to a smoking adviser.”

The template does not contemplate the possibility that I might give her advice on stopping smoking. Actually, though I say it myself, I am good at it. See the Crippen “Stop smoking in 28 days” programme.

I have had a lot of success with it.

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Thursday 17th May

Nicholas is an alcoholic.

He is now in his mid-fifties and is in steady employment working as an administrator in a software company. In his early thirties he nearly drank himself to death. His life was saved not by the NHS but by Alcoholic’s Anonymous. He has been dry ever since, with two lapses. The first lapse was twelve years ago. The second lapse was three weeks ago.

He stopped going to AA about ten years ago, which is a shame. But he felt that they were no longer right for him. He is a non-smoker and could not find a non-smoking group. Also, over the years and despite all they have done for him he began to find their approach a little too evangelical. And so, after his last lapse, he asked if I would arrange for him to have some support from the Alcohol Unit of the local psychiatric department.

By the time he came to see me, he had already stopped drinking again. He looked rough, and his gamma GT was over four hundred. When Nicholas drinks, he drinks. He had thrown away his BP medication and his cholesterol tablets and so, aside from the alcohol problems, he needed a medical “sort out”.

He is back on the straight and narrow now. His gamma GT is back in double figures, and falling, and his BP is back to normal.

He is an interesting man. We have talked at some length about why he lapsed, and how he felt about the lapse and how he felt when he was drinking. And he has been covering this ground as well at the alcohol group. One of the other members of the group was an Irish alcoholic, who we will call Seamus. Nicholas and Seamus have struck up a friendship.

Last week, Seamus turned up to the group ten minutes late. He had not been late before. When he sat down, it was clear that he had been drinking. He was not paralytic, but his speech was slurred, and he smelt of alcohol. When challenged by the group facilitator he admitted he had been drinking. He was asked to leave immediately. He had broken his contract. You are only allowed to attend the group if you are sober.

WTF is that about, doc, asked Nicholas. It is easy for us all to sit and chat when we are sober. But we need help when we crack and start drinking. That is when we are really fragile. If AA had not taken me in, drunk, dishevelled, dirty and desperate twenty years ago, I would not be alive today.

I don’t have an answer. I think the word “resources” comes into this somewhere. It is more cost efficient to help those who are helping themselves.

Nicholas will not be going to the alcohol group again. He is going to put up with the cigarette smoke and return to AA. And he is going to take Seamus with him.

The beatification of Blair

It is well know that Tony Blair is a religious man, that Cherie and the family are practising Catholics and that Blair himself has been quietly moving towards Rome.

Rightly and properly he has always maintained that his faith is a private matter.

Fascinating, though, to read in today’s Times that:

Blair will be welcomed into Catholic fold via his ‘baptism of desire’

Tony Blair will declare himself a Roman Catholic on leaving Downing Street, according to a priest close to him.

Father Seed said: “He’s been going to Mass every Sunday. He goes on his own when he is abroad, not just when he is with his wife and children.”

Another church source said that many of the early saints and martyrs were not baptised. Such people were held to have had a “baptism of desire”.

Saints and martyrs?

In view of the Prime Minister’s eminence we can surely expect an accelerated beatification. Canonisation is the final step. However, in the case of a candidate who is not a martyr, the church looks for another authentic miracle attributed to the candidate's intercession, as a sign from God of the candidate's heroic holiness.

There can be little doubt about Tony Blair’s heroic holiness. It is indeed chronicled every fortnight in Private Eye (see the latest sermon from The Vicar of St Albion here )

So, we all accept that he is heroically holy. But looking back over the last ten years, I am struggling to find evidence of a miracle.

Can anyone help?

Charlie and the paedophiles

"Over here, young man!"

Over the years, I have had a number of young men with serious psychological problems as a result of the sexual abuse they experienced as small boys. This sexual abuse was always inflicted upon them by adults in positions of trust and responsibility, frequently Roman Catholic clergymen. It would be wrong to suggest that the Roman Catholic Church has a paedophile monopoly. It does not. However, the Roman Catholic Church’s record of covering up for paedophile priests is a scandal of international proportions and a scandal which the current Pope has manifestly failed to address. But then perhaps he would not be expected to address it as he was himself one of the leading paedophile protectors.

What is it about this dreadful criminal offence that makes the so called leaders of society, and in particular the Roman Catholic Church, so two-faced? Condemn it publicly, but cover it up in private.

I was appalled today to see that the government, the Lord Chancellor no less, has taken a leaf out of Obersturmfurher Ratzinger’s paedophile protection manual.

The Lord Chancellor has been forced to disclose that he holds a list of judges disciplined for misuse of their computers, including viewing pornography.

The ruling on disclosure by Richard Thomas, the Information Commissioner, comes after Lord Falconer of Thoroton’s ministry, the Department for Constitutional Affairs, refused to divulge the number and rank of judges and magistrates who have been disciplined. But Mr Thomas said: “It is important for the public to know and be assured that the Lord Chancellor [now the Office for Judicial Complaints] thoroughly investigates each and every allegation of computer misuse by judges.”

…In its first ten months, the Office for Judicial Complaints has investigated 1,434 complaints against judges, magistrates and other judicial office holders, but no breakdown has been given as to how many relate to judicial misconduct. (source)

What is going on? In the modern NHS it is very hard to get appropriate psychological therapy for the victims of child abuse and by then the horse has bolted. We prevention, not cure. The perpetrators need to be locked up.

But, if the judges are all at it, who is going to lock them up?

MTAS whistleblowing

Big brother is watching

Back to MTAS, the second security breach, and the threat of prosecution.

I really cannot take it seriously, though the appearance of the above cameras across the road from my house concentrate the mind somewhat.

And yet it seems that, by testing the security of the system, I did break the law.

Today, in "Will Bloggers get the blame...", there is further detailed analysis:

Distressed at being informed of such a gaping loophole in the system he went to have a look for himself. This is a criminal offence - hacking a computer system. Unable to believe what he saw, he asked a few trusties to have a look themselves - another offence, incitment to hack a computer system.

Having committed these offences, what did the Good Doctor do then? He informed the Department of Health and the system was taken down within a few minutes, thus preventing said department from continuing in their own breach of the law. (Tim Worstall in The Register)

The prospect of legal action is too silly for words. Even Hewitt, in her last few days of office, is not stupid enough to draw further attention to her incompetence by taking whistleblowers to court.

In any case, as a reader points out, whistleblowers acting in good faith have legal protection under the Public Interest Disclosure Act 1988

Disclosures to Ministers
Where someone in the NHS or a public body blows the whistle in good faith direct to the sponsoring Department, the disclosure is protected in the same way as an internal one.

Wider disclosures
Wider disclosures (e.g. to the police, the media, MPs, and non-prescribed regulators) are protected if, in addition to the tests for regulatory disclosures, they are reasonable in all the circumstances and they meet one of the three preconditions.
Provided they are not made for personal gain, these preconditions are that the whistleblower:
• reasonably believed he would be victimised if he raised the matter internally or with a prescribed regulator,
• reasonably believed a cover-up was likely and there was no prescribed regulator; or
• had already raised the matter internally or with a prescribed regulator.

In deciding the reasonableness of the disclosure the tribunal will consider the identity of the person to whom it was made, the seriousness of the concern, whether the risk or danger remains, and whether it breached a duty of confidence the employer owed a third party. Where the concern had been raised with the employer or a prescribed regulator, the reasonableness of its response will be particularly relevant.

Phew!

I do not think Hewitt would like a judicial review of her prolonged stubborn failure to listen to the numerous warnings she received about the lack of MTAS security.

There is a further aspect to this.

Hewitt owed a duty of care to all doctors involved in MTAS to take reasonable precautions to ensure that their confidential details remained confidential. The magnitude of her failure is demonstrated in this excellent article on MTAS data security.

+++++++++++

I thought I was losing the ability to be surprised by the incompetence of MTAS security, but the revelations coming out from the court case brought by RemedyUK are breathtaking.

Regular updates here.

Democracy in action at WebCameron

"David is going to pick the questions from now on"

+++++++++++

Oh dear, oh dear.

What has happened to WebCameron?

Let us not be naïve as to the purpose of WebCameron but, love or loathe the Tories, there was a genuine opportunity to express ones views freely. In particular, there was a weekly opportunity for the readers to suggest questions and issues for David Cameron to address.

It’s all gone.

Why?

Some of you will be wondering what has happened to the ‘Ask David’ voting facility. When we implemented it, we thought it would be the best way for users to pick which questions go to David each week, but it’s become apparent that a majority of users felt they were being shut out. So instead, David is going to pick questions, comments, themes and topics from the forums (as well as comments on blog posts) on a regular basis. This way everyone has a fair chance of having their voice heard – and he won’t dodge the tricky questions! (Anonymous WebCameron Commissar)

Of course he won’t dodge the tricky questions. He will be talking about the new Tory Policy on grammar schools tomorrow. Ha! Ha! Ha!

Tim Montgomerie at Conservative Home may soon be looking at the situtions vacant after going completely off message today.

Grammar schools policy is "unforgivable" and a "bleak moment" for Conservative Party (Conservative Home)

The always affable Iain Dale is troubled too and concludes:

There's bound to be a great debate in the Party and that's a good thing. So I was disappointed to see David Cameron say that such a debate would be "entirely pointless".

Now it is becoming clear. A debate on this radical change in policy would be "entirely pointless" - as pointless as putting questions on "new improved" WebCameron.

What happened at WebCameron? Recess Monkey spills the beans in Tories dump web-guru

Madeleine McCann - the website

Madeleine McCann

There is now a dedicated website for Madeleine McCann.

There are lots more photographs, constant updates, and an opportunity to send messages of support to the McCann family.


Missing Madeleine

The NHS, Tesco and ten year old children.

Many years ago, more years ago than I care to remember, Wat Tyler (Burning our Money), James Bartholomew (The Welfare State We’re In) and Dr Crippen were at the same College at the same university. This was before blogging, before the internet, before even word processors. Dr Crippen used a typewriter and Snowpaque. Lots of Snowpaque.

It is a strange co-incidence – and it is a co-incidence, for there has been no discussion - that many years later there should be a meeting of minds when each of us considers ten years of mismanagement of the NHS, culminating in the recent MTAS debacle.

The NHS BLOG DOCTOR position has always been that:

A reasonable standard of health care should be available to all within a reasonable period of time without regard to income or status.

Nothing controversial there.

Day after day, all around me in the NHS, I see waste, complacency, mismanagement, financial profligacy and abuse. The controversy comes when I put forward my now unshakable belief that we must make a start by introducing a front end charge for health care, safety netted for those who genuinely cannot afford to pay. In simple terms there should be a “fee at the point of entry.”

Look again at the shortest and wisest post of the year on health care economics from “The Welfare State We’re In” - not from James Bartholomew himself, but from his ten year old daughter:

"When I was on holiday with mummy in Spain, when mummy was paying I didn't mind what I bought! But then she gave me 50 euros of my own to spend and then I didn't buy things in case, later on, I found something I liked better."

This is the short course in why capitalism works and socialism doesn't. It is a short course in why public services tend to be wasteful (ministers and the rest are spending other people's money).

When it is your own money, you don't waste it.

(From forth the mouth of babes)

Yesterday, we celebrated the demise of MTAS, but there is still much to be done. There are still thirty thousand careers to sort out. And then we must consider the cost of this debacle. Wat Tyler has begun his investigation. His starting figure is £6.3 million, but he will be travelling a long way north of that.

…having wasted so much time with MTAS, hospitals are staring down the barrel of a staffing crisis. As Professor Humphrey Hodgson, a liver specialist at the Royal Free Hospital, says: "We are in damage limitation in which we want to make sure that patient care does not fall between the cracks of this problem." …if you're planning to get ill, do it in the next couple of months.

Once again, the big lesson is that these top-down all-purpose masterplans just don't work. As with the Supercomputer, MTAS highlights the shocking lack of consultation with the people at the sharp end. Indeed, a spokesman for RemedyUK, the junior doctors action group, points out that ministers have still not included any of the junior doctors who have been affected by the problems on its review group.

No matter that the Commissars were responsible for the fiasco in the first place: they still apparently expect us to believe they're the only ones who can sort it out. When Hewitt gets fired this summer, the Department of Health will get its eleventh Secretary of State since 1985. In the same period, Tesco has had just two Chief Execs. Both of them joined the business straight from university and worked their way to the top. None of our last 10 Health Secretaries had any previous knowledge of healthcare, let alone how to run the world's third largest organisation.

Maybe the eleventh will be some hitherto unspotted healthcare management genius. But I don't advise holding your breath. (Wat Tyler: Burning our Money)

I suspect that both Wat Tyler and James Bartholomew would favour wholesale privatisation of the NHS. I would not go as far as that. We need to move away from the dogma of the left and the right wing. If patients had to pay for part of their care, abuse and waste would be dramatically reduced and, furthermore, patients would not put up with second rate service. They would insist on better treatment.

As the Wat Tyler film demonstrates, the NHS needs the management skills of a Leahy or a Maclaurin both of whom had thirty years or more experience of their organisation. We need to attract the best and to do that we need to pay an NHS chief executive a Tesco size salary and allow him autonomy to introduce proper business principles and efficiency into health care.

The end of MTAS

Patricia Hewitt defends MTAS on Question Time

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MTAS has been scrapped.

What more can I say? Well, just a few words, maybe. Just a tiny little gloat if I may. But first a word of acknowledgment to RemedyUK which was formed to do the job that should have been done by the BMA.

And now back to Hewitt. Still no apology from the bloody woman:

Health Secretary Patricia Hewitt said that after the first round of recruitment, the system would only fulfill a monitoring role this year. Instead, the recruitment process will be CV-based, and handled at a local level by medical deaneries. (BBC)

Note the characteristic face-saving piece of tosh about MTAS being used in a "monitoring" role. Ha! Ha! Next we will ask that nice Mr Mugawbe to monitor the Electoral Reform Society.

One slight concern for some of us. They may yet be criminal prosecutions for breach of security.

It also emerged that the MTAS website had been the subject of two security breaches. Ms Hewitt told the Commons earlier this month she was confident that criminal offences had not been committed. But following further investigations a report has been sent to the police. (BBC)

Vintage Hewitt. She cannot put three sentences together without telling a lie.

I was tipped off about the second security breach and, before informing the Department of Health of its existence, I most certainly checked it out by penetrating the system and accessing confidential information from it. I then immediately informed the Department of Health, as described here.

I am never one to waste police time, so let me say right away, "I done it. It's a fair cop, I want my brief."



Thankfully, I shall not be alone. The following will be in the dock:

Victoria MacDonald (Channel 4)
Dr John Crippen (NHS BLOG DOCTOR)
The combined staff of RemedyUK

Soon we may all be in jail together. A modern open prison where as “trusties” we will spend our time organising the library. Our own little Shawshank Redemption.

This seems a good time to react to an email I received today:

“Dear Dr Crippen, you recently published a picture of Gordon Brown laughing at a joke. Would you consider printing it again?

How to make Gordon Brown laugh

The email questions that Hewitt agreed to answer after her dreadful appearance on Question Time may now be of historical interest, but are fun to read to watch her squirming to avoid the inevitable.

Q: You have apologised three times in the House of Commons for the distress caused to young doctors by the MTAS failures. There is much evidence to prove that the interview system is deeply unfair and two key figures, Alan Crockard and Shelley Heard, have resigned in protest at the shambles. Please can you explain why you insist in going on trying to patch up a seriously flawed system?

Why not stop it now, find an alternative to protect patient care in August, save thousands of young doctors' careers and take a fresh look at how to implement MMC, which many doctors support? You could redeem your reputation overnight by doing this.

Amanda Willmott, Honiton

The answer to Amanda's question, and many others, may be found here.

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There is a serious question that now needs to be addressed, and it may be that Wat Tyler can assist.

How much has MTAS cost the tax payer?

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Just listened to Lord Rhymes-With on Radio 4's PM programme. Hewitt is hiding in the bunker looking at her diary. Rhymes-With refused to apologise, refused to admit there had been a disaster and talked only of "teething problems."

"A grandiose smoke-screen" said Matt Jamieson-Evans, a hospital doctor. Rhymes-With denied that and continued to flannel and lie.

"Is this a great advertisment for Hewitt?" asked the PM programme.

"I am very impressed with the way she works. She is not making wrong decisions" said Rhymes-With.

Dr Crippen predicts Rhymes-With will be spending more time with his family come the Coronation.

Madeleine McCann - cast not the first stone

Madeleine McCann

We have four children.

Some years ago, when my son was just three years old, we had a frightening experience.

Both Mrs C and I work. Dearly though we love them all, an evening meal with four boisterous young children is hard work. When, finally, the stories have been red, the “can I have a glass of water” ritual been done, and they are all asleep in bed, there is a sense of release, a sense of relaxation. The upstairs of our house is secure and, once the children were asleep, we were not in the habit of rushing upstairs to check them every two minutes.

I should explain that our house is on a road that can be busy, and there is a small river at the bottom of the garden. One evening, an hour after the children had settled, I was sitting at my desk paying bills. Mrs C was in the kitchen and at one stage took a couple of rubbish bags out to the bin. This involves walking round the house and so the back door was open and unattended for a couple of minutes. When she came back, because it was summer, and humid, she left the back door open. It stayed open for half an hour, maybe more, and during that time she was wandering round the house.

She went upstairs to get something and, because she was upstairs, she checked the children. Michael, our three year old, was missing. I can’t say we were over concerned at first. We searched his room, all the other bedrooms, the downstairs rooms and the garage. We could not find him. We were still affecting light-heartedness. This is too silly for words. He cannot have gone far. And yet, underneath there was a gnawing feeling of incredulity and fear. We searched the garden. The gate to the river was closed and it was unlikely that a three year old could have opened it. Unlikely. I walked a few yards down the road in both directions at the front of the house. Nothing.

I looked at my wife and said “We’d better call the police” knowing that she would say Don’t be silly, don’t be melodramatic, he is obviously somewhere in the house. She just nodded. “What number do I dail? Should I look up the number of the local police station?” She shook her head. I dialled 999.

The response was staggering. I heard the sirens with in minutes. Suddenly, there were two police cars outside the house, and a third arrived shortly after. There were police officers searching outside the house, back and front, and a female police officer with us repeating the search inside. There was a police dog handler on the way. The policewoman found Michael. He was curled up fast asleep under and behind the legs of the dining room table.

We should, I suppose, have been embarrassed but the feeling of relief was so overwhelming that there was no room for other emotion. The police were wonderful. They were as relieved as we were.

How often should you check on children who are asleep? I don’t know the answer to that. None of our children had gone wandering, or sleep walking, before or since but I accept that we should not have left the back door open and unattended. It was an error of judgment which, thankfully, did not result in a tragedy. We never left the door open again.

Were we at fault? Possibly. Probably. But however careful you are bringing up a large family of small children you make mistakes.

At what age can children go to the park by themselves? Or get a bus to school by themselves? Or go on a train? Or go into the centre of town? You feel your way. You talk to other parents. You first child pushes back the boundaries. The subsequent children get more freedom sooner, much to the oldest child’s irritation. “You never let me do that at his age”

I have been taken aback by many of the comments made about Madeleine McCann apparently being left alone for a short period of time. I do not know all the facts and I suspect that none of the commentators do either. Maybe there was an error of judgment. There but for the grace of God - see Mums for Madeleine

I do not know if there was an error of judgment and, frankly, I do not care. It is not relevant.

The task in hand is to find Madeleine McCann.

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Comments under the original article here please.

Madeleine McCann - the search goes on

It was confirmed yesterday British police have compiled a detailed photofit of a suspect seen near the McCanns’ apartment in Praia da Luz on May 3, the day Madeleine was abducted. The man, wearing light trousers and a blue top, had a partly shaven head and was spotted a few hours before Madeleine disappeared. (The Times)

Oddly, the photofit picture does not seem to have been released.

Meanwhile, Maddie’s parents remain convinced that their daughter is safe and well. Let us hope so.

The search goes on.

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Comments under the original article here please

Famine in the NHS

Pestilence, war, famine and death

Famine is a very destabilizing and devastating occurrence. The prospect of starvation led people to take desperate measures. When scarcity of food became apparent to peasants, they would sacrifice long-term prosperity for short-term survival. They would kill their draught animals, leading to lowered production in subsequent years. They would eat their seed corn, sacrificing next year's crop in the hope that more seed could be found. Once those means had been exhausted, they would take to the road in search of food. (Wikipedia)

An excellent article from Wikipedia on the long reaching affects of famine and an article with relevance to the heathcare famine currently building in the UK.

The billions poured into the NHS have resulted in little improvement in healthcare and so, to save money, Patrica Hewitt has started the slaughter of the draught animals; the nurses and doctors. Nurses and midwives have had a paycut. Hewitt, characteristically dishonestly, talked of a payrise but given the rate of inflation and the fact the “rise” was phased in, it was nothing of the sort. And the doctors? They face MTAS and then, for thousands, the prospect of unemployment and career destruction.

Doctors and nurses in the UK are indeed taking to the road. And once they are working in Canada and Australia, they will not return.

It gets worse. Now an increasingly desperate Hewitt is turning to the seed corn:

Hospital trusts appear to be raiding cash earmarked for medical education to help plug deficits, doctors warned today. The British Medical Association (BMA) said hospitals reported that money intended for education was being absorbed into general budgets and the Department of Health has "very little idea" of how it is being spent. (The Guardian)

Hospital trusts are raiding cash intended for medical education to help to plug deficits, the British Medical Association (BMA) claimed yesterday. The BMA asked 33 teaching hospitals for an account of medical education spending in the past five years. The question related to Service Increment for Teaching (Sift) money – extra funding for teaching hospitals. (The Times)

Where will the cash-strapped government turn next for funds to run the NHS? A word from “Captain Bob”

Gordon Brown

Soon, nothing will be safe.

Medical training meltdown - the review is a fiasco

Hewitt - the final days

"An emergency review of the appointments system for junior doctors is being dominated by government apparatchiks" leading doctors claim in a letter to The Times today.

MTAS in a nutshell

So who is in charge? “Nobody is,” said the official who spoke to The Times. “The system was developed in isolation from workforce planning. So it was impossible to find any one person who would ask: ‘Will this work?’ .”

The Times – Doctors’ job system fiasco.

The letter in The Times this morning, which was not from junior doctors, but from eighteen nationally eminent consultants, says it all. Little has been done by the government. Much could be done:

We have put forward several alternatives to the single interview. These were accepted as feasible in a private meeting we had with DoH members of the review body, and are similar to the unilateral rescue plan of the College of Surgeons. We have balloted 3,500 doctors and will publish this week results showing 75 per cent rejection of the single interview, 85 per cent support for a consultant boycott of these and a postponement of the unnecessary August 1 meltdown. Ninety per cent expressed no confidence in the Secretary of State and CMO. The will of the majority should be heard.

The Times letter in full here

The BritMeds 2007 (19)

First, the introduction of a new NHS BLOG DOCTOR award created to recognise egregious professional dickheads.




The runner-up for the first award was this irritating little pillock, but the judging panel were unanimous in selecting Dr John Coakely, the Medical Director of Homerton University Foundation and Jolly Important Hospital as the first prize winner for his sterling contribution to improving professional relationships between hospital doctors and primary care.

Well done, John.

Click on the award for full details.

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Dr Rant turns his mind to Tony Blair:

So Blair has finally announced his resignation. And with weary resignation we have been forced to watch a choreographed spin fest that rivals anything at the start of his disastrous reign.

Blair goes..........the further the better for the NHS

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Barely has Blair gone, than Dr Crippen has unearthed this little gem:



Dr Crippen was listening to Brown on the Radio this morning. Brown talked of the last last ten years as though a different political party had been in power. As though Tony Blair was a member of the opposition.

Too delicious for words

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Cancer in the third world

We see so many reports on "African" illnesses - malaria, HIV/Aids, malnutrition, guinea worm etc etc - it is easy to forget that people who live on this continent are just as prone to cancer as people in the "developed" world.

Life with leukaemia


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The Angry Medic is not angry this week. He is listening to a dying patient talking of his first love...

I loved her. And what's better, she loved me. My first love. And the universe was fair. The world was beautiful. For all its sham, drudgery, suffering and broken dreams, it was beautiful. I could live through anything that happened, because there was someone by my side. Someone to share everything with. Someone you knew would be there for you to rush to no matter what happened. Someone to face the world with. Your own little corner of God's great universe wasn't so small and lonely anymore…

A beautiful written post.

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Late abortions – it is never easy…

Anencephaly is a terrible congenital disorder where the cerebrum - the part of the brain responsible for thought, emotion, consciousness, everything above the most basic and rudimentary brainstem functions - simply does not develop. The majority of affected fetuses die before birth; survival beyond a few days is rare, and the disability in those who do survive is profound and total. Rather than carry a doomed pregnancy to term only to deliver a dead or dying baby, this woman had been admitted for abortion…

A moving and considered post from Good enough mum, both a doctor and mother.

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Sunbathing causes skin cancer. We all know that. But is seems we may be wrong. If you like heavy metal, you had better read this:

If the British weather is kind for once this Bank Holiday Monday, it will pour sunshine down on all of us. So, leave the denim at home, unless you are a heavy metal fan, and make sure your icecream doesn’t melt while you are sunning yourself.

David Bradley, from Cambridge, who writes the excellent Sciencebase looks at another theory in:

Do heavy metal fans get skin cancer?


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Tim is doing a Paddlethon for four important medical charities

Paddlathon 2007 -whassat then?

Footprints in the snow of a warped mind

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Are you one of those doctors who thinks that psychology is meaningless mumbo-jumbo?

Watch this. You WILL be fooled



Dr Crippen is grateful to Suman of The Amateur Transplants for drawing his attention to this video.


The Amateur Transplants of course were responsible for the wonderful (parental warning, deeply distasteful...) London Underground Song, and much more, all of which can be found here

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Computer game causes death from heart failure – you may avoid it by practising pranayama.

You've probably heard the horror stories about gamers who died after marathon gaming sessions. In 2002, a 27 year-old Taiwanese man collapsed after playing computer games for 32 hours non-stop. In 2005, a 28-year-old South Korean man who played computer games for straight 50 hours died of heart failure. The latter gamer stopped his game only to visit the toilet and to take short 'ubernaps.'

No I had not. And nor had I heard of pranayama. Yes, it’s a medical word. Own up. Who else has not heard of it?

Answer here, and more, in 25 Free Health Tips for Computer Nerds

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HRT doubles you change of breast cancer, and of ovarian cancer. YAWN

Now for some examples. What if I told you there was an easy way to double your chances of winning the lottery? It's easy, just buy two tickets instead of one….

The real story is explained here.

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GPs hate form filling and paperwork…

I try not to swear on this blog, but with all that in mind, where the shuddering FUCK does this new girl get off, casually writing an inaccurate, or at best, incomplete diagnosis across a form that has a big impact on my life?

But spare a thought for the patient when there is a cock-up

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Dr Ray does not approve of Dr Rant

The Dr Rant blog is well informed, well presented and funny but when I pointed out that the use of foul language did his cause no good at all I was subjected to a torrent of abuse more typical of a group of drunken chaves at throwing out time rather than a group of GPs....

Drunken chaves ?!! What would they be, Dr Ray?

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The second sentence is provocative, contradictory nonsense…

Alternative medicine and complimentary medicine are generally considered to be those treatments that take a more holistic approach to a patient. They are primarily concerned with the well-being of the body and mind rather than simply concentrating on the curing of the problem itself.

….isn’t it?

Health reporter

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Cheapo cheapo productions

These drugs have different side effects, different risks, one may be more suitable for one patient than another. I believe they all have a role, and in the private sector I am able to discuss with patients the pros and cons of each and come to a decision as to which is better for an individual patient. Why am I not allowed to do the same in the NHS, where the choice is docetaxel or nothing? Just because it is the cheapest does not make it the best choice.

A tale of three drugs : cancer in the UK without private health insurance

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From Australia, but it has to be read…

The other thing that worries me about socialized medicine is that there is no incentive there for the best-and-the-brightest to undertake the arduous work (and heavy cost) of obtaining medical degrees, so that they can be under the power of the Government, rather than allowed to strike out on their own. Then who will be our next doctors? The second tier students? The third? Socialism too often is a showcase for mediocrity. It doesn't work.

US Cancer Care 10X better than socialized UK

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Outbreak of killer disease in Scotland

This can cause muscle pain, serious flu-like symptoms, paralysis, blindness, arthritic, neurological, psychiatric and cardiac problems, and potentially death...

Best be careful, then.

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NHS don’t do Cartesian space

Fillling out my "Family Doctor Registraion" this morning, I see the question: "[Do you] live more than 1 mile in a straight line from the nearest chemist?" Oh Dear. The NHS could do with some kind of information system that stores geographic information.

Blacksworld

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Last blast of the trumpet against the monstrous regiment of women…

British TV standards are deteriorating because the BBC is "run by women".

No, it’s not John Knox. It’s Dr Michelle Tempest

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Gordon in, Patricia out…..a new team. But it…

….is the same bunch of cronies that has brought as the joys of MTAS, MMC, PFI, ISTCs, WICs, PBC, PBR, NHS IT scheme, ENDLESS RECONFIGURATION, QUACKS, and more. I have seen little evidence of their work doing anything that hasn't been downright bad for patients in this country.

The Ferret Fancier needs sedation

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This independent midwife insurance thing

The DK is not listening to Patrick Moore. Or maybe he is going soft in his old age. He is renting out space to girlies.

Why is it so important for independent midwives to carry on practising, even without insurance? Because, the IMA says, they provide "woman-centred, autonomous midwifery practice".

(You know, the sort that women had up until the nineteenth century, when women were most likely to die in, or of, childbirth, as I think were babies.)

Great stuff from Kate Newton

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Rita is in trouble…

This is day 7 of my unemployment as a doctor…

but she is still fighting

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Medical students still suffering…

I had my assessment with my consultant today. GUESS WHAT? She didn't turn up. *yawns*

Of short white coats…..

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A view from Morocco

Recently an English visitor became gravely ill with what looked like food poisoning…… I feel that if this had happened in the UK David would not be with us now. So on behalf of my family I wish to thank all those involved with David’s recovery and saving his life.

In praise of Moroccan doctors

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Now you see him, now you don’t

I'm frustrated about several things today……

Reports of Hospital Phoenix’s retirement from blogging are much exaggerated

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Last week, Ben Fenton suggested that pathologists do not need to have consciences.

If those doctors don’t want to do so, they should consider going to work in pathology, where most of the human beings they come across will already be past giving a damn about a doctor’s precious prejudices or their religious hang-ups.

Contrary to what Ben Fenton, the author of this article thinks, we do have religious issues with abortions…….

Pathologist anonymous speaks out.

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How much (little) alcohol is safe for women?

As evidence mounts that breast cancer could be exacerbated by alcohol, is it time for women to play safe and cut back or give up, asks Victoria Lambert

Are two drinks too many

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Poor women with large tattooed breasts will have to do the best they can.

Despite the slightly hysterical tone of the Observer's headline that 'NHS treatments must be rationed', the reality is that ALL public services are and always have been rationed. The debate is only about where one draws the line between services 'on ration' and services 'off ration'.

Raedwald takes a look at rationing

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It is easy being a GP; anyone could do it…

Recognise that this really is a very difficult job - if your trainer sometimes makes it look easy, remember that professional musicians or sports stars make their complex task look easy too.

A fortunate man

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Breast cancer and the open university

The philosophy essay is wildly overdue, owing to jaundice and consequent treacle (or dim sum). I have negotiated an extension to the deadline (several times, in fact, once by email from hospital, the Open University are being very helpful). This has made me revisit why I am doing the course in the first place, since I haven’t got much interest in acquiring an MA in Philosophy per se and in any case may well not make it to the end of the three years.

Metastases in Auspicious Dragon

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Lies, damn lies and statistics

A survey of doctors in the UK reveals a startling groundswell of anti-abortion sentiment. Almost one in five family doctors thinks abortion should be illegal. Well over half favour reducing the present 24-week legal limit on abortion procedures. Almost one quarter refuse to sign abortion referral forms. Pregnant women must obtain forms signed by two doctors in order to procure a legal abortion.

One in five UK GPs want to ban abortion

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Could anything be more grotesque than this?




I am afraid so. Freeborn John morphs the Blair photo. It can get worse

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We’re all done for…

Deaths from skin cancer and heatstroke could soar and Britain could be blighted by malaria, salmonella and a host of other heat-loving diseases as global warming takes its toll, officials have warned.

The People’s Medical Journal (PMJ)

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The British Standards Institute (BSI) has presented the ISO 27001 (Information Security Standard) to the General Medical Council (GMC).

Er...really!


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More gratuitous use of Tony Blair


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Dr Crippen challenge:

The best explanation of why the NHS wastes money

Can anyone deny (or improve upon) this brilliant analysis?

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The MTAS/MMC week

A quieter MTAS week, but the outrage still goes on.

Abusing doctors

Another shocking tale of incompetence and gut-wrenching cruelty thanks to MTAS has come to light. I have obtained copies of emails that show quite clearly that some candidates had their hopes raised by being told that they had successfully got jobs, only for this to be retracted in a later email and the candidates told they had no jobs at all.

The Ferret Fancier

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Competition? My hairy arse...

Yes, it’s Dr Rant (who else) taking another look at the junior doctor crisis.

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They are calling it Black Monday

THEY’RE calling it Black Monday. I had a stupid article all about bossing students around prewritten in my head, but felt there was no way I could ignore Black Monday and its implications. This month has been dominated by the plight of our SHOs.

The Daily Rhino takes a look at Patricia Blewitt

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

The BritMeds will now be published on Saturday morning, so please let me have your recommendations by Friday evening latest.

Madeleine McCann - the hunt must go on

When a child goes missing, probably abducted, the effect on the parents is devastating.

As a parent, I share Drs Kate and Gerry McCann’s anguish. All parents share the anguish, for it affects us all. Tomorrow it may be our child.

On a personal level, the McCann family back ground is so similar to mine. A GP and a hospital specialist with a large family. I listen to the news several times a day, hoping to hear that Maddie has been found. It is the first thing that I turn to in the newspapers.

Today, 12th May, is Maddie’s fourth birthday.

She has been missing for a week. The police in Portugal are already scaling down the local search.

Police in Portugal said they were winding down the hunt for three-year-old Madeleine McCann after three prime suspects emerged in the investigation...

reports today’s Daily Telegraph. If Maddie is not found soon, the story will gradually fade from the media. In a couple of months, people will be saying “Did they ever find that girl, what was her name?”

That must not happen.

We need to keep Maddie’s story on the front page. Dr Gerry McCann realises that and

….has been lobbying politicians and diplomats and mobilising friends and contacts in Britain. He has been developing ways to keep his daughter’s case in the public eye through e-mail campaigns, internet posters, celebrity appeals, persuading European retail chains to display Madeleine’s picture in their stores and even asking medical centres across the Continent to look out for a girl with a slight iris defect. (The Times 12 May)

Where ever Maddie is, someone, somewhere must have seen her. If every British Blogger puts a picture of Maddie on their front page, that will help.

I have collected a photo montage of Maddie and the McGann family below and put a picture of Maddy on the top right side bar.

I hope everyone else will do the same.


Kate McCann is blessed by Father Haynes Hubbard during a special church service in Praia Da Luz.

























Couragous parents who won respect for dignity and resolve (The Times)

On 12 May 2007, barely a week after Maddie disappeared, the Daily Telegraph printed this headline:

Madeleine hunt coming to an end

We must make sure that that is not true. The hunt must not end until she is found.

+++++++++++

Please visit this site, for full up to date details, in English and Portuguese, of the on going search.

Madeleine McCann

Missing in Portugal

Have you seen her?

McCann de Madeleine perde em Portugal




If you have any information, call this number:

+441883731336


++++++++++

And see:

Madeleine McCann - the search goes on

The Illusion of Choice : Grumble, Humble, Mumble & Bumble

We have several outstanding specialist departments in our local hospitals, and a fair number of good ones. There are a couple of black holes which we avoid.

As GPs, we are experienced consumers of secondary healthcare. In one of the good departments there are four consultants. Drs Grumble, Humble, Mumble and Bumble. Dr Grumble is outstanding. Best doctor since Galen. I will see him myself if he is still alive when I need him. Excellent bedside manner. Big private practice, but he always gives the NHS patients a square deal. Drs Humble and Mumble are pretty good too. I would not mind seeing either of them either. Then there is Dr Bumble. Oh! Dear me. The new boy. Always popping up at the Rotary Club to give a talk to the local great and good. I am not sure he washes his hands. His medicine is, well, I do not want to exaggerate..it is adequate, just about. Big private practice and a very short NHS waiting list. Oleaginous bedside manner with the private patients. Curt and dismissive with the poor folk. I do not like him.

Doris is seventy. I would like her to see Dr Grumble. Or Humble. Or Mumble. Until two weeks ago, I would have made a recommendation to her and written a referral. She would then have received an appointment a few weeks later. For the last ten years, I have referred at least half my patients to Grumble, and the other half have been split between Humble and Mumble. I have not sent any to Bumble

Educated choice like this is no longer possible. It has been abolished. Doris now has to choose and book, and she has to do it herself.

The choose and book commissar instructs me to write a generic “Dear Doctor” referral to the department and send the letter below, with a page and a half of instructions, to the patient.

click to enlarge

A few points

1. The first paragraph is dishonest. It is deceitful. They missed out the words “subject to availability.” There will be no appointments for most patients with Grumble, Humble and Mumble because their allocation will go quickly. Bumble will of course be available.

2. An intelligent middle class, middle aged patient will make light work of the letter. An old, not so clever widow in her seventies does not understand it. “Can’t I just see that specialist you recommend doctor, like we did before?”

Moving on from the letter the patient now turns to the instructions in the NHS Appointment Request Form:

click to enlarge

Look at Section 3.

Having found the password on the second page, Doris has to contact the hospital. She is not on the internet and does not have a text phone. She has heard of the internet, but not of text-phones. “Do I have to get one doctor?”

I advise her to go home and phone the number. Later in the morning she phones me back to say the number is permanently engaged, and also to ask if it is “safe” to give the password to anyone, or should she only tell the consultant. I advise her to keep trying.

The next day she comes in and sees one of the receptionists and asks for help. The receptionist gets through for her. As expected there is now only availability to see Dr Bumble, so that is what she agrees to do.

++++++++

Until 1997, I was able to refer Doris to any consultant in the United Kingdom. I would have referred her to Grumble. Or Humble. Or Mumble. But not Bumble. That freedom was removed at a stroke by the Blair government. For ten years there was no choice at all. Now we have "choose and book".

Doris will see Bumble, my least favourite specialist.

But Doris has the illusion of choice provided by a bureaucracy that she does not understand.

This is where your money is going.

The Crippen Diaries 2007 (19)

Not quite Emergency Ward 10

Tuesday 8th May

Mrs Jones had a shock over the weekend. She was taken to hospital by the paramedics.

Mrs Jones is 67. She has had insulin controlled diabetes for years, and it is well controlled. She is otherwise in good health. She is slim and takes lots of exercise. She goes everywhere on her bicycle.

She was going for an after lunch cycle ride when she heard the sounds of an emergency siren. A blue-light ambulance overtook her at some speed. She wobbled on her bike and fell off. The paramedics saw what had happened in their mirror, stopped and came back. She had not been knocked out. She was shaken up, but felt happy about going home. The paramedics asked her if she had any other medical problems. She said not initially and then said, “Well, apart from my diabetes.”

The paramedics insisted on checking her blood sugar. It was 16. That is high for me, she said. Then they asked her if she had perhaps had “a funny turn” making her fall off the bike. She said not, but they said they had better do an ECG. When they had done the ECG they said it was “probably” all right, but they insisted on taking her to hospital. They also said that the ECG suggested she needed some oxygen which was duly administered on the way to hospital.

She was seen quickly. The nurse repeated the blood sugar. This time it was 11.5. They also did an ECG which the nurse said was probably normal, but she should wait to see the doctor.

A young SHO arrived about an hour later and check her over. A diligent young man he must have been because, whilst listening to her chest, he noticed an old looking mole on her back. He advised her that she should “see her doctor about it.” He said everything was fine, the ECG was normal, and she could go home.

So Mrs Jones arrived today to have the mole checked. It is not a mole. It is a seborrhoeic wart. A feature of the maturing skin and nothing to worry about. And then she asked me what problem there was on the ECG that made the paramedics feel she should have oxygen.

I have not got a clue.

++++++++++

A long discussion with a young mother this morning. She has one child (at the moment) and it is coming up to MMR time.

She is highly intelligent and has been out on the internet. She has much the same views as I on Wakefield and is quite determined that her son should have the MMR. Well, in fact, I mean should have measles, mumps and rubella immunisations. She is going to pay to go to a private clinic to have them done separately. It is going to cost her a lot of money (which she can easily afford) and is going to subject her child to lots of injections when two would do.

I cannot talk her out of this course of action. She believes that a young immune system should not be challenged with three immunisations at the same time. It does not seem right. I ask her if her son had the DTP immunisations (three in one go - diphtheria, tetanus and pertussis). She smiles. She knows where this is going. But those immunisations have been around a long time and have been “tried and tested.” So has the MMR, I counter.

She smiles again. I know this is intellectually shoddy, she says, but it is an emotional call.

I cannot argue with this and I do not try. It is partially Wakefield’s fault, but it is also the government's. They handled the whole issue so badly. Rather than running Wakefield out of the country, they should have produced the defninitive research to show that he was wrong. Instead, they made him a hero, and the left wing media (in this case the BBC) did documentaries on him.

I do not think that politicians should have to use their children for photo opportunities, but it is sad that Tony did not quietly confirm that little Leo had the MMR. The word on the medical bush telegraph is that he did not. And why should he, indeed? It is a matter of parental choice. The Blair’s made their choice, just as they made their choice not to send their children to comprehensive schools.

The MMR debate is calming down now. The uptake is improving. Doctors as ancient as me will remember going through the pertussis immunisation controversy, now long forgotten.

It was much the same, and all nonsense.

++++++++++


Thursday 10th May

The first patient in needed, amongst other things, a blood pressure check.

I took it and it was 120/80. I took it again five minutes later, and it was 120/80. I entered his BP on the computer as 122/78.

Why the slight dishonesty?

Many doctors, and I am one of them, are not able to write down 120/80. I was trained by experienced hospital doctors who said that a BP reading of 120/80, the Daily Mail’s “normal BP” reading, most likely meant that the BP was NAD. Not actually done. All those TPR & BP observation charts on the ward that say 37, 72, 20 and 120/80 with their neatly drawn straight line graphs are too perfect to be plausible.

What a load of cynics we are.

++++++++++

Another demeaning request from a parent for a letter for the school. Angus is 12 and had an operation for a torsion of the testis three weeks ago. He went back to school last week, fit and well, but finds that when he runs round, and particularly if he does gymnastics or sports, that his groin his painful. His mother wrote to the sports teacher asking that Angus be excused active sports for two weeks.

The teacher refused. If you want your child excused from sport you have to get a letter from your doctor.

This is nonsense, and it keeps happening. This is a sensible family, a sensible boy and sensible parents who know their son well. Teachers seem so ignorant of parental rights and, indeed, of the law of the land. Parents are perfectly entitled to make decisions like this.

I advised the mother to stick up for her rights and refuse to provide such a letter. I will do one if necessary, of course. Or maybe I will just tell the school that Angus has a couple of verrucas. (I know, it should be verrucae)

Most teachers regard that diagnosis as worse than bubonic plague.

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

We have solved the problem of why Mrs Jones was refusing to take her thyroid tablets. (see 16th April )

She had noticed that her tablets had changed name from thyroxine to levothyroxine. This happened a while ago, but she only spotted it last month. “They are trying to fob me off with some cheap substitute.” For once it is not true.

The healthcare commissars have decided that drugs that we have been using for years have to change their name. So thyroxine is levothyroxine, bendrofluazide is bendroflumethazide and frusemide is furosemide.

There are lots of good sound Stalinist reasons for the change, but I wish the commissars could be forced to visit all the elderly patients who have been unsettled by this gratuitous meddling.

Happily, the district nurse was able to persuade Mrs Jones that levothyroxine was just as good as thyroxine.

++++++++++


Friday 11th May

The receptionist sticks here head round the door. Could you just sign this for Esmeralda Jones. Her mum says she will pick it up at lunchtime.

Esmeralda is eight years old. I have not seen her for eighteen months. She did see one of my partners at Christmas when she had an ear infection. I know she does a lot of drama and that she sings and dances. She was once in a TV advert. Now she has something lined up with the BBC.

click to enlarge

Some doctors just sign these forms without seeing the children. I do not. And it causes upset. I have no reason to expect that there is anything wrong with Esmeralda. On the contrary, I bet she is in excellent health.

But I don’t know.

She may have a heart murmur; she may have a long Q-T interval; she may be in the early stages of leukaemia. If she does have a long Q-T interval and pegs out whilst Jim is fixing it for her, will I get sued?

The second thing is I do not know what she is singing up for. She may be bungee jumping with Noel Edmonds.

And then there is the form itself. It is drawn up by the social services department without medical advice but probably with advice from a barrack-room lawyer. Barrack-room lawyers always prefer to “deem” rather than to “decide”.

And how do they know that the certificate will “last for up to six months”?

The only way to do this properly is to call Esmeralda in for a full-medical. The chances of finding any significant pathology in an eight year old are remote, but that is not the point. It is not necessary either. All we need to do is get the social workers to change the form to something sensible and signable.

+++++++++++

Mary, a 42 year old barrister, had me in fits of laughter this morning. It is as well she has a sense of humour. Mary is left-wing and, unusually for a well-paid lawyer, does not have private health insurance. She had fibroids which were causing her a lot of pain, discomfort and unpredictable erratic bleeding which could occur at any time and kept getting anaemic. She was on the urgent waiting list for a hysterectomy. The consultant had said he would get her in as soon as he could, but he could not say when as he no longer controls the bed allocation. That is done by the bed manager.

The middle class know how to push for medical care, and so Mary had taken to phoning the bed-manager to ask about progress. She could not get through to the bed-manager immediately. The bed-manager has a personal assistant, and the personal assistant has a secretary. Mary started with the P.A’s secretary and made her way up the food chain to the bed manager, who was unhelpful. She did, however, suggest that, if Mary was having problems, that she should talk to the Gynaecology Liaison Officer, who is there to “help and advise women with gynaecological problems”. The gynaecology liaison officer has a personal assistant and the personal assistant has a secretary.

She could not be bothered to work her way up this food chain, so she tried to phone the Consultant. He does not have a personal assistant. He does not have a secretary at the moment. His letters are being typed in New Delhi.

Mary is going to take out private health insurance.

Don’t get cancer in Britain - the Blair legacy

Tarceva : a drug for private patients

An embarrassing piece of research published today:

The UK has one of the worst records over access to new cancer drugs as stark inequalities exist across the world, a Swedish study has found.

Researchers ranked the UK in the bottom group for its "slow and low" uptake of drugs after analysing the sales of 67 treatments in 25 countries.

The US, Austria, France and Switzerland were the best, the Karolinska Institute and Stockholm School of Economics said. France had the highest five-year survival rate in Europe at 71% for women and 53% for men, compared with 53% and 43% in the UK respectively. (source)

We will put that on Blair's political epitaph, after the Iraq debacle. And how is the government going to deal with this? In the characteristic New Labour way. They are going to deny it. They are going to lie about it.

Lord Rhymes-With used to be thrown out of the bunker to issue the lies, but more recently it has been New Labour stud-muffin Andy Burnham, a man tipped for promotion after Gordon’s coronation, who tells the porkies.

Andy Burnham

“We resist any call to make the NHS a slimmed-down, emergency service, because that’s what it would become if we started rationing care. The NHS should continue to be comprehensive and universal. Further independence within the NHS should be considered only if it improves services. We are already devolving decision-making. ”

I was going to refer you to the DK’s character assassination of Andy Burnham but, frankly, it is too unpleasant for anyone of a sensitive nature to read. Best avoided.

Meanwhile, British doctors who, as reported on the Today programme this morning (listen here) , are at the forefront of European cancer research, are hanging their heads in shame.

Something wicked this way comes...

The King is dead. Long live the King.

The seamless transition from Blair to Brown, punctuated only by an unctuous coronation, is about to begin. Behind the scenes, however, it may already have begun.

Doctors have long known that that health care in the UK is rationed, and never more than it has been in the last ten years. Waiting lists, post-code lottery, PCT whim, NICE restrictions – sorry, meta-analyses - and so we go on. The government pretends it is not happening; the government talks of healthcare being “free at the point of entry”. But that famous phrase is meaningless if the door is closed. We know that Gordon Brown has imposed numerous stealth taxes on the country. He is now about to start stealthily rationing health care.

To pave the way, there has been a subtle change in political rhetoric.

Have you noticed that “on-message” New Labour lobby-fodder no longer talk of the NHS being “free at the point of entry”? Now they talk of it being “free at the point of need.” This does not sound like a radical change. Getting rid of Clause IV was radical. Do not be deceived. Getting rid of Clause IV was tokenism. Substituting “need” for “entry” is radical once you realise that those nice people at NICE will, notionally on behalf of the “people” but ever under the government’s watchful eye, be defining “need”.

For Gordon Brown, health care rationing is the policy that dare not speak its name. But if he can shift the NHS out of the political arena, make it an “independent” body, he can then disassociate himself from the cuts in health care provision that he knows are unavoidable. He can blame the BMA. He can blame the doctors.

Has the BMA taken leave of its senses?

Why is it suddenly espousing radical health care policies? Maybe word has quietly gone out from Brown’s apparatchiks that radical change is approaching and the BMA is trying to stay on-side with the new administration. Whatever the reason, the BMA has said:

“The NHS should have its own constitution and make clear that it cannot provide everything possible, focusing instead on core services that meet the needs of the great majority of patients most of the time.”

I am a member of the BMA. Was I consulted about this? I think not.

“Core services” are the two most frightening words Dr Crippen has ever heard in the context of the NHS. “Core services” are what the poor folk will be left with when the government has finished deciding what they “need”.

Andy Burnham, hotly tipped for a place in Brown’s Cabinet, looks and sounds like Old Labour.

“We resist any call to make the NHS a slimmed-down, emergency service, because that’s what it would become if we started rationing care. The NHS should continue to be comprehensive and universal. Further independence within the NHS should be considered only if it improves services. We are already devolving decision-making. ”

Health care is already slimmed down and rationed. It is neither comprehensive nor universal. But note Burnham’s penultimate sentence.

“Further independence within the NHS should be considered only if it improves services”.

This is the get out clause. The weasel words. Patricia Hewitt has told us that closing maternity units improves health care. If, like the BBC, the NHS is notionally independent, Gordon Brown can keep the disasters at arm's length, occasionally sacrificing a healthcare Greg Dyke to keep the media and the people happy.

Under the BMA scheme, the poor folk will have to survive with “core” services. A previous Labour administration destroyed secondary education by scrapping the grammar schools. Just as in the late 1960s the middle-classes en masse deserted the comprehensive system and entered the private schools, so now they will desert the “core service” NHS for the private sector. Once that happens, once the decision makers stop using the NHS, it will, like the state education system, be doomed.

The wealthy will not care. They will continue to receive excellent health care from properly trained doctors in a “fee at the point of entry” health service.

The poor folk will be left with their “free at the point of (government defined) need” NHS from which they will receive a dumbed-down, second-rate “core” service provided by “health care professionals”

How dare the BMA make policy statements like this without consulting the membership?

The Akond of Swat & the NAPC

Who, or why, or which, or what,
Is the Akond of SWAT?

Is he tall or short, or dark or fair?
Does he sit on a stool or a sofa or chair,

or SQUAT?
The Akond of Swat?

Is he wise or foolish, young or old?
Does he drink his soup and his coffee cold,

or HOT,
The Akond of Swat?

++++++++++

When I was a child, I adored the work of Edward Lear. Still do. The true identity of the Akond of Swat was a source of much frustration and mystery to a young Dr Crippen. I never did find out who he was.

I was put in mind of the dear old Akond by Dr Grumble. Not that I think that Grumble is the Akond (is he?) but he is running a teaser article at the moment to try to hook a diatribe from Dr Crippen. I shall resist the temptation. I am, however, grateful to Dr Grumble for, when I followed the reference in his article, I was introduced to the National Association of Primary Care.

I thought immediately of the Akond.

For who, or why, or which, or what…is the National Association of Primary Care?

Mea culpa, I have never heard of them. Mea maxima culpa you may say. So I have attempted to find out who they are and what they do.

Pete Smith OBE : The President

The President of the NAPC is Dr Pete Smith who looks like a “good egg” and must be because he has an OBE.

James Kingsland : The Chairman

The Chairman of NAPC is Dr James Kingsland who does not (yet) have an OBE but also looks like a “good egg”.

He was appointed Chairman of the National Association of Primary Care in September 2004, having served as a member of the executive since the NAPC’s inception. He has a wealth of experience in General Practice, medical education and medical politics.

There are other GPs and an administrator named as executive officers.

The NAPC must be a very important organisation as it is “shaping the future of Primary Care.” How do I know that? Because they say so on their logo:



They are shaping the future of my career and I have never heard of them. I feel embarrassed. I have read every word on their website (here) But I still do not know exactly what they do – other than “shape the future”.

Maybe that is enough.

If you look on the website you will find this under "What we do".

Influencing Policy: A key feature of the NAPC’s work is the role it plays in influencing the development of policy in its relationships with Ministers and Officials. Our meetings with government and civil servants enable us to channel information from our membership where difficulties are encountered; or where there are developments which have wider membership interest

This is important stuff. Maybe I should join. It all sounds so worthy. Sadly, you have to pay to join. The whole of my practice can join, but it is expensive. If all the GPs and PCTs in the country join, the NAPC is going to have a very tidy annual income. I wonder if Pete and James and the others are paid a salary for this sterling work?

The NAPC sounds like a sort of medical management consultancy. Management consultants are very clever and very well paid. I thought the BMA did this sort of thing. Is there any duplication here? But management consultants are better than the BMA. They will do it better.

Whatever “it” is.

What does the NAPC actually do?

++++++++++

And now back to my childhood.

Can he write a letter concisely clear
Without a speck or a smudge or smear
or BLOT
The Akond of Swat!

Do his people like him extremely well?
Or do they, whenever they can, rebel,
or PLOT
At the Akond of Swat?

The Culture Police : Nick Cohen looks at "dross on line..."

Nick Cohen - the scourge of bloggers

Nick Cohen, that well respected main-stream-media columnist, is one of the judges for the Lulu Blooker awards. It maybe he is not taking the LuLu shilling. It maybe he is doing it for the honour alone. Either way, he is quick to bite the hand that feeds him.

Nick’s opening gambit is

“Among the dross online..”

so we should not be in any doubt as to where he is going.

He quotes enthusiastically Oliver Kamm’s Guardian article which argued

…far from democratising intelligent debate, the 'citizen journalists' of the political blogs were sallow dogmatists who screamed abuse from behind the coward's cloak of anonymity at any writer who confronted their lame prejudices. 'Blogs typically do not add to the stock of commentary,' he wrote. 'They are purely parasitic on the stories and opinions the traditional media provide.’

Then, for a moment, it seems that he may sympathise:

No sinister authority figure decides whether your work is any good or, indeed, if it makes sense. The blook sits in cyberspace until a reader decides to buy it. With cheap, just-in-time printing technology, Lulu can publish a copy at a competitive price and post it to the buyer.

But then the sympathy disappears.

I can't speak for the other judges, but to me, the supposedly radical medium of the future seemed as parasitic on traditional publishing as political bloggers are on traditional newspapers.

It is difficult to get a book published conventionally. Any wannabe author has to meet the commercial criteria of agents and then publishers. Most fail at the first hurdle. Look at the struggle that J.K. Rowling had. The “professionals” may weed out some rubbish, but they also notoriously “weed out” books that later go on to be best sellers.

It gets worse. Authors who please the agent and the publisher and appear in print have yet bigger battles to fight before their work reaches the public. W.H. Smith’s, Waterstones and Richard & Judy have to like your book as well. It is a rare book – Captain Corelli's Mandolin comes to mind – that succeeds without getting the nod from the bookshops or daytime TV.

Lulu is doing a sterling job. The books are freely available for any and all to read. Wannabe writers can now miss the first three hurdles and have the freedom to present themselves directly to the public. The public, in their turn, have the freedom to make up their own minds without restraints imposed by the commercially minded, conventional publishing industry. Eventually, quality will out.

Why is the main-stream media so sniffy about Lulu?

Because they are frightened. They are in the same position as the typewriter industry a generation ago, or as the Roman Catholic Church was when, for a few moments, it took its mind off protecting paedophiles to resist the move to the vernacular. Heaven forbid that the general public should be allowed to make up their own mind about novels and the Bible.

How long will it be before a successful established author decides to cut out the middlemen and takes the next manuscript directly to Lulu? Watch the agents and publishers sweat when that happens.

It is not just internet novels that Nick disparages. To him, Lulu authors are

...as parasitic on traditional publishing as political bloggers are on traditional newspapers.

So what are we, the so called “political bloggers”, to make of this? I was gratified that NHS BLOG DOCTOR recently won an award for political blogging but, I have to say, the Crippen raison d'être is not political. It is to describe the day to day trials and tribulations of working in healthcare in the UK. Although I suspect that, by some, I am labelled as a “gun-toting” paid up member of the Conservative Party I am nothing of the sort.

I am passionately committed to the NHS as an organisation that

“should provide, within a reasonable and appropriate time, a reasonable standard of health care to all, independent of wealth and status”

I am critical, highly critical, of this government as it moves further and further away from that position whilst all the time playing lip-service to the concept of health care being "free at the point of entry" (or free at the “point of need” as they now say – and more on that subtle change at a later date).

How is this “parasitical” on traditional newspapers?

Parasitical or not, it might be be naïve to claim that NHS BLOG DOCTOR is apolitical but the real political bloggers are Iain Dale, the DK, Mr Eugenides, and Guido. Each of the four has enormously enriched political commentary.

The DK and Mr Eugenides are the masters of the “swearblogging” universe. This new art form of political criticism could not exist in the main stream media which still lives in the land of asterisk make-believe. Some apparently find “fuck” offensive but are untroubled by “f**k”. Can someone talk me through that? Asterisks or not, though, it is hard to believe that either the DK or Mr Eugenides will be asked to write leaders for The Times.

Do not underrate swearblogging. It is a source of constant amusement but also has a greater and better purpose. Anyone who saw Patronising Patricia on Question Time last week will have been disappointed by the anodyne and complacent panel members and chairman.



Despite the best efforts of a wonderful junior hospital doctor in the audience, they let Patricia off the hook. Why does she not resign?

Oily fish benefits from lemon-juice. Patronising Patricia would have benefited from a squirt of unasterisked Anglo-Saxon from the swearbloggers.

There is not much political lemon-juice in the establishment orientated main stream media. And so we turn to the internet.

Finally, Nick says, or quotes, the following:

...the web destroys culture because when editing goes and every opinion becomes equally valid, anyone who tries to distinguish between Shakespeare and a fool is dismissed as a bow-tied dinosaur.

This is main-stream media intellectual snobbery of the worst order. Culture can only survive if clever people like Nick are there to edit it for us. As they "edited" the Van Gogh output. Remind me, how many paintings did he sell?

The internet is a medium in which all can express an opinion. It is uncensored. The "culture police" have no influence. The reader may pick and choose as he pleases. The nonsense will be ignored. Persuasive, entertaining writing will be read. Do not patronise the public. We do not, indeed, need the bow-tie brigade to “distinguish between Shakespeare and a fool”; we can do that ourselves, thank you Nick.

Finally, remember this. We have to pay to read Daily Mail, the Sun, the Mirror and the News of the World all of which are closer to the Fool than the Bard.

Blogs, both political and creative, are free.


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

PS The main strength and weakness of blogs is that they are published unedited. Not so your column, Nick. It has been edited. I am surprised therefore by the solecism in this sentence:

I can't speak for the other judges, but to me, the supposedly radical medium of the future seemed as parasitic on traditional publishing as political bloggers are on traditional newspapers.

A tad pedantic but the correct use of commas is important.

“I can’t speak for other judges but, to me, the supposedly radical…”

A little tip for you and your bow-tied editor. In this context a comma should usually come after the conjunction, not before. The two commas are isolating a phrase that, if removed, still leaves a sentence that is grammatically correct. Yours is not.

Tut. Tut.

The BritMeds 2007 (18)

The MMC/MTAS round up is as usual at the end of the BritMeds but let’s start with Patricia on Question Time on Thursday night.



And an important point at the end about New Labour’s destruction of higher medical training. We covered this before:

Ten to fifteen years ago, the average orthopaedic surgeon would have had approximately 36,000 hours hands-on experience before he was appointed to a consultancy. Dr Andrew O’Brien, a specialist registrar in orthopaedics will have had approximately 8000 hours experience when he becomes a consultant.

In a nutshell (nutcase you might prefer) the new consultant will have three hundred per cent less experience than his older colleagues. So the next time you go into hospital make sure your consultant is aged at least fifty.

++++++++++

Then let’s compare Patricia at leisure, and Patricia under stress:

Patricia “at leisure” stars in “Hi, I’m Patricia Hewitt":




Patricia under stress:



+++++++++++

Following up from the story two weeks ago, it appears that

it is acceptable professional conduct for doctors to punch each other in the face even if a nose is broken.

Good old GMC


+++++++++++

Getting it off my chest

How it all began

Thursday night I discover a lump.
Next day finds me gabbling incoherently at a GP I’ve never clapped eyes on before. Sadly he agrees. There is a lump. Maybe, just maybe, it’s a harmless little fibro-adenoma or cyst or something.

And later

I screw up every ounce of courage I possess. My mouth is so dry I can hardly speak.
‘The lump’s malignant, isn’t it?’
He briefly touches my arm. ‘I’m sorry’ he says. ‘I’m afraid it is.’

And later

I come home from the unit clutching a pile of booklets. Even Husband is issued with one of his own. I devour them from cover to cover and studiously avoid the internet. There’s only so much I can take in at a time.

It seems a complicated business, this breast cancer, (the understatement of the year?) but I think I’ve got a Peter and Jane version sussed.

My breast cancer and me

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We used to trust this man. Ten years ago Dr Crippen trusted him and, indeed, voted for him. Remember, it was "24 hours to save the NHS" and "Education, education,education."

So, yesterday, we looked at what effect ten years of Blair has had on health and education.

He seemed so plausible then

The Blair Legacy

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Looney tunes “treatment” for autistic children

“I have personally been told that because I am not chelating my daughter, I am a child abuser. That I am a murderer. I have had threats of violence made against me, and a few people have even sent personal hate mail to my seven-year-old autistic daughter.”

Kevin Leitch is angry.

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It used to be major surgery having your gall bladder removed. Nowadays it can usually be done laparoscopically. But I had not heard of this:

a surgeon in Strasbourg has just carried out a vaginal cholecystectomy.

A vaginal cholecystectomy?! Why ever would you want that?


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Oh Brave New World

Under the new Bill, it is proposed that doctors, psychologists, nurses, occupational therapists and social workers could receive training that would enable them to have overall charge and be the responsible clinician for a patient who is sectioned. This could mean that for some patients there could be the possibility of no medical input at all.

So now nursy and the occupational therapist can lock you up if they think you are mad.

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May is mental health month

One of every three people you know will be treated for a mental illness sometime in their lifetime. If you know someone in your family who suffers from a mental illness, chances are there are others struggling as well. As many as 60% of those who suffer from mental illness self-medicate with alcohol or drugs.

Dare to Dream

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Whistle blowing

The integrity of medical research is under threat. Many cases have arisen which have demonstrated the inclination of our profession to act in a way that damages both science and the interests of the patients we serve. In many instances, organizations charged with maintaining integrity have colluded, almost routinely, to pervert science, to bully those raising concerns, and to obscure problems. These organizations include our medical Journals, professional regulatory bodies, drug regulators and even formal bodies devoted to maintaining "integrity".

More Scientific Misconduct from Dr Aubrey Blumsohn

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Of legacies and history : bye bye Blair

I am sorely tempted by the claims made by Tony Blair today to bring non-medical politics into this blog just this once. Like his fellow head of state George Bush, Blair is fatally wounded by Iraq and is now in search of a legacy to burnish his image for the history books. Somehow, I doubt that history will judge either of them so kindly.

Today’s event at the Kings Fund had a number of soundbites. Let us take a closer look at them.

Frontpoint systems

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Where is Dr Grumble taking us with this?

One of the joys of the take is that you are surrounded by bright, everchanging (shiftworking) young doctors. This week's were excellent. Today's were all were female.

Hands up all those who have never heard of Takotsubo syndrome

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Eat well, exercise…but die before you are thirty.

You can't make people happy by law. If you said to a bunch of average people two hundred years ago "Would you be happy in a world where medical care is widely available, houses are clean, the world's music and sights and foods can be brought into your home at small cost, travelling even 100 miles is easy, childbirth is generally not fatal to mother or child, you don't have to die of dental abscesses and you don't have to do what the squire tells you" they'd think you were talking about the New Jerusalem and say 'yes'.

Tony Plant has, sadly, been silent for a while, but take a look at this post from January.

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Rita Pal’s fight with the GMC continues. And, as a result of it, she has just been sacked:

RE: Fired from my locum post

At 16.14 today, I was contacted by my NHS Trust. They stated that medical staffing had contacted the GMC and been told that I was "under investigation". I was subsequently asked to leave. I therefore have no psychiatry post from today onwards.

But, unabashed, Rita continues her campaigns:

Today children we are about to enter the dark corridors of the GMC litigation bandwagon. The dark tower where they all sit is situated in the top most turret in London.

NHS Exposed


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Children at risk

The Children's hospital promised by Labour has failed to materialise. This has left the children of Leeds exposed to unacceptable levels of danger; as with several major specialties split between the two sites there are significant problems with transferring extremely sick children

Hewitt puts childrens’ lives at risk in Yorkshire

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In at the deep end

A chap comes to see me with "painful orgasms". Now, as the new female doctor I have to be on the look out for "those kind of patients" (said with a knowing nod) but he seems genuine.

Junior Doctor Spot

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An irritatingly naïve belief in the “magic” of MRI scans.

He was obviously in pain and unable to work properly, but struggled to get any meaningful treatment from his GP, despite several visits - just a prescription of anti-inflammatories. He really needed an MRI scan to properly assess the damage. In exasperation, Greg returned to his native Hungary to get an MRI scan

The Handyman

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The British have always cared more for their pets than for each other, and so this may make them take Lyme Disease more seriously.

Parasitology experts Bayer Animal Health is issuing a reminder message to all dog owners as the spring 'tick season' nears. During spring, blood-sucking ticks can be amongst the most common problems for the family dog – particularly in prevalent areas or 'tick hot-spots,' such as the New Forest, Salisbury Plain, The Lake District and Exmoor where tick-related diseases are so common that one local vet has termed them the 'Exmoor Syndrome'.

Yes, it can affect your dog too.

And Lyme Disease may have some more …er… practical uses. We may not be able to afford to renew Trident, but we always have nasty old germ warfare up our sleeves. Over now to Porton Down:

In an article I wrote entitled "Lyme is a Biowarfare Issue", you will find a large umber of facts linking the Lyme epidemic with biowarfare research, and which cannot be explained by "incompetence", nor even by coincidence. For example, Porton Down, the UK's main biowarfare research facility, has been studying Lyme and related tick-borne pathogens. This is nothing to do with "incompetence." Nearby New Forest area has the highest Lyme incidence in Britain, even by Steere camp figures.

More on Lyme germ warfare here.

I do not know what the British Lyme Disease Association will make of that.

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Dr Rant is turning his hand to medical biographies.

...he is an unelected hand-picked yes-man who gives the government's health policies a veneer of medical approval; the archetypal NuLabour apparatchik.

Who on earth is he talking about?

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A school - Lutterworth Grammar School if we want to ID it - has, through its medically-staffed surgery (a doctor and nurses), been supplying on request to those female pupils that ask what society chooses to call "the morning after pill".

or

Family and Youth Concern says that "schools should teach abstinence and not offer pupils contraceptives".

Take you pick. “A sometimes blog” takes his.

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You may think that “Care in the Community” for the mentally ill in the UK is appalling but let us be thankful that we do not have to consider this sort of option:

The American Psychological Association has teamed with the National Alliance on Mental Illness and the American Psychiatric Association to present a brief as Am