Another load of crap : redux

Nearly a year ago, in “Another load of crap”, I said:

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.

Dr Crippen : another load of crap

Memories are short. You probably do not even recall the appalling scapegoating of the unfortunate Rose Gibb. A furious public, whipped up by a cynical media, gave the thumbs down and Rose Gibb was thrown to the lions. Dismissed on the spot with no compensation.

Should the Chief Executive be sacked every time there is an avoidable death in a hospital?

Rose Gibb is in the news again. She is fighting for compensation. She is fighting to clear her name. Why, you may ask - I do - were the senior doctors, the consultant microbiologists not disciplined and sacked? Why were the infection control nurse specialists not sacked? Were they not even more at fault?

I will tell you why. The public has not been primed to accept the idea of doctors being sacked. Even more, there would be outrage if nurses, even specialist infection control nurses, our “angels”, were sacked. But administrators? We all hate them, don’t we?  There are far too many of them, and they don’t do anything, do they? Well, yes, there are too many of them (see the article below) and it is sometimes hard to work out what they do. But it is not necessarily their fault. They are instructed, on pain of dismissal, to hit government targets. Targets that, as Dr Grumble observes, are unrealistic and cannot possibly be safely hit. But, if Rose Gibb had not tried to hit those targets, she would have been sacked long before the outbreak of C. Difficile.

The official Healthcare Commission report on Maidstone and Kent NHS Hospital trust does not not provide happier reading.

Shambolic mis-management or, to be more precise, lack of management of infection in a Kent NHS Trust. A depressing catalogue of incompetence. Lack of leadership from the top – and by that I mean from Consultant Microbiologists, doctors with specialist training in infection and bacteriology - was the main problem. Add to that government pressure on non-medically qualified managers to increase hospital turnover with inadequate nursing resources and you have a receipe for disaster.

The chief executive of the Trust, Rose Gibb, has been instructed to fall on her sword and to do so without pay if the Secretary of State has his way. She, and many of her staff, may yet face criminal prosecution for manslaughter. I feel sorry for her. Far too reminiscent of John Byng. I feel sorry for them all. They were cutting corners to meet government targets.

As they (still) are in a hospital near you.

Clostridium Difficle : more diarrhoea

It is neither fair nor realistic to criticise hospital chief executives who are not given managerial autonomy. Give them autonomy and a realistic budget and then, if they do not deliver, you may sack them.

It was not Rose Gibb who should have been sacked. It was Patricia Hewitt. Tony Blair was never good at wielding the knife. The sacking of Patricia Hewitt would have been met with universal acclaim within and without the NHS. A chance was missed. It would have been well deserved and fair.

Rose Gibb is a victim. But then, "dans ce pays-ci, il est bon de tuer de temps en temps un amiral pour encourager les autres."  She should be compensated for unfair dismissal.

Mission Impossible : counting the cost of Labour's NHS legacy

There are now more PCT managers than primary care doctors in many areas, there are people with titles that make no sense and the output of their jobs often amounts to even less.

The Ferret

I did not believe that statement at first. I do now,  for I have seen the list that a GP made of all the administrators in her PCT who send her emails.

Your mission, should you chose to accept it, is to look at the list, study the job titles, work out what exactly it is that each of these people does, guess what salary they are paid and what index-linked pension they will each draw when they are finished, and calculate the annual cost to the taxpayer.

Good luck, Jim. The NHS will self-destruct in three months.

Preventative medicine

click to enlarge

Movin’ Meat is an ER doctor on the West Coast of America (you know, like Mark), and is responsible for drawing my attention to the entertaining but surely entirely fictional picture above.

Here's the odd thing.  You notice in the above graphic (obtained via DKos) there is a blurb titled "Defense Accessories," which reads in part, "Bottles of the President's blood kept on board in case he needs an emergency transfusion."

Um, really?  

Full story in : This is cool, and a little odd

All sounds a bit silly, particularly as there will (as a nurse points out in the comments - and do skim down for the one on dear old OJ) be O Negative (the universal donor blood) available at any hospital near you. Still, the security services will do anything they can to protect Mr Obama. 

Meanwhile, back in the UK, one speculates as to what is done to protect our leader. What might be found in the back of Gordon Brown’s Jaguar? It is allegedly bullet proof, but what is inside?  A Marks & Spencer sandwich? A copy of yesterday’s Evening Standard? Do we ever get this sort of thing right in the UK?

Dry stone walling

Dr Crippen adapting to change

Just had an email from someone who is not called Dr John Smith

Thought you'd be amused at my wife's recent conversation with a receptionist at our GP surgery. To set the scene, you need to know that my wife is a GP herself and I am a paediatric neurologist. Our 11 month old daughter has been unwell for a number of weeks with colds and we have been treating her accordingly. However, she got worse a few days ago and thought someone more objective could assess her and either reassure us or suggest appropriate management. So my wife phoned the health centre and asked if our daughter could see a GP.

The receptionist said that an appointment could be made in a few days time but there was a nurse practitioner who could see him quicker. My wife politely declined and said it was a GP she wanted to see. My understanding is that the matter should then have been dropped, but unfortunately she had to listen to reasons why the nurse practitioner should be consulted. My wife gave in and admitted her profession, implying that someone of equal or superior knowledge was required to assess our son.

This was greeted by "you of all people should understand the importance of supporting the nurse practitioner"... She politely declined.

Hmmmm - what is your policy on this?

Dr John Smith

Firstly, this story makes me feel ashamed.

We ensure that all patients who phone or present at the practice are seen the same day or, at any rate, speak with the duty doctor who can assess the degree of urgency. An appointment "in a few days" for a poorly child is unacceptable.  Reception staff are not allowed to trade symptoms with patients. I’m afraid that occassionally they still do. They have listened to us on the telephone and it sounds so easy to ask “simple” questions like “how long has she had a temperature” and “does she have a headache”. Well, any fool can ask questions and tick boxes but this is not the road to diagnosis. It is the road to NHS ReDirect and a writ for negligence.

Secondly, in my practice, we have a small number of “privileged” patients. Privileged patients are members of staff and their immediate family, and doctors and their immediate family. We always make sure that any doctor or a member of his or her family is seen on the same day, by a partner. Not by a salaried doctor. Not by a locum. Not by a GP registrar. Not by by a nurse of any grade. Straight to the front of the queue to see a partner. Yes, it’s a courtesy and, yes, it’s a perk of the job, if you like. We don’t get many. But it is more than that. As a doctor it is not easy to be objective about your own child’s illness. Most doctors swing between the extremes of apparent indifference (believe me, it is not indifference) and nervous over-reaction. It is even worse to be the doctor who sees a colleague’s child. You need calmness, honesty and objectivity that only years of experience can bring. It is far too easy to over-react and over-investigate.

Thirdly, we do not employ or use nurses in diagnostic roles. We have several excellent nurses in the health centre, running follow-up clinics for diabetes, asthma & COPD and so on, and they are very good in these roles. But we are not as clever as Lord Darzi whose wealth of experience in primary care allows him take responsibility for those well meaning but medically unqualified practitioners who are happy to pull a cork from the quacktitioner’s diagnostic tombola. A place for everything, and everything in its place. Dr & Dr Smith would not dream of letting a nurse practitioner try to diagnose their daughter, and nor would I. The money grabbing GPs who employ non-medically qualified practitioners would not let them near their children either. They are hypocrites, albeit wealthy ones.

Dr Smith’s daughter should have been seen immediately by a partner. If my daughter had a fit, I would expect Dr Smith to see her personally in his clinic. If a latter day quacktitioner appeared, I would be off.

Sad to say, these medical courtesies are disappearing. The medical profession itself is disappearing. I doubt that the tide of cheapo-cheapo productions practitioners can be held back. Real medical professionals - yes, I mean doctors - are gradually being replaced by a different breed of worker. A worker who calls himself a “professional” but does not know what the word means.


It’s a shame. When I go to the Lake District, as I do so often, I take pleasure in the dry stones walls. Soon there will be no one who remembers how to build or repair them. Why bother? It is so much cheaper and so much quicker to use modern materials.

A picture is worth a thousand words

click for full story

Guido displays the above picture. 

It was always so.

When we look at those much fiddled figures for debt and borrowing, the EC says that over the next two years our government will need to borrow the equivalent of 18.4% of GDP - twice the EU average. Hardly surprising that by 2010 we will have more government debt (71% of GDP) than the EU average, and that includes such long time basket cases as Italy and Greece. Remembering also that our figure excludes the vast bulk of this bank bail-out cash, just as it excludes all the PFI/public sector pensions Enron debt we've blogged so often.

So if we can't blame it on the bankers, and we can't blame it on incompetent foreigners, who can we blame it on?

Yes, that's right - ourselves.

We (well, more specifically, you) are squarely to blame for not learning the clear lesson of history. Labour governments always always ALWAYS end in economic disaster. Look, let me spell it out for you:

• Ramsay McDonald - economic disaster
  
• Clement Attlee - economic disaster
  
• Harold Bloody Wislon - economic disaster
  
• Jim Callaghan - economic disaster
  
• Bliar/Brown - economic disaster
  

See? See the pattern?

Trashed - by Wat Tyler

In the late 1970s the IMF moved in and took over from Callaghan and Healy. Brown is bouncing around the economic firmament like a pin-ball. Who knows where he will go next? Who knows what he will say next? Who knows where he will borrow from next? We can only hope the IMF move in again before the economic pinball machine says TILT.

What has this got to do with health care? The NHS only costs £2 billion a week. A few years of these NHS weeks has been given – yes, given – to the banks to balance their still unquantified toxic debts. And to encourage them to lend us more money. Just a minute. Have I got this right? I am going to have to pay yet more tax to give yet more money to the banks so that they can lend it back to me? Hello? Could we not just cut out the middle-man?

It will affect healthcare. For, as the debt piles up, debt which must be repaid by me and you, and our children and our children’s children, the next step will be cuts in public services. As Wat Tyler puts it:

And it does mean that from now until you are very old and very grey, you're going to be taxed to buggery and back. And it does mean that you'd better not try to use any public services, because they are going to be incinerated.

We have huge overseas debts we cannot conceivably repay without a prolonged period of high taxes, poor services, and low purchasing power. In my book, that's going bust.

We’re not going bust, huh?

How will the cuts in healthcare manifest themselves? Stealthily, of course, for that is the government’s way. Behind the façade of continuing “Good news, comrades, tractor production is up” type of announcements there will be frozen budgets; shrinkage of the healthcare workforce as jobs are not filled; less money in UK research (our position as a leader in medical research has long gone, but we will fall further down the league tables); more deskilling of the healthcare labour force as workers across the board are promoted beyond their competence; more diktats from NICE as the word “cheapest” becomes a synonym for “best”; more medical conditions to be reclassified as “social problems”; “top up” fees to be routine…the list is endless and the fraud breathtaking.

Was it ever more pertinent to say the following? :

I warn you that you will have pain – when healing and relief depend upon payment.

I warn you that you will have poverty – when pensions slip and benefits are whittled away by a government that won’t pay in an economy that can’t pay.

I warn you that you must not expect work – when many cannot spend, more will not be able to earn. When they don’t earn, they don’t spend. When they don’t spend, work dies.

I warn you that you will be quiet – when the curfew of fear and the gibbet of unemployment make you obedient.

I warn you that you will be homebound – when fares and transport bills kill leisure and lock you up.

I warn you that you will borrow less – when credit, loans, mortgages and easy payments are refused to people on your melting income.

• I warn you not to be ordinary
  
• I warn you not to be young
  
• I warn you not to fall ill
  
• I warn you not to get old.

Medical advertising

George Jones is a specialist rheumatologist (properly qualified - he has an MB BS and an MRCP) and works exclusively from two London private clinics, one in Wimpole Street, and one in St John’s Wood. He must be good. Over the years, he has collected a number of celebrity clients. He displays their names, and their testimonials. prominently on his website:

"George is an amazing healer, often able to correct things that no one else can. His technique...brings about a deep sense of emotional well being coupled with terrific physical results. At the end of a treatment one feels entirely put back together. I rely on George heavily to get me through any difficult period, physical, emotional or otherwise."

Gwyneth Paltrow 



"George has been pummelling me for years and I still live to tell the tale! 

He's a cool dude!"

Sir Paul McCartney 



"George has been treating me for over 10 years and it's not too much to say that during that period he has - on many occasions - saved if not my life, then certainly my sanity and certainly my ability to work. He's much more than a rheumatologist, he's a healer."

Emma Thompson 



"I've been to George as a patient myself and have also referred many people to him. I'm a firm believer in rheumatology. In the hands of a skilled practitioner like George, I truly believe that for many types of back pain, rheumatology is a better line of treatment than conventional medicine. He has a wealth of knowledge and tremendous experience in treating back pain. If anyone knows about how the back works and how to fix it, it's George."

Dr. Hilary Jones 



"George is simply the best there is. Minor or major pain is relieved with expertise, care, charm and efficiency. He has eased my aching muscles, straightened me when bent double, cured limps, twitches and strains, and no, the needles don't hurt!"

Sir Derek Jacobi 



"George works amazing wonders with his hands!"

Stella McCartney 



"I have been treated by George since 1985 when the Royal Shakespeare Company recruited him to maintain my fitness and to help avoid injury during the punishing run of Richard III. 

I have gone to him, on and off ever since. His skills are remarkable - he has 'healing hands', if that doesn't sound too pretentious and he is especially good at working with performers. When we get injured, we need people to understand that we can't take time off work - rest is not an option. 

I have seen George achieve quite extraordinary results, most remarkable when an actor injured his foot badly at a first preview of an RSC show, and yet was able with George's help, to walk without a limp, and dance, a few nights later for the opening of the show. Apart from being splendid at his work, George is a nice guy too. He's someone you can turn to for help, and the help he gives is of a very high standard indeed!"

Sir Antony Sher

I’m sure that George is an outstanding rheumatologist but he is going to get into trouble with the GMC. He could be struck of for this behaviour. The GMC takes a strong line on advertising:

The medical profession in this country has long accepted the convention that doctors should refrain from self-advertisement. In the Council’s opinion self-advertisement is not only incompatible with the principles which should govern relations between members of a profession but could be a source of danger to the public. A doctor successful at achieving publicity may not be the most appropriate doctor for a patient to consult. In extreme cases advertising may raise illusory hopes of a cure.

The professional offence of advertising may arise from the publication in any form of matter commending or drawing attention to the professional attainments or services of a doctor, if that doctor has either personally arranged for such publication or has instigated, sanctioned or acquiesced in its publication by others.

GMC (full regulations here, pp 14-16)

Despite these regulations, George Jones is not going to be struck off, for George Jones does not exist. But Gary Trainer does exist. Gary is a well-respected, registered and fully qualified osteopath. His practice is listed here by the General Osteopathic Council. All the testimonials above relate not to imaginary George but to Gary Trainer and are indeed prominently displayed on his website here.

The General Osteopathic Council’s code of practice has some rules about advertising, which are professional and sensible as far as they go  (see here : clauses 122 - 127) but they do not specifically cover the question of testimonials from named patients. Glancing around the websites of other registered osteopaths (see The Charlotte Street Osteopathic Practice, the Acclain Pain Relief Clinic, Coventry, and Bodybalance, Birmingham) the provision of testimonials on websites is common place for osteopaths, though mostly the patients (sorry, clients) are anonymised.

So, testimonial advertising is professionally acceptable for osteopaths and good luck to them. Maybe it is the GMC that is at fault.  The GMC is run by Victorian crustacea whose main concern is to make sure that doctors do not have sex with their patients. Time to come into the 21st Century. Maybe the rules should be changed. Maybe doctors should start advertising too.

“Dr Crippen is a good chap”
Mrs A.J. from Acacia Avenue

“Dr Crippen has been pummelling me for years and is a great dude”
Mr PM from Lowood Road

“Dr Crippen always has time for his patients”
Ms AK from Ambleside Grove

Call me old fashioned, but I don’t think I’ll bother.

How to kill off grandma - who needs Shipman?

Who is going to clean this up?

In Eric and Rhoda update : from bad to worse, I said:

Eric is still distressed. Three days after admission, a new shift of doctors came on, and the doctor of the day diagnosed dehydration, and put Rhoda on a drip. Eric thinks she became dehydrated because she is not able to eat and drink without help. Her sight is poor and it maybe she does not see the glass of water on her bed table. She can probably see the food but has not been able to eat it. On two occasions Eric has visited twice in one day, and found a plate of cold, untouched food on the table. The lady in the next bed is a bit of a busy body. She has told Eric that Rhoda is not getting any help and that yesterday she attempted to get to the ward lavatory, did not make it, and soiled herself. One of the auxiliaries shouted at her. Rhoda cried.

Dr Crippen

I have written about the lack of trained, hands-on caring nursing so many times, that I think it washes over most readers. Until, that is, one of their elderly relatives is suddenly hospitalised. Then I get an email starting, "I had not realised..."

So read this from a Consultant Psychiatrist:

When I saw her on the ward, she was lying in urine. She'd been incontinent (because she is). I went to find someone to sort this out, who attendeed and sighed, scolded her for "not pushing the buzzer" and blamed the patient. The patient has severe dementia. She has no idea what the buzzer is or what it achieves and certainly wouldn't be inclined to push buttons and coloured lights on dashboards on an acute medical ward. The healthcare assistant had no idea that her patient was demented, or what that meant...

On The Wards - by a consultant psychiatrist

This lack of basic nursing care is killing far more patients than Harold Shipman ever did. Why is there not an outcry? Why does the main stream media not pick up on it? Where is Panorama? I'll tell you where they all are. They are making mawkish documentaries about multi-millionaire author Sir Terry Pratchett, recently knighted for having Alzheimer's. That's good PR for this cynical government. Better than addressing the problem properly and so much cheaper. Bit like making school mistresses "Dames". Beats paying teachers properly, and who cares if the Dame is unprofessional.

Don't get me wrong. I wish Sir Terry Pratchett well, and he is doing valuable work for public awareness of Alzheimer's. But that is not what this is about. Ask any doctor or nurse. If, as and when Sir Terry deteriorates and becomes doubly incontinent, there will be more than enough money around to clear up all the shit and piss that he produces. Oooooooh! Dr Crippen! Don't be provocative. No need to use words like "shit" and "piss". But "shit" and "piss" are important features of end stage dementia. And if it is not "shit" and "piss" produced by Sir Terry, or Ronald Reagan, but, instead, produced by your grandma then there may not be someone to clean it up.

Most of you reading this think subconsciously that it does not apply to you. It will apply to some of you, believe me. So, think about it. When your nappy leaks, who will clean you up?

Roe v Wade : safe for another eight years

One of the many many good thinks about the election of Barack Obama is that the landmark Roe v Wade decision is now safe for another eight (we hope) years. Some of the fly-over states will continue to chip away at it, but the principle will remain.  It amazes me how some of the so called Pro-Life brigade who are otherwise rational people lose all ability to have a sensible discussion when the topic of a woman’s right to have an abortion comes up.

One of their favourite, specious old chestnuts is the story, which I cannot be bothered to recount, which has the punch line “you have just aborted Beethoven”. Iain Dale – normally one of the most rational and reasonable political bloggers – draws our attention to a topical rehash of the old chestnut. And he says:

This is a video from CatholicVote.com. It makes a very simple point. And one which even the most ardent pro-choicers will find some difficulty in countering.

Iain Dale.

The video is both mawkish and offensive and would be seen off in a second year civics class. Can Iain really believe otherwise?

Monitoring the Quacks

I was penning a few word about the plausible but ridiculous:

Complementary and Natural Health Care Council

The CNHC has been developed with the help of complementary healthcare practitioners and with support from the Prince's Foundation for Integrated Health. The Department of Health has consistently supported the CNHC throughout its start-up period and is committed to establishing the CNHC as the national voluntary regulator in the complementary healthcare field

CNHC

The Quacktitioner Royal himself is a supporter. Probably not much more to be said. Will Patrick Holford be involved as well? We wait with bated breath. The CNHC says that the first "profession" (sic - and you will be) they will be taking on board is the nutritionists.

I am grateful to a reader for saving me some time by pointing out a wonderful article in the The Daily Mash which says everything I wish to say and more, so much more. And what an inspirational photograph.

STRICT standards must be applied to alternative medicine, according to the voodoo priest who will run the UK's complimentary therapy watchdog.Papa Limba is the former Lib Dem candidate for Bristol North West. Haitian born Papa Limba said his first task as chairman of the Complementary and Natural Healthcare Council would be to identify which therapists were righteous shamans and which had the bad juju....

Full report in the Daily Mash

Eric and Rhoda update : from bad to worse

I saw Eric again today.

We met Eric last week (The carer's conundrum) when he was battling with the difficulties of managing his full time job and the care of his elderly mother, Rhoda. Despite his best efforts, Rhoda had yet another fall. She hit her head as she went down and was knocked out. So she is now in hospital. The CT scan has not shown any serious pathology. No evidence of any bleed. But, as old people do, she has “gone off” a bit more.

Eric is still distressed. Three days after admission, a new shift of doctors came on, and the doctor of the day diagnosed dehydration, and put Rhoda on a drip. Eric thinks she became dehydrated because she is not able to eat and drink without help. Her sight is poor and it maybe she does not see the glass of water on her bed table. She can probably see the food but has not been able to eat it. On two occasions Eric has visited twice in one day, and found a plate of cold, untouched food on the table. The lady in the next bed is a bit of a busy body. She has told Eric that Rhoda is not getting any help and that yesterday she attempted to get to the ward lavatory, did not make it, and soiled herself. One of the auxiliaries shouted at her. Rhoda cried.

Eric is now spending most of the day at the hospital. A lady in a suit with a clip board saw him yesterday, and told him that there was nothing medically wrong with his mother, and that she would be discharged at the end of the week. Eric knows that his mother has memory problems, obesity, myxoedema and diabetes and that she never recovered her mobility after the hip fracture last year. And he knows that she is generally much worse since this latest fall. Eric will not be able to manage.

Still, because she has been deemed not to be “ill” the NHS will not be providing residential care for her. Whether or not he will be able to “manage” Eric will take her home because he thinks that another fall is preferable to starving to death in hospital.

Two old ladies and the NHS

More years ago than I care to remember, in the run up to Christmas, I used to work in the small games department of a book shop in Accrington (Wardleworths, for anyone who knows Accrington). I remember an elderly lady who was looking for a game for her grandson. She asked how much a Monopoly set cost. It was 29/6d (yes, that long ago). She paused, looked sad and, opening her purse, asked, “Do you have a game like Monopoly for about three shillings?”

Last week, I went to visit Enid, a similarly elderly lady. Most family doctors have an Enid. Enid collects ornamants, and has done so for nearly fifty years. We are not talking Ming Dynasty. We are talking fairground. We are talking Toby Jugs. Enid particularly likes Toby Jugs. Two walls of her sitting room are covered, floor to ceiling, in shelves, all full of ornaments. She never throws one out. She used to dust them, but not any more. I don’t think she notices the dust. I am not even sure she notices the ornaments. Her long suffering daughter is not allowed to touch them. When Enid dies, there will be a skip outside her house the next day.

What have these two old ladies got to do with the NHS?

It goes something like this. Ten years ago, the local PCT chief executive had a problem with external maintenance of health centre buildings, car parks and gardening. He therefore appointed Fred Smith as his Area Maintenance Liaison Officer. Fred was given an office, a car, a secretary, a lap top computer and a pension and set off round the various sites in the PCT area. Six months later there was no improvement in maintenance and the chief executive could never get hold of Fred as he was always out on visits. So a Deputy Area Maintenance Liaison Officer, Doris, was appointed to liaise with her boss and the chief executive. She also had an office, a car, a secretary, a lap top computer and a pension. Fred’s been in post a long time now. He’s a nice chap. The position of Area Maintenance Liaison Officer is entrenched. He is known as the “Am-low”. The Chief Executive who appointed him is long gone. Fred’s little department is autonomous. He continues to do whatever he does. Maintenance of the buildings is still poor. There are not the funds for major repairs, but Fred has got it all logged and, maybe one day, if some money is found, something will happen.

Look back to 2004 when Stuart Rose took over at M & S:

Rose sacks directors as M&S continues to weaken

Stuart Rose, Marks & Spencer's chief executive, yesterday axed four directors from the board and warned that trading is continuing to deteriorate.

Daily Telegraph

Look back to last week, when Sir Stuart Rose addressed the economic crisis:



He may preface the truth with a dose of brazen PR but, make no mistake, Sir Stuart is trimming his portfolio. He is closing stores and he is sacking staff.

The NHS is the largest employer in the UK. The biggest cost within the NHS is salaries. The NHS is, like every other industry in the country, in economic crisis. Has it laid of any staff? Has it closed any inefficient hospitals? Think about it, have you ever heard of the NHS laying off staff? Surreptitiously it is in fact laying off doctors. Unemployment amongst newly qualified doctors is rising rapidly. But when did you last hear of administrative staff being laid off? It does not happen. A job in NHS administration is a job for life. A job as a hospital consultant is a job for life. Fred and Doris have a job for life followed by an indexed linked pension. Fred and Doris are Enid’s Toby Jugs, safe and secure on their NHS shelf. No one really knows what they do. These day they are not even dusted. And they are not alone on their shelf.  Believe me, they are not alone. 

Back now to games like monopoly. Another light bulb has gone on in a dusty corridor of the Department of Health. Someone has had an idea.

Patients are to get their own health budgets so they can pick and choose what NHS services they want.

BBC

The fraud upon which this beguiling statement is based is breathtaking. Do you really think that, as a patient, you are going to be given a book of blank cheques to buy health care at a time and place of your choosing?

Steve Barnett, chief executive of the NHS Confederation, which represents managers, said: "There is a growing body of evidence to suggest health outcomes are improved when the patient is directly involved in making decisions about their treatment and the way in which care is delivered by NHS staff.

ibid

Sounds good, doesn’t it. Soon someone will say that this will “empower” the patients. And notice the use of the new buzz word, “involvement”. No wonder Tubby Tritter has been promoted. He is now a Professor of Involvement.

"Should patients be allowed to spend their personal budgets on non cost-effective treatments? Should individuals be allowed to top-up their care? Should patients be allowed to invest personal budgets to be spent at a later date?”

ibid

Dr Crippen’s personal health care budget over the last ten years has only had to provide two tubes of Betnovate 100g (self prescribed, I’m afraid, Oh! God, I must own up to my appraiser). Can I keep the change? Perhaps I could have some Botox for those crows’ feet Mrs Crippen tells me I have developed.

The Jobbing Doctor has rightly asked for further and better information. Dr Grumble thinks it is a specious ploy to shake up NHS administration. Maybe. Sir Stuart Rose has a better idea as how best to shake up the administration. He would have had a skip outside Enid’s NHS house years ago.

Meanwhile, Dr Crippen is waiting for the old lady with her personal budget to ask about the price of a hip replacement. Eight thousand pounds, I shall say. Her face will drop and she will timidly ask if I have an operation “like” a hip replacement for five pounds. She won’t be able to pay the “top up” costs, so she will just have to stop whinging and struggle on with her paracetamol.

Health visitors : useful nurse-specialists

Regular readers will be in no doubt about Dr Crippen’s views on the plethora of nurse-specialists that is now swamping the NHS. The concept of a "useful" nurse-specialist is difficult to grasp, almost an oxymoron. Jobs that should be done by doctors are now being done - badly - by nurse-specialists whilst jobs that should be done by real nurses - i.e. hands on nursing - have been passed down the hierarchy to untrained auxilliaries who are often called “nurse” but do not have the necessary nursing skills to deserve the title. And so elderly patients lie in their piss and shit sodden pyjamas, slowly starving to death because no one is unimportant enough to be tasked with feeding them.

When it comes to nurse-specialists, health visitors are the exception that proves the rule. They were one of the original nurse-specialists although they were never known as such. They do not have much cachet within the NHS, or even within the nursing profession. To some, routine care in the community of new young mothers and their children seems mundane and unimportant.

The Health Visitor is a Qualified Registered Nurse, Midwife, Sick Children’s Nurse or Psychiatric Nurse with Specialist qualifications in Community Health, which includes child health, health promotion and education

The role involves promoting health in the whole community and we are particularly involved with families who have children under five and with the elderly population. Because most of us are attached to GP Practices we are also work with all patients registered with a GP Practice. We look at the broader picture to identify the health needs within their community and this allows us to affect local policy.

The role of the health visitor.

It does sound a bit dull, doesn’t it? Dull or not, the health-visiting job is crucial. There is no one better placed to pick up early evidence of child abuse than the health visitor. There is no one better placed to pick up early evidence of post-natal depression than the health visitor. And yet, the number of health visitors is falling, and the profession as a whole is grossly under-resourced. The dwindling number of health visitors attached to my practice are no longer able to cope with their workload, and are at their wits' end. In the last year, our two most experienced health visitors have taken early retirement.

Now, from the ivory towers of academe, comes some research, published in this week’s BMJ which purports to show that the work done by health visitors can be valuable. Well, once again to coin my favourite phrase, I’ll go to the bottom of my stairs. This “research” concludes:

"Training health visitors to assess women, identify symptoms of postnatal depression, and deliver psychologically informed sessions was clinically effective at six and 12 months postnatally compared with usual care."

Full details of this egg-sucking exercise can be found here in this week's BMJ

This research is bogus, offensive, otiose New Labour inspired drivel. I am not suggesting that there is not a problem with post-natal depression. There is. A big one. But, contrary to popular belief, post-natal depression is easy to diagnose. Provided you see the patient and provided you ask about it. Some women will present complaining of it. Many will not. They sit at home, in tears, feeling like failed mothers, and they tell no one. Not even their husband. If they do see their family doctor they put on their “happy face” and do not mention how low they are feeling. All the doctor has to do is ask a few sympathetic questions and usually all will come out. Sadly, some doctors do not routinely ask those questions. The patient is quickly out of the door with a supply of contraception and some iron tablets. The depression will go on and on until there is a crisis. A crisis which finally results in help being provided. A crisis that, occasionally, results in a tragedy. Always remember, a mother with post-natal depression feels like a failure, and will endeavour to hide her problems. But you do not need an "-ology" to pick it up. If the doctor has not picked it up, the health-visitor, who has the time to visit the mother and baby at home, is likely to be the safety net. Except that now we do not have enough health visitors. The remaining few are rushed. They cannot visit new mothers as often or for as long as they would like. So corners are cut. Diagnoses, inevitably, are missed.

Official figures reveal that health visitor numbers have fallen to their lowest number since 1994, threatening public health and the delivery of some of the government’s key health initiatives. Why has there been this decline? And what is the government going to do about it?

Listen to the full BBC Woman’s Hour report here

And what is the government going to do about it? Well, it’s not going to fund more health visitor posts, that is for sure. Instead, it is going to adopt the now classic New Labour strategy. It is going to blame the existing health visitors for not diagnosing post-natal depression and offer them more "training". If only those wretched health-visitors were properly trained, all would be well. This will have predictable effects on morale. There will be more early retirements, fewer health visitors and more undiagnosed post-natal depression. But New Labour will hide behind a trivial bit of research done by some men with beards - I fear Tubby Tritter is not far away - and by some women who have probably never in their lives visited an unmarried mother in a sink council estate.

Meanwhile, the government will continue to fund those trendy but ridiculous cardiac and respiratory nurse specialists. They are a poor and dangerous substitute for doctors but they are so much cheaper. At least they are only let loose on the poor folk. If you have a cardiac problem, and want to be treated by a doctor, keep paying the BUPA subscriptions. 

Going public with gonorrhoea

Guido reminds us to pay tribute to the late, great Patrick McGoohan but obviously has not yet noticed a “little bit of news” that almosts slips by in a side column of page 4 of today’s Times:

Personal data gathered by one government department will be available to other areas of Whitehall, local government and agencies under proposed legislation published yesterday. This will open the way for the bulk sharing of information across government, and reverses existing policy, in which data can only be used for the purpose for which it was gathered. Jack Straw, the Justice Secretary, defended the proposal, saying that it was intended to improve public services and help to fight crime.

Opponents said that it was a further step towards a “Big Brother” state and that the Government had a poor record on protecting sensitive data. Mr Straw said that the information sharing orders, published in the Coroners and Justice Bill, would have “very strict controls”.

The Bill also includes an overhaul of the coroners’ service and resurrects proposals for parts of inquests to be held in secret.

The Times

Why is this not a front page headline? Has the MSM finally sold out to Big Brother? Inquests in "secret"? In secret? That's the end of habeas corpus. Lock 'em up. Kill 'em. Have a secret inquest. Dario Fo, where are you now? We need you. Steve Biko's inquest was a charade, but at least we all know that it was. 

Departmental information sharing? They always said it would never happen. I did not believe them then, so I should not be surprised now. This is why I will not upload my patients’ data to The Spine. Don’t be paranoid, some say. What have you got to hide? Personally, not much. I had an inguinal hernia repair twelve years ago and, frankly, I don’t care who knows. But do you want your bank, your insurance company, your employer and the police officer who stops you for speeding to know that you had an attack of gonorrhoea last year?

Maybe you don't mind. I would.

Racist abuse : the Sooty, the Paki and the Staff Grade

Kuldip Dhillon and the Prince

Both Prince Harry and the Quacktitioner Royal himself are racist. It runs in the family. A life time's close exposure to the Queen Mother and the Duke of Edinburgh can have no other result. They probably do not realise that they are but that only goes to mitigation. Is it intrinsically worse to talk about a "Paki" than it is to talk about a Brit, or call a Welshman Taffy? Yes, of course it is.  "Paki" is a term of racial abuse. "Brit" is not. I suspect the whole of Prince Harry’s unit used the word Paki. That does not make it any better and is a sign of the insitutionalised racism that still exists in the army. I am even more uncomfortable to read that the Quacktitioner Royal and his nice but dim friends at Cirencester Polo Club call Kuldip Dhillon, a fellow member of the club, “Sooty”. I am appalled to read the following:

Last night Mr Dhillon said that the nickname was “a term of affection”. He said in a statement: “I have to say that you know you have arrived when you acquire a nickname. I enjoy being called Sooty by my friends, who I am sure universally use the name as a term of affection with no offence meant or felt.

The Times

"I enjoy being called Sooty by my friends." Oh! Dear God, how can this highly successful business man allow himself to be patronised by these appalling people?

One member of the club, who asked not to be named, said that the sobriquet was a way of “putting two fingers up to political correctness”. He added: “Charles, along with both of his boys, have called this chap Sooty because it is his nickname and he is perfectly comfortable with it. I suppose that we all see this as a sort of running joke about political correctness.” He added: “They [the princes] are no more racists than I am, and I use the word to address this chap whenever I see him, too.”

Ibid

The use of the word “Sooty” is disgraceful. Of course he does not want to be named. He is racist. As are the Princes if they did but realise it.  The British upper-class have always been racist. It is in the blood. Think of the Queen Mother. Dreadful woman.

The Queen Mother was a racist snob who excelled in extravagant living. Amid all the grovelling, hypocritical tributes paid to her this week, here are some facts to remember. The Queen Mother referred to black people as "nig-nogs" or "blackamoors". She backed white minority rule in Rhodesia. She criticised Lord Mountbatten, viceroy of India, "for giving away the empire" and his wife because "her mother was half-Jewish".

Source

The Duke of Edinburgh is no better. His racism is legendary.

During a visit to an electronics factory in Scotland, Prince Philip saw a messy fuse box and said it looked "as though it was put in by an Indian".

source

Kuldip Dhillon is a naïve Uncle Tom to allow this to go on. Some people will do anything to get close to Royalty. As for the club itself, you can just see it, can’t you. They are looking for some up-market, latter-day punkah-wallah, and Kuldip fits the bill. As long as he knows his place, which is made clear from the outset.

"OK, Kuldip, old chap, you are rich, we want your money and your clout in the club, but we will be calling you Sooty."

"Thank you, Sahib" .

I wonder if, next week, the Cirencester Polo Club will be calling the President of the United States “Sooty”?

I hate this sort of thing. I particularly hate it in the NHS where, sadly, occult racism has always been prevalent. I have not come across doctors being called “Sooty” but there have been many sotto voce remarks about our “non-reflecting, hot-country” colleagues. A while ago I wrote an article about the position of “Staff Grade” doctor. (See Playing the White Man). Staff Grade is a “non-career”, “non-training” cul-de-sac position in the medical hierarchy, used to house doctors who are not going to make it as consultants. Staff Grades get a lower salary than consultants and do not themselves have the benefits of private practice. They do the work whilst the boss is away on the Yellow Brick Road. Many Staff Grade doctors have the qualifications and experience to be consultants. Why, you may ask, did they not make it? Why, you may ask, is the position often known as the “wog grade”?

There were howls of anguish, and accusations of racism, the last time I said this. The truth hurts.

A doctor who was offered a training job in an English hospital stated:

"After I'd got the job, I asked the consultant how he normally short-listed for the post. He told me that he put all the CVs with English names into one pile, and all those with non-English names into another pile, and looked at the English pile first."

See Playing the white man

The NHS would not have survived had it not been for the large number of doctors who have come from the Indian and African sub-continents to work in the UK. And yet, many of them have been treated shamefully. It is still going on in a hospital near you, both in medicine and in administration:

Institutional racial discrimination is blocking black and ethnic minority NHS staff from senior positions, an independent study has confirmed. Only 8 per cent of senior managers are from non-white backgrounds compared with 12 per cent of the working-age population, an assessment commissioned by the NHS Institute found. The problem is caused by "racially biased recruitment" practices, overseas qualifications being undervalued and the "institutional culture" found in the NHS, according to the report, Access of BME Staff to Senior Positions in the NHS.

source

It’s appalling. And what hope is there for a change in culture when we are merely amused to hear that racist fools like Prince Charles think it is endearing to call people "Sooty"?

Herbal treatment of the menopause : more from the Department of Wibble

Today’s dose of wibble comes from two eminent herbalists: Jenny Jones of the Herb Society, and Jane Gray, president of the National Institute of “Medical” (sic) Herbalists. They are in the news today because of an article in the Drugs and Therapeutics Bulletin. (DTB) Few outside the medical profession have heard of the DTB, which is a shame, as it is an excellent source of genuinely unbiased information about drugs.

DTB's aim is to provide informed and unbiased information on medical conditions, medicines and other treatments to enable people to make informed choices. True to this objective, DTB has always been wholly independent of the pharmaceutical industry, Government and regulatory authorities. DTB is also free of advertising and other forms of commercial sponsorship. All contributors are asked to declare whether they have any interests or relationships they think might influence their comments. These potential conflicts are taken into account during the editorial process. In addition, the extensive peer-review process exposes potential conflicts of interest. All comments must be supported by appropriate evidence.

Drugs and Therapeutics Bulletin

The DTB has been looking at the role of herbs in the treatment of menopausal symptoms. Straightaway we enter the lunatic world in which “natural” is equated with “good” and “drug” is equated with “evil”. If you want to make your doctor’s heart sink, ask him whether what he is prescribing is ‘natural’. My stock response to this is, “You mean, ‘natural’ like cowdung?”. To which the patient normally says, “Oh doctor, you are a tease, you know what I mean, is it a “drug”?

It's natural

No, I don't know what you mean. Of course it is a drug. A drug is any substance which, when taken, has an effect on the body.

Drugs have good effects and bad effects. Which are good effects and which are bad effects depends on what you are trying to achieve. Beta blockers, inter alia, slow the heart rate. Digoxin also (usually) slows the heart rate. Slowing the heart rate can be good or bad, depending on what therapeutic effect you want. Ventolin (salbutamol) opens up the tubes in the lungs. It may also reduce uterine contractions, which can be helpful if a woman is threatening to go into premature labour, but not so helpful if she is two weeks past her due date.

Drugs may be naturally occurring or they may be man-made. Often, they are naturally occurring but have been purified, qualified and quantified by man. Or, the naturally occurring drug may be synthesised in the laboratory.

Nasty, poisonous digitalis

If you are in atrial fibrillation, you can boil up a foxglove soup and gently sip it  if you wish, or you can take a precise dose of digoxin as prescribed by your doctor.

Purified, safe foxglove

The fact that a drug occurs naturally says nothing about its safety. Bella donna is a naturally occurring plant, better known as Deadly Nightshade.

Deadly Nightshade

Deadly Nightshade is both natural and potentially lethal. Any yet, it’s active ingredient, atropine, when purified and used in appropriate (and small) doses, is a very useful drug.

There is a certain sort of Guardian reading, tree-hugging woman who is insistent on having treatment for her menopause, but also equally insistent that the treatment should be “natural”. Do not mention Premarin to her. She will tuck into goose liver pate, fillet steak, white veal and battery farmed chicken eggs, but will not hear of collecting the urine from pregnant mares. She is lacking in oestrogen, but does not want the doctor to give her oestrogen, either horse or man made. No, she wants Black Cohosh. “It’s natural, doctor”.

Trouble is, there is no evidence that Black Cohosh works. (There will be a flood of comments saying “It worked for me”. Yawn.) The DTB has been looking at herbal treatments for the menopause. In particular, it has studied:

Black Cohosh
Red Clover
Dong Quai
Evening Primrose
Ginseng
Wild Yam
Chase Tree
Kava Kava

The full article is essential reading if you are interested in the menopause, but you will have to pay to do so if you are not a subscriber. Mind you, it’s worth taking out a subscription to the DTB if you are genuinely interested in drugs. As always, the DTB approaches the subject with an open mind. Its main conclusion is that there not enough data to make a definitive judgment on the efficacy of herbal treatment of menopausal symptoms, but the data that does exist is not encouraging. There is however already enough data to raise serious concerns about side effects.

Side effects of herbal treatment

• Evidence suggests a possible association between black cohosh and liver toxicity,33,34 and the MHRA's Commission on Human Medicines has advised that it is important to inform users of black cohosh about this.
  
• Kava kava (Piper methysticum), which was previously widely used for anxiety, including that associated with the menopause, has been banned in the UK because of reports of liver damage with the herb.
  
• Ginseng appears to be well tolerated, but has been associated with unwanted effects such as headache, sleep problems and gastrointestinal disorders.16 Interactions have been reported between ginseng and warfarin (leading to a reduced INR), but the data are inconclusive and there may be differences between species. (On the other hand, gingko is thought to potentiate the action of anticoagulants.)
  

DTB

But don’t expect a lack of evidence about efficacy and worries about side effects to deter the herbalist wibble merchants. Jenny Jones of the Herb Society said:

"A lack of evidence does not necessarily mean a lack of effect. Not much clinical research has been done and we do need more. But there is not the funding to do this type of work.”

Reasonable enough. But then Jenny puts the pencils up her nose and starts to wibble.

"As a practitioner I can tell you these remedies do work for some women."

BBC

Enter Jane Gray, the President of the National Institute of “Medical” Herbalists, pencils already in situ

Jane Gray, president of the National Institute of Medical Herbalists, said: "In general, herbal preparations are extremely safe and possible side effects are generally mild - especially when compared to the possible side effects from a conventional treatment like HRT."

BBC

Jane Gray’s statement is rubbish. Many naturally herbs, such as Deadly Nightshade, are potentially lethal. As already stated by the DTB and, indeed, by Jenny Jones before she put her pencils in, there is not enough evidence to make a definitive judgment. And the liver toxicity that caused Kava Kava to be banned is hardly “mild”.

The National Institute of “Medical” Herbalists (NIMH) is fraudulently mis-named. The layman might assume that, as they are “medical”, that they are doctors. They are no more doctors than is “Dr” Gillian McKeith. As they are not doctors they skate on thin ice when they purport to be qualified to treat medical conditions.

Nick Panay is a well known gynaecologist with a specialist interest in the menopause. He approaches herbal treatment with an open mind. To a doctor, having an open mind means looking at the evidence. He has been looking at the evidence about red clover, and says:

"Some women will find herbal remedies beneficial. We have been studying red clover isoflavones and have found they have a small benefit above placebo. But just because these are alternative treatments it doesn't mean they are entirely safe. Any treatment can carry side effects."

Dr Nick Panay

If the herbalists were reputable and scientific, you would expect them to give wide publicity to the DTB and also to the work done by Dr Nick Panay. Sadly, that is not how they work. To the herbalist, when science comes in at the door, common sense goes out of the window.

Herbalist is asked to read the Drugs and Therapeutics Bulletin

NIMH has done its own “scientific” trial on the herbal treatment of menopausal symptoms. It is only two pages long, and can be found here.  Their study shows that herbal treatment produced a "notable improvement in symptoms." Sadly, the methods used to run their trial were so unscientific that no one could take the results seriously. And that is the problem with all these wibble merchants. They will not do scientific trials and they ignore the results of the scientific trials that others do. 

If you decide you want to have treatment for your menopausal symptoms, I would stick with the oestrogen.

The carer's conundrum

Recurrence of increasingly common problem.

Eric is 57 years old and works for the NHS in administration. At one of the local hospitals, actually. I’m not altogether sure what he does. Something to do with data management about bed state, admissions and so on. He is a very conscientious worker. I can’t remember him ever have time off work other than three weeks for a bilateral inguinal hernia repair about twelve years ago. He lives with his wife, Mary, who works for the Post Office. I do not see much of either of them.

I saw Eric today for the first time in five years. He was close to tears. He wanted me to sign him off work for two weeks for “stress”. He has already had one week off on a self-certificate. The underlying problem is Eric’s mother, Rhoda. Rhoda is a widow and lives 20 miles away. Or she did. In fact, three weeks ago, she moved in with Eric and Mary. Rhoda is nearly 90, a little cantankerous, mild short-term memory problems, obesity, myxoedema and maturity onset diabetes. But she was managing brilliantly until the hip fracture last November. Now she cannot manage at all. The OT and physios have said she has “mobilised well”. And they they ticked the boxes to prove it. Fact of the matter is, though, she cannot dress or undress without help, she cannot use a lavatory without help (and that includes bottom wiping) and if she is left for more than a few minutes she gets very distressed. She had another fall, which is why Eric moved her to his house.

Rhoda will not go into a nursing home and, anyway, Eric does not want her to. So he has been staying at home to look after her. It’s a full time job, so he wants time off work. Which is why he is stressed. I signed him off for two weeks. He might be able to take unpaid leave, but he will not be able to pay his mortgage if he does that.

I told him that I cannot keep doing this. I should not really have done it today. He looked appalled. He talked bitterly of the malingers in his office who take several weeks a year off work with “man flu” and hangovers and the like. “I have never done that,” he said. And he hasn’t. Apart from the hernias I can’t remember him ever having time of work. “And now, when I am in difficulties, real difficulties, no one will help.”

I still cannot keep him signed off work on a full salary to be a carer. “But how am I going manage?”

I don’t have an answer.

Assaulting nurses

Violence in hospitals has always been a problem. (Surprisingly, it is not always the patients who are violent.) I am grateful to the Magistrate for drawing my attention to new legislation that has just come into effect. It is now a specific offence to behave in a way that disrupts NHS staff in England. It’s OK to carry on as normal in Wales though, so if you have had a few pints, and want to assault a nurse, or cause a disturbance in a hospital, best to get a train to Swansea.

Section 119(4) Criminal Justice and Immigration Act 2008 came in to force today [1st Jan 2009] ; as a result the offence in section 119 became operational (see section 153(5) of the Act for commencement provisions). Note however that at the present time the offence is not applicable to Welsh NHS premises.

Section 119 creates a new offence of causing a nuisance or disturbance to NHS staff on NHS premises. It addresses behaviour which disrupts NHS staff in the performance of their duties and affects the delivery of healthcare.

The Magistrate

Dr Crippen is a great fan of “the Magistrate”. He is one of the best writers on the internet and brings both a breath of fresh air and a dose of commonsense to the day to day workings of the legal system. So we can assume he welcomes legislation to protect NHS staff. Well, he might, if the legislation were comprehensible. Sadly, this new legislation is a bit of NuLabour window dressing. The new legislation demonstrates NuLabour's continuing obsession with rules and process, and ties itself up in knots as it tries to define “hospital” and “NHS employee” and so on.

In order to commit the offence, a person must, without reasonable excuse, cause a nuisance or disturbance to an NHS staff member whilst on NHS premises.

A nuisance or disturbance can include any form of non-physical behaviour which breaches the peace, such as verbal aggression or intimidating gestures towards NHS staff. A person will not commit the offence if he or she has a reasonable excuse for causing the nuisance or disturbance or refusing to leave the premises.

ibid

So, if you want to assault a nurse, and cannot get to Wales, and do not have “a reasonable excuse” (a "reasonable excuse" ??) to indulge in some verbal aggression, wait until she has got to the bus stop outside the hospital. The statutory provsions go on and on and on. They are a delight for those who (like Dr Crippen) collect examples of otiose obfuscation. But they are of no practical use.

 Any hairy-arsed old custody sergeant could find appropriate charges to deal with this kind of behaviour. Why has Parliament wasted time and money enacting this rubbish? Surely it's not aimed at tomorrow's tabloid headlines?

I have nothing to add - 2009 deserves a better start then this.

The Magistrate

Disposition of the offal

My ageing Greek friend is widening the debate on the Batista kidney.

You donate a kidney to your wife, then she goes and divorces you. So naturally, you want it back…

Mr Eugenides

What a vulgar little man Dr Batista must be, you may be thinking. His gift of a kidney to his then wife was an absolute gift. Let's be honest though. There is a macabre appeal to the idea of a court directing that the kidney be returned to the loin of origin.

But when Mrs B claims half of Dr B’s wordly goods, as she will, on the basis that all the housework and childcare that she did during the marriage enabled Dr B to build up his career and become a high earner, why should Mr B not reciprocate by asking for compensation for the pain, suffering and health care risks that he accepted so that his wife could lead a normal life off dialysis? A life so normal that she now has her own high-earning independent career.

Dr Richard Batista

...the attorney says the $1.5 million demand "reflects damages, including how much money she made as a result of being able to continue working and not having to go on dialysis." So the dollar figure isn't based on the price of an organ (which would be considerably cheaper, based on the going rate of kidneys abroad); it's based on the income one spouse accrued thanks to the other's sacrifice. And sacrifices between spouses are treated differently, under the law, from sacrifices between strangers or friends. There's a tradition and expectation of common benefit. You and your spouse become one flesh - in this case, literally.

See Human Nature

A fascinating problem. Thank God Lady McCartney did not donate an organ to Sir Paul. Perhaps in future, though, we will have a “disposition of the offal” clause added to the pre-nup. I don’t know what the law should be. My ageing Greek friend might have been able to help had it not been for an unexpected attack of somnolence.

It's those practitioners again

Some years ago, a 71 year old patient of mine, who we will call Bob, presented with an acute urinary tract infection. (UTI) Bob is a retired physics teacher, so he is far from stupid, and knows a thing of two about science. He does not have much in the way of a medical history, which is just as well, as he gets very anxious about seeing doctors.

I sent an MSU off, and treated his UTI with trimethoprim, and two days later he was better. He was a bit bemused (frightened) that I wanted to do some tests. I explained that we needed to make sure he did not have diabetes, and also we needed to check out his prostate. His blood sugar was normal, but his PSA was slightly raised. His prostate was firmly enlarged, particularly on the left. We have (?had) an excellent urology department locally. Bob saw the then senior consultant. His PSA had remained slightly raised over the next few weeks and so, inevitably enough, he ended up having a prostate biopsy. This showed a localised very low grade, early prostate cancer.

The consultant discussed all the options. Bob was very enthusiastic about “watch and wait” surveillance. Many patients are not. Since then, Bob’s PSA has been static. He has had two more prostate biopsies, both of which show that the histology has not advanced. Bob sees the consultant every six months, and I see him in between. So far, nearly six years later, Bob is fit, well and asymptomatic.

Now there is a problem. Bob’s consultant retired a few months ago. Because Bob is just on “routine follow-up” his file was reallocated to the Urology Consultant Nurse Quacktitioner. She has the usual alphabet soup after her name, far more letters than me, but she is not medically qualified. She is actually very sweet but, sadly, totally out of her depth.

The PCTs have asked hospital consultants not to cross refer outpatients to each other. Suppose that an experienced cardiologist sees a patient about her heart murmer and happens to spot, say, a BCC on her nose. He has to write to me, to ask if I will agree to refer the patient to the dermatology clinic. It’s crazy but, crazy or not, those are the rules. Consultant Nurse Quacktitioners, however, are too important to be bound by such rules. Bob came to see me, looking terrified. Nursey had said that she thought he ought to see an oncologist. Bob does not want or need to see an oncologist. He was happy to have his surveillance carried out by a specialised urologist – and, for that matter, by me.

Why did nursey do this? There had been no change in Bob’s symptoms, no change in the histology and no change in the PSA. What was needed here was another ongoing DECISION. A challenging decision. Doing nothing about cancer requires courage. “’Watch and wait” surveillance is something that needs to be done by grown-ups who have been to medical school. Imagine how different it would have been if Bob had seen the SpR instead of nursey. The SpR would undoubtedly have concluded that Bob could continue on surveillance only but in view of the magnitude of the decision, might well have consulted the consultant (that is what they are there for) to check that he was in accord with that decision. And the consultant might well have stuck his head round the door, asked Bob how he was, glanced at the histology and the PSA and then agreed with the decision. That is how it used to work. That is the medical apprenticeship system.

So why didn’t nursey do the same? Because she is not an SpR. She is more important than that. She is a “consultant” in her own right. In the urology department, she is at the top of the tree. She does not ask for advice. She gives it. She can make a referral if she wants. And she does want, because she does not have the medical training to make a decision about Bob.

I’ve chatted to Bob. I have reassured him. I have stopped the referral. I have made certain that, in future, he will be followed up by a doctor in the urology department, not by a nurse. Bob is happy again. Nursey is miffed that I have overruled her. I don’t care. Actually I do. Life was so much less stressful when we all did the jobs for which we trained.

It is going on all the time now. Practitioners are everywhere. I write about them from the family doctor perspective. An experienced hospital SpR writes about then from the hospital perspective.

The saddest thing about these new roles is that they are expensive and it would be much simpler to employ people with tangible skills who can actually get things done, as opposed to this new generation of obstructive, small minded, management-compliant 'practitioners'. The problem is that this trend is getting worse and it is showing no signs of reversing, the management like this new breed of compliant yes men as they will always do as they are told, they lack the expertise and power to actually stand up and fight for the interests of their patients.

See Beware the practitioner

These days, though, if you are unlucky, you may not survive long enough to get to the hospital.

“The vast majority of paramedics are excellent and brilliant professionals, however the system is rotting in such a way that it is dragging everyone down with it, the small minority of dangerous paramedics will be made more dangerous by the political pressures that they are subject to…

… The classic paramedic training does not equip the paramedic to make an assessment with a view to recommending non-conveyance. The doctors who constructed that course were wise folk who knew that it is much more onerous to declare a patient fit than to send them for further investigation.”

It’s all changing now. See The Rotting System - the Ambulance service.

Ben Bradshaw gets it wrong - again

Hamish and the pillock

I don’t know how it works for Hamish up in Bridlington but in my practice (and many modern ones) we are democratic to the point of tedium. The “senior partner” is the one who has been there the longest. The senior partner reigns, (s)he does not rule. The duties of the position, such as they are, are purely ceremonial. We have an “executive” partner, appointed by mutual consent, usually one of the younger partners, who does the paperwork. The rest of us do a bit of this and a bit of that.

Hamish may be a "senior partner" but apparently he only works one day a week in his practice and so it is likely that his duties as “senior partner” are likewise purely ceremonial. Indeed, if he tried to exercise any excutive powers, it is unlikey his partners would stand for it. Mutatis mutandis, he probably does not have much input into major practice decisions. So when his practice decided, with other local practices, see here, to run the local polyclinic, there may not have been anything Hamish could have done about it. Even if he had wanted to.

There is a time for tact. A time for dignified silence. But Ben Bradshaw could not resist a well-publicised gloat.

Health minister Ben Bradshaw said the news represented confirmation that the government was right to pursue the policy.

"I am delighted by this vote of confidence from the head of the BMA in the new GP-led health centre programme."

BBC

Hamish is now sitting at home sticking pins in a wax effigy of Bradshaw, a major league pillock, who has been promoted way beyond his level of competence. More bad politics, Ben.

The destruction of the NHS : government plans leaked

There is going to be bloodshed at the Department of Health when Alan Johnson finds out who leaked the goverment's confidential plans for the further "development" of the NHS. Full details of the leak here.

Having a sickie : the malingerer's protocol, from Benylin

I suppose I should not pass judgment about Benylin in any of its many manifestations. I have never taken it. I have never prescribed it. I have never recommended it. Indeed, I routinely advise patients that most of these compound cough bottles are offensively overpriced, and a complete waste of time. The makers of Benylin are now conspiring with their advertising advisers to make another fast buck by promoting absenteeism. They are trying to validate the behaviour of those already inadequate people who think that a bad cold is a reason to take a day off work. As the video above shows, they have been doing it in North America for awhile. How do they justify this cynical behaviour? They say they have talked to 'experts'. The word “experts” should be said in hushed tones. It sounds good, but means nothing. It is like the non-specific use of the word “scientists” – as in 'scientists' have said that “WiFi radiation causes ME”.

However, James Whitehead of JWT said the firm had been told that taking a day off sick could help workers return to their jobs fit and healthy. He said: "We've been advised by health care experts that by taking one or two days off work, staying in bed, you can break that cycle and you can get to work healthy and productive."

The advert has been referred to the Advertising Standards Authority.

Bosses slam "throw a sickie" ad

Benylin has even designed a skivers protocol, Take a Benylin Day : How to call in sick. And followed that up with some Benylin games to play to pass the time whilst you are skiving. Skiving and taking Benylin of course. So lets take a detailed look at what Benylin are trying to sell you:

Benylin for chesty coughs

Every five mls contains: Diphenhydramine hydrochloride 14mg, Levomenthol 2mg.

Diphenhydramine is an antihistamine, available by itself OTC (Benadryl). You can see a full discussion of its properties, uses and side effects here. No mention of chesty coughs, and do read up on the side effects carefully.

Levomenthol is smelly. It smells of menthol. It makes you think of doctors, and hospitals, and old fashioned inhalations. Try buying some Menthol Crystals BP and putting one in a bowl of hot water. It’s cheaper.

Verdict: Overpriced. Ineffective unless your symptoms are hay fever related. How does this treat ordinary cheasty coughs? And anyway, if you are cheasty, you need to cough. A cough is Nature's way of getting the gunge off your chest. One of the reasons elderly patients get pneumonia is that they cannot get the mucous of their chests.

Benylin Chesty Coughs “Non Drowsy”

Each 5mls contains Guaifenesin 100mg, Levomenthol 1.1mg.

We have already done levomenthol. Guaifenesin purports to be an expectorant. If it is an expectorant, why on earth isn’t it in Benylin Chesty Coughs as well?  People with chesty coughs need to expectorate (cough up phlegm). Trouble is, expectorants don’t work.

The British National Formulary says the following:

3.9.2 Expectorant and demulcent cough preparations
Expectorants are claimed to promote expulsion of bronchial secretions but there is no evidence that any drug can specifically facilitate expectoration.... However, a simple expectorant mixture may serve a useful placebo function and has the advantage of being inexpensive.

Demulcent cough preparations contain soothing substances such as syrup or glycerol and some patients believe that such preparations relieve a dry irritating cough....Compound preparations are on sale to the public for the treatment of cough and colds but should not be used in children under 2 years; the rationale for some is dubious. Care should be taken to give the correct dose and to not use more than one preparation at a time, see MHRA/CHM advice.

Verdict: Don't waste your money.

Benylin cold and flu max strength

Each capsule contains Paracetamol 500mg, caffeine 25mg and Phenylephrine hydrochloride 6.1mg.

I have never understood why the manufactures of cold “cures” are so keen on caffeine. Personally, I would rather sleep but, if I want some caffeine, a cup of coffee will do nicely. Paracetamol is paracetamol and needs no introduction and phenylephrine is put in as a decongestant, to “dry up” runny noses and so on. Have a look at the side effects here

Verdict: Don't waste your money

I am not saying the Benylin is dangerous, though I would never personally recommend it, and particularly not for children. But, if you stick to the recommended dose, you should not come to any harm other than financial. Trouble is, a lot of people routinely overdose on cold cures, particularly the liquid ones. See here.

Benylin has become a multi-million pound international business. Huge profits are generated by tantalising adverts that seem to offer a cure for the incurable. Medical science does not have a solution for viral upper respiratory infections. Steam inhalations give some symptomatic relief and you can put some menthol in if you like, but it is the steam that helps. Personally, I prefer a long soak in a hot bath. Aspirin and paracetamol help the temperature, aches, pains and headache that one often has at the beginning of a viral infection. The current vogue is to take ibuprofen (probably because it is newer and therefore perceived to be “more effective”). It’s probably OK but I have a personal little worry that the tonnage of OTC ibupforen that people are currently ingesting may cause problems. (see here, for example). My grandmother always recommended a generous measure of whiskey, with a spoonful of honey and a squirt of lemon, all topped up with hot water.

Grandma Crippen's cold cure

I would not suggest there is much of a scientific evidence base for this treatment but both Mrs C and I find that, at the onset of a viral infection (well, actually, at pretty much any time), a glass of grandmother’s nostrum, sipped slowly in a steaming hot bath, whilst reading a good novel is more pleasing than anything available in the chemist. Indeed, I would go as far as to say that there is no known better treatment for a bad cold. But then, that is what they say about Benylin.

Do you remember the major fraud?



If you have a cough, did you know that nothing is more effective without a prescription than Benylin? I certainly did. And what a clever piece of advertising copy that statement is.

It would be more pertinent to ask if you believe that there is anything less effective than Benylin.

Mobile phones in the NHS

NHS hospital new pay phone system

There is a wonderful short scene in the first episode of the West Wing when Toby Zeigler ridicules the ban on mobile phone usage on aeroplanes. (I could not find the clip on YouTube and I don’t know how to upload it – help!). There has always been a similar ban on mobile phones in UK hospitals. The unspoken hush-hush hidden agenda was assumed to be that mobile phones might interfere with machines that go ping causing sudden and unexpected deaths. As Toby would tell you, that is complete bollocks.

More plausibly, perhaps, you might think that someone decided that the constant use of mobiles might be irritating to staff and other patients. And so it might, but that was not the reason for the ban either. The reason mobile phones were banned in hospitals was mindless authoritarianism. Second-rate managers love such authoritarianism and those clipboard carrying senior nursing officers delight in having yet another reason to tell people off. It makes their day pass more quickly.

It was only many years after the mobile phone ban that some bright spark realised that phones, like hospital car parks, might be used to extract money from patients. An expensive payphone system was introduced. Had the cost of calls been just a few pence, the phones might have been used and appreciated and a little revenue might have been generated. Sadly, the system was designed with the usual commercial incompetence that permeates the NHS. The phones were clunkingly inefficient and preposterously expensive.  No one used them. A lot of money was wasted. But what’s a few million within the NHS budget?

The rules banning mobiles in hospitals have in any case always been unenforceable, doubly so as the staff use their own mobiles all the time. Unenforceable laws bring a system into disrepute and so, finally, the DoH is backtracking. The truth is creeping out. It took five years, but we finally got there.

The updated Department of Health guidance comes five years after technical experts said hospital-wide bans on mobile phones were not needed.
BBC

Speaking personally, other peoples’ mobiles drive me mad. The patient sits down. The phone goes. “I’m sorry doctor…I’m AT THE DOCTOR’S, CAN I PHONE YOU BACK?” The phone goes back in the pocket but they do not switch it off. Three minutes later, it starts ringing again. I do not give a second chance. I press the little red button at the side of my desk. The trapdoor under the patient’s chair opens and I can get on with my morning.

The detoxification fraud

Christmas and New Year has, as usual, been a prolonged period of general excess; too much rich food; too much booze; too many high calorie snacks. Wherever you are, wherever you turn, there seems to be an open box of biscuits or chocolates which, for eleven and a half months of the year, you would not touch.

We took the tree and the cards down last night and normal service has been resumed. The feeling of excess is replaced by a craving for cornflakes, beans on toast and iced water.

This is a great time of year for the nutritionists and other quacks to start flogging their dubious wares. The purveyors of colonic lavage will be busy. I’ve taken a couple of days off work this week. Luxury. Pure luxury. The BBC Radio 4 TODAY programme is much more enjoyable when one is not going to work. I was dozing gently when I heard the words “Detox in a box” but then, thank God, the two more reassuring words, Ben Goldacre. Ben was up against an egregious quack called Nas Amir Ahmadi MD

Nas Amir Ahmadi MD

Nas Amir Ahmadi MD, as she calls herself, has a website from which she flogs extremely expensive fad food. She has an “angle”. She is doing business under the fraudulently misleading label of “detoxification” underwritten with an eclectic concatenation of cod science. Put up against Ben Goldacre, I thought it was going to be a turkey shoot but, quite extraordinarily, the mellifluously fluent, Teflon-coated Nas Amir Ahmadi MD took the hits without ruffling a feather. Her website says (as of 9.00 am Monday 6th January 2009 – alteration expected soon, but I have saved the page just in case**):

Detox benefits, -Healthy Eating Diet 


Weight loss achieved naturally

So what are the benefits of detox? What does it actually mean?
Detox is a bodily process that transforms health threatening toxic substances from our environment, diets, as well as our own bodies into something harmless or excreted.


One of the most complex detoxification functions is against heavy metals such as lead, mercury, cadminum, nickel, arsenic, and aluminum.

Detox in a Box

How does Detox in a Box help the body get rid of cadmium? We charitably assume she means cadmium, unless there is some new, hitherto unidentified poison called cadminum. You can’t tell if people are blushing on radio. Nas Amir Ahmadi dealt with this by brazen faced dishonesty. Or maybe it was naïve incompetence. Listen to her here and decide for youselves.

Do take a look at her website. It is written by an illiterate. Not only can she not spell cadmium, she does not understand English grammar.

From the 2 objectives and various benefits provide a strong healing process for our body. They strengthen our body to further cleanse out waste we have accumulated since childhood that has resulted in our body being congested, inflamed, and damaged.

Once our bodies are not kept busy dealing with all these cleansing process, it can its focus on doing the more important things like fighting back cancer and chronic degenerative diseases, restoring our health, and repairing the damage in our body.

Detox in a Box

There is so much cod science that I hardly know where to start and, given free reign, could go on forever. But here are a few questions:

1. How precisely does Detox rid the body of heavy metals?
   
2. How does it “scavenge” free radicals?
   
3. Why do we need to be scavenged of free radicals?
   
4. What “waste” have we accumulated since childhood?
   
5. How does Detox in a Box “purify” the blood?
   
6. How does removing “wheat” and “dairy” allow the body to rest?
   

It’s all the usual nutritionist garbage. Free radicals. “Wheat”.  "Ridding the body of dairy". I particularly love the last one. It makes me think of throwing out my favourite Pink Floyd LP.

Dairy

So, who is on the “team” at Detox in a Box? Who is advising Nas about nutrition? It’s Diane Quick. She trained at the Institute for Optimum Nutriton. As so often, all roads lead to Patrick Holford. Caveat emptor. 

Angela Voisey is the office manager:

Angela Voisey

"As a mum of two lively children I am always aware of what I am eating and what I am feeding them. So when I was introduced to Detox-in a box, it was very exciting to hear that such a business existed" say Angela.

Detox in a Box is an easy target for anyone with a modicum of common sense. But there some serious points. In the first place, why do the BBC give people like Nas any exposure at all? There is no such thing as bad publicity for these people. “Dr” Gillian McKeith is still trading, and I have no doubt that Nas Amir Ahmadi MD will continue in business as well. Nas is not a doctor, by the way. MD stands for Managing Director, not Doctor of Medicine. Nice try, Nas.

In the second place, family doctors are inundated with New Year's resolutioners all looking for a quick fix for months or years of excess. There isn't a quick fix. Much can be done, but it takes time and patience and it involves following a lot of advice that is deemed to be boring. More exercise, less alcohol, a balanced diet, and don't eat in between meals. You know it makes sense really but your heart starts to sink, allowing Nas or one of her cronies to pounce with promises of easy solutions.

Ben Goldacre rightly but idealistically recommends moderation throughout the year. Most people overdo it at Christmas, and there is nothing wrong with cutting back in January. Dr Crippen recommends throwing the half-eaten boxes of chocolate away with the Christmas tree. Then, a long walk followed by a simple lunch such as baked beans on wholemeal toast with a large glass of iced water.

++++++++++

**  And, sure enough, Nas has changed her website already (it's 12.45 pm)  Cadminum (sic) has disappeared. In fact all reference to specific metals has gone. No explanation given for the change. No apology. Nothing. Fortunately, I kept a copy of the original page. So did Ben Goldacre. Interested pedants like Drs Goldacre and  Crippen can view the ORIGINAL page here, and the altered page here.

Barack Obama : MMR & autism, the wibble and the woo

Galileo faces the Inquisition

There is a bit if a hoo-ha going on at the moment about the suggestion that Barack Obama believes that the MMR vaccine causes autism. The ever-appalling David Kirby has poured fuel on the flames by further suggesting that the Obama team has no interest in helping the large number of American citizens who do suffer from Autistic Spectrum Disorders (ASD).

Kevin Leitch is responsible for the LeftBrain/RightBrain web-site which has, over the last two or three years, grown from a small blog into an internationally respected, dispassionate resource about autism. I will leave him to deal with Kirby’s allegations

Returning to Barack Obama, the following quote is being bandied around with relish by the anti-MMR brigade:

"We've seen just a skyrocketing autism rate," said President-elect Obama. "Some people are suspicious that it's connected to the vaccines. This person included. The science right now is inconclusive, but we have to research it," he said.

Barack Obama

This is often printed in conjunction McCain’s more unequivocal statement:

"It's indisputable that (autism) is on the rise among children, the question is what's causing it. And we go back and forth and there's strong evidence that indicates it's got to do with a preservative in vaccines."

John McCain, Texas town hall meeting, February 29, 2008.

Guilt by association. The juxtaposition of the two statements makes it easy to read more into Barack Obama’s views than is there. Nonetheless, though not as forcefully stated as McCain's, Obama's views are still worrying. By saying "this person included", it does seem that he is suggesting a causal relationship between vaccines and autism. And it’s not a misquote, either. He did say it. But it is a misrepresentation. Put some pictures to the words:



The words alone become a disingenuous misrepresentation. Obama went on to say:

The science right now is inconclusive, but we have to research it. We can't afford to junk our vaccine system, we have to figure out what's happening. If we keep on seeing the increases in the rate we're seeing, we're never going to have enough money" to take care of these children.

The fact checker

It’s still not the resounding denial of a relationship between MMR and autism that I would have liked. The scientific evidence to date is overwhelming. There is not a jot of evidence to suggest a causal relationship. But it’s always difficult to prove a negative. More encouragingly, the Official Obama/Biden position on MMR and autism has been made clear by them in a formal, on the record policy statement:

Do you think vaccines should be investigated as a possible cause of autism?

I believe that the next president must restore confidence and open communication with the American people. This includes environmental policies and government funded research. An Obama administration will go where the science and the facts lead us, whether it is about climate change or toxic heavy metals in our environment.

(Full statement here)

These are of course the carefully crafted words of a politician on the stump, desperate to be rational and yet, at the same time, even more desperate to offend as few people as possible. But if we can take him at his word that he will

“go where the science and the facts lead us”

there will be no problems. LeftBrain/RightBrain will, as always, continue to go with the facts and the science. Sadly, the irrational autism fanatics will, as always, deny or ignore the science and go with the wibble and the woo. Guess to whom the Age of Autism have given the 2008 Galileo award?

It's bloody awful being a patient...

A reader gives me another excuse to show my favourite video by pointing out a newspaper article written by Dr Sarah McMahon, a pseudonymous junior hospital doctor.  It's an article telling of nursing care as it should be, as it used to be but now rarely is. It is an article that describes the demise of the NHS.

...all the technology, pharmacology and surgical procedures in the world are of no use if patients are not clean, fed and cared for...

...this is the Government’s legacy in the NHS: the denigration of basic care. Ward staff struggle with a mountain of paperwork and protocols, with meaningless targets and lengthy pro forma documentation. In short, they are obstructed from doing their work.

Where's the care in today's NHS?
Dr Sarah McMahon

It's time to get our nurses back to nursing. It is time to stop wasting money (your money) on people like Tubby Tritter and Ridiculous Rachel both of whom are beyond satire. 

The 31 day rule : cancer games

Yesterday, a pleasant New Year’s Day lunch with David, an old friend who is an eminent oncologist. David’s wife is a psychiatrist. Mrs C is, of course, a breast radiologist and is currently the lead clinician in her breast unit. After the teenagers had disappeared the conversation turned, inevitably enough, to medicine. NHS BLOG DOCTOR readers are familiar with the Two Week Rule. When I, as a family doctor, write TWR on the top of a referral letter, I set off a cascade of consequences which are threatening to deluge my hospital colleagues.

Most of the general public will not have heard of the 31 day rule. The 31 day rule says that, once a cancer has been diagnosed, treatment must be started within 31 days. The hospital employs 31-Day rule commissars. The cancer is diagnosed. The clock starts running. The commissar gets out her clipboard. Woe betides the oncologist if treatment does not start on or before the appointed day.

Sounds reasonable, you may say. You may even say that 31 days is far too long. Why does treatment not start immediately? The answer is straightforward. For a lot of cancers, the treatment will start within a week or two. For other cancers, and breast cancer is commonly one of them, a number of staging investigations such as CTs, MRIs, bone scans, and PET scans may need to be done. We are not working in the USA or France. Not all hospitals have PET scanners. The patient may need to go elsewhere for the investigations. And all the time, the clock is running, and the 31-Day commissar is watching. A lot of thought and discussion may be needed. There are different treatment modalities, different international protocols, and all need to be discussed at the MDT meeting. The 31-Day commissar is still watching. Though not medically qualified, she at least understands the need to do “tests”.

Finally, a decision as to the best treatment option or options is made. The commissar rubs her hands. Let’s get on with it, then. Unfortunately, there is one more stage that doctors like to go through. Discussing the options with the patients. This is never more important than with a woman who has breast cancer. She will want (and has the absolute right) to have the options put before her. She may, for example, prefer wide local excision. She may prefer a mastectomy. Some women do. She may want surgical reconstruction and, if she does, she will want to discuss that in detail with the surgeon. Often the woman will say she wants a few days to think it over. To discuss it with her husband. To discuss it with her daughter. To discuss it with her family doctor.

The commissar does not like this. She does not really understand it. She will not stop the clock, but nor is she prepared to let it run over the 31 days. What is to be done? The commissariat has made a decision and issued instructions to David and Mrs C. The patient will be allowed to have a few days to think it over. Or a few months if she likes. To avoid breaking the 31 day limit, the patient must be discharged from the hospital clinic. If, as and when she decides which treatment she wants, she must return to her GP and ask him to re-refer her back to the hospital.

To the commissariat this is the perfect solution. As soon as a patient is discharged from hospital, the “event” is “deemed” to have had a “successful outcome”. A target has been hit. Points have been scored. The GP then refers her back, presumably on a second TWR basis, and that gives the hospital a luxurious 14 + 31 days to start the treatment. The work has already been done. Treatment starts promptly. Two more targets are hit. More points are scored.

Good news, comrades. Tractor production is up yet again.