Madwife goes for a swim

People wonder why I frequently use the term madwife.

A lack of insurance means hundreds of independent midwives up and down the country could be forced to stop work in the face of government guidelines by the end of next year. Partner at the Ashford-based Kent Midwifery Practice, Kay Hardie, said:

“No one will insure us."

"We are a high risk group and the pot is small for any coverage because we work outside the NHS. We offer invaluable one-to-one care for pregnant women and many more are choosing alternative methods to give birth. We hope that the Primary Care Trusts will buy our services in the same way they do for GP services."

So now the madwives are running a campaign to ask the government (aka the taxpayer) to pick up the tab. Let us hope that the government does not fall for this one.

Kay, no one will insure you because you are dangerous. Insurance companies are not interested in the pros and cons of home births. They are interested in risk assessment. And you are not a good risk. But you don't understand that, do you?

Following numerous comments and emails, I sent details of Kent Midwifery Practice to Helen O'Dell who is the Midwifery Officer for South East Coast Local Supervising Authority. She has replied as follows:

Dear Dr Crippen

You are able to refer directly to the NMC and enclose the details that you have sent me. There is an information leaflet on the NMC website regarding how to make a complaint. I will ask for an investigation to take place. If there is any further information that you think is relevant please forward it to me.

Regards

Helen

I have therefore also sent copies of the email to the NMC.

Helen O'Dell can be contacted at : helen.odell AT nhs.net or Helen.O'Dell AT southeastcoast.nhs.uk and the email address of the NMC is : fitness.to.practise AT nmc-uk.org

Madeleine McCann : first anniversary of her abduction

Three days before my mother died, we had an argument. Can’t really remember what it was about but, as they say, “words” were exchanged. It was over and forgotten within an hour and yet, after she died, I felt bad about it. Does that mean I was a bad son? I think not. Some years later I can now smile about it, as would my mother.

Kate and Gerry McCann have analysed every second of every minute of the day before Madeleine was abducted. If only they had known, there are many things they would have done differently. Sadly, for Kate and Gerry, as time passes, unless Madeleine is found, they will not be able to smile.

We approach the first anniversary of Madeleine’s abduction. Kate and Gerry McCann continue to hope and continue to search. They have now broadened the appeal and are addressing the problems that arise when any child disappears. The Times today has today featured their campaign. When I looked at the article on the internet this morning there were already half a dozen comments, most of them profoundly unsympathetic. One or two were downright offensive. The Times has now removed all the comments.

I do not understand how people can react in this fashion. Kate and Gerry McCanns decision to eat out on that fateful night may have been ill advised. I do not know. I do not have all the facts. I was not there. If they did make a mistake, they will be more aware of that than any commentator, and will relive it every day. I do not believe the Kate and Gerry McCann are bad parents. If they did make a mistake, they are even more deserving of our sympathy.

The chances of finding Madeleine cannot now be good. But should we not be supporting the McCanns rather than forever criticising them?

++++++++++

Fine Madeleine McCann website here

Lies, damn lies and Gordon Brown

I am still trying to recover from the Prime Minister’s brazen effrontery on this morning's Today programme.  I was listening to it whilst reading the Times. You may “listen again” here.   The juxtaposition of Prime Ministerial lies and the real news is breathtaking. Unusually, Gordon Brown did admit to something short of papal infabillity on the question of how the abolition of the 10p tax rate was handled but, for the rest, it was a Panglossian tissue of lies.

Secret tax adds £200 to the cost of family cars
The Treasury admitted to The Times last night that it was quietly abolishing the exemption for older cars from the highest rates of vehicle excise duty. This means that owners of larger cars bought since March 2001 will find that their road tax will rise steeply from next April.

Private school demand is highest for five years despite big fee rises
The government, pledged to improved the education system, has been in power for 11 years. Forget the dinner party chatter. People are voting with their feet: "Independent schools have had the biggest increase in pupil numbers in five years as parents dig deep to avoid the state system." Explain that, if you will, prime minister.

Threat of fuel protests returns as cost of petrol hits £5 a gallon
What is Gordon Brown doing about this? Laughing all the way to the bank. "If prices remain at current levels, the Treasury could receive as much as an extra £2.5 billion."

London, one of the richest cities has 650,000 poor children.
So much, then, for Gordon Brown’s pledge to take children out of poverty

I was particularly taken by Gordon Brown’s continuing mendacity about health care. The “deep clean” programme was fraudulent (see Two days later) ; focus group determined window dressing wasting over £90 million of taxpayers’ money. The threat of MRSA and C.Difficle continues unabated. The causes are multi-factorial but, in the UK, unsustainable throughput of patients and inadequate nursing care are two parameters that the government could influence. If you are going to keep real nurses in nursing, you have to pay them properly and treat them properly.

And then he said that he had increased GP's hours and made them “more available” to patients. No he has not. The new programme has not yet been introduced. GPs will be paid for doing this extra work from the beginning of April but will not start doing it until some unspecified time (depending on PCT) in the future. Characteristically, the government has not taken advice from the profession as to how best these extra hours could be used. Complex rules and regulations have been issued in the normal top-down way forcing us to work in a protocol driven, inflexible and inefficient manner.

My practice is and always has been open during the “core hours” of 8.00 a.m. to 6.30 p.m. Unlike many practices we do not close for lunch, and we do not close on Wednesday afternoon. In addition to the core hours, we do a weekly late night surgery, which is very popular with patients. We also provide a walk-in clinic from 7.15 a.m. to 8.00 a.m. which again is much appreciated. In terms of total additional hours we already exceed the requirements of the new regulations. However, the government has decided that the extra time must be in blocks of not less than an hour and a half, that all the appointments must be ten minutes and must all (varies from PCT to PCT) be bookable forty-eight hours in advance.

We could meet these requirements easily. We could advance book the morning and evening surgeries with ten minute appointments. It would be so much easier. When I do the two hour late night sugery I will see about twenty patients, depending on demand. These will usually be patients with acute problems and, mostly, for them a shorter appointment suffices. It would be so much easier for me to book twelve ten minute appointments a week in advance. A fifth of advance bookings do not turn up, which would give me time for paperwork, and seeing the eight or nine patients who do tip up will be a doddle. We could do a Saturday morning surgery as well. To do it properly, to meet demand, this would have to be a walk in service. We are not allowed to do that. It has to be ten minute appointments, booked in advance. Again, this would mean booking twelve patients, seeing the nine who come, and then home for coffee. For our eighteen thousand patients the “improvement” in service would be imperceptible.

I know more about quantitative and qualitative patient demand than the government. When I was setting up a co-operative, and later investigating so called “advanced access”, I researched it in detail, and I continue to monitor it for the practice. Demand can be divided into two broad catgeries; acute and chronic. Most of a GPs work load is looking after the old, the very old, the very young and then, more across the age range, but still predominantly elderly, people with serious on-going illness. These people are not interested in Saturday morning, early morning or late night walk-in access. The other group, smaller in number but larger in demand, is composed of people with acute minor illnesses, hay fever, UTIs, URTIs and so on. These people do not want to book a ten minute appointment two days in advance. If a women wakes up at six o’clock in the morning with acute cystitis, she wants to be seen ASAP and, at our health centre, she knows that if she comes down at 7.15 a.m. she will be seen and treated and on her way home before 8.00 a.m. The commuters, off to work early in the morning, with acute problems are also seen immediately.

When the new regulations come in, if we are to meet the letter of the law (there is no spirit behind it) then all this will have to go. We will see fewer patients outside core hours and we will not be allowed to cater for walk-ins in the same way. Some practices are going to take a more cynical approach. They are going to turn the extra money down and work to rule. We could do that. Only open between 8.00 a.m. and 6.30 p.m.; close for lunch for two hours each day; close on Wednesday afternoon; introduce universal ten minute appointments and tell all the “walk-ins” to go away and “walk-in” to the local HCP staffed “walk-in” clinic. I do not think many GPs will do this, but some will.

The government will continue to say that they have improved the service. The only losers will be the patients. You may think that primary health care is not working well at the moment in terms of meeting demand. Maybe that is correct. But the fact that it works at all is due solely to the goodwill of most family doctors. I expect the usual flood of “waste of time over-paid lazy GP abuse” in the comments column. I shall try to ignore it, but it will be another slice off the morale salami. I shall turn to Dr Andrew Brown, and see how he copes (Are you my doctor? : A fortunate man)

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

For more details of Gordon Brown's lies about the size of the tax burden, look at Brown's Porkie Fest

Calling all mothers who bottle fed their babies

There is a minor discussion going on under the BritMeds about "lactation consultants". It deserves a more public airing.

Proposition

Mothers who decide to bottle feed their babies are not second-class mothers

One of the many things I hated about madwifes (by which I mean the lunatic midwifes, not the kind and caring ones) is the way they treat mothers who decide to bottle feed their babies as failures. Some post-natal wards have "breast-feeding" rooms. The bottle feeding mothers have to make do in the corridor. Even more infuriating is the latest bit of nurse-specialist twaddle, the "lactation consultant". In an excellent and entertaining post, Two weeks on a Trolley described the gratuitous activities of these supernumeray twerps:

The subject of my whineing on his paricular run of nights is the rather grandly named "lactation consultant" who visits our neonatal unit on occasion. Now, I'm not sure what exactly a "lactation consultant" does. I know she wears a power suit and talks to mums about breast feeding. I'm not 100% sure why we need her. She looks expensive....  Two weeks on a Trolley

I think it is reasonable to point out the benefits of breast feeding to all pregnant women. But after that it is their choice. Just as it should be their choice as to whether or not they have an epidural. Some mothers do not wish to breast feed. So be it. That does not mean they are bad mothers and the exercise of their choice does not justify the attacks to which they are subjected by proselytising "lactation consultants". And pity the poor mother who has an epidural and then elects to bottle feed. She is likely to be bullied and persecuted. 

Anti-bottle feeding propaganda from health Nazis

If there are any mothers out there who chose to bottlefeed, I would be interested to hear of their experiences, positive and negative.

Vitamin and enzyme supplements

click to enlarge

Alison, a highly intelligent patient, came in last night clutching something a friend had cut out of one of the Sunday papers. Alison is in her late sixties, had a heart attack four years ago, has two coronary artery stents and has a cholesterol of 4.1. She is on Simvastatin. Her friend is also on a statin. They compared notes. The friend started to get painful joints on the statin and so started taking CoQ10. Her joints are much better. Alison is a keen walker and, after a few miles, her knees hurt and so reasonably enough she has concluded that CoQ10 might help. And you can buy CoQ10 for "only" £15.19 from Boots. What is more, Boots advertise CoQ10 on the internet, with a lot of other vitamin and enzyme supplements.

Kaneka Q10 (Coenzyme Q10)
Natural source, high quality and purity. Important for the production of energy from food as well as being a powerful antioxidant.  Boots

Reading the question/answer under Drug Dilemma illustrated above, note that the answer is from Ingrid Haltink MBant DipION who is a "Consultant Nurtritionist." Like Patrick Holford only not as famous. Patrick Holford is one of the leading nutritionists in the country. He is so famous that many doctors now watch his every move.

Every GP in the country is faced with situations like this. There are so many red-herrings and plausible but scientifically nonsensical strands in Alison's presentation that it is difficult to know where to begin. How should the conscientious GP advise Alison? What I would like to say to her is that Co Q10 is medical wibble; that a lot of people in their late sixties get painful knees and that such pain is variable and intermittent. Temporal proximity does not prove a casual relationship. Suck a tea-bag and you may find the pain goes away. Statins classically cause painful muscles but not, usually, painful joints. I would like to say that many nutritionists are purveyors of medical wibble, and that anyone can call themselves a consultant. Heavens, we even have consultant nurses now. 

As any experienced GP will tell you, this sort of frontal assault rarely works. And Alison has more ammunition. She reads The Times and so is a big fan of Thomas Stuttard, their red wine imbibing, PSA obsessed medical correspondent.

When discussing coQ10 in supplement form with patients, doctors usually insist that it shouldn't be used in place of any prescribed medicine. Its value is as a supplement. Nor should it be used by a patient taking Warfarin, or suffering from any disease that results in bleeding or bruising. Boots has introduced a new natural form of coQ10 called Kaneka Q10 and from today is offering a seven-day trial pack to those with a lack of energy attributed to low levels of the coenzyme. There is a money-back guarantee if the patient's energy doesn't improve. Thomas Stuttaford in The Times

That is one of the most disgraceful bits of "medical" (sic) journalism I have ever read. How dare he use his position to advertise nonsense like this? Trouble is, people of Alison's generation think The Times is still a paper of record. They also think that if something is in a national newspaper, it "must be true". So I took refuge behind the excellent Ben Goldacre. He writes a blog called "Bad Science". Alison does not "do" blogs but she has heard of the Guardian, and Ben writes in The Guardian, so what he says must be true.

Pep, zing, oomph, energy. You won't find them here

Doctors love pills: so do the public, and the media, and of course so do pill companies. When one pill dies, another must take its place. Are you feeling tired? Demotivated? I bet you are. But there is a solution - a pill - pushed by no less than Dr Thomas Stuttaford of the Times. Just two days ago in an article about "office tiredness" he cheerfully rehashed a press release on Boots' exciting new pep pills. He opines at length on how tired we all feel in the office. So tired....  (Ben Goldacre)

Supporting British servicemen - the British Legion Campaign

In real life, Dr Crippen has had a number of ex-serviceman patients. To the average Brit, the concept of an “ex-serviceman” means an elderly man proudly displaying his war medals on Remembrance Sunday. To a practising doctor, ex-serviceman more frequently means a young man, severely injured in the prime of his life.

Britain is currently at war in two countries. Iraq and Afghanistan. Our sanitised news bulletins present these wars without showing violence. Heavens, we would not want to upset all those middle class TV suppers. Most days, the newspapers report the name of a soldier who has been killed, a soldier like the squaddie from Holyhead. What the news does not show, and what the newspapers rarely describe, is the soldiers who are injured. Amputees with burnt faces are not photogenic. Soldiers with brain injuries, physical or mental, act strangely. It is all most unpalatable for the general public. Best ignored. Fortunately, the RAMC looks after these injured service men at Headley Court, which is located in leafy-laned Surrey. I read through about a third of the objections but gradually began to lose the will to live. A few are supportive, some movingly so. (Proud to be British)

In Proud to be British I named and shamed the Leatherhead Nimbys who did not want those nasty injured servicemen cluttering up their leafy lanes.

In Pity the Poor Soldier I wrote of the plight of an injured ex-serviceman

David was a paratrooper. He was a career soldier. He was blown up when the vehicle in which he was travelling went over a land mine. He has a vague memory of flying up in the air, but nothing else. He sustained horrific injuries to one leg. The medical care he received from the army was first rate. He lost count of the number of operations. Finally, he was honorably discharged from the Army. He is no longer “able bodied” or not in terms of being a paratrooper. He cannot play rugby. He can and does play squash. He is, of course, lucky to be alive. He knows that. And yet, his chosen career has gone. Does he keep in touch with Army friends? Not really. Paratroopers are not very good with injured ex-colleagues. He has met some of them for a pint a couple of times, but he feels uncomfortable, almost ashamed.

Pity the poor soldier who fights in an unpopular war.  (Pity the poor soldier)

In Quacktitioner goes to war we looked at the way the government is trying to save a few pence by sending undertrained soliders into the battlefield

The senior officers who have proposed an accelerated training course for 900 fast-track recruits for Afghanistan have admitted that there would be risks for the Army’s “reputation, duty of care and performance under pressure on operations”.The Ministry of Defence said that civilians recruited into the Army under the proposed accelerated training programme for Afghanistan could be signed up for less than 15 months as part of a plan to meet manpower shortages.These specially selected recruits would be badged as members of the Territorial Army, not as regulars, although officials admitted they would fulfil the role of regular infantry. (Quacktitioner goes to war)

The government has no shame. It is desperate to ensure that the public does not get to hear of the disgraceful treatment some of our soldiers receive:

Des Browne, the Defence Secretary, is trying to prevent coroners from being highly criticical of the Ministry of Defence over the deaths of British troops killed in action. In a highly unusual move, Mr Browne began legal moves yesterday to prevent coroners from using language prejudicial to the MoD when issuing verdicts on the deaths of troops who die on active service. Lawyers for Mr Browne went to the High Court to challenge comments made by a coroner in Oxfordshire after an inquest of a Territorial Army soldier in Iraq. Private Jason Smith, 32, died of heatstroke in 2003. Andrew Walker, the assistant deputy coroner of Oxfordshire, recorded at his inquest in November 2006 that Private Smith’s death was caused “by a serious failure to recognise and take appropriate steps to address the difficulty that he had in adjusting to the climate”.  (The Times)

The government cannot stop inquests, so it adopted two other underhand strategies. It is trying to silence coroners. It is also trying to ensure that soldiers and their families cannot be legally represented at inquests. The British Legion says the following:

Inquests can be very confusing for the families of Service personnel, particularly for those without knowledge of the legal system or the military. Solicitors can be expensive and funding is only available in “exceptional cases” where the family is financially eligible. The power to grant public funding for representation at inquest lies with the Lord Chancellor. Interestingly, all cases where someone has died in prison, in police custody or detained under the Mental Health Act 1983 are automatically classed as “exceptional cases” and the need to meet the financial eligibility criteria can be waived. However, Service families need to apply to the Lord Chancellor fortheir case to be classed as “exceptional” and they must meet the financial criteria. We are demanding that all Service families should be provided with legal advice, representation and advocacy during inquests at public expense. (British Legion)

Does not seem much to ask. The British Legion is running a campaign to get automatic legal support for servicmen and their families. Along with other bloggers, such as Guido, I endorse that campaign. Find out how to support our servicemen here.

"Productive Ward" - more codswallop from the nursing hierarchy

I was flabbergasted to find that yesterday the Royal College of Nursing was complaining that:

An increase in paperwork is preventing nurses from spending enough time caring for patients, nurse leaders claim. The Royal College of Nursing has called for extra investment to help nurses cope with non-essential paperwork, such as filing, photocopying and orders. A poll of 1,752 nurses found that a fifth of the time of a standard nurse is spent doing non-essential paperwork. BBC

I suppose it is good to welcome the hierarchy of the RCN on one of their rare visits to the Planet Earth. Better late than never to notice that the nursing profession is bogged down in paperwork. Speak to any doctor in the UK and he or she will tell you that it is becoming impossible to find a nurse who will do hands on nursing. Most of the ambitious nurses have been “promoted” to senior posts from which they churn out reams of meaningless protocols. The few remaining “hands on” nurses dare not lift a finger without first checking a protocol and ticking a box. And we are not talking here about protocols for complex medical procedures such as lumbar puctures. We are talking simple things like handing out lunches or feeding patients.

Age Concern has reported

Nine out of ten nurses do not always have time to help patients who need assistance with eating, despite shocking levels of malnutrition in older patients. Six out of ten older patients are at risk of becoming malnourished or their situation getting worse while in hospital. Age Concern

Why has this happened? Nurses are chronically understaffed of course. Let us not forget that. But also they are pressurised by their masters to fill in forms. If the form is not filled in, they get into trouble. If the patient is not filled with food, well, no one notices apart from the patient, and no one has the time to listen to him. Then we have an intervention from the Chief Nursing Officer, Christine “Flabby-Jowls” Beasley who says:

Christine Beasley CBE

"Nurses should spend their time caring for patients, not having to carry out unnecessary administrative tasks."

We are all with you there, Flabby-Jowls. But then she goes on to say:

"However, some paperwork is necessary for good patient care. It is important that we look at the way wards are run to help increase time spent with patients. For example the Productive Ward programme, produced by the NHS Institute, helps nurses and other front-line staff find ways to release time to care."

Even the starting premise is wrong. Flabby-Jowls say “find ways to release time to care”. A characteristic bit of nurse-speak. She does not think before she opens her mouth. Should nurses not be caring all the time?

What on earth is the Productive Ward Programme? You have never heard of it. So Dr Crippen is going to take you through it so that you can begin to understand why the few remaining “hands on” nurses are in despair; why 25% of nursing students drop out of nursing before qualification; and most of all why doctors are sick and tired of nurse-specialists and nurse-consultants. Remember that things like Flabby-Jowls' “Productive Ward Programme are introduced (sorry, “rolled out”) by nurse-consultants and people of their ilk.

The NHS Institute has found that ward nurses in acute settings spend an average of just 40% of their time on direct patient care. Recent research by Nursing Times also shows that nearly three in four ward nurses say that is not enough and 90% of those polled say that patient care suffers as a result. The Productive Ward is an innovative and practical programme of work which aims to help turn around this situation by releasing time to care. More than that it's a systematic and inclusive approach to improving the reliability, safety and efficiency of the care that you deliver. By creating a really strong focus on the processes of care within your ward setting the Productive Ward will significantly increase the proportion of time you spend providing direct care to patients, improve the experience of both staff and patients and organise your ward so that space works for you rather than against you – saving you time, effort and money.

Did you really read through all that? Well done. Now you get to see a video of “Productive Ward”. Watch it. It is almost unbearable but please persevere. It introduces you to “Productive Ward” at its best.



There are two more videos to watch. Episode 1 “The Journey Begins…” and Episode 2, “The Realities of Implementation” both of which may be found at the NHS Institute for Innovation and Improvement.

The "Productive Ward" House

The Productive Ward module structure is described in full on line here. I will quote but one short paragraph chosen for its priceless first sentence.

A ward leader implementing the Productive Ward will start with the Ward Leader's Guide. Then, with the ward team, they will first work through the foundation modules (Knowing How we are Doing, Well Organised Ward and Patient Status at a Glance). These provide both a solid foundation for the more challenging 'process' modules (more details below) and a grounding in basic improvement principles.

Can you imaging working for people who produce psychobable and videos like this? Working for An “Assistant Service Improvement Facilitator” like Kirsty Bray? And has Productive Ward really delivered? Let’s talk with Nicky Proctor, Staff Nurse in Plymouth.

Nicky Proctor

Hi Nicky. How has Productive Ward helped you?”

"I’ve been particularly involved in sorting the new Feeding and Airways cupboard; previously, the contents were in three places and you had to go to all three to get what you needed; now there’s just the one location and it has been a real positive, definitely saving time." Nicky Proctor

Well done, Nicky. You have tidied up a cupboard. 

You think I am making this up, don’t you? Sadly not. It is for real. Nickly exists and can be found here.

By this stage you must be beginning to understand why doctors’ hearts sink when a nurse-consultant approaches. How can this rubbish be foisted on the once proud nursing profession? The answer is simple, and takes us back to Flabby-Jowls herself.

Don't mention Hattie Jacques to the new chief nursing officer. After only two weeks in her new post, Christine Beasley has already had her fill of references to the "oooh, matron" character embodied by the Carry On star. By Beasley's own admission, it is now two decades since she went near a bedpan. The Guardian

That’s right. She has not had any practical nursing experience for years. Years and years. Look at her c.v.

Career 1962: began training at Royal London hospital and worked as a staff nurse before taking 10 years off to have a family; 1984: assistant director of nursing, Ealing health authority (HA); 1986: assistant general manager, community services, Ealing HA; 1987: director of community nursing, Riverside HA, London; 1991-92: acting chief exec, Riverside HA; 1994: acting regional nurse director, North Thames regional HA; 1995: regional nurse director, North Thames; 1998: regional director of nursing and operational development, NHS London; 2002: head of development and nursing, Directorate of Health and Social Care; 2003: partnership development director, NHS modernisation agency.

Nursing, real nursing, has no chance of surviving whilst ridiculous women (and men) like this are running the profession. Flabby-Jowls has no “hands on” nursing experience. The same applies to most of the upper echelons of the profession. And does she think she is a good role model for nurses and patients?

Obesity is a huge concern for the nation, and a cursory glance at a typical nursing or midwifery conference reveals that a signif icant proportion of this stressed workforce are failing to follow the healthy eating agenda, hampered by the often dismal offerings of hospital canteens and the curse of disrupted eating patterns on shift work. Beasley's response is surprisingly at odds with the idea of the "role model" aspiration the government has for smoking. She says: "Sometimes it is very useful to share the same problems with patients, because you recognise it is difficult." A case of a mixed message, to nurses and the public alike. (The Guardian)

Christine Beasley's eating habits are a matter for her. But, one wonders, if she were not sitting at a desk producing protocols all day but instead rolled up sleeves, went down to the ward and learnt how to do some basic nursing we would not all be better served? It is not going to happen.

For the time being, doctors are (with difficulty) surviving in this environment, for even the lowliest houseman is better trained and more knowledgeable than the nurse-consultant and can take a step back and laugh. The junior nurses cannot. If they do not follow every diktat of preposterous people like Christine Beasley, they will be out of a job.

Another load of crap

Sitting here watching the Panorama programme on C. Diff I am getting angrier and angrier.

Please let's not crucify Rose Gibb again. She is not personally responsible for C. Difficile. What happened in Maidstone is not exceptional. But Maidstone is to be the scapegoat and Rose Gibb is to be held responsible.

Don't get me wrong. There is a problem. And all doctors know there is problem. And we know how to solve the problem. There are not enough nurses. The government targets have increased the throughput of patients to unmanageable proportions. Beds are too close. Sheets are not changed. The bed occupancy rate is unsustainable.

But the media is, as always, going OTT and exaggerating the problem.

C. difficile superbug 'kills one elderly patient every hour in the UK' – and that's a world record. Ten times as many elderly patients are killed by the hospital superbug Clostridium difficile in the UK than in any other country, a medical expert has claimed. Around 6,500 people die of C. difficile in British hospitals every year – a rate of one an hour – and the infection kills four times more people than MRSA. (The Independent)

Lying bastards. Anything for a headline. There are 365 days in a year and 24 hours in the day. 365 x 24 = 8760

So it is not "one death an hour". You may thing that is a trivial, pedantic point. It is not. It is typical of the way the media behaves. The headline will go round the world. The truth will be forgotten. And the truth is that it is not Rose Gibb who needs to be dismissed. It is not her fault. The fault lies at the feet of Gordon Brown, Tony Blair, Alan Johnson, and Patricia Hewitt. And do not be fooled by the deep cleaning initiative. It was a con. An expensive con.

And so Panorama finishes with some mawkish, comforting piano music played over a commentary describing how much improvement has been achieved at Maidstone since Rose Gibb left. The sort of music that lulls you into a false sense of security, that suggests that all is well in the world now that nasty old Rose Gibb has gone.

Don't believe a word of it.

The Britmeds 2008 (27 April)

Let's start with some humour and a glorious example of medical wibble, from Respectful Insolance, who collects such things.

Those with an interest in Kinoki may like to purchase some Kinoki Detox Footpads. Meanwhile, back on Planet Earth, more stress for Tom Reynolds:

His wife lets us in, it's one of those houses that are so clean I feel bad about traipsing my boots all over the carpet. Our patient is a man in his eighties sitting in a chair. He's spotlessly clean, wearing a shirt and a tie, hair brushed back. I bend down to his eye level and start talking to him, my hand snakes out and automatically takes his wrist. I feel for a pulse. Bom………Bom………Bom……… His heart is beating around 25 times a minute. It should be sixty or more. It's no wonder he looks so ill.
(Random Acts of Reality)

Another insightful post from surely the kindest family doc in the country who tells of dealing with that most difficult of challenges, treating a colleague:

Then today I was given a compliment that really pleased me, by a junior hospital doctor. “Hey, this GP thing really works” he said...

Dr Andrew Brown : A fortunate man

Most doctors would happily agree to taking considerable pleasure in recent reports that not only are vitamin supplements a waste of time but, as we have always said, may even be dangerous. Now the "anti-oxidant" loonies are out on the warpath

Count Dracula joins other celebrities, like Sir Cliff Richard, Gloria Hunniford, actress Jenny Seagrove and Carole Caplin (Caplin a "celebrity"? Some mistake, surely. Ed) , who have spoken out to defend supplements after recent medical studies suggested that antioxidant supplements did not benefit those taking them, and might even be harmful. (Dr Aust's Spleen)

The Cambridge Angry Medic is strugging with his dissertation and his supervisor, Simon Baron-Cohen (no, not that one):

Just yesterday I handed in my third-year dissertation, which was on one of the theories of origin of autism and dyslexia. (Funnily enough, one of my friends remarked since I started typing this dissertation she's noticed some of the symptoms of both autism and dyslexia in ME. Maybe it's got something to do with the fact that I started typing this dissertation 36 hours before the deadline. Losing that much sleep can't be good for you. Just ask the little green fairy sitting on my shoulder. --Editor) Cambridge Angry Medic

Do you believe that John Prescott really has bulimia or that he was just trying to flog his new book. Kindly folk like Iain Dale give him the benefit of the doubt whilst cynics like Dr Crippen and Guido (Pass the sick bag, Pauline) were less sure. The Devil does not "do" uncertainty.

Now, my theory is that, so pronounced is this curse, it was Brown who was responsible for Prescott consistently losing his lunch... (The Devil's Kitchen)

Dr Crippen is concerned about the dumbing down of the health service. But dumbing down is happening across the board. It is not just in health care. Archbishop Cranmer takes a look at education and, in particular, at the standard of mathematics examinations:

1. Teaching Maths In 1970:

A logger sells a truckload of lumber for £100. His cost of production is 4/5 of the price. What is his profit?

2. Teaching Maths In 1980:

A logger sells a truckload of lumber for £100. His cost of production is 4/5 of the price, or £80. What is his profit?

The progression through to 2018 is...well, take a look.

Archbishop Cranmer

Dr Crippen hates the way we are filling up our children with mind-altering medication just because at times we find their behaviour inconvenient. Now it seems there are even more reasons for over-diagnosising ADHD

"My daughter is a junior in high school who is preparing to take the ACT. She is an excellent student with a 3.75 grade-point average, and she wants to apply for early admission to college.

"Given this background, you can imagine my surprise when she asked that I take her to the doctor to get a prescription for ADHD medication. I was blown away. She says many “smart” parents have their children tested and diagnosed with attention deficit disorders so the students have the advantage of prescription medicine and un-timed standardized tests.

"Is this really a trend in education?" (Four seasons)

Dr Michelle Tempest, psychiatrist and author of "The Future of the NHS" is back after an absence:

As I wrote before, to Gordon Brown the NHS is 'Not His Specialty'. Hence, the NHS, is likely to be the number one battle ground in the next election...
The Psychiatrist Blog

Dr Crippen hates, HATES this modern trend to try to turn patients into "customers" and "clients" a trend started by social workers and then enthusiastically take up by mental health nurses. God, I hate it. The Shrink has taken a look at what the patients (clients, customers, whatever) feel about it.

Frontier Psychiatrist asked, "Whether I should describe people who use psychiatric services as 'patients' or 'clients'/'service users'." We asked in-patients, day hospital patients, out-patients, home visits and day respite patients what they wanted to be called. We then did it all again, months later. We then did it across the entire district. We then asked a carer forum. We then asked another carer foruim. We then asked the local Alzheimer's Society branch. Locally MIND isn't that active with older adults, but we asked them anyway. The response was almost 100%, we should address them as... (Lake Cocytus)

Don't tell Wat Tyler at Burning our Money, but apparently we (by which I mean we the taxpayer) are forking out for a salary and pension for "lactation consultants". These ridiculous creatures are off shoots of the Madwifery Mafia. I hate them. I always hated the way that madwives persecute women who do not want to breast feed. Mothers who bottle feed are treated like second class citizens by these preposterous women. A "crack unit of health care professionals" discusses the problem:

The subject of my whineing on his paricular run of nights is the rather grandly named "lactation consultant" who visits our neonatal unit on occasion. Now, I'm not sure what exactly a "lactation consultant" does. I know she wears a power suit and talks to mums about breast feeding. I'm not 100% sure why we need her. She looks expensive....
Two weeks on a Trolley

If there is one thing that doctors dread more than anything else, it is being asked to help at an accident

How many people have dreamt about being a hero at the scene of an accident? For the majority it will remain just a dream, one in which they are cool, calm, confident and heroic. For others, this dream becomes real, but the reality of the situation is somewhat different to the heroic dream.
I'm a medical student, get me out of here

Rita is, as always, on good form and is looking at medical news beyond the headlines

Paul Cosford is a brave man because he has told the manager what everyone in the NHS thinks. We don''t like NHS managers. They have too many parking spaced allocated to them while all of us have to drive round the car park a million times over until a space is freed. (NHS Beyond the Headlines)

In the light of recent headlines, Mentalnurse takes a look at the intolerable pressures on nurses:

Eight out of 10 nurses say they have left work distressed because they have been unable to treat patients with the dignity they deserve, a poll suggests. This probably won’t be news to a lot of nurses who have been too overwhelmed by workloads to ensure basic standards of care are met. (A little bit of dignity)

In a rather spiteful post, Mousie takes a look at some of the New Labour bureaucracy that tries to control and regulate hospital admissions:

Upstairs from A&E is the GP Admissions Centre or GPAC. (Where would the NHS be without its beloved acronyms?) GPAC is, essentially, a ward where patients are sent when they have been seen by a GP who doesn't know what to do with them wants them to have a specialist opinion. The kind of specialist opinion that is usually provided by the most junior doctors in the hospital, natch. (Mousethinks)

Last year, THERE WERE NO DEATHS FROM MENINGITIS C. The newspapers mentioned it, I suppose, but it did not get the headlines it deserved. Why will the media take no interest in stories proving the value of childhood immunisations. Blacktriangle takes a look at JABS and the rabid newspaper reports criticising the immunisation when it was introduced.

Far from being a “a self-help group neither recommends nor advises against vaccinations”, JABS are an organisation with a deep antipathy to vaccines founded in scientific ignorance. This may be more obvious now, but the above comment shows that the propensity to this view has always existed. (Black Triangle)

Doctors are filthy disgusting people. English doctors may be dirtier than Welsh doctors. Or could there be a little more to it than that?

Above are the figures from death certificates (from England and Wales) which mention Clostridium difficile. That's the infection that's caused and spread by doctors. Certainly that's the bit the government would like the public to hear. Because, despite the government's best efforts, doctors are continuing to cause this infection to spread. (Dr Grumble)

Menstrual moans. Emma is struggling with her period - again - and takes refuge is a wonderful video make over

I woke up this morning feeling crazed. Does anyone else feel like they are psychotic during their period? I feel like I am totally unravelling, like if this video were run in reverse (Mommy has a headache)

Life in the NHS writes

It is sad that the government is having to launch yet another initiative, this time about dignity, it is annoying that this might yet turn into another tick box audit type issue. It would be easy to say that the nurses / doctors / etc are just less caring, that they are in some way falling short. (Treating people with dignity)

The waste of taxpayer's money on failed IT projects beggars belief and continues as yet more money is poured into the NHS IT salary bucket. Why does this happen? Consider a view from outside the NHS

But I heard something that made me wonder about one thing and I decided to blog about it. There were several CIOs and heads of technology from various health authorities and hospitals around the country. And the discussion became so bizarre that I had to literally and vocally challenge them. Their basic point was, their CEOs had no idea about technology... (The Daily Salty)

There has been a lot of hysteria in the press about problems on maternity wards. Midwifemuse tries to take a sensible look at the problems

In the same week that we find out about 3 more maternal deaths at Northwick Park, the maternity unit which was until only recently under special measures for 10 previous deaths, there is a report about a baby’s death at an adjacent unit ” Mothers heartbreak: How 30 blunders by hospital killed my newborn baby”. It’s difficult when you read articles in newspapers, obviously the reporter has interpreted the report that the press association has issued and highlighted the issues which s/he feels are important. The problem with them deciding what to publish is that it is often misleading as they don’t understand the importance of seemingly minor facts. (Foetal distress not acted upon)

The Jobbing Doctor is taking a look at ME or Chronic Fatigue Syndrome and has come across a new and quite extraordinary treatment

I have a difficult problem to contemplate. This relates to one of the most challenging group of patients I see. These are people with Chronic Fatigue Syndrome, Myalgic Encephalitis (ME) and other ill-defined syndromes. One of my patients is having treatment with courses of daily infusions of... (Evidence Based Medicine?)

If only we really knew what causes schizophrenia. Dare to Dream takes a look at a recent research paper

More than 200 studies have suggested that schizophrenia occurs between 5 and 8 percent more frequently than average in children born in the winter or spring. Scientists realized that viruses, which are most prevalent in the cold, dry winter months, could be one of the factors influencing this correlation. (Dare to Dream)

A busy doctor and mother of two small chidren is Blogging for Autism

We've all read the newspaper articles and the magazine stories and the heart-wrenching True Life stuff about Our Autism Nightmare or My Child's Terrible Affliction. So we all know about autism. Don't we? Helpless, hopeless, a life-destroying disaster that renders a child incapable of enjoying life or doing any of the things normal people do, unaware of what's going on around him, and, barring miracles, devoid of hope for any sort of future. In other words, the general public thinks about autism in pretty much the same way as it used to think about physical disability.... (Good enough mum)

A few weeks ago we laughed at the story of Jack Straw visiting an old peoples' home and asking one of the residents is she knew who he was. She replied, "No dear, I'm sorry I don't but if you ask matron she may be able to tell you." Now Faith brings us some more much needed humour from the psychiatric ward.

I’ve just been told this story by a friend and I can’t stop laughing so I thought I would share. A friend of a friend just started her new job on a psychiatric ward and was doing a bit of a “meet the patients”, so to speak. She asked one of the patients if he knew why he was there. His reply.... (Message from God : Part 1)

The Labour Government, yes, the Labour Government...look, I know Clause IV has been abolished, but this is till supposed to be a LABOUR Government, continues with the back door privatisation of the NHS

The privatisation and destruction of the NHS continues apace, the government has one intention, to open the market up to big profiteering multinational corporations, and it is patients that will be bent over and shafted in the process. (Wake up and smell the Coffey)

The Voice of Reason has a child safety panic attack when she sees this:

My heart stopped for a full minute... (This morning's heart attack)

The government is plodding on with its reforms of medical training despite opposition from those being trained:

The naive proponents of MMC believe that their revolutionary new methods of training, consisting of lots of paperwork and lots of hot educationalist waffle, will increase the quality of training so much that a reduction in hours will have no effect on training. Any trainee on the ground will tell you how dumb this approach is, as the reduced hours has resulted full shift rotas replacing older more training friendly rotas, while there is far more cross cover than ever before, meaning that more time is spent doing mundane admin as opposed to the juicy training bits of the job. I won't comment on the paperwork burden, other than to say that chopping down trees only trains lumberjacks. (The sinking ship)

Angus, from Life with leukaemia, is going bald. Has he found the answer? A high street pharmacist like Boots would not do anything disreputable. Would they?

I noticed Boots Pharmacy promoting a Hair Retention Programme - "9 out of 10 men keep their hair with our Hair Retention Programme". Curious, I picked up a leaflet. Let us quote ... (Hair retention ? solution)

Finally, sexually transmitted diseases are forever on the increase. Perhaps we could learn something from the US Army medical core who tell us about the virtues of the American way and the perils of being treated by a "clap doctor" or "druggist" (pharmacist)

Oxford Union changes its mind : invitation to Chris Langham is withdrawn

Following widespread outrage and criticism, the Oxford Union has withdrawn its invitation for actor Chris Langham, jailed for downloading child pornography, to address students. The Bafta award-winner was due to give a talk on 27 May about his conviction and his "vilification" in the media. Ben Glazer, spokesman for the Oxford Union, said:

"We probably should have realised the uproar it would cause but hindsight is a great thing, it was probably a mistake."

Probably?

The offer of public platform to Chris Langham caused offence to the numerous victims of child pornography, the children themselves.

Chris Langham, award winning writer and actor turned national pariah is a victim, right? His imprisonment for downloading some of the worst examples of child abuse (rape, torture, you know, the really nasty stuff) an overreaction that has destroyed the life and career of a good man. A man who has done nothing wrong, a man with a laudably clear conscience. Yes?

Well, actually Chris, no. No, no, no. You’re not the victim; you’re not even a victim. You’re the aggressor, the protagonist, the one who does, not the one who is done to. (The Fall and Rise of Chris Langham)

Mistreating junior doctors - more trouble with jobs

The MTAS debacle was briefly in the public eye last year but all is now quiet as far as the general public are concerned. Meanwhile, our junior doctors to be are still being messed about. Patricia Hewitt has gone, but chaos remains.

Final year medical students are currently in the run up to finals after five years of study. It is stressful. It was bad enough when I did it but I knew that, provided I passed, I would get a decent job. I did not know for certain which job, but it would be one I had chosen. It is not like that anymore. I have just received an email from a final year medical student who has been through the job application process, been offered a job and accepted it (subject to finals). She says the following:

I'm a final year medical student and have very recently been told that the funding for my F1 post has been withdrawn by the NHS. This left me a little shocked as after the rather lengthy process of the application I got my first choice and had the chance to work in a job that I particularly wanted to do. Now it seems that they have cut the number of new posts (I believe from 12% to 5%) and as such all those due to work in those posts will no longer be doing so.

On the plus side I have been guaranteed a job and will be working somewhere, in some job. And I will have some limited choice as there are those who have failed finals already or left for other reasons. However, this is not quite what I had hoped for. Nor, was it what I wanted to hear so close to finals when my mind is already busy enough.

I've had a search around on the internet to see if I could find more information on this but couldn't find anything so I was wondering if this was something that you had heard about. To be honest, I think a part of me just wanted a bit of a whine to someone who I thought would be sympathetic to the crappy position that that NHS has put a number of their future junior doctors in.
I am now in limbo.

Suzie P.

Well, Suzie, there will be a torrent of comments saying things like “why should she be guaranteed a job” but also many supportive ones from others who have been let down in various ways by the system. All medical students who pass finals should be guaranteed an F1 job. It is part of your training. Until you have done that year, you are not a real doctor and, apart from considerations of humanity, it is economic nonsense for the country not to allow a doctor to finish his/her training.

Suzie P. should join Remedy UK if, indeed, she has not done so already.

Taxing the poor

Trained for a life of poverty

I am going to adapt (shamelessly, sorry Iain) a short article from Iain Dale about stealth taxation.

Did you realise Alistair Darling put a penny on income tax in last month's budget? The car tax rises announced in March have added £2.5 billion to Treasury coffers. Revenue neutral, they said. It will improve our carbon footprint, they said. Yup, by achieving a 1 per cent emissions reduction. And who's hit most by this tax rise? You're ahead of me ... It's the not so well off, of course. (Iain Dale)

So, if you are a newly qualified nurse earning £20,000 a year (give or take – full details of nursing salaries here) living in a Band D house with a family and driving a ten year old Renault Espace, you'll be paying another £120 council tax, an extra £200 income tax and another £600 for food. Another Triple-Whammy Labour income bombshell.

Nurses aren't stupid. They have grown wise to these stealth taxes. So when they are offered a pay rise of 2.4 per cent they feel insulted. They feel more insulted that Brown should try to tie them into a similar pay rise for three years, until he is safely past the next general election. They know the real rate of inflation – i.e. their own cost of living index - is far higher. They are not being offered a pay rise at all. It is a pay cut. A substantial pay cut. This is why teachers are on strike today. They too have seen through Brown's deception and lies.

As regards nurses, this scenario is of course too silly for words. A house, car and family? What nurse at the start of her/his career expects to have a house, a car and a family to support? Nurses at this stage have none of that and frequently are helped out financially by parents or better-paid partners.

Crazy.

How to make money out of the NHS

Sarah Chilvers (left) takes over another general practice

Remember last year when there was a spat in Derbyshire after a contract to run two general practices was going to be awarded to US based United Health Europe? That take over was stopped and instead the contract was awarded to home grown private company ChilversMcCrea.

Welcome to the website of ChilversMcCrea Healthcare, the largest alternative provider of NHS primary care services in the UK. The company was established in 2002 by Dr Sarah Chilvers and Dr Rory McCrea to deliver high quality primary healthcare services in locations that were suffering under the then existing model of provision. (ChilversMcCrea)

It all seemed promising. ChilversMcCrea reported:

ChilversMcCrea assumes management of Creswell and Langwith Practices from Derbyshire County PCT

After a protracted period of negotiation Sarah Chilvers and Rory McCrea, on behalf of ChilversMcCrea Healthcare, were delighted to assume the responsibility for the management of these two very high profile practices from Derbyshire County PCT.

Sarah Chilvers, CEO, commented: "The situation with these two practices has received a huge amount of media coverage in the past year and it is fantastic news that we are able to begin delivering on our promises to patients and staff. The consultation process has involved patients at every possible opportunity and I wish to express my thanks to the patients for their support and patience. Now we can all move forward and put into practice many of the plans we have been discussing over the summer." ( ChilversMcCrea News)

And how is it all going? Very well you would assume from all the smiling happy faces at ChilversMcCrea. No mention of any trouble. But more information is available from the HealthcareRepublic:

An emergency meeting has been called today in a Derbyshire village where private GP-led firm ChilversMcCrea took over the surgery last year. The meeting has been called at Langwith by Scarcliffe Parish Council in response to a ‘flood of complaints' from patients. Patients have condemned the surgery building as ‘nothing short of Beirut'. (full report here)

I have never been to Beirut but I suspect this is not a compliment. And who exactly is Sarah Chilvers, the chief executive at ChilversMcCrea?

Sarah Chilvers D.Prof MBA BSc (Hons) RGN RHV

Sarah is nurse specialist. But I will not get on my hobby horse. Does anyone know what went wrong in Derbyshire? I do not think Sarah Chilvers is going to tell us. The "news" column on their site should perhaps have been entitled the "good news" column

++++++++

P.S. Anyone wanting a job in the Derbyshire area should look at ChilversMcCrea's site. There are a lot of vacancies. 

Woman unable to perform oral sex sues the doctor

I found this little nugget, as so often, via Kevin MD. 

So a lady came into the ER (not mine but one nearby where I work) for a possible fish bone stuck in the throat...

Full story from ER Stories - Shocking, Hilarious, Bizarre, and Sad Tales from the Emergency Room

Doctors who commit suicide

A reader points towards a worrying article in Newsweek

The unsettling truth is that doctors have the highest rate of suicide of any profession. Every year, between 300 and 400 physicians take their own lives—roughly one a day. And, in sharp contrast to the general population, where male suicides outnumber female suicides four to one, the suicide rate among male and female doctors is the same. (Newsweek)

Most people who commit suicide are depressed and doctors suffering from depression are reluctant to seek help. And once they decide to commit suicide, they are usually successful. They know how to do it.

Why do doctors get depressed? 

It is the peculiar strains of the job. Doctors feel responsible for their patients in a way and at a level that other carers cannot understand. When a patient dies, most doctors feel a moment of guilt and responsibility, even though their management of the patient has been faultless. Difficult to describe the sinking feeling you get when, on a Monday morning, your secretary says "could you phone the coroner - there has been an unexpected death."

Morale in the UK medical profession has dropped to an all time low. We are generally reviled by the national press and by right-wing pressure groups, such as the Taxpayers' Alliance, both of whom portray us as lazy and over-paid. This suits the government who is in the process of introducing a lower level of quasi-medical care throughout the NHS. It is hard to be told that a job for which you trained for ten years can be better done by an HCP who is educationally and intellectually inferior and has no real medical training. You feel devalued. You know that, however "nice" and "caring" the HCP is (and they are) the patient is being short-changed. You know, also, that the great and the good and the privately insured will see doctors, not HCPs. To those of us committed to the principle of a decent standard of health care for all, that is wrong. But if you try to express that wrong, you are deemed to be politically incorrect and are shouted down.

FORTY years on, Orwell's Newspeak is finding its apotheosis in New Labour's modernised National Health Service (NHS). However, whereas the original form of Newspeak restricted the range of words in order to limit the expression of dissent, the contemporary form deliberately distorts the meaning of words in order to mislead and manipulate. The Changing Workforce Programme of the NHS Modernisation Agency is planning the development of a new category of health professional...

...the core GP task of providing a first-line medical diagnostic service, without recourse to excessive, unnecessary, and potentially harmful investigation and referral, is not one that can be delegated to anyone who does not have a full undergraduate medical and postgraduate GP education.  (Iona Heath)

Nonsense says the government, intent on saving money. Nonsense say the hubristic HCPs

Most of all, though, the low morale is due to the doctors' inability to discharge their personal responsibility  for the management and welfare of their patients, a responsibility that cannot be delegated, and a responsibility that is peculiar to doctors. The constant need to fight an impenetrably inefficient, dumbed down NHS to try to get a decent level of care for your patients is a receipe for low morale.

Pass the Prozac

Grand Rounds from the voice of reason.

Dr Val Jones MD

Welcome to Grand Rounds 4.31, Dr. Val's edition of the weekly rotating carnival of the best of the medical blogosphere. There are many approaches to summarizing submissions to Grand Rounds, and I have chosen one that has never (to my knowledge) been used before...

It is all over there at Dr Val and the voice of reason. See what they are thinking in the USA.

The Desktop meme

Don't normally do these things but, if the ageing greek and the DK have done it, how can I refuse?

Now I shall send it to Wat Tyler. Bet he is tidy.

Go away, Mr Langham

There is something peculiarly repulsive about paedophilia. Chris Langham was convicted on several counts of viewing child pornography. I had thought that he was a sickeningly depraved pervert but I gather now that that is not the case. He is not a criminal. He is himself a victim.

Mr Langham, 58, of Kent, has denied 10 counts of indecent assault and two counts of a serious sexual offence on a girl under 18 between 1996 and 2000. He also denies 15 counts of making an indecent image of a child in 2005. The court heard police raided his home in 2005 and found images of young girls "being degraded and sexually abused". (Source)

David Wilson, writing in the Guardian, also mistakenly thought he was a pervert:

We do not know what these indecent photographs look like, but the fact that Langham has been remanded in custody perhaps suggests that they were "level 5" images, which involve children being, for example, anally or genitally penetrated by an adult.  (When is paedophilia not paedophilia?)

How wrong can you be? We are all so prejudiced against paedophiles. Some view it is a crime worse even than murder. In moments of temper most of us have said or thought, “I could kill you”. We understand the basis of the common domestic murder and, when the culprits are released on licence, we are not troubled as to where they live. We do not understand paedophilia, so we are prejudiced against people like Chris Langham.

Langham, 58, told police who raided his secluded family home in Golford, near Cranbrook, Kent, that he downloaded images of girls as young as seven being sexually abused and tortured by adults to research a new character for the hit BBC2 television show Help.

He denies 15 counts of making an indecent photograph of a child between September and November 2005.

He also denies 10 counts of indecent assault and two counts of buggery between January 1996 and April 2000. (source)

Chris Langham was also accussed of grooming a young girl from the age of 14. She collapsed under cross-examination. The jury did not find her a credible witness, and found him not guilty of all charges relating to her. So we have to assume that it is normal for a middle aged man to take a 14 year old girl for dinner at The Ivy, and commendable to take her to hotel rooms to give her breathing exercises to help her acting. How could this unreliable girl make all these allegations against poor old Chris.

However, the jury of seven men and four women took only two hours and 40 minutes to reach their verdicts, clearing Langham of any involvement in six indecent assaults and two charges of buggery on a teenager. His alleged victim, who had a history of mental illness, had told the court that she had lost her virginity to Langham a few weeks after her 14th birthday, when he was starring in 'Les Miserables’ at the Palace Theatre in London.

Langham had told the court that he had only had oral sex with her, and that was when she was 18. (source)

He “only” had oral sex with an 18 year old girl who had a history of mental illness. Nothing illegal about that. How dare people criticise him? It’s our prejudices again. We may put up with murderers living in our community, but not paedophiles. We do not want them living next door, thank you, or on the same street, or close to our schools, or walking in our parks past those playgrounds in which we spent so many long hours when the children were young. Why on earth should we feel like that?

A juror sobbed yesterday after being shown disturbing images from the child pornography allegedly found on the computer of the award-winning comedy actor Chris Langham. Maidstone Crown Court was shown five images taken from child porn video clips before Judge Philip Statman halted proceedings when a female juror became upset.

The prosecution showed the jury the images from the clips so that they could see the quality. The female juror is one of four women and eight men trying the case. Some of the other jurors also appeared distressed while viewing the images. A second woman held her face in her hands while the 20-second clip was played while Langham avoided watching the videos by shielding his eyes with his hands.
(source)

Our prejudicial behaviour poses a legal problem. When the paedophile has served his sentence, “done his time”, paid his “debt to society” does he not then deserve to be left alone?

The 58-year-old Bafta-winning actor, who wept as he was sentenced, had downloaded images and videoclips of children as young as eight-years-old. On Friday at Maidstone Crown Court, Judge Philip Statman said: "Some of the children viewed are clearly prepubescent, others are fully developed, some of the children are clearly of Filipino extract.

"All have had inflicted upon them horrifying sexual abuse and, I want to make this absolutely clear to you, I must think first of those children. They are too young to consent.

"When one sees their faces, in my judgment, they are vacant and lacking in expression ... you never ever see the faces of the perpetrators. 

Your activity took place in the comfort of your own home, no doubt at the time feeling safe in the knowledge that you would never be caught. (source)

I think Chris Langham does deserve to be left alone. I do quite genuinely feel sorry for him. I would feel sorry for anyone who has forfeited their right to live in a decent society. I particularly feel sorry for his wife and children. I think he should remain on a sexual offenders’ register. I think he should be closely monitored by the police who should have input into where he lives. Other than that, despite all my “prejudices”, I am happy to leave him alone. Trouble is, he will not leave me alone. He keeps popping up all over the place. For you see, Chris Langham is out to prove that he has been wronged. It has all been a big mistake. Chris is a victim. He was himself abused as a child (he says) and so he was looking at paedophile pornography to try better to understand what happened to him. Or did he need to look at it to help research a script he was writing? We have heard that one before, from another “victim” of paedophilia:

"I think I may have been sexually abused as a child and I was doing research into it. (WHO said that?)

Watch Chris Langham shedding his crocodile tears in Dr Connelly’s video. When you have done that, we should move on to talk about the elephant in the room that has so far gone unmentioned. I mean the victims of paedophilia. No, not you Chris. The real victims. The children. The children who were abused to provide you with sexual gratification. Tell me, Chris, when you used to watch those films, did you masturbate? Or am I not allowed to ask that of a “victim”? Am I just showing my “prejudices” again?

Clearly indicating that he was considering imposing a lengthy jail sentence, Judge Phillip Statman said that the images found on Langham’s computers - several of which were of the worst, level 5 category - "well and truly passed the custody threshold". Ordering Langham to be remanded in custody until sentencing, the judge told him: "In my judgment - and I have thought long and hard about this - it would be a misplaced kindness to give you bail at this stage." (source)

Anna (not her real name) was, as a child, a victim of sexual abuse. I know Anna. She is grown up now. She is happily married. She has children of her own. She does not get her credit card out to purchase paedophile pornography so that she can “understand” what happened to her. She knows exactly what happened to her. She still finds it difficult to deal with and she is still seeing a therapist.

Anna does find one thing hard to understand. Why is Chris Langham being allowed access to the media to portray himself as a victim? There was Anna, and all the others who were abused in childhood, thinking she was the victim.

Anna tells her story to Niki Shisler in

The Fall and Rise of Chris Langham
Chris Langham, award winning writer and actor turned national pariah is a victim, right? His imprisonment for downloading some of the worst examples of child abuse (rape, torture, you know, the really nasty stuff) an overreaction that has destroyed the life and career of a good man. A man who has done nothing wrong, a man with a laudably clear conscience. Yes? Certainly that was the message coming loud and clear from Langham’s ‘rehabilitation’ interviews……
Niki Shisler : Letters from my life

Chris Langham has already been allowed an hour of tearful self-indulgence with Dr Connelly. Now, believe it or not, he is to go to the Oxford Union to explain his “vilification” by the media. The Oxford Union has form in this area. It was they who gave a platform to David Irving  the Nazi apologist and holocaust denying "historian". And to Nick Griffin of the BNP

Ben Tansey, the current President, says

"We do not invite speakers for publicity. We were recommended Chris Langham and we thought he was a very respected figure in his profession being a Bafta winner. I know some people might have a few reservations but he has served his time in jail. He will be talking about the run-up to his conviction and how he has been vilified in the media so quickly."

Ben is a tad ingenuous. If this is not about publicity, what is it about? Still, I suppose when you have already had a holocaust denier and a leading racist to dinner, why should you not have a paedophile as well? It is, after all, about freedom of speech. I wonder if Ben will be inviting one of the real victims of paedophila along to give their point of view. So I have emailed him:

Dear Mr Tansey

As a doctor I frequently have to deal with the real victims of paedophilia. The real victims are the children who are sexually molested against their will to provide sexual gratification for men such as Chris Langham. I note you are giving Mr Langham, a convicted paedophile pornography viewer, a platform. Freedom of speech is important. So is balance. Will you also invite one of the victims of sexual abuse to speak on the same platform?

Yours sincerely

Dr John Crippen

I await his reply with interest. Maybe Anna will offer to speak. Maybe she will find the prospects of being in the same room as Chris Langham too upsetting.

Dead bodies and Ash Cash

Have you checked in recently at The Daily Rhino?

If you haven’t, you should. It is written, well written, by a junior hospital doctor, and it is fun. He writes for the Medical Student Magazine, as did I. The Daily Rhino gives you some excellent insights into what it is like to be a young doctor. Beer, sex and hard work. Well, something like that.

The Daily Rhino has been picked up today by the BBC. By the PM programme no less.

Our main story this week came to us via listener Pauline Levey. She emailed to suggest we take a look at 'ash cash'. This is a fee that's required in order for doctors to release a body for cremation. It's currently set at a level of £71 each for two doctors, paid in cash on top of the doctors' NHS salaries. Pauline - whose mother was cremated a year ago - says the charge is unfair and cruel. Here she explains why. (BBC)

As the Americans would say, sorry for your loss, Pauline, but you are naive. You do not seem to mind that the undertaker charged you a couple of grand for the funeral, but I suppose that is different. I do not know if the words are yours, or the BBC's, but who ever wrote them is a poisonous fuckwit. Doctors do not hold on to bodies and blackmail families to pay them a fee before they will "release" them. It's the law of the land. The law insists that checks are made to ensure that people are dead before they are burnt.  Do you have a problem with that?

The Daily Rhino has not helped, for he has been writing about Ash Cash.

Ash cash. The sixty two pounds a doctor pockets every time a patient they have certified pops their clogs and is burnt to a crisp is nothing short of infamous. Known as the house officer’s privilege, it is the fund for Thursday night drinks all over the country. A colleague working on care of the elderly has effectively gone up a banding due to the vast amounts of ash cash he rakes in. No comment on his quality as a doctor, of course. Ahem. Yet when we are filling in the form, we all answer ‘no’ to the question ‘Do you have any pecuniary interest in the patient’s death?’ Despite some noble souls donating their cheques to charity, the rest of us catch ourselves secretly hoping that families opt for cremation. If a terminal patient is known to several doctors, we also hope they survive just until we’re on call and then we’ll be the one called to confirm, see the body after death and head down to patient affairs before anyone else beats us to that cheque. Well, perhaps that’s just me.The Daily Rhino

When you are a young doctor, death means nothing. It is something that happens to people on a different planet; to people older even than your grandmother. When I was a young houseman, I had to fill in death certificates. Then, if the patient was for cremation, and they usually were, I had to fill in the first part of the cremation form. This meant stating that I was certain as to the cause of death but most importantly that I was sure the patient was dead. To reach that state of certainty, I visited the hospital morgue, inspected the body, and then, drawing on my wealth of medical experience (I signed my first cremation form 48 hours after I first qualified) filled in the form. I had not got a clue what to put, but the secretary made lots of helpful suggestions, and I survived. Not a pleasant business. Best not to think about it. Best to laugh it off. And one did get paid a fee for doing it, which we called “Ash Cash” because that was traditional, and funny (ha! ha!) and eased the pressure. We used to crack jokes about death, and cancer, and foetal abnormality, and children with deformities too – ever seen the acronymn “F.L.K” in a child’s notes? It means “funny looking kid.” Ha! Ha!

I still go to the morgue. It is usually at the undertakers. Unlike the hospital morgues, commercial undertakers are not as scrupulous about refrigeration as I would like, but you don’t want to know that, do you? The undertaker’s typist opens the fridge, and slides the body out. Nowadays, the body is not from a different planet. It is not a body at all. It is a patient. Someone I have known for maybe twenty years. Someone whom I have looked after. Someone who is younger than my grandmother, younger indeed than my mother. And I look, and identify, and check they are dead, and feel sad, and a little guilty (could I have done better?), and above all else I satisfy myself that they are truly dead, and I wash my hands, and I fill in the form, and the typist jokes about this, that and the other, and she gives me a cheque, which I do not look at (I think it is for about £40) but which I will hand to the practice manager when I remember, and I drive back to the health centre to deal with the living, and I think that one day not long from now someone will slide me out of a fridge and look at my cold, dry eyed cadava, and I am quiet for the rest of the day, and when I get home the children notice and ask why I am quiet, and maybe I shout at them. I wish I was young again so that it could all be fun and “ash cash”, but that is not possible. My skin is no longer Rhino-thick for now I understand what I am doing, and how important it is that I do it properly. The last job you do for your patient. Important, then, to get it right.

What fee should I be paid for this work? I have not got a clue. The last funeral I organised for a close member of my family cost over £2000. £80 of that went to the doctors who made sure that their patient was dead. Is that too much? Beats coffins with fingernail scratches on the inside of the top lid.

I don’t care what the fee is. There is no amount of money you could pay me that would make me feel comfortable about this job. Young doctors deal with it, as did I, by cracking macabre jokes. I cannot do that any more.

John Prescott and bulimia

John Prescott and friend

Sometimes I think Iain Dale is too nice for this world. He has just put up a sympathetic post about John Prescott and his "bulimia".

The revelation of John Prescott's bulimia is not to be laughed at. Bulimia is a serious condition and he is to be praised for his decision to be honest about it. Most people believe bulimia only afflicts young girls who don't want to put on weight. It doesn't. It can affect anyone, as John Prescott's case clearly confirms. (Iain Dale)

Well, OK, Iain, we all have a soft spot for the old rogue. But I have patients with bulimia, and it ain't like this. John Prescott is a man of excess, and good luck to him. Michael Douglas was a man of excess too

Some people simply can't help being 'sex addicts', according to a new "discovery" by scientists. (Daily Mail)

Maybe poor old Prezzy can't help that either. Ho! Hum! I am too old and cynical. I cannot buy into the idea that this kind of behaviour represents illness. I am more taken with the diagnostic skills of my learned colleague, Dr G. Fawkes, who presents a clinically persuasive picture in Pass the sick bag, Pauline.

 The more fascinating question is what on earth prompted John Prescott to make this extraordinary public confession?

Fraudulent qualifications

If it were announced tomorrow that 18% of doctors had fraudulently misrepresented their qualifications, there would be a national outcry. The Health Care Republic reveals today that:

18% of nurses using the Nurse Practitioner title do not have the qualification

Ask yourself carefully why no one is bothered.

The Health Care Republic also reveals that

13 per cent of nurses who are prescribing do not have the prescribing qualification.

It is scary enough when they do have the "qualification". It's all about professional standards, I suppose. Real professional standards. How many of these nurses will be struck off? Don't hold your breath. 

Psychiatry on the cheap

Psychiatric risk assessment

The sad case of Mark Corner is once again in the news. Four years ago he murdered two young women. The case is in the news again because Mark Corner is a schizophrenic who was under the care of a consultant psychiatrist, Dr Eric Birchall. A year before the murders Dr Birchall decided that it was not necessary to keep Mark Corner detained in hospital, as he was only a “low risk” to the community. He was discharged to the care of the Community Mental Health Team.

I do not know the facts of the case other than the scanty details in the newspaper. But this tragic case covers many issues that concern me.

Newspapers love “mad axe murder paranoid schizophrenic” stories. Please remember that most schizophrenics, like Emily, are helpless, hopeless people who pose no threat to anyone.

There is a desperate shortage of hospital beds for the mentally ill. Desperate. Successive governments have closed many of the traditional long stay mental units, and the ethic now is “care in the community”. It’s cheaper. Consultant psychiatrists are put under overt and covert pressure to turf mentally ill patients out of hospital at the first opportunity.

Proposition. All schizophrenics should be compelled to have life-long institutionalised hospital care. Tuck them all away, under lock and key, out of sight, out of mind. That proposition is not acceptable and, even if it were, there are not enough beds. So someone – and it should be a consultant psychiatrist – has to decide who is safe and who is not. What standards should they apply? Hunch? Balance of probabilities? Beyond all reasonable doubt? However clever, however caring they are, they will occasionally get it wrong.

It was said that Dr Birchall “failed to use approved monitoring systems”. Easily said. Sadly, there is no monitoring system short of constant one-to-one supervision that is guaranteed safe. An experienced psychiatrist will pick up early warning signs, if there are any. But he does not have the time to see all his patients regularly and personally. A psychiatrist might have 200 mentally ill patients under his care. He has to delegate. Unless he works in a teaching hospital, he is unlikely to have an experienced registrar to share the load.

So, it is care in the community, monitored by the kind, caring, hard-working, cheap, non-medically trained CMHT members. They will play at doctor by filling in their tick sheets, and complete their risk assessment protocols, and find much wood and no trees. They confuse caring with competence. They are neither qualified nor competent to make psychiatric diagnoses, but you cannot tell them that. They do not understand. They will not have it.

The tragedy of Mark Corner is a tragedy of lack of resources. Not enough hospital beds. Not enough psychiatrists. Doctors forced to discharge patients who would be best kept in hospital, and to delegate medical care to HCPs who have no medical training. It has been going on in psychiatry for years. Now the government is “rolling it out” (as they would say) in all medical disciplines. We learnt last week of HCPs doing ECG telephone triage of chest pain patients, a practice that an American doctor called “stunningly asinine”. It is much the same in psychiatry. You get what you pay for. And for the schizophrenics, that is not much.

Polyclinics

Pretty Polly Clinics

It is not easy at the moment to say anything positive about family doctors. Any suggestion that they may be providing a valuable service is nowadays met with a tirade of jealousy from nurses, particularly the oxymoronic “consultant nurses”, who cannot get through the day without asserting that they can do any job a doctor can do, and probably do it better. Then the right-wing Taxpayers’ Alliance wades in with one of their tabloid headline grabbing ad hominen attacks on public sector salaries.

This is a perfect starting point for the government to introduce the polyclinics. They sound wonderful, don’t they?

(....continued here)

The Quacktitioner Royal and alternative therapies

"Wibble wibble"

Prince Charles, the Quacktitioner Royal, has been in the news again for his continuing advocacy for a variety of alternative so called therapies, the majority of which are wibble and possibly dangerous wibble if used instead of proper medical treatment. I had a quick glance at his "Complementary healthcare : a guide"

He has two categories of alternative therapy:

Utter wibble

Acupunture

Aromatherapy

Bowen technique

Cranial therapy

Homeopathy

Naturopathy

Nutritional Therapy

Relexology

Reiki

Shiatsu

Relative wibble

Chiropractic

Osteopathy

Herbal medicine

Alexander Technique

Massage therapy

Yoga

The relative wibble category needs a little explanation. The groping therapies such as chiropratic, osteopathy, Alexander Technique, massage therapy and yoga have good placebo effects and can be relaxing. But none of these "treatments" will cure serious illness. I am particularly uneasy about chiropractors who play with XRay machines.

Steer well clear of wibble, and be cautious of relative wibble, particularly if the fees are high or if the word "cure" is used by the practitioner. My main problem with the Prince's Foundation for Integrated Health website was that it is mind-numbingly dull. I tried to read it but I kept falling asleep.

I don't understand why the Quacktitioner Royal feels qualified even to discuss matters medical, let alone make recommendations. I wish he would stick to architecture.

The Mayor of London : Ken, Boris or what's his name?

The Mayor of London?

I stopped going in pubs years ago because I could not stand the smoke. I have now been able to stick my head back in the door. Depending on where you go, it is stale beer and sweat. You can't win. The London mayoral election does not effect me. I suppose I would vote for Boris, on the basis that I would vote for anyone to get rid of Ken, but it's the choice from hell.

Now a worrying story from Recess Monkey. Boris voted against the smoking ban in the House of Commons. I can understand that on the basis of a non-paternalistic, libertarian approach. Recess Monkey implies...well, no, he more or less states that Boris may have other reasons for his vote. Other reasons that may mean London pubs once again being smoky. Still, maybe that will be a compensation for the thimbles in which some of my collegues think wine should be served.

See "Is Boris in the pay of the tobacco industry?"

Stunningly asinine

Kevin MD, one of the leading medical bloggers in the USA, has picked up on the story that cardiac nurses are proposing to use ECGs for telephone triage of patients with chest pain. They know a thing or two about cardiology in the USA. And about taking legal responsibility for your actions. What is his verdict?

Stunningly asinine

Kevin MD

Dr Crippen has not been talked round. Maybe you can talk Kevin MD round. His comments are open. See what the Americans think.

Second rate cardiology for people without private health insurance

But if the ECG is normal, you have to use your brain

I was just going to bed but decided to have a quick look at Dr Rant. His article is called

"More dead cheap patients"

I wish I had left it until tomorrow. Now I am going to have bad dreams and I shall be late to bed because, before I go, I have to write this:

This is about fuckwits; in particular a fuckwit called Emma Wilkinson who styles herself as a "health" reporter, a fuckwit called Karen Gibbons who is a "service improvement manager", and a collection of hospital fuckwits called "cardiac nurse specialists".

Emma Wilkinson is a fuckwit for a number of reasons:

• She uses words like "robust" and "roll out"
  
• She does not understand ECG technology
  
• She does not let her lack of understanding stop her from pushing the government's latest scheme to fob off people who do not have private health insurance by keeping them out of hospital.
  

Emma's article is about introducing a new scheme whereby a GP can use a gadget to record an ECG on a patient and then transfer the ECG data via the telehone line to a cardiac nurse fuckwit who will interpret the ECG and tell the GP what it says. This way, patients with chest pain who have not had heart attacks do not need to be sent to hospital unnecessarily.

Sounds good, doesn't it? There is but one little flaw in this of which Emma Wilkinson, Karen Gibbons, the cardiac nurse fuckwits and, apparently, a GP called Dr Lieberman, seem to be unaware:

You cannot exclude a heart attack by doing an ECG.

I have put it in large red letters so that nursey and the others will understand. It is possible to have a rip-roaring, barn door heart attack in evolution and have a completely normal ECG. The ECG will change in due course but if you don't act immediately on the clinical picture the patient may die.

Let us look at Emma's article in detail.

A patient suffering chest pains is a common problem faced by GPs.

True.

It can be a sign of a serious, life-threatening heart attack.

True

However, in many people, the symptoms will be caused by some other, less worrying, condition.

Bollocks. Utter bollocks. For the majority of patients who are having a heart attack, the clinical diagnosis is obvious. It may not be obvious to nursey, but then she is not trained in diagnosis. Then there are a small number of patients in whom the diagnosis is uncertain. Once the diagnostic possibility of a heart attack has arisen, both groups need immediate hospital admission.

The only way to get a proper diagnosis is with an Electrocardiograph (ECG) - a machine which monitors the patients heart rhythms, which means a time-consuming trip to hospital.

Bollocks. The ECG may prove a heart attack but cannot exclude it.

But a pilot in Greater Manchester and Cheshire of hand-held ECG monitors in GP surgeries has cut the need for hospital referral by 60%. GPs get an instant read-out but more importantly they can get immediate expert advice from the hospital over the phone. The technology is simple - they simply hold the device next to the phone line and cardiac nurses at the other end of the line interpret the readings and advise whether the patient needs hospital treatment.

Bollocks and bollocks again. I can read an ECG myself, thank you. Been doing so for many years. I do not need nursey to help, particularly as it is clear she does not understand them. The decision as to whether the patient needs admission is mine and mine alone and I am not going to take "advice" from a 5 GCSE fuck-wit who has read the Dorling Kindersley Pop Up Book of Heart Attacks and thinks she is a doctor.

Dr Jonathan Lieberman, a GP in Manchester who has been using the hand-held device in his surgery said he sees at least one patient a week who needs an ECG and who previously would have been referred.

"Before you would have sent them to casualty where they would have had to wait for four hours. Often you don't think it is a heart attack but you can have that confirmed there and then. It means you're not having to waste time. Patients love it - they don't have to go traipsing off to hospital."

Back to medical school Dr L. Or buy an ECG machine and go on a course. If you cannot read them yourself, fair enough, send the patients up to hospital for ROUTINE ECGs but not do  "emergency" ECGs on patients with possible heart attacks. Send them into hospital.

Karen Gibbons, service improvement manager for Greater Manchester and Cheshire Cardiac and Stroke Network, said in other parts of the country there were waits of several weeks for ECG reports to get back to GPs after patients had the test.

"They turn up at the GP and get an instant answer which negates the need for a second GP appointment as well as negating the need for a referral to secondary care," she said

Bollocks and bollocks again. An ECG gives an "instant" answer to nothing. It is but one test - an  important one - amongst many. Dopey Doris, the cardiac nurse specialist,  may say all is well on the telephone because the ECG is normal. What a shame she does not know about dissecting aneruysms and pulmonary emboli and... well, there is neither time nor space to go through the differential diagnosis. I suppose there may be some GP surgeries who do not have their own ECG machines. It is time they got one but please don't start using them to decide if a patient with chest pain needs to go to hospital. And, whatever you do, as the organ grinder, please do not start phoning the monkey for advice.

There IS a place for ECGs in the emergency situation; they distinguish between STEMI and non-STEMI infarcts and, if there is a choice of destinations for the ambulance, judgements can be made about the best receiving hospital. But for most GPs, there is only one hospital, and a diagnosis of heart attack means immediate admission, not phone calls to the monkey. Do an ECG by all means if there is time whilst you are waiting for the ambulance but remember that a normal one does not exclude a heart attack and you still need to get the patient to hospital as quickly as possible. Just keep your fingers crossed that it is a hospital with medically trained staff (aka doctors) who understand ECGs.

As Dr Rant says, the "diagnostic telephone call" approach to possible heart attacks will be "dead cheap". So keep paying the BUPA subscriptions. Or emigrate. 

++++++++

And now bed. It must be late as an advert has just appeared on TV suggesting that if I text "PULL" to a certain telephone number I will be able to chat to the woman of my dreams. Extraordinary. Do people really do this?

Cruel and unnatural - the killing is about to start

An interview with Professor Robert Blecker

Sad but not unexpected news from the Supreme Court in the USA.

By a seven to two majority they have decided that execution by lethal injection does not infringe the 8th Amendment to the Constitution and is not "cruel and unusual" punishment. There are numerous studies of the efficacy of lethal injections and those who wish can study the lengthening list of botched executions here.

US executions were on hold until the Supreme Court had made its decision. They will catch up. Governor Kaine of Virginia for one cannot wait to get cracking on the back log. The USA will once again take its place alongside the Peoples' Republic of China, Pakistan, Saudi Arabia and Iran. These five countries are responsible for nearly 90% of the word's executions. 

Hard to believe that most Americans support the death penalty, but that seems to be the case. As for Professor Robert Blecker, well, what can one say?

Dumbing down the out of hours service

New Labour out of hours HCP

Over ten years ago I was heavily involved in setting up a GP co-operative to rationalise and manage the out of hours on call committment. We had active support from the government including access to and meetings with both Norman Lamont and Virginia Bottomley. The co-operatives were a cost efficient method of ensuring that patients received quality out of hours care form local experienced family doctors.

We started our co-operative from nothing. I remember when I and one other colleague opened the first bank account with a float of a couple of thousand pounds raised by approaching other local GPs. We drew up a business plan and approached the bank manager for help. We needed to rent premises, buy or rent half a dozen cars, purchase expensive radio equipment and above all take on staff to run the co-operative. We assured him that we already had fifty local doctors behind us and that there would be many more. The bank manager smiled benignly and struggled not to be patronising. We left with nothing but his good wishes. We went ahead anyway. Within six months the fifty doctors had turned into four hundred. We set up a non-profit making company and took the risk of guaranteeing the expenditure ourselves (that makes me shiver in retrospect). Three years later we had a co-operative covering the best part of three counties and a turnover well over the million mark. Now the bank manager took us out for lunch.

I am not trying to boast. I am not an entrepreneur.  The co-operatives were born of desperation. GPs were at their wits' end trying to meet the out of hours demand and do their normal jobs during the day. I am told by friends in business that the normal response rate for fliers sent out asking for money is less than 2%. We sent out fliers to local doctors asking them to trust us and send a non-returnable £100. Our success rate was over 90%.  By the millenium the co-operatives had grown to become the most powerful and successful independent health care companies in the country. They provided excellent care. The doctor you saw might not be your own doctor but he would be a local doctor who probably knew your doctor and certainly knew all the local hospitals. We did not use locums. We did not use German or Polish doctors. We did not use doctors who were not fully accredited family doctors. We did not let junior hospital doctors without GP training do any of the work. We did all the shifts ourselves. They were busy and tiring but we managed. It was so much better than being perpetually on call for one's own practice. The strain of on call work is not seeing patients, it is lying awake in bed, unable to sleep, waiting for the phone to ring.

The conservative government had supported us enthusiastically. Why wouldn't they? It was a no-cost option for them. But they did more. They allowed existing finance that was available to PCTs for out of hours work to come to us. It was only a small part of our overall budget, but it made a big difference. Without government support we might not have survived. It all changed in 1997. The Labour government did not like co-operatives. They had no control over us. We were independent, private, not for profit companies owned and controlled by the GPs. The co-operatives flourished. The Labour government wanted control - doesn't it always? -  and there was only one way they were going to get it. By taking over responsibility for the out of hours work. Which is what they did. They made two mistakes. They completely underestimated the amount of work we were doing and they did not realise that the co-operatives only flourished because GPs worked for them for free. So they gave away the out of hours shop and in return they got the co-operatives.

All they had to do now was staff them to cope with the volume of work. They could not do it. Despite paying a fortune to fly in European doctors, they cannot meet the demand. A demand that they have fuelled. There was only one thing for them to do. Dumb down.

Nurses are undertaking out-of-hours patient visits to save the cost of sending a doctor. Private firms running the after-hours services for health trusts are also using less-qualified emergency "first aiders". Leaked emails show the firms are monitoring the number of home visits GPs make as well as how long the medics spend on telephone consultations. Those not judged "cost effective" are being warned they will lose their after-hours work. One company has told its GPs they should aim to visit patients at home in just 11 per cent of cases. Doctors are also under pressure to refer fewer patients to hospitals at night or over the weekend. (Daily Mail)

Dr Mark Reynolds, the medical director of On Call Care, which provides out-of-hours medical services in Kent, told staff that the firm was introducing a five per cent reduction in doctors' hours. He also implied that some doctors spent too long talking to patients and referred too many patients to hospital. From now on the company would monitor how many home visits doctors made, the number of referrals and how long they spent on the phone with patients, he said. In the email, Dr Reynolds said: "We have to make this reduction to balance our budget, but also to try to get the most cost-effective use of our valuable doctors." (Daily Telegraph)

This story was broken by the GP magazine PULSE which today carries a more in-depth analysis

GPs working for out-of-hours providers are being placed under pressure to reduce their home visits and hospital referrals, amid warnings that financial pressures may be compromising quality of care.

Pulse has learned that a series of providers across the country have introduced moves to performance-manage GPs, in some cases accompanied by cuts to the number of doctors on call. (Full story here)

Out of hours work was always the most onerous and stressful part of the job and was never adequately paid. And yet, like me, most older GPs went into family medicine determined to provide good out of hours care for our patients. Then demand changed from out of hours emergency medicine to routine medicine at all times of the day and night. I was not coping. Had the co-operative I helped set up not survived, I would have resigned. The co-operatives did survive. They were, I suppose, independent contrators suppling health care services to the NHS. Why did they work when other outside services such as the notorious contract cleaners did not work? Because the GPs knew what they were doing and were committed to providing a decent level of care.

Had the Labour Government left us alone we would still be providing that care.

I will take back responsibility for out of hours work if I can have my co-operative back. But I want it back with no strings attached, and I want to be left alone to run it as I see fit. As I ran it ten years ago. I don't see Gordon Brown doing that. Maybe this is one for David Cameron.

++++++++++

Monkey doctor from Dansmills Art

Can we trust the drug companies?

Big business

Two weeks after I started NHS BLOG DOCTOR I wrote an article - Mrs Crippen's Vagina - about the ethics of drug companies and, in particular, the way that eminent doctors are given brown envelopes stuffed with...sorry, are given "honararia" to allow their names to be put under dishonest advertising copy masquerading as academic research.

The Journal of the American Medical Association now reports in an editorial

Impugning the Integrity of Medical Science

The study by Ross et al1 illustrates that clinical trial articles and review articles related to rofecoxib frequently were written by unacknowledged authors who were employees of for-profit information industries, and often attributed first (or primary) authorship to academically affiliated investigators who either had little to do with the study or review or who did not disclose financial support from the company.

...it is clear that at least some of the authors played little direct roles in the study or review, yet still allowed themselves to be named as authors. Individuals, particularly physicians, who allow themselves to be used in this way, especially for financial gain, manifest a behavior that is unprofessional and demeaning to the medical profession and to scientific research.

JAMA

I discussed this in detail in Prostitution and the Medical Profession. How, as a family doctor, can one really know whom to trust? I have lived through the reversal of opinion on HRT, the favourite drug of the 1980s, now fallen out of favour. My biggest fear at the moment is the unquestioned acceptance of statins. Soon, half the middle aged population of the western world will be taking them. This is big business. Very big business. The research is favourable, but who sponsors most of the research?

One problem at a time

"I've got a little list, I've got a little list"

“I don’t come very often, doctor, so I have saved it all up” says the patient taking out a sheet of Basildon Bond, both sides covered with compact hand-writing, usually in green ink. The doctor’s eyes glaze over. He wades through the problems and, when he has finished, the patient pulls out a repeat prescription form and says, “Whilst I am here, could you just do this for the wife, to save her coming down?”

The next patient comes in looking at his watch, clearly fed up that he has been kept waiting. Some patients assume that because a problem is medical it must be dealt with immediately. Whatever the doctor does, someone will be upset. So we do our best. We have not put up one of these dreadful “One problem at time” notices in the waiting room, nor would we. Very occasionally, I have stopped a patient in the middle of a long consultation and gently suggested that, having dealt with the serious problems, it might be reasonable to come back for another appointment to deal the less serious ones.

Of course, as always, the government and the media cannot resist yet another dig at GPs.

This weekend the Department of Health condemned the restriction and said it should be withdrawn. It said GPs, who earn an average of £110,000 a year in England, were paid enough to make time to listen to patients who have more than one illness.

The Times

Bastards.

I do not mind wading through a long list of problems. But if I do and, as a result, you who are due in next are kept waiting for three-quarters of an hour, will you promise me you will not complain? I cannot be in two places at once. Tell me what you want me to do.

Don't lick the dog

You have to laugh as our nation of animal lovers struggles with the news that you might catch MRSA from Fido. The news comes from a study carried out on 260 dog owners in Cheshire. Why Cheshire, you may ask? Not Alderley Edge, you can be sure.

Through a previous doorstep survey in Cheshire, the researchers identified 260 dog-owning households that were then invited to complete a questionnaire. The main person who performed dog duties was asked to complete the questionnaire. Participants were encouraged to complete their questionnaires by offers of money-off vouchers for dog food and local boarding kennels.

NHS Choices

Bribing people to take part in trials? Is that not what Andrew Wakefield is charged with by the GMC? Ethical or not, our doggie lovers are in denial:

This controversial study has, according to the news story, irritated dog lovers. One said that you are more likely to catch a disease from a child and another that the study has told us nothing but to use a bit more common sense.

Best not lick the baby either then.

The destruction of the NHS

Professor Alan Maynard

Up in York, Alan Maynard, Professor of Health Economics, is forever keeping his beady eye on the the government’s real NHS agenda. In 2005 he wrote a paper entitled “Physician Productivity in the UK NHS”. It was presented in Australia and, perhaps because of that, did not get as much publicity as it deserved. I am grateful to the Witchdoctor for drawing my attention to it.

“Radical reform in the roles of the workforce other than physicians is taking place. Pharmacists and nurse prescribers are to be given the right to prescribe the full formulae, although medical groups (e.g. the Committee on the Safety of Medicines) are now questioning the safety of such policy. Nurses are being trained to carry out endoscopy, anaesthetics and minor surgery.

These reforms are part of Blair’s frustration with the slow rate of change in NHS service delivery. At the outset, he offered more funding in exchange for the NHS ‘acting smarter’. This exchange, he believes, has not been met by providers. More expenditure has not been accompanied by improved service delivery. Consequently, he is seeking to undermine the monopoly power of physicians with investment in other skill groups with enhanced roles. This bold policy is largely evidence free; many assert that nurses may be retrained to take over medical roles cost effectively but the quantity and quality of trials are poor.

Such issues have yet to inhibit the Government!”

Professor Alan Maynard

The words are Alan Maynard's. The hightlighting is mine. Be under no illusion. This is what is happening to the NHS. The government hates independent professionals. An NHS run by the less intelligent, less independant, protocol bound 5 GCSE brigade can be controlled. The government will write the protocols and the HCPs will follow without demur. You can have half a dozen HCPs rather than one GP or one consultant. The financial savings will be huge.

The government has played the PR game, manipulated the media and undermined the medical profession. It is not politically correct to suggest that the average doctor might have more intelligence, more skills, more ability and more training than the average HCP. To do so is vulgar. Nurses and HCPs are just as good as doctors. The general public is beginning to believe this. The nurses and HCPs have believed it for several years. Last week I wrote a post pushing for nurses to be better paid. (here). There was not a single comment from a doctor suggesting that this was inappropriate. Indeed, doctors are supportive of their nursing colleagues who continue to nurse. A day or two later I did a short post on what I thought was a relatively minor matter; the government’s meanness in imposing a devious pay-cut on hospital doctors by deciding to charge them for the hospital accommodation most of them are forced to use. It was called "Looking after hospital doctors". It unleashed one of the most poisonous threads of vitriol I have ever seen on NHS BLOG DOCTOR as the nurses waded in with their paranoid “we are as good as the doctors” tirade. Battle royal commenced. Reading through the argument one is tempted to say “a plague on both your houses”, but the root cause of the problem is the arrogant assumption by the HCPs that they are as skilled as doctors and entitled to the same financial reward.

Perhaps you believe that doctors are no longer necessary and that their jobs can be done by less able people. That is now the government’s policy and, financially at any rate, it is working. The NHS is moving into financial surplus. No, that is not a Patricia Hewitt/Darlingesque lie. It is Alan Maynard again:

In the real NHS of everyday primary and secondary care, job tenure and career progression depended on fulfilling government performance targets. Expenditure control became diluted and deficits emerged. The expenditure brakes were consequently applied vigorously. As the brakes were applied complementary budgets, in particular those to fund education and career training, were plundered.

The political distress caused by the deficits has led to greater conservatism in the use of NHS allocations. The NHS budget in the UK now exceeds £100 billion and the nice issue is how much of that should be retained at the centre to bail out inevitable mistakes by some of the constituent parts of the NHS. The Department of Health currently has a surplus of £1.8 billion, a relatively small percentage of the total NHS budget. Strategic Health Authorities have been instructed to maintain these surpluses.

Professor Alan Maynard in OnMedica

How can our infection ridden service, a service in which the maternity and perinatal mortality rate are  rising, a service in which hospital doctors are unemployed whilst their jobs are done by HCPs, a service in which both hospital doctors and, despite pay rises, GPs are demoralised be successful? Only if you define success on the basis on one criterion. Saving money. And what happens if you save money in this way?

The answer is clear : Pay peanuts, get monkeys. HCPs are moving out into the community to “take over” from the GPs, and HCPs are running the hospitals. Various men with beards have been recruited to push the message.



So plausbile. But ask yourself this. If the Duke of Edinburh or Tony Blair arrived at this hospital, do you think they would see an HCP or do you think a doctor would be found?

Even more worrying is the question that Alan Maynard asks. What will the government do with so called profits? It is clear the money is not going towards patient care. Some of it has gone on fruadulent initiatives such as the risible “deep cleaning”. Where will the rest go, I wonder?

Is this prudent contingency planning? Or is it a fund to finance the planned and un-evidence based reforms of Darzi? The DH refuses to reveal to taxpayers the purpose of this hoarding.

Professor Alan Maynard

Time will tell. Perhaps some of the money will be spent on more men with beards who will involve us all in the decisions and thus make the cuts more palatable. This gives me another opportunity to feature my all time favourite NHS propaganda video which stars a tubby bearded gentleman and the wonderful Rachel Horley, who tells us that:

"The key to involvement is developing the learning capacity of everybody to recognise and realise the potential for involvement. The challenge for us is to find practical and creative ways of developing the capacity of everybody through learning and development opportunities both within formal learning and also in everyday work capacity."

She really does say that. Honestly. I have asked before, and will ask again. What does it mean?



Admidst the gloom of the NHS it makes me strangely happy to think that Rachel Horley is being paid by the taxpayers to "involve" us all in healthcare. Well done, Rachel.

Sweet dreams of Patricia

I am not an economist. Well, actually, I did do economics “A” level but that was in a different age when “events, dear boy, events” were regarded as more important than economic theory, and Sir Peter Gershon had not been invented.

If I need economic advice, normally I consult Wat Tyler. But now things are getting so serious, so gross, that even I am noticing. Northern Rock fell apart and the taxpayer picked up the pieces to save the government’s face. The next day, the poorest workers in the country are having their tax increased by a Labour government. Look at the reality of that as described by the excellent Village Postmaster. I just paid 116p a litre for a tank full of diesel. The property market is crashing. That does not affect me directly because I am not buying or selling. But it means that a huge sum of money in housing equity disappears. Was it real money, or virtual money, or just a dream? When I did “A” level economics I learned that for every credit there was a debit and the bottom line was always zero. Now there are billions of pounds worth of debt out on credit cards. Does that money really exist?

I listen to that nice Mr Darling. Last week on the Today programme, he told Evan Davis that

our economy is immensely strong.

Today, he is reported as saying that the present turbulence is

the biggest economic shock since the Great Depression.

I suppose that technically those two expressions are not mutually exclusive but then today he moved into territory that used to be occupied by Patricia Hewitt. Say the NHS, sorry, economy has never been stronger, and then start blaming everyone else. In Mr Darling’s case, it is the World Bank and the IMF

which risk being marginalised and ineffective unless they adopt to modern issues.

This advice to two international financial organisations from a man who could not manage the nefarious money grabbing activities of an over-promoted northern building society. I have the same feeling of unease and anger as I had when Patricia Hewitt was (not) running the NHS.

Still, at least Mr Darling is not as patronising as Patricia.

Tyler has trouble in the trouser department

Following on from yesterday's post about the Observer and the suggestion that pharmacists should have a diagnostic role in the treatment of sick patients I was about to put pen to paper, so to speak, when I came across a post by Wat Tyler from last week. Somehow, I had missed it.

Please raise your 125ml glass to Wat as, in "Jade will see you when she has finished her pie", he tells the sorry story of trying to get the pharmacist to discuss his sore willy.

What more is there to say?

The Observer lynches incompetent GPs

Alan Johnson and Gordon Brown at the Royal Marsden Hospital, London, pitching for the cancer vote

A reader has just told me about a lead story in this morning’s Observer.  I wish he had not. It has spoilt my morning. It will spoil my day. The head line is particularly difficult to deal with. In transactional, “parent-child” terms, it portrays GPs as naughty children who need a “warning”, a rap over the knuckles. The story is based on an interview with Mike Richards, one of the government's cancer czars, or whatever it is we are now supposed to call them. 

I actually know Mike Richards, though he does not know I know him, and so I will suppress the temptation to call him an egregious little prick, because he is not. He is a nice guy. He is well meaning. Bumbling professor type. He used to use a stethoscope but he has put that down, and picked up a pen with which he now advises people how best to do a job he no longer does himself. On top of that, the Observer has, as journalists always do, sub-edited and sensationalised the piece to present it as yet more knocking copy directed against GPs. Let us not forget that the current government agenda is to undermine GPs in the public eye so that, as we are gradually replaced by salaried health care professionals, the general public will see this as a “good thing” and not as the cost cutting exercise it really is.

If you can be bothered (and of course this is the problem upon which journalists trade when they sensationalise - few can be bothered to check sources) to look at the DoH report (Cancer Reform Strategy) you will see it tells a different story. Note first of all that this is not a piece of medical research. It is a political document with a photo-opportunity introduction by Gordon Brown and Alan Johnson. Their presence means there is a political agenda.

Turn to Chapter 3, page 43, “Diagnosing cancer earlier”. I am not going to go through it in detail. It says, quite rightly, that late diagnosis of cancer is a major factor in the prognosis of cancer and that we need to concentrate on improving earlier diagnostic accuracy.

Mike Richards CBE (knighthood in pipeline)

Mike Richards has never worked in general practice and so is not aware of the challenges of diagnosing disease early in its evolution. GPs see people presenting with conditions before they have developed any classical symptoms at all.

It is mid-May. The chest specialist sits with George, a 58 year old man who has lung cancer and whose CXR shows a four inch inoperable tumour. George has been a heavy smoker since he was a teenager. “I went to my GP last November with a cough and all he did was give me some antibiotics” says George. “It was not until April, when I coughed up some blood, that he finally referred me to you, and even then he did not get me an appointment for two weeks.”

Bloody GP, another late diagnosis.

Let’s look at the back story. George does not like going to the doctor but has nonetheless been to his GP two or three times a year, usually with a productive cough. On each occasion the GP has treated George with antibiotics, warned him about smoking, suggested an appointment in the practice “stop smoking clinic” (turned down by George) and arranged a CXR at appropriate intervals. The last CXR George had was nine months ago and was normal. When the GP saw George in November he diagnosed bronchitis, prescribed appropriate antibiotics, asked George yet again to stop smoking, and told him that he wanted to see him ten days later for a follow up. George did not attend because, although he was still coughing, he felt a lot better. Had he attended, given that he still had symptoms, the GP would have arranged another CXR which would probably (not definitely) have been abnormal. George would then have been referred. But George did not come until April the following year when he had coughed up some blood. Most worryingly of all, George told the GP that he had finally stopped smoking and had not had a cigarette for three weeks. The GP referred him immediately under the Two Week Rule.

Last year, I referred a middle aged smoker to the chest clinic under the two week rule because, although his CXR was normal, he had persistent haemoptysis. Because his CXR was normal my concerns were ignored. He was seen not by the chest physician but by the respiratory nurse quacktitioner who did what she always does - performed respiratory function tests which, predictably enough, showed a degree of emphysema. The haemoptysis continued and so I wrote another letter to the chest physician expressing my concern. He called the patient in immediately and the bronchoscopy showed a small and, due to its position, sadly inoperable lung cancer. Two weeks lost. It would not have made any difference but that is not the point.

I slip into anecdote. The early diagnosis of lung cancer is difficult, but easy compared to ovarian cancer. Do GPs sometimes not diagnose a cancer when the patient first presents? Certainly. Do we consider the possibility of cancer in these patients? Yes, we usually do which is why we “safety net”and bring the patient back for review. Are GPs perfect? Of course not. Do GPs sometimes make mistakes? Of course we do. But that is not the issue raised by the Observer.

The Observer’s spin on Mike Richard’s political document says that the late diagnosis and treatment of cancer is due to professional negligence by GPs.

That is not true.

The evidence of the gate-keeping role of GPs is that it is safe and effective. Do some patients slip through the net? Of course. So let us abolish GPs and have direct patient access to all the cancer clinics. That is fine by me, if that is what people want. But the queues will be out of the door and round the corner and the system will not cope. It is not coping as it is. You may think that “if only the GPs got the patient to hospital more quickly” all would be well. The delays and inefficiencies are even worse once you get there. If I refer a 45 year old with rectal bleeding under the two week rule, he will be seen within two weeks (target met), but may not get the colonoscopy for three months.

Is there a better system? Are there people who could do this job better than GPs? Perhaps there are and, if that is the case, then let’s go for it. And here we may see the real but hidden agenda that the Government is promoting through the mouth of its office-bound, compliant, knighthood in the pipe line, pen-pushing professor. If you read Chapter 3 of the Cancer Reform Strategy did you notice this:

3.64 Although GPs may play the key role in helping diagnose cancer, other primary care professionals can also play an important role. For example, the role that pharmacists have played in helping promote awareness of the signs and symptoms of lung cancer and in encouraging people with a persistent cough to visit their GP, provides an excellent example of the enhanced contribution that can be made. Social workers may also play an expanded role in helping identify potential cancer symptoms amongst at risk groups, such as older people or the disabled. We will therefore involve professionals such as pharmacists and social workers as we develop the National Awareness and Early Diagnosis Initiative.

Now we see where this is headed. The task of early diagnosis of cancer is clearly too difficult for highly trained family doctors, so we are going to involve chemists and social workers. That is the thin edge of a wedge that is going to make me keep paying the BUPA subscription.

Two days later...

Good to know that the Countess of Chester Hospital led the way with “deep cleaning”. The hospital web site proudly proclaims

Health Secretary Alan Johnson was yesterday reported to have said that fewer than 50 of the 170 hospital trusts in England have began their ‘deep cleans’, which are being developed to prevent superbug infections such as MRSA and Clostridium Difficile. The Countess of Chester Hospital has already commenced their ‘deep clean’ initiative which is expected to be successfully completed by 1st April 2008.

In response to the Department of Health’s November 2007 paper “Improving Cleanliness and Infection Control”, the Trust successfully deep cleaned Theatres in November. The deep clean for wards and acute units started in Women and Children’s on 3rd December 2007, with an additional five units and wards being completed so far. In addition to the £2m that the Countess currently spends annually on cleaning, the Trust has invested an additional £325,000 for this initial ‘deep clean’ initiative.

Do please go to their web site and watch their “deep clean” video here

The year's cleaning bill for the hospital, including the "deep clean", was £2.325 million and it was all finished before the end of the financial year, appropriately enough on All Fools' Day.

Two days later, on 3rd April 2008,  the following article appeared in the local paper:

Superbug outbreak at the Countess of Chester hospital

The Countess of Chester has been hit with a superbug outbreak

A WARD at the Countess of Chester Hospital remains closed following an outbreak of superbug, clostridium difficile. Ward 43 is being used for isolation purposes and has been closed to visitors since last Friday when the hospital's NHS Foundation Trust declared the outbreak. Up to 26 people were affected at the peak of the problem, but Andrew Duggan, marketing and communications officer for the Countess, confirmed the number of cases had now fallen to 17.

Mr Duggan said: "It was caused by an influx of patients in the one ward that were infected. Dr Virginia Clough, medical director and director of infection prevention and control, said: "Infection control procedures are in place and the position is now stable.

The hospital website now says

The Trust has a zero tolerance approach to hospital acquired infections. The following measures have been put into place to protect patients and minimise the risk of patients acquiring this infection in the hospital: 

1. Ward 43 is still an isolation ward, but is now open to visitors. All visitors must report to the Ward Manager on arrival
   
2. Other infected patients are being isolated in side rooms on other wards. Visitors to isolated patients must report to the Ward Manager on arrival
   
3. Extra cleaning has been introduced in affected areas, including 3 times a day bleaching.
   
4. Strict hand hygiene for staff and visitors is being enforced in all wards
   

Good to know that strict hand hygiene is now being enforced - as opposed to whatever it was that was being enforced before.

Real doctors have always know that the “deep cleaning” initiative was a scam, a £95 million scam, a scam with the sole purpose of lulling the public into a false sense of security in the run up to the general election that never happened because Gordon Brown lost his bottle.

What are the real causes of hospital infection? Inadequte contract cleaning as seen in Leeds, lack of nurses and unsustainable patient throughput in the chase to hit the government targets.

Wine to be served in thimbles

Government approved wine glass

Professor Ian Gilmore, today issued the following directive:

From 1st May 2008, public houses well be serving beer in 50ml Customs & Excise certified glasses. Wine will be served in thimbles and spirits will be delivered by aerosol, one spray behind the ears will give the faintest aroma of alcohol. Cigarettes will be reduced in size over the next twelve months prior to their complete abolition. Professor Gilmore commented that there was overwhelming medical evidence that both alcohol and tobacco were harmful to health. (BBC)

I know that far too many people drink too much.

I know that far too many people smoke too much.

I do care. I am happy to provide advice on these and many other issues if asked. I am happy to diagnose and help with any health problems that arise. I am happy for the government to study medical research when formulating policy.

I am not happy to issue diktats to public houses about the size of glasses. If the government wants to issue such diktats that is a matter for them but, if they legislate to tell me what size of glass I am allowed to use, they may find they lose my vote.

If I write a long article warning of the dangers of alcohol induced liver disease, I hope you read it. That is as far as I want to go. That is as far as any doctor should go. If I were in government I would be targeting teen drinkers, Alcopops and the general youth drinking culture. But I would do so by using education and persuasion. By using Saatchi & Saatchi not the the police force.

I did not go into medicine to tell you how to run your life. I am frustrated by the government’s attempts to turn me into a medical Stalinist. Ian Gilmore should go back to his day job. This is not a job for doctors.

Where there's brass there's muck

Dark Satanic Mills

Two years ago, in Joseph Lister and the plastic dog turd, I wrote about the effects of contract cleaning on our Health Centre. Those interested in matters hygienic may like to know that the turd is still there, untouched, but now unrecognisable due to dust. A year later, in Filthy Patricia, I wrote about hospital contract cleaning nationwide, and a depressing picture it was too.

Another  year later, it is time for another update on NHS hygiene. Dr Crippen is grateful to an NHS BLOG DOCTOR reader in Yorkshire who writes in to tell of

a "groundbreaking development" – the first in the country...as part of the national strategy for improving decontamination services.

Sounds promising, tell me more

The healthcare company, a subsidiary of B Braun Medical which employs 28,000 people worldwide, signed a contract in June 2006 with Leeds, Bradford, and Calderdale and Huddersfield NHS trusts to decontaminate all the hospitals in West Yorkshire's surgical equipment.

Dr Crippen was educated in Yorkshire and can tell you that canny Yorkshiremen do not throw their money around. 

Braun Director David Thorpe said: “We are delighted to have been chosen to provide decontamination services on this exciting project and look forward to working in partnership with the three Trusts and their existing decontamination staff.” (Leeds NHS Trust News)

So, OK, David how much is this going to cost

[Braun] built a £4.8m "super-centre" in Pudsey, providing modern disinfectors and sterilisers, and since May 2007 hospitals have been transferring their decontamination services away from their in-house teams over to B Braun, with Leeds hospitals due to transfer in June and August 2007.

£4.8 million, eh? Super! How have they got on?

A Yorkshire health trust has been forced to cancel operations because of contaminated instruments. Leeds Teaching Hospitals NHS Trust has demanded "urgent meetings" with the company it uses to sterilise its surgical equipment. It acknowledged last night there had been "problems" with its new contractor since leasing out the service last month and apologised to patients. One woman, whose hip revision surgery has been postponed twice because of dirty equipment being returned on the morning of her operation, said she had been told by her surgeon that the problem was so widespread that one Leeds hospital had been forced to return 14 trays in one day.

Full story from Tom Smithard : Yorkshire Post

Oh! dear. Another £4.8 million down the toilet. How do lovers of the "free market" and "tendering for services", like the DK, explain this?

Looking after hospital doctors

No expense spared

The government probably has not noticed that morale amongst junior hospital doctors, even those who have jobs, is at an all time low. If it has noticed, it does not care.

As well as "awarding" the juniors a below inflation pay "rise" (sic) the government has introduced another stealth tax. Hospital accommodation used to be provided for resident doctors for free. Indeed, residency within the hospital when on call was compulsory. Gordon Brown has had a brilliant idea. From next year, residency within the hospital will not be compulsory. All the doctors can go home at the end of the day. Those who chose to stay in the hospital are now going to be charged £400 a month for the privilege. So, no more quick naps in your own little room when you get a lull during a long on call shift. And if you live in Coventry but have to do a six month job in Watford, which is too far too commute from your home, well tough. That's £400 a month additional expenditure, please make your cheque payable to Gordon Brown. And, yes, you do have to keep paying your mortgage in Coventry and, no, you cannot claim that £400 a month against tax because of duality of purpose. You might use that room for recreational purposes.

The government announced yesterday (07/04/08) that it would implement in full the recommendations of the DDRB (Doctors and Dentists Pay Review Body) – which means FHO1s (foundation house officer 1s) will not be compensated for losing the right to free accommodation. BMA council chair Hamish Meldrum said the treatment of junior doctors was an 'outrage' and 'completely unacceptable'. ‘The loss of free hospital accommodation means doctors graduating from medical school with massive debts will effectively be losing £400 a month – a 20 per cent pay cut. (BMA)

Medical students from less privileged backgrounds who cannot rely on Daddy to pay their way through medical school are already saddled with a student loan debt of approaching £30,000. Now they face a 20% cut of a salary that was already way below that which they could obtain in other professions.

Very soon, we will have no doctors left. And then what do we do?

Where have all the nurses gone? - revisited

Click to enlarge

Dr Crippen firmly believes that the main reason 25% of nursing students drop out of their training courses is their disappointment at being subjected to endless psychobabel spouted by a  senior nursing hierarchy none of whom have done hands on nursing for years. I quoted a post from a student nurse - powerful but anecdotal.

A mentalnurse writer is dismissive.

Dr Crippen reckons he’s got the answer, in the form of an email from a “soon to be ex-student”, allegedly, complaining about the nature of her course. Apparently, there’s too much “theory” (don’t know what of), not enough information on sticking tubes and needles into people and - oh the horror - far too much emphasis on communicating with patients. Something like that. I glazed over, I have to admit, as we’ve all heard this sort of stuff time and time and time again

Mentalnurse can be a bit of a prick at times. Or (it’s multi-authored) this one can be, which ever writer it is. Note the snotty use of the word “allegedly”. Trouble with the Mentalnurse team is that they have swallowed a volume or two of psychobabel themselves and frequently forget what nursing is supposed to be about. If they ever knew. Yes, we have heard this “stuff” time and time again, and we are not going to "glaze over it"or put a glaze on it. We are going to keep going on about it until the tosspots in nursing eduction get their act together.

In Angels, one and all the DK partially agrees about the education content but thinks the fall out of student nurses is more likely due to the activities of the poisonous psychopaths who inhabit the upper echelons of the nursing hierarchy and act like:

total and utter f...... c...s  to their students

I think we are both right. Different sides of the same problem. These unpleasant women (not being sexist - this behaviour comes mostly from female nurse) who enjoy bullying students on the wards have alter egos in, if you will pardon the oxymoron, nursing academe. They are responsible for the increasingly ridiculous content of the nursing course. They have not seen a real patient for years and have forgotten that hands-on care is the most important part of nursing. Some, like the mental nurse team, are articulate and well meaning, but still lack insight. Others are, well, best left for the DK to describe in his inimitable prose.

Faith, a twenty something year old student nurse, recounts one of her seniors saying to her:

“You are an immature and unprofessional bitch...... You’ll never get a job on this ward when you qualify. I don’t know what you might say about my nurses.”

What did she do to deserve that, you may ask? She tells us here. Actually, it doesn’t much matter what she did. Whatever she did - even if it was a sackable offence - you don’t talk to student nurses like that.

Isolated incident? Anecdote? Sure. Trouble is, I have seen and heard too many stories like this over the years. The rot in the nursing profession starts at the top and permeates down. What is the best way to turn a human being into a bully? Keep bullying them yourself, they will learn quickly enough.

Ask yourself this. Why do young (and a few not so young) people go into nursing? Do they want to look after patients, or do they want to "interact with clients"? Do they want to read long discourses on the psychodynamics of inter-personal relationships, or do they want to care for patients who are ill?  And by care, I mean hands-on care. Day to day patient contact. Nursing is a caring profession, a noble profession if that does not sound too mawkish, that was founded on the concept of caring for fellow human beings. Skills learned by apprenticeship. It’s all gone now. The nursing hierarchy have jumped onto the perceived “skills escalator” to prove they could be equal to doctors, leaving their own jobs to be done by those who do not have the training. Stupid. Nurses were always the equal of doctors, or any other professionals, whilst they were nursing. Now so many of them have become the laughing stock of the NHS. Jargon spouting technocrats with clipboards whose only role is to annoy people. Read this comment from another student nurse:

Thinking about the actual stuff I've learned about medical conditions, it's laughable. We had one morning in which the whole of neurology and neurosurgery was covered. 2 hours on diabetes (and even that only focused on DKA). Let's be generous, and say I've had 3-4 lectures on heart disease. We had 3 hours each on rheumatoid arthritis, dementia and the physiology of shock. That's about the sum-total of our training on that kind of thing. In addition, we had 3 (broadly similar) lectures on the principles of pharmacology (nothing on individual drugs). The rest has been endless and uncritical ranting on government policy, nursing models, psychology, sociology, evidence-based-practice and so on. This is not to say that those things don't have a place, but I don't think they're quite as important as being able to describe the physiological processes involved in leg ulceration, or understanding just why it is that you should avoid giving digoxin to someone bradycardic, or metformin to someone in renal failure.

As for placement - with a few notable exceptions, the sheer bleakness of placements has just depressed the hell out of anybody who's capable of independent thought. Individual skills can be learned from other nurses on the wards, but attitudes, processes, the knowledge of the qualified nurses, the ward environment itself are all just so... awful. If I can help it, I will never set foot on a ward again. In the community, or more specialised areas like ICU, the nurses really do know their stuff and aren't afraid to take on a bit of responsibility for things. In the ward, nurses seem incapable of all but the simplest tasks. Need a bed bath - that's fine. Develop chest pain - why don't you go sit back on your bed and I'll mention it on the ward round in 2 hours/days/weeks.

Clinical skills wise - yes we're outdated, hugely. I've worked both as a student and an agency HCA in settings right across the spectrum of healthcare, from nursing homes to specialist intensive care units. I can't think of a single environment where skills such as taking blood samples, cannulation, administration of IV drugs, defibrillation, catheterisation of men, recording ECGs, cutting nails, and all the dozens of other "post-registration" skills haven't been required.

What other profession in the 21st century trains its practitioners (badly) to perform only a fraction of the job?!

Before Mentalnurse starts throwing the word 'allegedly' around, the original comment is still to be found here.  Whatever your own view may be, 25% of student nurses are dropping out of the course. Something is wrong. Something needs to be done. There is no room for ostrich-like complacency as exhibited by the purveyors of psychobabel:

Attrition is a multi-factorial issue, one that doesn’t lend itself to glib explanations and easy answers. Nor should it always be problematised. For some students, dropping out will be exactly the right thing to do. Either they find out they don’t really want to be nurses, or they discover that they’re actually more interested in something else, or they decide that it’s just not the right time in their lives to be studying. Would that more students came to the same conclusions before they found themselves staggering and struggling, already burnt-out and miserable, through the second and third years. (Mental nurse)

“Attrition is a multi-factorial issue that should not always be problematised”. Wow! Lovers of the English language will be reaching for their sal volatile. Dropping out is always the right thing to do when the course is crap. And if 25% are dropping out, something is wrong. Badly wrong. Those who care about real nursing will start tackling this egregious problem.

Roller coasters cause autism

A landmark case from the Supreme Court in the USA.

In Erickson v Surgeon General the court decided unanimously that roller coaster rides cause autism. Jane Erickson was only six years old when she went for her first roller coaster ride. Eleven days later, she developed a feverish illness and although she seemed to make a complete recovery, her personality changed and she was diagnosed as suffering from autism. The quantum of damages has yet to be decided, but is expected to be well into seven figures.

In the UK, owners of Alton Towers and Thorpe Park reacted by saying that, whilst they accepted no liability for any cases of autism arising in any of their customers, until further clarification had been received no one under the age of 18 would be allowed on the roller coasters.

The case has been publicised by Ariana Huffington, nee Stassinopoulos, famous in the UK for being the late, great Bernard Levin’s squeeze, but famous in the USA for squeezing Mr Huffington and then setting up a mega-blog called The Huffington Post.

Is Mrs H left wing or right wing? Both it seems, although it depends upon which day you catch her. She gives column space on her maga-blog to a journalist called David Kirby who has a track record for publicising scientifically unproven causes of autism. A few days ago he wrote about the Supreme Court case. Well, acutally, it wasn’t the Supreme Court, and it wasn’t roller coasters, but the word “thiomersal” appeared and that always makes me want to reach for my revolver.

Orac is a scientifically trained American surgeon who writes Respectful Insolence. You will not have to read very far before you come across the word “woo”. The world of autism is full of purveyors of “woo”. They purport to be able to “cure” autism with a variety of methods some of which would not be out of place in a 17th Century witch hunt. Of course, many of these people are bonkers. I hesistate to say they are evil, but sometimes you do wonder.

For an unbiased assessment of the recent American decision you should turn, as so often, to Kevin Leitch, himself a parent of an autistic child.

So what of David Kirby? Is he bonkers? Most certainly not. If he were, it would be easy to dismiss him. He is far more dangerous than that. He comes across as sincere and genuinely caring. So you can’t dismiss him out of hand. I fear Andrew Wakefield may be able to convince the GMC that he is entitled to shelter under the same umbrella. So how do we describe people like this? I turn once again to Aphra Behn, surely one of the best wordsmiths on the Internet, who in

Quacktitioners 1 - sincerely woowoo

has expressed more elegantly than I a categorisation of the purveyors of woo. Essential reading. 

How the BBC "apologises" (sic)

"Kind middle-age man" (BBC)

A few days ago I highlighted Jane Asher's vitriolic attack on GPs which the BBC featured on its premier current affairs programme. My main concern was lack of balance. The attack was broadcast without comment and without giving a doctor the chance to put the other side of the story. I made a formal complaint. Today, I have had this response:

Dear Dr Crippen

Thank you for contacting us regarding 'Today'.

I understand you felt Jane Asher made inappropriate comments regarding GPs in the edition broadcast 7 April. I can assure you that views expressed by guests in our programmes are not representative of the BBC. We simply aim to offer a forum for debate. However, I do note that you feel more balance was required on this occasion. I would like to assure you that we have registered your comments on our audience log. This is the internal report of audience feedback which we compile daily for all programme makers within the BBC, and also their senior management. It ensures that your points, and all other comments we receive, are circulated and considered across the BBC.

Thank you once again for contacting the BBC.

Regards

Gary Sullivan
BBC Complaints
______________________

It beggars belief, doesn't it. "We would like to assure you that the views expressed by Mr Hitler are not representative of the BBC." Well, yes they are, Gary, if you broadcast them without comment and do not put the other side of the story. There was no forum. This was a partisan diatribe by a normally temperate person trading on her celebrity to comment inaccurately upon a topic about which she knows nothing.

That is the way the BBC does things these days.

++++++++++

And news just in. I replied to Gary's email asking him if the BBC would allow a doctor to put the other side of the story, and have just received this reply:

This is an automated response from BBC Complaints.

We are sorry, but our email system can only receive your email if it is submitted using our pre-formatted webform. We realise this is an inconvenience, but webforms allow us to manage the many emails we receive each day more efficiently and this makes best use of the Licence Fee.

Hello John, got a new motor?

It must be over 25 years ago that I used to go to the Comedy Store to see the then embryonic "alternative" comedians. A mixed bunch. Rik Mayall was brilliant. I remember even now his absurd, surreal poem dedicated to Vanessa Redgrave. Some were less funny. Some were not funny at all. French and Saunders were particularly dire. It was clear that they would not go anywhere. They did, much to my surprise, but I still do not find either of them remotely funny. That will probably offend countless fans so, whilst I'm at it, let me say that I hated Morecambe & Wise too. What did people see in them? I found the Queen's speech far funnier. I was too young to catch the Goons the first time round, and am not impressed when they are recycled. I would rather have root canal treatment than watch Bilko.  Nor do I like the Marx Brothers, and Dad's Army leaves me cold. Not even a snigger. Yet I count myself as having a good sense of humour.



The humour icons for me are Tom Lehrer, Beyond the Fringe, the Galton and Simpson Hancock, Tommy Cooper (why was that man so funny - I remember going to see him live with Wat Tyler). Small, selected doses of Monty Python (there was a lot of dross) are welcome. Fawlty Towers and Blackadder (apart from the first series) are pure genius.  More recently, Green Wing hit the spot and my children have just introduced me to Black Books which is exquisite. How did I miss it first time round? If you missed it, get the DVD.

It is hard to qualify one's own sense of humour. I know there are many who share my dislike of Morcambe & Wise and French & Saunders. Is it possible from my list of likes and dislikes to define in the abstract what is likely to make me laugh? Is their anyone who shares the same likes and dislikes or is my list far too eclectic?

But on to Alexei Sayle. I was lucky enough to see his original stand-up act which included the famous  "Hello John, got a new motor" spot. This was long before he made the record. It was the funniest act I have ever seen on stage. I was laughing so much I came out with rib pain.

I was put in mind of all this because Iain Dale has "got a new motor" and it is a gas guzzler. Most politicians pretend they cycle everywhere and keep their Chelsea Tractors hidden away. Iain has gone public and is taking a lot of flak.  Is he being irresponsible, or merely refusing to be constrained by political hypocrisy?

The NHS is "safe in our hands"

The Healthcare Commission staff survey reports the following

*25% think NHS trusts do not see patient care as their main priority - 29% are undecided

*74% of staff think they are not valued by their employers

*78% think the communication between staff and managers is poor

*77% think they are not involved in decision making

*39% of hospital staff said satisfactory hand washing facilities were not available

Add to that the fact that 25% of student nurses are quitting the profession before they have completed their training.

Add to that the fact that, despite significant increases in pay, morale in general practice is worse that is has been in a generation.

Add to that MTAS and MMC which destroyed the careers of many young men and women who had recently qualified as doctors. Many are leaving medicine altogether. Others are leaving the country.

Why has this been allowed to happen? Dr Rant seems to have the answer here - not for the faint hearted.

Where have all the nurses gone?

Guy's Hospital student nurses

Tomorrow morning the Times will reveal the following:

A quarter of student nurses quit before the end of their course, at a cost of more than £98 million a year. Figures obtained by Nursing Standard under the Freedom of Information Act showed that 26.3 per cent of student nurses due to finish in 2006 left early. Of 25,101 who started degrees or diplomas, 6,603 dropped out before the end. The problem is slightly worse than two years ago when the attrition rate was 24.8 per cent, the magazine said.

Why is this happening? Dr Crippen thinks the answer is here.

The Crippen Diaries - 2008 : April (2)

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

April 2008 (2)

Avril is 58 and is on hormone replacement therapy. She came to see me today for a renewal. She has been on it now for nine years, since her menopause. She is on a continuous combined no-bleed preparation and has had not problems. She does not smoke, she has regular mammograms (all normal), there is no family history of breast cancer, she is not overweight, her blood pressure is normal and she keeps very fit. She is a keen ice-skater. We have discussed the percentage increased risk of breast cancer, and the other pros and cons and I have told her that, as far as I am concerned, she can stay on it. But she still worries about it, even though she wants to take it.

Towards what I inaccurately thought was the end of the consultation she suddenly looked a bit embarrassed and said, “Do you mind if I ask you something?”

Last week a friend of hers who has carcinoma of the cervix asked her to go along with her to see her private gynaecologist to provide morale support. Whilst her friend was in with the doctor, she chatted with the secretary who was of a similar age. The conversation turned to HRT and the secretary said she was strongly in favour of HRT and advised Avril to stay on it. She then asked which preparation she was on and, when Avril told her, her face dropped. “I don’t think that is the best one for you. Go back to your doctor and ask him if he has heard of this.” She scrawled a word on a piece of paper which Avril now took out of her bag and handed to me, saying “have you heard of it doctor?”

The word was Livial. I have heard of it. 

I agonise about how long it is reasonable to keep prescribing HRT for older patients. Oh to live in the certain world of the typist. Life must be so much easier.

+++++++++

Eric gets early season hay fever and has been suffering already. The bog standard Loratadine (none of that desloratadine nonsense) I prescribe for him usually works, but this year his eyes have been more itchy than normal which is troublesome as he is a graphic designer. So he went to the pharmacist for advice. The Opticrom eye drops were nearly in his hand when the chemist said, “Just a minute, are you not a diabetic?”

Eric has Type 2 diabetes and it is well controlled.The pharmacist said that as he was diabetic he was not prepared to recommend anything and that Eric should see his doctor.

Now do not get me wrong. I had no problem seeing Eric. I have no problem with the pharmacist sending Eric to see me and I have no problem with the pharmacist declining to recommend medication. But you have to ask yourself, if pharmacists are taking over the medical world, and are going to diagnose, and prescribe and monitor chronic illness how are they going to cope if they cannot comfortably deal with a mild manifestation of a common condition like allergic conjunctivitis in a patient known to have hay fever?

++++++++++

As a rule of thumb, if a patient comes in and asks to see a nutritionist it is safe to assume that they are mad until proved otherwise. Ben is 29 and very fit. He runs a small company making cat litters. Each to his own, but he is not short of a few bob. He presented today and said that he had been feeling out of sorts. His personal trainer had suggested he might have lactose intolerance and so Ben had been eating more yoghurt. I asked him to talk me through that, but he could not explain. He also thought he might be deficient in zinc. It is usually zinc. Occasionally magnesium. I waited for him to move onto intestinal thrush but thankfully he did not. There is always an evil temptation to refer people like Ben to someone like Patrick Holford - they deserve each other - but, as Ben was “a bit run down”, I managed to escape with a blood test for anaemia and under-active thyroid. Why do patients like Ben always arrive when one is stressed and half an hour behind?

Three year pay cut for the nurses

Silencing the nurses

Gordon Brown has put an 8% payrise on the table for the nurses. Brilliant. 8% sounds good doesn't it, particularly if you forget to divide it by three.

The proposed deal would give over a million staff an increase of 2.75% from April, followed by further increases of 2.4% in 2009/10 and 2.25% in 2010/11.

It is a con. In real terms, this is another big pay cut. Gordon Brown will quote figures to prove it is not, but the figures are from the land of Gordon Brown make believe. The REAL inflation rate is higher, well above 3% a year. Wat Tyler has a graph showing the real figures. Take a look here.

There is another agenda. Gordon Brown wants to be re-elected in 2010. He does not want bad publicity from angry nurses during the election campaign. DON'T BE FOOLED. Do not accept this derisory pay rise. Above all else, do not let Gordon Brown shut you up before the next election.

Destroying the independence of the English legal system

Nigel Rumfitt QC

Successive Labour governments have destroyed the English secondary education system. They are in the process of destroying the university education system by compelling the universities to admit under qualified students from sink comprehensives. They are destroying the NHS by undermining the medical profession so that they can be replaced with poorly trained but cheaper HCPs. It is only right and fair, therefore, that they should also destroy the English legal system. And when you see what a thorn in the side of government an independent lawyer can be, is it any wonder that Gordon Brown wants to bring these turbulent professionals to heel?

The government has made a start by trying to impose a contract on barristers who work in the legal aid system. So far the barristers are resisting but will, in due course, be starved into submission. The next attack is on the English judiciary. English judges have traditionally been highly intelligent and have been educated at leading Universities. New Labour does not like that. So they are proposing to allow judges to be appointed from the Crown Prosecution Service, that well know bastion of legal mediocrity.

Hundreds of state prosecutors could be free to become judges under top-level moves to end a ban on Crown Prosecution Service employees entering the judiciary. Baroness Scotland, QC, the Attorney-General, and Sir Ken Mac-donald, QC, the Director of Public Prosecutions, are both strongly in favour of the changes, saying that it would make the judiciary more diverse by widening the pool of women and ethnic minority lawyers who could be judges. (The Times)

There is no intrinsic merit in diversity. Very few ambitious high flying law graduates make a bee line for the CPS. For good reason. And do not be distracted by the guff about getting lawyers with "prosecution experience". Independent QCs both prosecute and defend. The agenda here is simple. A salaried, controllable judiciary full of government placemen. Cheap and obedient. And what of those eminent independent barristers? Be patient. They will all be retired in a few years. Enter his Honour, the Judge Quacktitioner.

Fingerprinting

In the meantime, the next time you pass through Terminal 5, enjoy the fact that no one asks for your finger prints. They were going to ask for the fingerprints of Nigel Rumfitt QC. He is an independent criminal barrister. He both prosecutes and defends but is not beholden to the government. Nor does he work for the CPS. See what happened here:

I refuse to be fingerprinted

Nigel Rumfitt QC

You will not find a salaried legal quacktitioner doing that.

Jane Asher

Jane Asher

I have always been a Jane Asher fan. When I was a small child she was stepping out with Paul McCartney and so much in the news. The Beatles en masse were frequent guests at the Asher household in Wimpole Street (or was it Harley Street?). Jane’s brother Peter had a one hit wonder with “A world without love” (what ever did happen to Gordon?). Jane went on to marry the greatest living British cartoonist, to bake some cakes and, in her spare time, do a little acting. Then at medical school I came across “Talking Sense” written by her father, the late, great Richard Asher, a wise and learned physician who first described myxodematous madness and, more famously, Munchausen’s syndrome. Richard Asher had an ability to see the wood amongst the trees. Take a look at his wonderful article, “The danger of going to bed” written in 1947

The children of doctors, rather like GPs' receptionists, often think that some of the medical training to which they were proximate has somehow osmosed into their own cerebral cortex. The wise ones have insight. The less wise tend to be free with their own unsoundly based medical advice. Having so much respect for the Asher family, I was disappointed this morning to find that Jane Asher had accepted the BBC's offer to fill the regular ‘five minutes of gratuitous criticism of GPs’ slot. I would have thought someone of her manifest intelligence would know better. Sadly not. It was all the usual stuff.

GPs are incompetent, uncaring, unethical and negligent. If it was not for them, then patients with “...insert your favourite illness...” would be so much better cared for.

Jane Asher is the President of the Parkinson’s Disease Society (PDS). The PDS is an excellent organisation, does a lot of work for its members, and rightly and properly is forever trying to exert pressure to get more resources. PD can be a wretched, bloody disease. Unlike breast cancer, it has no social cachet. People with PD lose their facial expression and may look unresponsive and gormless. They dribble. PD makes you shake and act in a physically odd fashion. It can remove your ability to communicate, both verbally and in writing. Think how embarrassed many people feel when they watch Muhammed Ali on television. As always, with one or two honourable exceptions like Michael Fox and Mohammed Ali, celebrities with PD rarely go public. They hide away. Because it is an unfashionable disease it is ignored and under resourced.



This morning, Jane Asher laid the blame for most of this at the feet of GPs. We are incompetent because we fail to diagnose the condition. We are uncaring because when we do diagnose it, we do not bother to refer the patients to neurologists, OTs and physiotherapists. We are unethical because sometimes we diagnose patients as having PD and put them on medication but do not tell them what the medication is for. We are negligent because we do not bother to treat or refer PD patients for the depressive problems that so many of them develop. You don’t believe me? Go to the Radio 4 Today programme “listen again” spot (7.19) whilst it is still there.

The BBC is perfectly entitled to highlight the failings of any profession. But when they are going to devote a whole “news” item to the failings of doctors, as described by Jane Asher who is not a doctor, it would have been reasonable to ask a spokesman from the Royal College of General Practitioners to put the other side of the argument. But that is not the way of the biased BBC. When they have a political point to make about doctors, there is no fair play. And why, exactly, did this item appear on a news programme this morning? PD is no more topical this week than it was last week. This item was “placed”. I wonder why?

So let me try to put the other side of the story. I am sure there are some GPs who are bad at dealing with PD patients. I am equally sure that most GPs do their best. Some GPs have particular interest in and expertise with PD. In our practice we refer all patients with PD to neurologists. Is there a delay in diagnosis? Certainly. In its very early stages it is difficult to diagnose. Do we sometimes not tell patients that we think they may have PD? Many older patients fear PD and so, when you notice that elderly granny is doing a little “pill rolling”, which neither she nor her relatives have noticed, should you jump on her and say “this looks like PD”. You tell me.

Our local neurologist is kind and charming. He gets all the PD patients. Frequently, he will say "I think this patient may have early PD but I have not told her at this stage." Is that wrong? He used to follow them all up three or four times a year. Now, with all the targets and cuts in resources, he sees them twice a year if they are lucky. In the meantime, we keep an eye on them and adjust their medication.

I agree with Jane Asher that it is wrong to put a patient who is compos mentis on medication without explanation. But what do you do with a patient who is partially demented and terrified of PD? You make a judgement. You discuss it with the family, if there is a family. OT and physio for PD patients? Routinely arranged when available. Have you any idea how stretched those resources are and what the waiting lists are like? And then there is depression. It is common in PD patients. I would be depressed if I had PD too. And so we treat it. Not always easy because of drug interactions but we treat it. Do we routinely refer them to psychiatrists? Absolutely not.

I could go on about the many other problems associated with PD. The dribbling. The constipation. The lip-smacking. The dementia. The side effects of the medication. The social embarrassment.

Jane Asher paints a picture of a world full of resources to help patients with PD if only the idle GPs did not put up so many barriers to care. It is not like that. The problem, as so often in the NHS with unfashionable illnesses, is lack of resources. I was, as always, upset and further demoralised by yet another dose of GP bashing. It was made much worse as it came from someone for whom I hitherto had enormous respect. And, much as I support the PDS in its aims, I now worry about its principles.

A patients' guide to medical careers - find me a doctor for the Duke

Is there a doctor in the house?

Just caught up with the normally excellent Aphra Behn's

Patients' guide to Modernising Medical Careers.

A couple of weeks ago there was a mass lobby of MPs organised by Remedy but sadly the turn out was not good. It is hard being last year's news. MTAS and MMC did reach public consciousness during the days of the blessed Patricia but I fear there is now a general perception that the problems have been solved. Tooke has been ignored. Polymath Darzi is casting an eye over the problem, therefore all is perceived to be well so let's move on.

All is not well, and for many hospital doctors the only way of moving on is by leaving the profession or the country. We are all relieved that the Duke of Edinburgh has recovered from his bad cold but do you really think that, before he went to hospital, he popped into the local branch of Boots  for a little advice from the pharmacist and a  Benylin cough bottle? Do you think that the "respiratory nurse quacktitioner" will be visiting Buckingham Palace to follow him up? Do you think that, whilst he was in hospital, there was no doctor available to monitor his every need? Do you think that NHS patients get the same service in hospital?

Forget it. This is what really happened:

The Duke, who has enjoyed robust health throughout his life, had been ordered to go into hospital by the Queen's personal physician. Despite suffering from a heavy cold, the 86-year-old protested that Dr John Cunningham, who was treating him, was over-reacting. Typically, the Duke grumbled and complained. He did not want to go in," said one Buckingham Palace courtier. "You know what he's like. But, having failed to shake-off the cold and battled the infection for a week, he accepted the advice of Dr Cunningham, who has been physician to the Royal Household since 1993. (Daily Telegraph)

Dr John Cunningham is one of he most respected and eminent physicians in the country but he is a renal, dialysis and transplantation specialist. I was waiting with trepidation for an announcement that the Duke had gone into renal failure. But no. Probably John Cunningham was summoned because he is trusted by the Palace, and they do not know that renal physicians do not "do" chest infections. Or not for the common folk anyway, as we saw here. Still, seeing even a renal physician beats seeing a pharmacist or an HCP for your bad cold. The common folk can only fantasise about medical care like this. For the ordinary NHS hospital patient:

The long and the short is that there is already inadequate cover on the wards - our wards, where your mother’s recovering from a fall, where my father-in-law has pneumonia, where your sister has breast-cancer, where your daughter’s having a baby - and this inadequate cover is a direct result of the restrictions placed on doctors’ choices by the government policy called “Modernising Medical Careers”.  (Aphra Behn)

The government has mounted a cynical but brilliantly successful campaign to demean and undermine the medical profession. The general message is that doctors are overpaid for doing jobs that, mostly, can be done by people with lesser skills. In hospitals and in the community that means the rise of the HCP. There was a quacktitioner fest only last month at Birmingham Hippodrome where a whole load of HCPs talked about "competencies" (HCPs are never "competent", they always have "competencies" - like knowing what number to call when they think they need a doctor.) Do you really think that the Royal Family, and the "great and the good" are going to allow these idiots anywhere near them when they are ill? Do you? Only the "ordinary folk" get treatment from this lot. But the government is in favour because it saves so much money. It is much cheaper than training and employing doctors. 

Read the Aphra Behn article. I will not quote too much of it, or a I may get bitten by an angry blogger. But you will have noticed my mealy-mouthed use of the word "normally" in the opening sentence.  To explain that, I must needs share just a few more of Aphra's words with you.

There is now a two-layer career structure for doctors in hospitals, with generalist posts providing ward-cover and specialist posts including training and career progression. Doctors who want to be generalist and do the same thing year after year become GPs, work normal hours and don’t risk being sued for misunderstandings or mistakes. (Aphra Behn)

All jobs have their repetitive elements. How many grommets and tonsillectomies does an ENT surgeon do each week? As for GPs not getting sued, well, take a look at the most recent Medical Protection Society  GP's cock-up reports.

Charlton Heston & the National Rifle Association (NRA)

Sad to hear today of the death of Charlton Heston. I can still remember as a small child seeing that famous chariot race. The film itself, Ben Hur, has not other wise passed the test of time. Too long, too slow and far too mawkishly “holier than thou”. The chariot race, however, has stood the test of time and is as good as ever. Always remember, there were no computer graphics then. People were killed filming that race.*

Charlton Heston did not pass the test of time either. In his declining years he allowed himself to become an effete figurehead for the National Rifle Association (NRA)

Charlton Heston and the NRA

There is a British National Rifle Assciation too, founded in 1859, but their mission statement is to “promote target shooting throughout the United Kingdom” and not, like their colonial big brother, to guarantee a citizen’s right to carry an AK47 in the car.

It was easy to dismiss Charlton Heston and indeed Michael Moore famously made a complete fool of him



It would be a mistake, however, to dismiss the NRA out of hand because it was for a time, and unwisely, fronted by Charlton Heston. There are many far more formidable supporters of the NRA, and of the right of the American citizen to carry arms. One such is Glenn Reynolds, a Professor of Law in Tennessee, and writer of Instapundit. I doubt Michael Moore would have the courage to take on Glenn Reynolds in open debate. Read a coherent explanation and justification of the Second amendment in:

GUNS AND GAY SEX: SOME NOTES ON FIREARMS, THE SECOND AMENDMENT, AND “REASONABLE REGULATION”

We should expect courts to treat the regulation of gun ownership with the same skepticism previously applied to the regulation of gay sex74 and communist propaganda.

Professor Glen Reynolds
(full paper available here)

Meanwhile, back in the UK and free of the second amendment (though never forget that the second amendment has its origins in English law), from time to time GPs are asked to sign certificates confirming a patient’s suitability to have a shotgun licence. I do not do this. I probably would if I worked in a rural area and it was a farmer who was asking but that has not happened. Some of the people who ask for such certificates are of a certain sort; they probably own a pitbull terrier as well as a shotgun.  As for the others, well, who can tell if they are suitable? I would not mind issuing a statement saying that there was no evidence in their medical records of them suffering from mental illness, but how can I possibly say that someone is “suitable” to own a shotgun.

I can’t. So I don’t.

+++++++

Apparently not - see here

The NHS safe is in Gordon Brown’s hands

Half a pound of tuppenny rice,

Half a pound of treacle.

That’s the way the money goes,

Pop goes the weasel.

Up and down the City road,

In and out the Eagle,

That’s the way the money goes,

Pop goes the weasel.

Every night when I go out

the monkey’s on the table.

Take a stick and knock it off

Pop goes the weasel.

Within seconds of arriving in office, Gordon Brown and Ed Balls mounted a stealth raid on UK pension funds. The effects of that are still working their way through.  A little later Gordon went down to the bank vaults and sold off a huge tranche of British gold. The asset stripping is to continue.  Gordon Brown has realised that the NHS owns a lot of real estate, particularly in London.

“Don’t worry” said a government spokesman “we will not lose our hospitals because once we have sold them, we are going to lease them back.” That is a one-off capital profit that will fund the NHS for a few weeks, and then an eternity of debt for you, your children and your children’s children.

In other words, Gordon Brown is taking the NHS to the pawn brokers. And why is he doing that?

The recent upsurge in the pawnbroking industry’s fortunes came during the 1980’s credit boom and has continued through to today with customers now preferring this convenient form of High Street borrowing – customers that many banks turned their backs on during the hardships brought on by recession.

National Pawnbrokers' Association

Because no reputable bank would lend him money.

+++++++++

There is no room for complacency. As Guido observes, the IMF has warned the Labour government about mounting debt and profligate borrowing again and again and again and again and again and again, and again and again.

Medical misogyny

In Vivre La Difference, Tim Worstall touches gently on the vexed issue of women in medicine.

On the one side we have the obvious facts of biology: it doesn’t matter how much time a man takes off as paternity leave, he’s still not going to give birth. On the other we have the subject of our EQSQ personality tests, that certain other attributes are not distributed equally across the sexes. We expect to find more men (but not exclusively men) at the systemizing end of the spectrum, more women (and again, not exclusively women) at the empathizing end.

How long does it take to train a surgeon? Fifteen to twenty years was the traditional yardstick, but that was in an era when doctors in training routinely worked a 100 hour week. Now, we hear today that the 48 hour week will soon be rigourously imposed. Consultants such as Mrs Crippen still do not understand why these regulations do not apply to her. Can anyone explain? But I digress. Trainee surgeons, even the males never mind the females, are not getting the hours.

Ten 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. (UK surgical training crisis)

Dr Sarah Blayney does not share Dr Andrew O'Brien's insight. Sarah is 24 and in her first year of work after graduating. She works at Arrowe Park Hospital, in the Wirral. She feels that the current system left doctors with very little choice or flexibility:

Dr Sarah Blaney

"The training jobs as they stand are all or nothing. You either do all the hours or don't get the post. I want to pursue a career in hospital medicine, which will mean me committing to a minimum of five years of fairly hefty on-calls. At the moment I am 24, single and am enjoying life. But in four or five years time my situation may have changed and I may not want to work those hours."

Is that right Sarah? You do not get offered a job if you are not prepared to work the hours? Well, as Grandma Crippen was wont to say, "I'll go to the bottom of my stairs."

She said flexible working would be particularly relevant to female colleagues wanting to start a family, but said male colleagues were also interested in changing their hours. For example, some wanted to take time out to travel, she added. "It should not need to compromise training. Doctors appreciate that they need to put the time in. It's about having more flexibility."

Sarah lives in cloud-cuckoo land. She wants the job but she is not prepared to do the hours. If you want to be a hospital consultant you have to train for many years during which you must work long hours. Sarah needs to grow up a little. You can’t expect to pop into the hospital to do occasional clinics at a time of your own choosing in between school runs, parent-teachers association meetings and back packing holidays. Life is not like that.

Being a hospital consultant requires commitment, dedication and long hours. There is provision for paid maternity leave. What more do you want? Get a child minder like everyone else does. If you won’t do the hours, you can’t have job. Get a part time appointment in the Family Planning Clinic. Just because you are a girlie, you can’t expect medical training to be turned on its head. (Doctors in cloud cuckoo land)

But back to Tim Worstall who finishes by saying:

No, I don’t know what the answer is either: but it is something of a problem. There really are professions out there where years and years of long hours are the current route to being a full professional. How do we, how can we, if we already accept that those years of intense preparation are necessary, combine this with the career breaks and part time work that women with children both need and want? Anyone got any ideas?

Yes, I have.

This is not just about maternity leave, which the NHS gives (probably only because of its legal obligations). It is about working conditions, which are poor,  and the pay, which is dreadful. Perhaps not surprising then that doctors like Sarah Blaney want more 'benefits in kind'.  Consider, though, other careers for high-flying university graduates. If a female law graduate turned up for an interview at one of the big city solicitors and talked of 48 hour weeks and back packing holidays she would be shown the door. And rightly so. But, unlike her medical collegeagues, if she took the job she would be extremely well paid from day one, including during her training period, she would have huge fringe benefits (gym, BUPA and so on), she would get maternity leave on full pay and, when she returned, she would easily be able to afford child care. Even more importantly, she would be treated as a valued employee and she would be looked after. The NHS has no valued employees and looks after no one. In particular, it treats women with indifference bordering on contempt.

Clifford Chance is one of largest solicitors in the world. Start training there as a female and you can expect to work 80 to 90 hours a week. And yet:

We are delighted that Aurora and The Times have recognised Clifford Chance as one of the Top 50 places Where Women Want to Work in the UK. (Clifford Chance)

Why should women want to work these sorts of hours? Because they are valued and sought after. Take a look here. Look at the precise details of the career prospects for graduates. There is not a single NHS hospital in the UK that offers any of this.

Obesity : is surgery the answer?

The dieter's trousers

Many truly obese people are searching for a quick answer to their problems. Sadly, there isn't one. Ultimately, it is all down to calorific balance. Slimming is big business. Very big business. Put "diet" into Google and you get more hits than if you put in "bible". The drug industry has moved into slimming in a big way. In my view, the drugs they produce are rubbish; possibly dangerous rubbish. Bariatric surgery is always an option. Have a band put round your stomach so that it is physically impossible to eat big meals. For the right patient, it can be dramatically effective. But it has to be combined with life-style changes and, in particular, exercise. For the wrong patient it will not work. Banding will not stop the truly determined persevering with booze and liquidised Ben & Jerry's

Chris Oliver is one of the "right patients". We met him before in the early days after his operation. Chris weighs 118 Kg at the moment. For those in the colonies, that's 260 lbs and, for me, it is 18 stone 8 lbs. Hardly the sugar plum fairy. But Chris was 168 Kg when he started and, much more to the point, he has started a graduated and now intensive exercise programme. He is getting fit. Very fit, I suspect, looking at the details of the exercise he is doing. And that is what it is all about. Changing life-style permanently.

Chris also happens to be a doctor. Well, a surgeon actually. His views on anti-obesity drugs seem to co-incide with mine.

I was phoned for my views on weight loss drugs by the Edinburgh Evening News and now see that not surprisingly I've been quoted. I expect I will get into trouble! However I have never taken any of these weight loss drugs. No GP ever offered them to me. Literature from NICE on Obesity has not really given major support to weight loss drugs although its very difficult to negotiate through these guidelines. I really rather think the money should be spent on anti-obesity education programs and initiation and enhancement of physical activity.

Chris Oliver

Well, if Chris does get into trouble, I shall be in the dock with him. These drugs are, as I say, rubbish.

I have recently been battling with the PCT to get similar sugery for one of my patients. Like Chris, she is not mad. She has struggled unsuccessfully with her obesity and both she and I think she is a good candidate for surgery. Unlike Chris, she has not been able to have the surgery done privately. So it is down to the NHS. Unfortunately, as far as the NHS is concerned, she has to prove her need for surgery and in producing that proof, my opinion, her opinion and the opinion of the surgeon are not relevant. Gordon Brown's opinion is what counts. I wrote recently about how she has had to struggle through all sorts of Stalinist bureaucracy to meet criteria drawn up by non-medically qualified commissars. Meeting these criteria involved inflicting a great deal of ritual humiliation upon her, including a couple of weeks of faecally soiled knickers whilst she took a very brief course of one of these silly anti-obesity drugs. (full details here)

She got there in the end, and the surgery is scheduled for later in the year.

Gordon Brown and anger management

Gordon Brown to target anger management

Dr Crippen was perplexed when last week, for no apparent reason, the lack of facilities within the NHS for anger management received some unexpected publicity. One always fears another government initiative, another target.

One in four says they worry about how angry they sometimes feel and 64% think people in general are getting angrier. But most people would not know where to seek help. Mental Health Foundation chief executive Dr Andrew McCulloch said: "In a society where people can get help for depression and anxiety, panic, phobia, eating disorders and a range of other psychological and emotional problems, it seems extraordinary that we are left to fend for ourselves when it comes to an emotion as powerful as anger. (BBC)

The reason for the sudden interest can now, via Iain (the Dementor is dementing) and the Financial Times Westminster blog, be revealed:

I’ve no idea if this one is true. It came to me from a Labour MP who is no fan of the PM. But apparently Gordon Brown recently got through three mobile phones in one week by hurling them against the wall in anger. Could be nonsense. However, the fact that it seems even remotely believable is a sign of the times. (Financial Times)

I hear cannabis is very calming, Prime Minister.

Nadine Dorries MP - her position of the week

Poor old Nadine Dorries MP. She is getting quite a reputation in the blogosphere for itinerant bloggers who want to stop off somewhere for a bit of a laugh. This week, she is taking the characteristic stance of the anti-abortion brigade on contraception.  She thinks that moral homilies are contracpetive and superior to more conventional methods. Strange. You would think that those who were so against abortion would be handing out condoms on the street. But they do not. 

This week, in Beyond the School Gates, Nadine is talking of “Providing Support and Communicating With Young People” by which she means she is trying to stop teenagers having too much sex.

Throughout the session it struck me that the discussion focused on dealing with the consequences of teenage sex, in the form of STIs and pregnancy; whereas the fundamental problem, the fact that sex is now regarded as a recreational pastime, no relationship required, is largely ignored. Much easier to focus on how quickly we can get treatment to an infected sixteen year old, than how we get the same sixteen year old to think twice before having sex again, until at least within the confines of a stable relationship.

She was not impressed by the government's recent campaign.

I was surprised to see the Department of Health focusing on a campaign targeting the use of condoms.

Why?

Everything this government does is target orientated. But on one point, I agree with her. DUREX did the job much better. Well, they would, wouldn’t they! They held a student design compettion for condom ads and, by popular acclaim, the advert at the top won. Dr Crippen’s favourite advert was:

There were many excellent ones, all available on the DUREX web site. Take your pick from here. Nadine may like the posters but somehow it is hard to believe she is keen on contraceptive advice:

The money that the Department of Health spent on their campaign could have been used on developing a national standard for sex education within schools, which taught the principles of self respect and at least began to address the issue of values, morals and ethics within education and wider society.

Here we go again, Nadine. Sex education is about sex education. What has this got to do with “self-respect”? Teenage sex does not ipso facto mean loss of self-respect. And you cannot address  “values, morals and ethics” in the way Nadine means. She wants to lay down a list of her moral absolutes and have them taught in schools as universal ideals. Values, morals and ethics evolve. Much as Nadine’s might like to try, they cannot be imposed in the class room.

It would be easy to dismiss Nadine as well-meaning but mis-guided. But that is not possible. She is an MP and, not only is she an MP, she is bonkers. Deliciously, delightfully bonkers. No wonder she has turned off the comments facilitlity on her self-promoting propaganda web-site. Why do I say she is bonkers? Consider her next suggestion.

How does she want to “inform” teeangers about “values, morals and eithics”?  Through magazines. Nadine says:

The former editor of Australian Cosmopolitan told us that magazine editors take their jobs incredibly seriously. I am sure they do. I am also sure that one of the few lines of communication into the teenager’s world is through the pages of teen magazines.

Absolutely right Nadine. Such magazines do influence teenagers. Cosmopolitan in particular adopts an unequivocal position on matters sexual. In fact, if you look here, they have a new position every week.

Sex Position of the week.

The see-saw

Perhaps the position of the week is only meant to be adopted “within the confines of a stable relationship” though for some reason Cosmo does not mention that.

Poor old Nadine. She really does need to get out more.