Project 2010 : Two nurses have been trained to use word processors

NHS BLOG DOCTOR regular readers know how enthusiastic Dr Crippen is about the increasingly ubiquitous HCAs and HCPs. Health care assistants do jobs that nurses should be doing whilst health care “professionals” do jobs that doctors should be doing. The skill set required for either job is shall we say…er…flexible. Always worth applying for posts like this provided you have not trained as a doctor or nurse. Militant medical nurse is on sparkling form.

I have also lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for 12 years. I never used to use foul language until working in the NHS got to me. Obscene times call for obscene language.

Militant Medial Nurse

You would not think it was possible to dumb down the NHS any further than by using HCAs and HCPs to care for patients. But you can, if you are truly desperate to save money and win Foundation Hospital status. Like they did in Stafford.

On paper it looks good. Replace all the leaving HCA's and nurses with cadets and trainees. In some places they are called apprentices. They are on minimum wage and do not get shift differentials to work unsocial hours. The 16 year old kids are on less than minimum wage.

Others have no interest in nursing and just want a paycheck. Macdonalds would be much easier love. Some figure this out after about 2 weeks and leave. Others cannot even spell their names, have no chance of getting into nursing school BUT think that they are already nurses simply because they have a job on the ward caring for patients. Their confusion is understandable. First of all, their uniform is identical to a nurse's uniform except for one tiny little detail. They have a dark green stripe on the sleeve. Nurses have a light green stripe.

Here come the kids. God help us!

Notice that wonderful bit of stealth dumbing down? You dress the kids exactly like nurses. It makes them feel important and it fools the patients. Those old fashioned uniforms the nurses used to wear at the famous teaching hospitals all look a bit quaint now, but you knew immediately who was who, and where they were in the hierarchy.

++++++++++

Meanwhile, Nurse Ratchet is out on day release and, such is the shortage of nurses, that there is talk of letting her back to work on the wards.

After a short lived blog in 2006, which resulted in a bit of a furore, I have decided to return to the fray. Call me masochistic. A senior nurse in an acute hospital, I often wonder exactly what it is we are trying to do these days - and Dr Crippen drives me mad.

Nurse Ratchet

Her first sally into the blogosphere attracted a lot of attention, particularly from Dr Rant and Dr Crippen:

For too long now Nurse Ratchet has been reading blogs by erstwhile members of the Medical profession; and while the views and observations on the whole are to be commended, there runs a theme throughout of "Nurseism", or "Nurseogynism" - or even "Nurse-o-phobia". These self-satisfied, pompous, narcissistic fellows (I assume they are fellows?) take great pleasure in patronising nurses who have the temerity, nay the bare faced cheek to aspire to something greater than lovingly wiping an arse, mopping a piss soaked floor… (Nurse Ratchet)

Nurse Ratchet and the five-per-cent

At the time, I said:

Dr Crippen is a strong supporter of nurses who do nursing. He does have this old fashioned idea that nurses went into nursing with some commitment to providing personal hands-on care for patients. Nurse Ratchet dismisses old-fashioned nursing and moves on to “something greater than lovingly wiping an arse”. (sic) This sort of attitude patronises the few real nurses who still do real nursing. More worryingly it exemplifies the “Project 2000” mentality that is destroying nursing care in the UK.

Nurse Ratchet disappeared for awhile and has now returned saying she is mad. I can see why. She has gone off to do a degree in nursing, and now realises that everything Dr Crippen said was true. In her own words :

I am currently struggling through a degree in nursing, not because I’m finding it hard, but because I find it incredibly dull. I don’t think it will make me a better nurse; I’m doing it because at my level of seniority I’m expected to have a degree. I trained before P2000, so in academic terms, am at the bottom of the pile. However – I can nurse – it’s what I was trained to do. I doubt whether writing an essay on the “Sociology of Nursing” will make me more able to deal with an emergency situation, or comfort a relative, or juggle the 3000 things I need to juggle to get through the day. Am I ever going to write a research paper? No. Will learning about management styles make me change mine? No, it seems to work quite well as it is. I’m not saying I don’t want to learn, I just don’t want to be patronised.

Education through fear : Nurse Ratchet

There you have it. The destruction of British nursing summed up in one paragraph. Real nurses, by which I mean nurses who do hands on nursing and are proud to do it, nurses like Nurse Ratchet (before she was forced to take the shilling from Flabby Jowls) are regarded as second class citizens because they have not studied for some ludicrous BSc (Bedpan) at the Univeristy of Formapoly in Oswaldtwistle.

For those of you that may have missed it, I caused quite a stir some years ago with a short lived blog that was initially written in response to Dr Crippens unwavering dismissive and often very patronising, attitude towards Nurse “Quacktitioners” , and their wont to misdiagnose , or rather diagnose, above what he perceives to be their level of medical expertise. I was surprised at the lack of support that nurses showed each other (and still am frankly), and in a burst of solidarity for my fellow professionals, decided to attempt to redress the balance.

Welcome Back. I think.

Poor old Ratchet. No wonder she has gone mad. She has seen the light. I feel as sorry for her as I would feel for Bertrand Russell if there really were a heaven and he woke up in it after he died. How will Ratchet cope? Will she regain her sanity? Well worth following.

"Nursing Times" magazine reveals the truth

If we have to pay for research like this, the NHS is truly finished

When all else fails, blame the family doctor

"They weigh 80 stone, claim thousands in benefits - and can't work. Who do they blame? Anyone but themselves.

It's a fantasy all right, but we're to blame. We're the ones funding £22 grand a year to house, feed, and clothe the Chawners of Blackburn (pic above). And to keep them in all the saturated fats, sugar, and Gaviscon they will ever need. Why should they work?

Wat Tyler

Wat Tyler draws my attention to the Chawner family of Blackburn.

'Some days I barely eat at all,' declares Emma Chawner, daughter of the house and, at 17 stone, its lightest occupant. 'I don't have breakfast most days. Sometimes I don't have lunch either, and might only have a salad roll for tea. I'm always eating lettuce and apples and stuff.' (Dr Crippen has a simple technique to deal with people like Emma)

Too fat to work

Of course, the media (and the Chawners) want to blame their family doctor.

Work and benefits aside, there is clearly an issue here about the burden placed on the health system by families like the Chawners. Has their GP ever suggested that they lose weight, for their health's sake?

'Not really. What would be the point?' says Philip. 'It's not our fault that we are this size. OK, so they have sent me to a dietician, but what can they do? It's all in the genes.'

Emma agrees. 'It's the way we are. Some people are born thin, some fat. We've tried everything but nothing works.'

May I just confirm that, in a way, it is my fault. For, if you come to see me, I will not comment on your size, your weight, your appearance, your smoking, your drinking or any other part of your life over which you exercise choice, unless it is essential and relevant to the problem you bring to me. If you are obese, you can come to see me about your warts, your breast cancer, your holiday immunisations, your recent bereavement, whatever it may be, secure in the knowledge that I will not start making gratuitous suggestions about diets. On the other hand, come to see me about your arthritic knees, your high blood pressure, your poor exercise tolerance and so on and I will, gently and politely, talk to you about your weight and offer you help and support to deal with it. If that is what you want.

The government does not realise that an ever larger number of people are now frightened to go the doctor as they worry he will start criticising their life style. Now the government is setting up a health police force for forty year olds. As my colleague, the Jobbing Doctor, has pointed out, this is a complete waste of taxpayer's money. As always, Sebastian and Samantha and all the other neurotic middle-class worried-well will pile in to take advantage of their "right" to an unnecessary health check. Our surgeries will be clogged with more unnecessary, unproductive work. The targets will be hit, the bonuses paid, and the taxpayer squeezed whilst the patients with real illness struggle even harder to get an appointment.

Throwing nurses to the lions

I have never been good at arithmetic. When, as a hospital doctor, I had to add drugs to drips, do dilutions of chemotherapy, I used to sweat. It is so easy to make an arithmetic error.

I am in good company.

NASA lost its $125 million Mars Climate Orbiter spacecraft as a result of a mistake that would shame a first-year physics student—failing to convert Imperial units to metric… Mary Hardin, a spokeswoman for NASA's Jet Propulsion Laboratory in Pasadena. "Propulsion people talk in pound-seconds of thrust and navigators talk in newton-seconds," she says.

"There was a different propulsion supplier for the Mars Climate Orbiter, and its data package was in English [Imperial] units" No one adapted this data-processing software for the second probe, so JPL's navigation software thought the numbers it received were newton-seconds rather than pound-seconds. The attitude thrusters only made small corrections, but the error was enough to leave the probe 100 kilometres too close to Mars when it tried to enter orbit.

Source

Joanne Evans, a newly qualified community nurse in Wales, is in trouble. She miscalculated an insulin dose. She made a decimal point error and gave 85 year old Margaret Thomas ten times her required dose of insulin. Mrs Thomas died. There are lots of issues here. Inexperienced young nurses working alone when in years gone by they would have been in pairs. The training of nurses – perhaps too much theory and not enough practical training. Too much paperwork, of course. Pressure of work. There is a desperate shortage of nurses working on the community. The slightly odd attitude that nurses have to the prioritising of dangerours drugs. This has always baffled me. Insulin is the most dangerous drug that community nurses administer and yet they are extraordinarily laid back about it. Compare the way they deal with insulin with the way they deal with morphine. OK, morphine is a controlled drug, but the fuss and paperwork that surrounds its use is disproportionate. It is hard to kill someone accidentally with morphine. Not so with insulin.

There can be no doubt that Ms Evans was negligent. There may well be a civil action against her. But gross negligence can, when it results in death, give rise to a charge of manslaughter. The Crown Prosecution Service assessed the case and did not feel it was appropriate to bring criminal charges. The coroner, however, disagreed. She has brought in a verdict of “unlawful killing” and so the CPS will have to reconsider.

The inquest heard Ms Evans was “tramautised” by an unpleasant experience with a previous patient when she visited Mrs Thomas at her home in St Luke’s Road, Pontnewynydd, Pontypool, south Wales, on June 2, 2007. Recalling how she realised her error later that day, Ms Evans told the inquest: “I was thinking ’Oh my God, if I’ve given her that much she’s gone’ and I couldn’t believe it.

“It was very extreme circumstances and there was an error on my part and I’m really sorry, I will always be sorry.”

Coroner Mary Hassell said it was with a heavy heart she returned her verdict but Ms Evans’ actions had been “more than cavalier”.

She also criticised Ms Evans’ employer – Gwent Healthcare NHS Trust. Ms Hassell said that while senior trust management had now decided community nurses should be given a list of equipment to carry, almost two years after Mrs Thomas’s death this had still not happened.

Wales on line

Mrs Thomas' son is a doctor, a consultant radiologist. In a dignified statement, even he expressed surprise at the verdict brought in by the corononer’s court.

I feel sorry for Joanne Evans. She does not deserve this. A criminal court is not the right forum to consider her case. If we start doing this to our nurses, the system will fall apart. The nursing hierarchy will react, as they always react these days. They will spew out a load of protective protocols listing yet more tasks that nurses are “not covered” to do.

This sad case is the tip of an unpleasant iceberg. Not an iceberg of criminally negligent nurses, but an iceberg of poor resources, of lack of practical training and most of all, of a manifest lack of support from management. Joanne Evans is not Beverley Allitt. She is an inexperienced nurse who made a mistake. Joanne Evens is as much a victim of the system as was Mrs Thomas.

Dumbing down : twelve years of Labour

No, it is not a joke from a Christmas Cracker. It is a question from an Edexcel GCSE physics paper. There are further examples of this dumbing down in an excellent article from Amused Cynicism. It is particularly depressing that, despite all the dumbing down, the education achievements of are children are still poor.

At GCSE 54% still fail to gain 5 A-C grades including both English and Maths

Chris Woodhead

It is going to get worse for, as Wat Tyler describes this morning, it is proposed to:

...scrap the teaching of history in primary schools in favour of lessons in Twittering. According to the Guardian:

"Children will no longer have to study the Victorians or the second world war under proposals to overhaul the primary school curriculum. However, the draft plans will require children to master Twitter and Wikipedia."

It's such an outrageous suggestion, you wonder if it's a deliberate wind-up... But it isn't - it's a serious proposal drawn up by Sir Jim Rose, the former Ofsted chief (ie Mrs McNulty's predecessor).

full report Wat Tyler

Welcome to the New Labour fantasy land in which no stone is left unturned to make sure that exams are so easy that all may pass. And who needs teachers? Anyone can be a teacher. It's easy. You don't need to train to do the job. Housewife's "with an interest" take over as "teaching assistants", and failed bankers are to be fast tracked to the top of the profession.

One thing's for sure - the only children on whom this nonsense will be inflicted are those whose parents cannot afford private school fees. Paying customers would never accept it. Paying customers who have the freedom of making their own choices almost invariably choose what the state education commissars disparagingly refer to as "traditional education".

Wat Tyler

Tyler's article is essential reading, but deeply depressing. Doctors are only too familiar with dumbing down. It has been happening in the NHS for even longer than it has in education. In education, exam standards are reduced to lower and lower levels so that the sink comprehensives, led by a headmaster who has been patronised (literally and metaphorically) with a knighthood (same tactic as allowing some nurses to call themselves "consultants"), staffed largely by untrained amateurs and an occasional demoralised supply teacher, can justify their existence. Once proud universities are blackmailed into reducing their entry requirements so that poorly educated students from these schools can get in. The social mobility that was once provided by grammar schools has long gone. Only the children of the well-heeled middle class who can pay the fees get a decent education.

Last week, a patient of mine who has heart failure was seen, not by a hospital doctor, but by a cardiac nurse specialist. Do you think that, when Tony Blair had his heart problem, he was followed up by a nurse or by a doctor?

Independent midwife struck off : but many others continue to ply their dangerous trade

Deborah Purdue : struck off the register

There was enormous relief amongst doctors and sensible midwives when the RCM announced that Deborah Purdue, the independent madwife whose main claim to fame is that she delivered JK Rowling's babies, was struck off the register. This was a direct result of her lazy, incompetent and negligent mismanagement of a home birth that ended in avoidable and unnecessary tragedy for the poor baby. Read the report on the case.

Mad Wife Struck Off

Publish at Scribd or explore others: Research madwife struck off

What is particularly appalling about this case is not just the negligent incompetence. It is the arrogance. It is the lack of insight. It is the lazyness and indifference. Both the madwives went for a walk leaving the poor mother without any sort of trained supervision. Still, at least the pregnant women of Dorset and Wiltshire will be safe from this dreadful woman. Or I hope they will be because, staggeringly, Deborah Purdue and her partner are still on the internet plying their trade. Can you believe that they have not taken down their adverts? Maybe they forgot. Maybe Deborah is going to be reborn as a doula, and monitor clitoral pulsations.

Meanwhile, doctors and sensible midwives continue to worry about the safety of gullible pregnant women in Kent, where Kent Independent Midwifery practice still seem to be in business, and still advertise a quality of obstetric care that makes doctors shiver. Is it any wonder that doctors have labelled practitioners like this as "madwives"?

Virginia Howes

Regular readers will recall that Virginia Howes and her colleagues feature with great pride the stories of their home management of high risk pregnancies. Virginia Howe's story was a catalogue of horrifying obstetric practice and can be read in full here. Shortly after NHS BLOG DOCTOR drew attention to their account, this story was taken down from the Kent Midwifery site, but then later reappeared in what Virginia Howes calls an "updated" version. It was rewritten in a question and answer format on their new pseudo blog (pseudo blog because only they are allowed to comment on it) in a way that they obviously feel justifies their mismanagement of the case. This demonstrates so well the arrogant closed minds of the independent madwives. They will not listen to science. They will not listen to any colleagues who disagree with them. They carry on practising as they see fit. If mother and baby survive, they think that retrospectively justifies the care. That was what Deborah Purdue thought too. 

Take a look at some of the findings that resulted in Deborah Purdue being struck off:

Charge 1(b)

The WHO document states that a vaginal examination is one of the essential diagnostic actions in the assessment of the start and the progress of labour.

The registrant has explained that she wanted Patient A to go through the process of child birth with minimum intervention from herself. However the registrant did not conduct a vaginal examination until 4 hours and 25 minutes after her arrival. In her labour notes the registrant has recorded that Patient A had vomited on a number of occasions. In her evidence she has stated that vomiting could be an indication that the baby could be born very soon. She has also stated that Patient A was not in established labour. Had the registrant conducted a vaginal examination on arrival or shortly afterwards at Patient A’s home then this would have provided her with an accurate clinical picture of what stage of the labour Patient A was in. Therefore the panel is satisfied that the registrant failed adequately to safeguard the foetal well being of Patient A. We therefore find the facts in charge 1(b) proved.

That is clear. The Royal College of Midwives and the World Health Organisation think that vaginal examinations are essential. Purdue was struck off because she did not do such an examination until 4 hours and 25 minutes into the labour. What are Virginia Howes views on vaginal examinations in labour?  She is unequivocally clear in her pseudo-blog pseudo-discussion:

Why aren't you in favour of routine vaginal examinations?

Vaginal examinations are an intervention in normal labour. There is no evidence that they should be done routinely. I do perform vaginal examinations if I think the findings will help to plan the care of the woman, change the plan, improve the care, or that the information I will receive cannot be obtained in another way.

Virginia Howes did not do a vaginal examination until 5 hours after the labour had started and even then only because her patient asked her to. Virginia considers she knows better than the RCM, her professional organisation, and she knows better than the World Health Organisation.

Charge 2(a)

The NICE guidelines, Care of Women and their Babies during labour states:-
Your midwife will check you and your baby’s progress by monitoring your blood pressure, temperature and pulse and checking when you have emptied your bladder, how often you are having contractions and how far your labour has progressed.

Deborah Purdue was struck off for not carrying out this essential monitoring. What is Virginia Howes attitude? In her original account of the labour she said:

About an hour after her birth Sharon had another large blood loss and felt slightly clammy so I lay her down on the sofa gave her some syntometrine and looked for my blood pressure cuff. It was no-where to be found! I had it during labour but now it was lost. To date on day 3 it is still not located. I was concerned that I might have a woman who was compromised and so I called a paramedic.

There were two madwives present at this labour, and neither of them could find a BP machine when their patient was having a post-partum haemorrhage. Read Virginia's account yourself. How worried does she sound about the absence of this basic, crucial bit of medical kit?

It was through luck and not judgement that mother and baby survived this home birth. Had either died, or been compromised, Virginia Howes would have faced charges from her own professional body and possible criminal charges as well. But such is her obsessional belief in the merits of home birth that nothing will dissuade her. Kent Midwives are still plying their trade. Virginia Howe's colleague (I do no have a picture of her standing in a river) proudly boasts of another home delivery:

Jane certainly had an interesting previous birth history including 2 caesarean sections and 2 induced labours. It was the on-going kidney disease that was the most concerning however and how pregnancy and birth might adversely affect her. Jane could most certainly be considered ‘high risk’ which is why she was unsupported by the NHS in her wishes for a home birth.

Kent Madwifery Practice

Kay Hardie was not going to let a history like this stop her taking responsibility for a home birth and that is what she did, assisted by her colleague Virginia Howes. Read the account in full. Note in particular the antagonistic and critical way both of them talk about anyone, doctor or midwife, who suggests more conventional care.

Kent Midwifery Zone

Many doctors routinely use the word madwife to describe practitioners like Virginia Howes and Deborah Purdue. It seems accurate. Do I actually think that Virginia Howes is "mad" as in mental illness? No, I don't. I think she is "mad" as would be a parent who let a ten year old drive a car on the motorway. I believe she is mad in that she is not able to have a rational discussion about the dangers of home births. Some of her obstetric practices are so out of kilter with recommended practice that, like Deborah Purdue, she would be struck off if a baby or mother died. I believe that she is a liability and I would strongly advise any patient of mine that she is too dangerous to employ. The insurance companies think the same. None of them will insure the Independent Midwives. This is, if you like, whistle blowing. I have named the names. I have described, repeatedly and in detail, what is going on. I have blown this whistle long and loud, and no one is listening. In particular, the RCM, who are aware of Kent Midwifes, have turned a blind eye.

Does there have to be another tragedy before something is done?

Paedophile pornography on social networking sites

Who knows what our teenage children get up to on the internet. We do not have any filters or blocks on our internet access at home. We do not believe in that sort of censorship and, in any case, if they want something and cannot get it at home, they will get it somewhere else.

All four of our children are avid Facebookers. Seems harmless enough though I must say I have concerns that, once you join, apparently you cannot take your data off. It stays for ever. Can that really be true? And our every more controlling New Labour government is now considering storing Facebook data for its own nefarious purposes. 

I was concerned to hear to today, though, that a MySpace user in the USA is being prosecuted for publishing paedophile pornography on MySpace; a picture of naked fourteen year old girl. And it seems we are not talking a bikini on the beach holiday snapshot. The case is complicated, for the picture was not publised by a lurking pervert but by the fourteen year old girl herself.

The case comes as prosecutors nationwide pursue child pornography cases resulting from kids sending nude photos to one another over cell phones and e-mail. "We consider this case a wake-up call to parents," said Passaic County sheriff's spokesman Bill Maer. The girl posted the photos because "she wanted her boyfriend to see them."

The National Center for Missing and Exploited Children spotted the pictures and notified a state task force, which alerted the Passaic County Sheriff's Office. The office investigated for a month and discovered the Clifton resident had posted the "very explicit" photos of herself, Maer said.

source

This case raises all sorts of legal and moral issues that I admit to finding fascinating.

The teen, whose name has not been released because of her age, was arrested and charged with possession of child pornography and distribution of child pornography. She was released to her mother's custody.

If a teenage girl takes pictures of herself naked, is that really “possession of child pornography”? Surely not. The law has gone crazy. Putting such pictures up on the internet may be a different matter. But what about MySpace friends of this girl who arrive at her page? The page and picture is downloaded to their computer and suddently, under UK law at any rate, they could be in trouble. The law is struggling to keep up with computers. A number of highly compicated laws have redefined the act of “publishing” so that it now encompasses a wide number of semi-automatic acts that computers and hard discs can “commit” on behalf of their owner.

If my two teenage sons had happened on this girls page, they might well have recommended it to others. This seems to be a problem in the USA

The American Civil Liberties Union has asked a federal judge to block the prosecutor from filing charges, saying that the teens didn't consent to the picture's distribution and that the image is not pornography, in any event. Called "sexting" when it's done by cell phone, teenagers' habit of sending sexually suggestive photos of themselves and others to one another is a nationwide problem that has confounded parents, school administrators and law enforcers.

Teenagers "sexting" each other may be all sorts of things, but it should not be lumped in with paedophile pornography. The law is way behind the reality of modern technology. We should not be using laws designed to catch serious criminals to entrap randy teenagers. "Sexting" is just the 2009 version of what used to happen behind the bicycle sheds in the 1960s. Is "sexting" happening in the UK? It probably is. I do not know. Maybe I should get out more. I asked my four teenagers if they have ever done it, and they said they had not. But then, they would say that, wouldn’t they.

Testing for prejudice : apply the "Jewish Test"

Read this article through carefully. Do you find it offensive?

Therapists are still offering treatments for Jewishness despite there being no evidence that such methods work, research suggests. A significant minority of mental health professionals had agreed to help at least one patient "reduce" their Jewish feelings when asked to do so. The survey, published in the Journal BMC Psychiatry and conducted by London researchers, involved 1,400 therapists. Many were acting with the "best of intentions", said the lead author.

Only 4% said they would attempt to change a client's racial or religious orientation, but when asked if they would help curb Jewish feelings some 17% - or one in six - said they had done so.

The incidence appeared to be as prevalent in recent years as decades earlier.

"Of course it's incumbent on a professional to assist a client who wants help, but this should be done using evidence-based therapies - exploring their distress and helping them to adjust to their situation," said Professor Michael King of University College London.

"We know now that efforts to change people's Jewish orientation result in very little change and can cause immense harm.

"We found it very worrying that there was a significant minority who appeared to ignore this - even if they had all the right intentions."

'Right to treatment'

The Royal College of Psychiatrists says all Jews have "a right to protection from therapies that are potentially damaging, particularly those that purport to change racial orientation". In the US, where there has been heated debate on the issue of "curing" Jewishness, The American Psychiatric Association (APA) has urged all "ethical practitioners to refrain from attempts to change individuals' racial orientation".

However there are organisations which campaign both for an individual's right to seek treatment and a professional's right to offer it. They point to work by Robert Spitzer, a psychiatrist who lobbied for the removal of Jewishness from APA's list of mental illnesses but went on to suggest in a controversial 2001 study that therapy could bring about change in religious orientation. Researchers in the UK are launching a website to collect stories from around the world about such therapies. They hope in this way to uncover stories from India, South America and China where little is known about the prevalence of such practices.

Derek Munn, of the Jewish Rights Campaign Group, said: "The conclusions of this research are a welcome reminder that what Jewish people need is equal treatment by society, not misguided treatment by a minority of health professionals."

What a load of nonsense you are saying. Offensive nonsense at that. In fact it is neither offensive nor nonsense. There are many "right-on" articles written in the would be liberal press about homosexuality that are in fact biased and prejudiced. Some of my best friends are gay... argh! So how do you tell if an article on homosexualty is fair and reasonable. After all, the therapists were acting with "the best of intentions."

Many years ago, a wise old Jewish psychiatrist said to me,

"It's easy to detect occult prejudice in any text. Use the Jewish test. Substitute "Jew" or "Jewish" every time a word such as "gay" or "homosexual" appears. When you have finished the subsitution, read the article through. If it does not make you cringe, it is probably OK."

The above article is on the BBC website today here. The substitutions show just how appalling the ideas about psychiatric treatment are. We still have a long way to go to stop prejudice like this.

Foreskins : "put 'em on the block, chop 'em off, said the butcher, merry merry men are we..."

The middle-class, worried well of America have always had a phobia about foreskins. “Chop it off” as early as possible was the usual approach and it is still unusual to see an adult American male who has not been circumcised. There was also (? still is) a widely held belief in the USA that boys who were circumcised were less likely to masturbate. This sort of silly propaganda, coupled with subtle, sotto voce suggestions that American women preferred circumcised men,  had the predictable effect. Parents insisted on circumcision and doctors, or many doctors, did not refuse. Would they have refused if there were no fee involved? After much effort from some of the medical profession, common sense was beginning to have an effect and more new born babies were escaping the knife.

At the same time as the worried-well, middle class Americans were continuing to inflict surgery on their new born boys, a campaign was started by adult males who had been circumcised at birth and resented it:

The inalienable body ownership rights of infants and children continue to be addressed within the U.S. legal system in lawsuits asserting that the only person who can legally consent to a circumcision is a person making this personal decision for himself. The reports of dissatisfaction with parental circumcision decisions by circumcised men help to illustrate this point. Performed on their penises without their consent, thousands are now undergoing foreskin restoration, either medical or surgical, to reconstruct what they consider was violently taken from their bodies early in their lives. The Declaration of the First International Symposium on Circumcision acknowledges the unrecognized victims of circumcision and, in support of genital ownership rights of infants and children, states:

"We recognize the inherent right of every human being to an intact body. Without religious or racial prejudice, we affirm this basic human right.''

Due to the lifelong consequences of the permanent surgical alteration of children's genitals, it becomes imperative that children have the right to own their own reproductive organs and to preserve their natural sexual function.

Human sexuality

Despite the protests, middle America still does not like foreskins and so some new research in the New England Journal of Medicine has been warmly welcomed:

Male circumcision significantly reduced the incidence of human immunodeficiency virus (HIV) infection among men in three clinical trials. We assessed the efficacy of male circumcision for the prevention of herpes simplex virus type 2 (HSV-2) and human papillomavirus (HPV) infections and syphilis in HIV-negative adolescent boys and men.

NEJM March 2009

There are further articles to be found in the NEJM.

Prevention of Viral Sexually Transmitted Infections -- Foreskin at the Forefront. NEJM 360: 1349-1351.

An engaging pun. Foreskin at the Forefront. Ho, Ho. This article was written by Drs Golden and Wasserheit. Hmmm. Golden and Wasserheit. Might one or both of them be Jewish, I wonder?

Then in Infectious Diseases there is an article entitled

Male Circumcision and STI Prevention: More Good News (sic)

We can see immediately where this article is coming from. Why is it “good news”? Must have been written by a women. If routine cicumcsion were to be re-introduced, most males would call this bad news. This article concludes

Studies conducted in Africa have shown that male circumcision decreases the rates of several STIs in men and in their female partners. Such benefits should guide public health policy for neonatal, adolescent, and adult male circumcision programs in areas such as Uganda, where prevalence of HIV infection is high. Whether circumcision confers similar benefits in other settings is unclear.

Source

Quite. A study conducted in Uganda has little relevance to Middlesex and Massachusetts. There is a more important point.The main cause of sexually transmitted diseases is casual or careless sex. Even if it were proven beyond doubt that foreskins might facilitate the transmission of bacteria and viruses (and you could make an argument that a foreskin might protect against the transmission of bacteria) that in itself is not a reason for chopping them off. Exactly the same argument could be applied to the labia majora, minora and the whole vulva. Which of those should we remove?

Dr Colm O'Mahony, a sexual health expert from the Countess of Chester Foundation Trust Hospital in Chester, said the US had an "obsession" with circumcision being the answer to controlling sexually transmitted infections.

He said: "Sure, a dry skinned penis is a bit less likely to contract HIV, herpes and possibly genital warts but it will get infected eventually."

Dr O'Mahony also said pushing circumcision as a solution sent the wrong message.

"It suggests that it is women who infect innocent men - let's protect the innocent men. And it allows men who don't want to change their irresponsible behaviour to continue to sleep around and not even use a condom."

BBC

Why inflict this procedure on babies who do feel pain and who cannot consent? The logic would be to leave the decision about circumcision until the child had reached the age of 16 and could then make up his own mind. Always remember that this odd, obsessive belief that foreskins are intrinsically dirty comes from a nation who are so prudish that they have to call a lavatory a “rest room”. Mind you, Mrs Crippen’s mother still likes to “pop round the corner” and she is not American.

Taking the piss

Digital Gatso

An increasingly common and heart-sink presentation to family doctors is, “I’m sorry to bother you, but I just need a letter…”

Perhaps you would help me draft a letter for Mr David Jones, whom I saw today. Mr Jones is a 43 year old physics teacher. At this rather early age he has developed benign (yes, it’s been fully checked out) prostatic hypertrophy. He has been offered but declined surgery, and I don’t blame him. He only has to get up once at night and, although he has to go a little more frequently during the day, he has always said it is not a problem for him.

Three weeks ago, driving home from work, he was photographed driving at 39 miles an hour in a 30 limit. It’s a new camera on a local road. I have nearly been caught by it myself. I sympathise. I hate these wretched cameras.

Mr Jones is not going to pay up and take his points. He is going to fight. He is challenging the summons. He tells me that he was driving a little faster than normal as he was desperate to get home for a pee. He wants me to write a medical report justifying this behaviour because of his underlying medical condition.

I don’t think they would be impressed with this west of Ealing Broadway. Should I tell him not to be so silly, or should I do the report? If the latter, what should I say? And how much should I charge him?

Gladiators

The comments under the recent post about Natasha Richardson and Medical technology were diverted/hijacked/subverted (you chose) by yet another spat about hierarchies within the NHS. The A & E Charge nurse (and others) were upset (again) and there were some vitriolic ripostes. All good stuff. I suggested that someone might like to put a few words together to vent their spleen, and here it is:

WASN'T IT GEORGE BERNARD SHAW who said the biggest problem with communication is the illusion that it has taken place? Take Dr Crippen’s recent item on the untimely death of Natasha Richardson, a piece ostensibly lamenting the loss of hard earned medical skills. I was reminded of Del Boy’s phrase ‘he who dares wins’. In my mind, the post contained a sort of longing, or even a veiled hint that once upon a time a gutsy medic would not have just stood by while an expanding haematoma claimed such a vital life?

The ensuing thread contained the usual assortment of commentators: some grateful to Dr Crippen for his marvellous writing, then we had a few technocrats (although doctors first and foremost) like Crippo and Richie who illuminated the discussion with their specialist, insider knowledge – clever buggers both, but with an instructive and engaging rather than pompous modus operandi. Crippo even confessed that he never goes to bed without a copy of Bad Science in easy reach, but I digress.

Your humble Charge Nurse threw in his usual two-penn’th, but what followed was not pretty. His innocent observations led to all manner of accusations from our now apoplectic host. The NHS is a crock of shit and it’s all because of protocol loving bastards like you - why can’t you see it, frothed Dr Crippen. He went on to accuse his great bete noir, the ‘nurse specialist’ of suffering a subtle form of mental illness, or was it intellectual impoverishment. He even claimed that he had witnessed a gaggle of over promoted nurses thrash a recently qualified doctor with state of the art clip boards.

What a miserable state of affairs - a celebrated GP and battle-hardened nurse tearing at each others metaphorical throats. Doctors are arrogant pricks, nurses aren’t clever enough to be radiographers, etc (yawn) etc. Finally, a light went on. The NHS long ago hit a sizeable iceberg. Many words have been devoted to the shocking state of affairs in Tunbridge Wells, and Stafford, to name but two recent abysmal failings. Yet while the ship slowly sinks those who should really know better continue to squabble amongst themselves... ad nauseam. Why can’t they hear each other? After all, it’s not as though there is not a keen desire to provide the kind of standards that all NHS patients should feel entitled to receive. Now what was Shaw saying about communication - you have to be clever to understand that sort of stuff, and I’m not just talking about 0-levels, if you know what I mean.

The A/E Charge nurse

A couple of points arise:

Take Dr Crippen’s recent item on the untimely death of Natasha Richardson, a piece ostensibly lamenting the loss of hard earned medical skills.

The use of the word "ostensibly" suggests that there was a more important sub-text. Not in my mind, there wasn't. The advance of medical technology has indeed meant the loss of some medical skills. The advent of echocardiograms has meant that the cardiologists' stethoscope is no longer important. Old skills that enabled doctors to diagnose cardiac murmurs are dying out. No longer will I get letters from a cardiologist talking of a "deafening third hard sound" (yes, he was a bit of a pillock). Of course, we now realise that a lot of those implausibly precise diagnoses made by the cardiologists were wrong, but they still sounded good at the time.

In my mind, the post contained a sort of longing, or even a veiled hint that once upon a time a gutsy medic would not have just stood by while an expanding haematoma claimed such a vital life?

No, that is wrong. It was far more than a veiled hint. Once upon a time, a gutsy medic would indeed not just have stood by, but would have drilled. There are still a few who still would. What a shame one of them was not there. Maybe, in the end, A and E departments will be safe if run by protocol spouting HCP automatons. Doctors will be reduced to the state of the Irish Astronaut. Remember that one? The Irish Astronaut and the Chimpanzee are launched into space. Once in orbit, the chimp opens his mission instructions envelope. It's a long list of tasks. Adjust speed, trim, height, inclination, speed and so on. It takes him two hours to work through all the tasks. When finally he finishes, the Irish Astronaut opens his instructions. There is only one. "Feed the monkey"

The HCPs who populate NHS Direct, and the Darzi Polyclinics and, increasingly, the Accident & Emergency departments are unfailingly polite and helpful, provided always that you do not want them to make a decision.  They will not be drilling anything. They offer their protocol defined medicine with pride. If your illness fits the protocol all may go well. If your illness goes off protocol, you are in trouble. A doctor has had ten years training in which he learnt to look at the whole medical jigsaw. The HCP proudly clutches but one piece of the jigsaw. Try to take him outside his circumscribed area of pseudo-knowledge and his circuitry melts. He does not know what he does not know.

The NHS now embodies the Peter Principle. Staff are promoted to their level of incompetence. Nurses no longer do “hands-on” nursing. They are “too posh to wash”. Real “hands-on” nursing care is unimportant and is delegated to well-meaning but untrained auxiliaries. Patients are not washed properly. They are not turned. Pressure sores abound. MRSA is on the rise. Diabetics are given the wrong food. Elderly patients become malnourished. Food is put in front of them but taken away two hours later, cold and congealed, because no one is unimportant enough to feed them.

The nurse-specialists meanwhile have clipboards and protocols and walk round telling others how to do their jobs. White van drivers have done a first aid course, been dressed up in green uniforms and “empowered” to make diagnoses. Disaster follows disaster as they decide who should or should not be taken to hospital. GPs are styling themselves as GPswSI (GPs with a special interest) and pretending that they are consultant physicians. And so it goes on. If only we all carried on doing the jobs for which we trained. Auxiliaries are not nurses, nurses are not doctors, GPs are not consultants, and paramedics are not traumatologists. But you must not criticise what is done under the touchy-feely umbrella of equality. Last week, a patient of mine with severe heart failure was seen by a cardiac nurse specialist. Do you think that when Tony Blair had his cardiac problems he was treated by an HCP? Do you? Why not? Why should my patients have to put up with a third rate service that Tony Blair would not go near? Why do I now tell my patients to keep up their private health insurance?

Over the last ten years, the NHS has surreptitiously moved into the territory of two-tier medicine. The “free at the point of entry” door to the NHS is open to all but, once you are through it, you will not be happy with the second-rate, HCP run service you find. Often, the only way to guarantee being cared for by a doctor is to go privately.

That gets me angry.

I see patients with pressure sores, lying in their own excrement, in beds that were not clean when they were put in them, starving to death because no one is unimportant enough to feed them whilst nurses sit around nursing stations filling in forms.

That gets me angry.

Not a day goes by that I don't have to listen to complaints about poor care in hospitals. Not just poor nursing care. Poor medical care too. There are no firms, there is no longer a houseman, the most junior member of the team who knew all the patients he admitted, and followed them through.

That gets me angry.

I care about my patients. I no longer feel like their family doctor. I feel more like their personal gladiator. I have to go out and fight on their behalf. I don't want to hear all this crap about consultant nurses doing this, that and the other. If nursey wants to be  a doctor, why doesn't she do some exams and go to medical school? That is exactly what Dame Cicily Saunders did. I don't want my patients to waste their money going to the local "Nurse led Stroke Clinic". I want them to go to a Stroke Clinic. Why do we talk about "Nurse led" clinics? It is to make a perceived virtue out of cost cutting. To cover up for the fact that there are not enough doctors. Why is nursey in the clinic anyway? Why isn't she on the wards helping patients who have had a stroke eat their lunch? How do you think her time would be better spent? You won't find a nurse-specialist who will answer the question.

That gets me angry.

The NHS that used to provide a reasonable standard of care for all, independent of wealth and status, is disapprearing before our eyes.

That gets me angry.

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See this comment from a nurse with insight under Sarah Harman watch (1)

I shall probably be shot for saying this, but the common factor in very many of the horror stories seems to be nurses. Endless excuses are made - not enough staff, too busy, not enough training etc etc. But I have personally seen many instances where there is a clutch of nurses round the computers, but none in the ward. Nurses all seem to want to be doctors, or at least look like and be treated as doctors, and few of them want to nurse. Hence Nurse Practitioners. Since the start of the ridiculous Project 2000 this has escalated. (ducks down below the parapet)

Wasn't me who said it, guv!

Non jobs in the NHS

The Fat Bigot has recently written an excellent short piece on the definition of "non jobs". As regards the public sector he says:

My idea of a public sector non-job is necessarily affected by my view of the proper role of the State. For example, I see no good reason for the State to tell people what to eat. We all receive quite enough information on that subject throughout our lives from parents, teachers, friends, spouses, television and radio that there is no need for a single penny of tax to be spent on the matter. Exit Healthy Eating Initative Facilitators and Five-a-Day Counsellors, non-jobs of the first water.

A brief thought about non-jobs : the Fat Bigot Opines

A pharmacist from Cornwall writes to NHS BLOG DOCTOR to advise of the position of

Head of Cornwall & Isles of Scilly NHS Low Carbon Programme

Salary : £52,007 - £64,118

currently being advertised by the West Country NHS. Some feel the salary of £52,007 - £64,118 pa is too low, for a pay award is pending. What does the job entail?

The post holder will be responsible for the development, implementation and delivery of national, regional and local policies for climate change, mitigation/adaption and carbon reduction, developing inter-agency and inter-disciplinary strategic plans and programmes, to deliver key carbon reduction/climate change targets.

Wow. In excess of £50K a year, plus indexed linked pension, plus (I suspect) a car, a laptop, and a leatherene executive swivel chair just to do that?  That's a lotta dosh. And what, exactly, has this got to do with the NHS?  For anyone interested in applying, the full job description is here.

Publish at Scribd or explore others: Brochures & Catalogs

To all parents with teenagers : check your roof

An 18-year-old has secretly painted a 60ft drawing of a phallus on the roof of his parents' £1million mansion in Berkshire. It was there for a year before his parents found out.

This made the Crippens very happy this morning. We hope it makes you happy too.

Sarah Harman watch (1)

A reader emails to point out that Sarah Harman is at it again.

A solicitor representing a number of the families of the 13 people who died of C-diff at Eastbourne District General Hospital said the case had 'striking similarities' to a similar outbreak which killed 90 patients cared for by Maidstone and Tunbridge Wells NHS Trust. Sarah Harman, of solicitors Harman & Harman, which specialises in medical negligence, said that the hospital had failed in its duty of care. Ms Harman said comparisons could be drawn between the Eastbourne hospital and Maidstone and Tunbridge Wells NHS Trust which came under fire in October 2007 after a report revealed 90 of its hospital patients had died from the disease.

Ms Harman, the sister of Deputy Leader of the Labour Party Harriet Harman, said: "We have been instructed on behalf of some of the families. Having dealt with the Maidstone case we are seeing a lot of similarities. Elderly people, sometimes in very good health, possibly with just a fracture or a medical problem which is not life-threatening end up dying of C-diff. This case is very similar to the one at Maidstone and Tunbridge Wells NHS Trust. It's very disappointing that we don't provide better care to the elderly."

The Argus

Clostridium difficile is a real problem at the moment. Poor hospital hygiene and bad nursing care, or lack of nursing care, may contribute but there are many other factors, not least the over prescription of antibiotics, particularly broad spectrum new cephalosporins, within hospitals. But this case has yet to be heard. Sarah Harman is already acting as judge and jury. Time was when solicitors would have confined their remarks in public to a short sentence saying for whom they were acting. Clostridium Difficile is another bandwagon (after Stafford and Jade Goody) upon which Sarah Harman seems all to ready to jump.

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Dr Crippen welcomes information from readers about ambulance chasing lawyers.

Orgasms and Childbirth : again

I suppose you can do it most places, but I still don't buy into this one, however much the media takes it up. I don’t get the Sunday Times, so I am grateful to an NHS BLOG DOCTOR reader who draws my attention to an article from last Sunday entitled "Orgasm and Childbirth."

I am sure that true believers will even now be casting my wax effigy, and I know I am intolerant and irascible, but this article reduced to me to helpless tears of laughter. I particularly draw your attention to the story from Isobel Patterson, 31, a lawyer from Brighton.

Like most mothers-to-be, I was terrified by the idea of birth. A typically pragmatic lawyer, I had decided on a hospital birth with every painkiller at my disposal, even before I became pregnant. I couldn’t see the point in bravely trying to go it alone when medical science could offer me so many options to make it easier.

As my pregnancy progressed without any complications, however, my feelings changed. I began researching more natural, alternative methods. I plumped for a doula. I loved the idea of a woman who would come to my home when I went into labour and was totally independent of the hospital, but experienced enough at delivering babies to help me through it. (Doulas, unlike midwives, don't assist in the actual delivery or provide medical care, but act as professional coaches who offer emotional and practical support during childbirth.)

Doula is an old new word, now much in vogue in the USA, and recently appearing in the UK. Isobel loves the word and uses it six times. This Doula must have been very effective:

My pelvis began pushing downwards involuntarily and my legs were trembling as I experienced a prolonged orgasm that lasted what seemed like hours, although during birth your concept of time is very different. I know now that it was probably more like a series of orgasms over an hour. My husband said afterwards that I was shouting, “Oh my God, it’s so beautiful, it’s like making love”, over and over again. I was trembling and smiling. The doula said my clitoris was pulsating and I kept closing my eyes in ecstasy with each passing wave as the baby moved downwards.

Hours of pulsating clitoral ecstasy sounds great, doesn’t it? No wonder Isobel’s husband did not know what to say. And the article even gives a little bit of scientific hocus-pocus to explain how this happens

During labour, there is a huge hormonal change in the body, with increased prolactin, beta-endorphins and oxytocin being released. These molecules of ecstasy help to push the baby down into the birth canal.

Molecules of ecstasy. Prolactin. Hmmm. Well, if there are any medical students reading, I would not recommend mentioning that as one of the actions of prolactin in your next pharmacology viva.

I think the bit that made me happiest was when Isobel said:

After the birth, I was so excited that I wanted to share what had happened with friends, but their reactions quickly taught me that this was probably something I should think of as my own private but wonderful experience and keep it to myself.

To “myself” and the Sunday Times. Ha! Ha! Ha!

Once we have had a good laugh at Isoblel’s unconscious self lampoon, is there a serious point to be made? Yes, there is. Whatever your views may be on home births, a home birth without even a midwife, without even an independent madwife, present is too dangerous to contemplate. You can start from the assumption that anyone who calls themself a “doula” is bonkers and, in the UK, may be acting breach of the criminal law. They may confine themselves to observing the occasional pulsating clitoris but what they do is pretty close to purporting to provide medical care.

And what, I wonder, would Obersturmführer Ratzinger make of women having sexual climaxes as their babies stimulate their vaginas during labour? This takes the concept of original sin to a whole new level. What would God think? I am not able to speak for God but fortunately Maryl Smith from Aloha in the USA can.

As a midwife for 26 years and holder of a theology degree, I see no conflict between birth with pleasure and the scripture. Childbearing was a gift given at creation, not at the fall, and "pain" can be interpreted as a mother's heart agony now that her child can sin and her love incurs life's pain.

Maryl Smith

Pain is a “mother’s heart agony now that her child can sin”. That explains everything, then.

This Sunday Times article is a crock of shit from beginning to end. I hope no one buys into it. I am staggered that a reputable newspaper publishes it.

Grand Rounds : a look at the medical blogosphere by an American nurse-specialist

Code Blog is written by a Geena, an American intensive care nurse - yes, indeed, a nurse specialist - and takes a look at the week's writing in the medical blogosphere and beyond. She looks particularly at various medical opinions on the tragic death of Natasha Richardson.

The biggest news this week, of course, has been that of Natasha Richardson’s death from a seemingly innocuous skiing accident. Several medbloggers stepped up to give us insight into what may have happened. PalMD wrote A simple bump on the head can kill you, which explains basic anatomy (and a very… realistic picture) of the brain and how traumatic brain injuries affect it. Inside Surgery wrote Natasha Richardson’s Brain Injury to provide us with a detailed rundown as to what happens to patients who have suffered a traumatic brain injury - from pre-hospital to in-hospital care all the way to recovery and/or end of life. Lastly, Dr. Crippen weighs in on the comments floating around regarding Richardson’s care in Canada in a post neatly titled The wussification of the American medical profession. The term “gobstopping pomposity” will be with me for a long time. I have made it a life goal to use that expression flawlessly in a sentence someday.

Full details at Code Blog : Grand Rounds

Britain has always led the world in confectionery. Maybe the children in the land of the free do not have access to gobstoppers. How deprived is that?

Cynthia Bower : April Fool

Any study of the mechanisms of a soviet style bureaucracy requires patience. There are dozens of interlinking commissariats which report to and on each other and they are run by an even larger number of commissars. The commissars all have portentous and similar sounding titles and move frequently between the various commissariats. Trying to ascertain who is responsible for what is challenging and often, just when you think you are there, the commissariats will be renamed and some poor performing commissars will be sent off to the Gulag or, more usually these days, promoted out of harm’s way. Please be patient as I try to take you through some important changes in NHS administration.

You may not have heard of the Care Quality Commission.  It is an amalgamated quangopoly, due to start work on All Fools’ Day. It has eaten up the Health Care Commission, the Commission for Social Care Inspection and the Mental Health Act Commission.

Be patient, comrades. The truth will emerge.

You should have heard of the Health Care Commission. They are the ones who published the report on the appalling state of health care in West Stafford. The public still does not understand how so many unexpected deaths went unnoticed and unreported for so long. Nor does Dr Crippen.

We need still more information about commissariat structure

West Staffordshire hospital was under the governance of the West Midlands Strategic Health Authority until February 2008. The West Midlands Strategic Health Authority (SHA) had all the mortality data for West Stafford at the same time as the Healthcare Commission but, unlike the Healthcare Commission, West Midlands SHA  did not understand the significance of them. They thought the unexpectedly high death rate was merely a statistical aberration caused by faulty computer coding. So they ignored it.  As was said last week in the House of Commons, the SHA “had the wool pulled over its eyes.”

The Care Quality Commission (CGC) is charged with monitoring and maintaining standards of care in the NHS. Commissar Cynthia Bower is the new and first Chief Executive at £200,000 a year.  She was, until recently, the Chief Executive of West Midlands Strategic Health Authority and so must take overall responsibility for the West Stafford debacle. I don't normally read the "soar-away, sizzling" Sun but they are on the money today.

THE NHS boss in charge of the filthy hospital where up to 1,200 patients died in “appalling” care has a new job — as a top health WATCHDOG. Cynthia Bower will start on APRIL FOOLS’ DAY — in a move branded a “cruel joke” by relatives who lost loved ones. Her appointment emerged as PM Gordon Brown yesterday apologised for the “inexcusable” failings at Stafford Hospital.

Cynthia Bower

Mark Bennett, 38, whose mum died while a patient [in Stafford Hospital], said: “This is like some kind of cruel joke. It isn’t fair that someone with a connection to this appalling incident should be in charge of a body that oversees hospitals.”
The Sun

One should perhaps not hold Cynthia Bower completely responsible for all the deaths in Stafford. It takes several years for hospital services to become as bad as they were in Stafford. Cynthia Bower only took over that position in 2005.  Some of the blame must fall on her predecessor, who was David “ex-communist Thatcherite” Nicholson. He has moved on from West Midlands Strategic Health Authority too. He is now Chief Executive of the National Health Service.

Onwards and upwards, comrades.

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The Cockroach Catcher's report contains wide coverage of the malfeasance and mire of the "commissar protection protection programmes" in place in Stafford:

Health Secretary Alan Johnson: 'We should be spotting these issues earlier and getting rid of incompetent executives'”

The chief executive of Stafford Hospital, which was condemned yesterday for ‘appalling’ emergency care that may have cost hundreds of lives, took a pay rise of up to £45,000 while the hospital was being investigated. Martin Yeates, who was suspended on full pay by the Mid-Staffordshire NHS Trust on Monday, was told in a letter on 23 May 2008 of the initial findings of the Healthcare Commission's investigation, detailing the chaotic conditions in the A&E department, with unqualified receptionists assessing patients, a shortage of nurses and doctors and a ‘complete lack of effective governance’.

The letter was copied to the Department of Health but Mr Yeates remained in his post for nine more months, until he resigned two weeks ago, before being formally suspended by the trust.

Full report at Mid Staffordshire : unbelievable, unbelievable, unbelievable

What is a 'surgeon'?

A sensible patient of mine has private health insurance and also has an inguinal hernia. A happy combination. A mate of his had just been to one of the “pile ‘em high, sell ‘em cheap” hernia repair factories which advertise in the press and on the internet. The friend was delighted with the service he had received and was back at work within a week. My patient showed me a card that the doctor who did the surgery hands out. It said:

Mr Albert Smith FRCS

Consultant Surgeon

The Plausible Private Clinic

My patient wanted to know if I could recommend Mr Smith. I googled him (It is a verb now and you don’t need to capitalise it. I despair.) and found various internet sites explaining all about hernias but little about Mr Smith. In particular, there was no evidence that, aside from his private work, he has an appointment as a consultant in an NHS hospital. So I checked his registration on the GMC website. Mr Smith is a doctor. He is qualified. But he is not on the GP list, nor is he an accredited specialist.

I asked one of my partners if Mr Smith was entitled to call himself a “consultant”.

“Oh! Hell, yes” said my partner, “anyone can call themselves a ‘consultant’. The better question is whether, if he is not an accredited specialist, he is entitled to style himself in a medical context as a ‘surgeon’.”

Does anyone have a precise and legally correct answer?

The death of Jade Goody and cervical screening

Happy Welsh woman : is this the way to advertise smears?

However cynical one is, few have not been saddened by the tragic death of Jade Goody. Things may have got out of proportion somewhat with even the Prime Minister paying tribute, but it is a story that has touched a lot of hearts, and is receiving a lot of attention in the USA. (See The Blog that ate Manhattan)

From the medical point of view it has been a “good news/bad news” story. There has been a surge in demand for cervical smears and there is albeit anecdotal evidence that, as a direct result of Jade Goody, more women from similar less privileged backgrounds are coming forward.

The bad news is that there is already media and political pressure to extend the cervical screening programme.

Until 2003, the NHS had been inviting women for testing at age 20. But the age was raised to 25 after research suggested a negative effect.

This is because some experts say although women in their early 20s may have detectable changes in their cells, these are mostly natural and clear up on their own. Also, treating this can lead to complications in later life, such as difficulties carrying a baby in the womb during pregnancy.

BBC

This decision was reached after careful thought. It should not now be changed because of Jade Goody. But that is what the public and the politicians may want. Already, ex-nurse, minor health commissar Ann Keen, who has been “inspired” by Jade Goody is already on the case.

This is not the way to do it.

The "wussification" of the American medical profession

I am a frequent visitor to KevinMD. It’s the best place on the internet to get an immediate, up to date birds’ eye view of medicine as it is seen in the American medical blogosphere and beyond. The only problem with KevinMD is that it is no longer possible to comment under his posts.** My recent post on the Natasha Richardson tragedy was partially inspired by a report on KevinMD in which the Americans were discussing what had happened but in a rather pompous “Dear oh! Dear, she would have been saved if this accident had happened in America” sort of way.

UPDATE : The gobstopping pomposity of the Americans continues. I feel a post about unemployed black American diabetics who cannot afford insulin coming on. An NHS BLOG DOCTOR reader in America emails me about this:

Did Natasha Richardson Die from Socialized Medicine?
David Henderson

In Britain, people who don't like the long lines and sometimes low quality of the NHS can pay for better themselves and can even buy insurance for this higher-quality care. This is Britain's safety valve for socialized medicine. And Canada's safety valve? It's called the United States. In David R. Henderson and Charles L. Hooper, Making Great Decisions in Business and Life, I tell my own "safety-valve" story involving my father, who spent his whole life in Canada.

Library of Economics and Liberty

It is an outrageous slur on Canadian medicine to assume it would have been “done better” in the USA. It might possibly be true to say that, if a similar patient was seen in the USA, provided always they were rich or fully insured, they might have had quicker treatment. If they were one of the forty odd million Americans with no medical insurance, they might have had no treatment at all.

Natasha Richardson might possibly have been saved anywhere had neurosurgeons intervened earlier. As I said in the original post, it is easy to tell people how to save lives from the comfort one’s armchair. I believe, though, that the delay in this case was caused by too much reliance on medical technology. In the prevailing medico-legal climate in America, it is very difficult for doctors to do anything without first ordering a battery of defensive medical tests.

KevinMD has suggested that I am talking about the “wussification” of American medicine. I love the word and will undoubtedly borrow it. Once I know what it means. I suspect what he means is that the American medical profession is so frightened of being sued that they are practising medicine so defensively that it is actually, on occasions, harming their patients. I think that is true and, anecdotally, friends who work in America agree.

Defensive medicine means subjecting patients to endless tests, most of which are medically unnecessary, so that you never “miss something.” How do you decide if a test is “necessary”? Sometimes, it is not easy. Supposing, for example, I see a fit, intelligent businessman for a pre-employment medical and general health advice. He has no urinary or prostate symptoms and there is no family history of prostate cancer. Should I do a routine, opportunistic, “screening” PSA on him? The Americans are pretty hot on screening, so let's see what they say:

American College of Preventive Medicine Does Not Recommend Prostate Cancer Screening With DRE, PSA

News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD 

Release Date: February 5, 2008

February 5, 2008 — Information is not adequate to recommend screening men for prostate cancer with digital rectal examination or measurement of prostate-specific antigen (PSA), according to a position statement by the American College of Preventive Medicine (ACPM) published in the February issue of the American Journal of Preventive Medicine.

Source

That is clear. I am not going to do opportunistic PSA screening. And that is what Dr Daniel Merenstein MD of Baltimore, USA thought too. The date was July 19, 1999. He saw a highly educated 53 year old patient for a physical examination.

I discussed with him, and documented in his chart, the importance of colon cancer screening, seat belts, dental care, exercise, improved diet, and sunscreen use. I also presented the risks and benefits of screening for prostate cancer and documented the discussion. I never saw the patient again and, after I graduated, he went to another office. His new doctor ordered PSA testing without discussion the risks and benefits of screening with him. Unfortunately for the patient, his PSA level was very high and he was subsequently diagnosed with incurable advanced prostate cancer.

The patient sued. A British judge would have thrown this case out. Find out here what happened to Dr Merenstein.

So, Kevin, yes, I do think that American doctors are in danger of “wussification” but I say that with sadness, not with ill will. After Dr Merenstein’s experience, I do not blame them. Do remember, though, that what happens in America this year...   Medico-legal litigation is ever on the increase in the UK, largely due to the barrel scrapings of our legal profession who have started chasing ambulances. 

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** Apologies.  It IS possible to comment on Kevin's post. Click on the title at the top, and then cursor down to "post a comment".

Inland Revenue vendatta : let's catch the crooks

McNulty Mug shot

The Inland Revenue is currently persecuting doctors. It may be that this is a government inspired vendatta to try to claw back some of the money paid out to consultants and GPs over the last few years. They have not gone for me, yet, nor for anyone in my practice. They are, however, investigating Mrs Crippen as regards her motoring expenses.

Neither Mrs Crippen nor I know much about tax. We have both heard about “duality of purpose” though.  If you own a car, and use it for travelling between hospitals, for on call duties, and also for running the children to school, and for holidays, rightly and properly you cannot claim all your motoring expenses against tax. But how much can you claim? Neither of us has a clue. So, we employ an accountant who specialises in doctors. We give him the details of our car expenses, and tell him what use we make of the cars for work and for “social and domestic” purposes. He tells us what percentage of our motoring expenses we can fairly claim, and that is what we do. And have done for twenty years. And it has never been challenged. 

Now it is being challenged by the Inland Revenue. The correspondence has been going backwards and forwards for eighteen months. We have spent hours closeted with the accountant. Mrs Crippen has had some rude letters from somebody fairly low down in the Tax Office. So rude, in fact, that our accountant has made a formal complaint about them. It has been and still is a very stressful experience, particularly as there is the underlying inference of dishonesty.

The stupid think about it all is that the amount of money in dispute is only a few hundred pounds a year. Yes, yes, I know, count the pennies, we should all pay what is due, you should not evade tax and so on. We agree. Which is why we have always been meticulous about taking proper advice on a subject about which we know nothing, and following the advice. If it turns out that the advice given by our accountant over twenty years is wrong, that is going to have repercussions for the several thousand clients for whom he acts. The Crippens do not evade tax. Frankly, we are so disorganised that (and we now know this from the detailed audits the accountant has just done) we do not even avoid tax liability. We have not claimed for other things for which we could have claimed. We will be doing that now. Whatever the Inland Revenue decides on the motoring expenses, they will be the net losers. But that will not matter. They will have hit their target.

What point am I trying to make? I know a few of the usual suspects will write in and say “fat cat” doctors are overpaid and should be paying more tax. That is not relevant. What we need, above all, is certainty. Which is what, incorrectly, we thought we had. We may end up having to pay a few hundred pounds (plus interest) to the Inland Revenue. How much will collecting this money have cost the taxpayer? That’s not relevant, you may say. Tax should be paid. Fine. But remember, because the tax offices are in the public sector, time costs are ignored. So it is OK to spend ten thousand pounds to recover one hundred pounds. It’s the principle.

For the time being, the stress continues. Background current affairs, Fred the Shred’s tax-paid pension, the bank bails-out and so on, are all very irritating. But what is this morning making Mrs Crippen choke over her cornflakes is Tony McNulty MP.

Mr McNulty accepted that his use of taxpayers' money for the property looked odd. The employment minister is the latest MP to be caught claiming the Common's controversial "additional costs allowance" for a property that is not strictly his home.

Mr McNulty lives with his wife Christine Gilbert in a house she owns in Hammersmith, three miles from Westminster. Yet the minister has been claiming up to £14,000 a year in parliamentary expenses to help pay for another house he owns in Harrow, 11 miles from the Commons, in which his parents live.

The MP can claim the money because the house is in his Harrow constituency and so qualifies him for the second home allowance. After the arrangement was disclosed by the Mail on Sunday this weekend, Mr McNulty announced that he had decided to stop claiming the money, which he has benefited from since becoming an MP in 1997

Daily Telegraph

This odious little crook has been caught with his hand in the till. As soon as he was caught, he took his hand out. He is a fruadster. He should resign. He should be in court. MPs expenses are a national disgrace. Most of them may be “at it” but that is not the point. It is a question of honesty.

A former minister has admitted that MPs view the maximum £23,000 they can claim in second-home expenses as a "target to be aimed for" and not as a way of repaying "legitimate" costs.

The remarks by Chris Mullin, a Labour member of the all-party standards and privileges committee, amount to the first admission by an MP that the much-criticised Additional Cost Allowance is seen as something to which they are automatically entitled.

Daily Telegraph

Mrs Crippen’s parents are in their eighties now. Perhaps she should start claiming travelling expenses for the frequent visits she makes to see them.

Natasha Richardson & medical technology

The Lady from the Sea

There are three medical procedures that can be dramatically live-saving. Most doctors would love to say that they have successfully carried out any one of these procedures in an emergency. Opportunities are few and far between so apprentice learning (see one, do one, teach one) is rarely possible. Most of us would admit to being terrified of being in a situation in which one of these procedures was needed.

The three procedures are:

1. Relieving a tension pneumothorax
2. Performing a tracheotomy
3. Drilling burr holes into a skull.

The desperately tragic death of Natasha Richardson has saddened us all, particularly those of us who are keen theatre goers. I last saw her about five years ago in a production of Ibsen’s The Lady from the Sea at the Almeida. The theatre is small and I was lucky enough to be close to the front and so, at times, was only a few feet from her. The play is not often done. I felt privileged to see it with her in the lead. An unforgettable evening.

The events on the nursery slopes of Mont Tremblant were puzzling to the lay man. An apparently trivial blow to the head resulting, within a matter of hours, in a death. Every doctor and medical student in the world knew what was going on. This had to be a sub-dural or epidural haemorrhage.

Epidural haemorrhage

A blood vessel inside the skull ruptures. The bleeding starts and continues unremittingly. After a lucid period, there will usually be a headache and, as the brain is compressed, a lapse into unconsciousness. You have precious little time to act. The treatment is easy. You do not wait. You drill a hole in the side of the skull and let the blood out. If you are not in a hospital, you grab the handyman’s drill. Just do it. Of course, if your diagnosis is wrong, or you drill through the middle-meningeal artery, or drill the wrong side, you may cause more trouble than you prevent. You may even kill the patient. So it needs a brave doctor to do it.

Once again from Kevin MD, I learn that the American doctors (not Canadian) are discussing the tragedy. The American are pompous in their approach:

Did the Canadian health system fail Natasha Richardson?

Their conclusion is that her death may well have been caused by delayed intervention and the Americans graciously conclude that:

The biggest loss of time was when the initial EMS response was declined, the fact that several hours passed before a CT scan was performed, and the delay before making the decision to transport her to a tertiary care center in Montreal. Those delays could conceivably happen in the United States as well.

I disagree with this conclusion and I do not like the cosy American  concession that “those delays could conceivably happen in the United States”. How kind.

The sole question that every doctor who has read about this case is asking, is why were the burr holes not drilled much earlier? It is a very easy question to ask from the comfort of your armchair as you watch the news. Both Mrs Crippen and I asked it. But what must also be asked is whether, had you been the doctor at Mont Tremblant, you would have been brave enough to start drilling?

I believe that what may have contributed to her death was nothing to do with being in Canada rather than America. Yes, there may have been a delay, but the important underlying question is why was there a delay?   I believe the delay was due to medical technology. CT scanners, MRI scanners and helicopters. That sounds counter intuitive, but think about it. These days, and particularly in the medico-legal climate prevalent in North America, it would be a brave doctor indeed who did not wait for the CT scan before drilling the burr holes. It would be a career making or career breaking decision. Few American doctors are brave. Defensive medicine is the order of the day. You cannot have a migraine in the USA without someone ordering an MRI scan.

Had this accident happened at base camp on Everest in a helicopter-blocking snowstorm, a doctor would likely have drilled. Had this accident happened in a ski resort forty years ago, before CT Scanners had been invented, a doctor would likely have drilled. Then a subdural/epidural haemorrhage was a clinical diagnosis. Apparently minor head injury, lucid interval, headache, sudden deterioration in consciousness, a dilated pupil… all adds up to an obvious diagnosis.

Medical technology has deskilled doctors.

Quacks taking over Winchester

Professor Papa Limba, emeritus Professor of Homeopathy and personal physician to his Royal Highness, the Quacktitioner Royal,  is the former Lib Dem candidate for Winchester North.

Daily Mash

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

A distressed nurse in the south of England writes in to tell me that the quacks are taking roost at the Royal Hampshire Country Hospital, Winchester.

You are warmly invited to a day of Homeopathy presented by Doctors,Dentists and Vets working in the Wessex region. You will learn about the history of Homeopathy and its basic principles and philosophy.

What is the NHS doing giving floor space and credence to this nonsense?.

We will present the latest evidence showing positive benefits in a range of conditions.

At least it will be a short meeting. Full details here:-

Homeopathy in Practicequacktitioner

Publish at Scribd or explore others: Brochures & Catalogs

Being chased by Sarah Harman

The ink has barely dried on the report from Stafford Hospital, but that does not stop a certain sort of solicitor touting for business. I was appalled to see this appear today:

Stafford Hospital Crisis

20 March 2009

If you, or a family member have been the victim of poor care at Mid Staffordshire NHS Foundation Trust then you may be entitled to compensation. Following the publication of the Healthcare Commission Report into the standard of care at the Stafford Hospital and Cannock Chase Hospital, wide ranging criticisms were made, particularly in respect of A&E admissions. If you feel that you, or a family member, has suffered as a result of poor care you can talk to our experienced legal team, in confidence, on 0844 561 1159 or complete the online enquiry form.

Harman & Harman solicitors has over 25 years of experience in dealing with complex medical negligence cases against NHS Trusts across the country and recently obtained compensation for victims of the Maidstone C Difficile outbreak, as well as obtaining compensation for a number of patients who had been sexually abused by David Britten.

Yep. That’s right. It’s Sarah Harman. Again. What a vulgar, self-publicising woman she is. Must be a bit of a contortionist too because the last time we saw her, she was on the Jade Goody bandwagon. Can you be on two bandwagons at once?

Patricia is back!

I had forgotten how repellent Patricia Hewitt sounds. Whatever criticisms one has of Postman Pat, he at least is not political ipecac.

I shivered as I heard her voice on the radio. She wants to slip a clause into the new coroner’s bill, preventing those who cart relatives over to Switzerland to see those nice people at the counter-intuitively named Dignitas from being prosecuted. At the moment, assisting suicide is a criminal offence and the only reason that there have been no prosecutions is that the DPP has decided that they are not “in the public interest”. It’s a classic British fudge. We are good at such fudges and, though illogical, it is often best not to change the status quo. Look what they have done to the House of Lords.

Patricia wants to decriminalise assisting suicide but only provided, she says, that the patient is terminally ill and also “of sound mind”. If she were still secretary of state for health, I would accuse her of trying to save the NHS money. She is not, so I don’t know what her motivations are but if I were an elderly wealthy relative of hers, and she appeared with a couple of plane tickets suggesting a weekend break, well, I think I would stay at home.

I have always found it illogical that patients with severe, unresponsive depression are not allowed to avail themselves of the services offered by Dignitas. Everyone has a bit of “depression” these days and so few realise that there is no illness worse than real, serious, unresponsive, unremitting depression. I have a handful of patients like this; socially isolated, no job, no family, no friends, no money, nothing to look forward to, not much to look back on, chronically depressed despite medication. They want to die, but have not always got the nerve to do it. Please, can someone explain, why is it that if, as and when they get terminal cancer, they will not be allowed to have help with suicide? For that matter, why should they not have help with suicide for the depression alone?

Tales from the CMHT : more journeys

Many years ago, when the NHS psychiatric services were still working, it was easy for a GP to get help from secondary care.

To over-simplify, patients with mental health problems saw their GP. If he could not deal with them, he referred them to his medically trained colleague, the Consultant Psychiatrist. The Psychiatrist carried out an assessment, and formulated a plan. He might admit the patient. He might suggest that the GP put the patient on different medication. He might suggest that the patient was followed up by secondary psychiatric care services and, when that happened, might enlist the help of CPNs.

Nowadays, in many areas, and certainly where I work, there is no direct access to psychiatrists. They do not even read our referral letters. The letters all go to the CMHT, the community mental heath team. “Team” is the NHS word for diffusing responsibility. The CMHT is cheapo-cheapo productions mental health care. It consists of a group of people who are not medically trained (apart from the psychiatrist) and who live together in a pseudo-egalitarian medical fantasy world in which all health care workers are equally skilled, equally valued and equally important. Right on! Because none of the individuals on the CMHT is skilled enough to think outside his tiny area of pseudo-expertise, the CMHT subdivides into all sorts of skill categories so that protocols can be issued and acted upon. 

I hope you all read Lake Cocytus, which is written by “The Shrink”, a manifestly caring consultant psychiatrist. I wish he worked in my area. I think a couple of pints with him would be therapeutic. Let him now take over the description of the CMHT skills “teams” whilst I sit back and giggle:

A care coordinator will stick with a patient as they move through Single Point of Access, Assessment teams, Early Intervention teams, Crisis Resolution teams, Home Treatment teams, In-patient care, Rehabilitation Teams, Severe Enduring teams and so on. The fact that a patient's bounced from team to team doesn't matter - the care coordinator will remain a stable point of contact. The fact they've squillions of people to tell their tale to and no continuity doesn't matter - their care coordinator will be that continuity. The fact that each team will have a different doctor (somewhere, that's accessible some of the time, to some people) won't matter - the care coordinator will magically ensure that biomedical and psycosocial psychiatrists and GPs seemlessly deliver the same consistent care.

The Shrink

Sounds a bit confusing, doesn’t it? But don’t worry. The Care Co-ordinator will sort it all out and see the patient through. And to show how important he is, the Care Co-Ordinator has been given a new title. He is now called the “Journey's Facilitator” for, naturally, the patients are, as always, on a journey. His task will be much easier now as demented patients are to have GPS tags.

It will be comforting for relatives of patients with dementia to know that, when granny goes wandering in her night-shirt,  the few remaining CPNs will now be sitting in the CMHT office in front of a computer screen, singing songs in their quiet, mellifluous Irish voices as they track granny's progress down the central reservation of the M6. They will report to the Journey’s Facilitator who will phone the family and advise them to call NHS Direct. Or maybe the Automobile Association.

Quacktitioner Alerts 2009 (1)

Andrea Street, 34, and Jennifer Ansell, 39, told a mother it was not necessary to feed her baby boy vital medication, the Nursing and Midwifery Council heard   Source

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Another sad but classical example of the results of dumbing down health care. A doctor prescribes antibiotics for a new born baby for sound clinical reasons. The midwives do not understand those reason. Well, not their fault. They have not been to medical school, so why should they understand? They don’t know what they don’t know. But what is their fault is their arrogance in not following the instructions of someone who is superior to them, and does know what he is doing.

Arrogant midwives have always been a nightmare, particuarly when they go "independent" but they do not have a monopoly of stupidity. This sort of avoidable tragedy is now happening all over the NHS. Not just in Stafford. Everywhere. Nurses, midwives, paramedics, receptionists and so on, all of them now collectively called HCPs (HCP = there is no doctor available, will I do?)

Doctors are  medically trained and insured. They still make mistakes. How many more mistakes do you think are going to be made as healthcare is handed over to people who have not been to medical school? And the independent midwives, the "madwives", do not even have insurance.

Flirtatious women deserve to be raped

Or so two fifths of the great general public seem to think.  Thank God we are not governed by "the people". If we let public opinion rule the country, we would be back to hanging and flogging, probably both to be done in the presence of the public. And yet when the fickle pubic take their place on a jury in a court of law, they are held up to be a bastion of our civil liberty.

The people who determine whether a crime has been committed, the sole deciders of fact, are the people through the jury. That’s the fundamental part of our legal system.

Tim Worstall

Can't argue with that. But therein lies a problem

It seems that two-fifths of the public believe that a woman should be held at least partly responsible for being sexually assaulted or raped if she was flirting with the man before the attack. So, a women who flirts with a colleague at the office party has surrendered her absolute right to say “no” to sexual intercourse.

And if [a jury] thinks that women might indeed contribute to their rape then that’s just the way that it is

Tim Worstall

Some bastion of civil liberty!

The world has gone mad

Wat Tyler & Dr Crippen

More NHS trusts should be offering cash vouchers as incentives to people who adopt healthier lifestyles, a government adviser says. Professor Julian Le Grand, chairman of Health England, said financial incentives could be key to reducing smoking, alcohol and obesity rates. He said vouchers could be exchanged for anything from food to gym membership. Some trusts are running pilot projects, but the government said there was no consensus about their effectiveness. In Dundee, smokers are being offered £12.50 a week to spend on groceries if they go a week without smoking.

BBC

I find this more offensive than the suggestion that alcohol should be heavily taxed to encourage people to drink less. I suppose there is some perverse logic. The money raised from penalising drinkers could be used to pay people to give up smoking.

Please leave the tax payer alone. Julian le Grand needs to go back under his stone in the pond of nonsense and I need to return to my place in the balcony with Wat Tyler.

The country has gone mad.

King's College Medical School accused of racism

King's College Medical School

Just under a year ago, I wrote an article about King’s College Medical School dumbing down its entry requirement. This was the Extended Medical Degree Programme (EDMP)

(EMDP) aimed to attract bright students from state schools in inner London who had A-level results that were far too poor to gain entry to medical school and show that, with the right help, they could succeed. Students would normally require two As and a B at A level, but the scheme, called the Extended Medical Degree Programme, accepted those who had managed no better than three Cs.

The Times


…many of the students who are from lower professional and managerial groups have a Black African heritage and from families headed by women….Many of the students classified as being from semiroutine and routine backgrounds are from South African families.

British Medical Journal

The selected students have an extra year at medical school and they are hot-housed. They have regular additional tutorials compared to “ordinary” students. Currently, the programme is supported by two full time academics; one part time administrator; four part time academics and 15 postgraduates and academics who provide about 130 small group tutorials per year. A conservative estimate for the total cost for this is £190,000.

This is racial discrimination. It is not acceptable. It is no excuse to say that it is “positive” discrimination. I wrote about a young patient of mine

Robert ... is 19 now. He failed to get into medical school last year. He does not belong to any modern “right-on” minority. He is white and heterosexual. He does not have dyslexia, tracking disorders or ADHD. He probably puts C of E on forms that ask about religion. He is the only child of a single parent family. His father was killed in an RTA when he was a toddler. Robert went to one of the local comprehensives. It is not a sink comprehensive but it is not good. They rarely get anyone into Oxbridge. They supported Robert as best they could. He got 4 A*s, 5 As and a B at GCSE. He went on to do Maths, Physics, Chemistry and Biology for AS level and got 3 As and a B. He was offered 2 As and a B to get into medical school (probably a slightly lower offer than he would have got had he been at a private school). He got an A and 2 Bs. By his own admission, he “cocked up” the maths paper. So Robert is not going to medical school

Dr Crippen

Robert feels bitter about the EDMP programme. Do you blame him?

I hate all this so much. I hate the way that Cambridge University (and just wait for the others to follow) has just been castigated for saying that it is going to take only the brightest students, the students who have managed to get the new A* at “A” level. You do not solve the problems of poor state education by forcing the Universities to dumb down.

One of the students taken on in 2002 by King’s College Medical School under EMDP dumbing down was Virginia Jibowu. Virginia Jibowu has had problems whilst she has been a student. She has failed some exams. She feels she has been badly treated and subjected to racism. So she is going to sue King’s College.

Virgina Jibowu

A BLACK medical student who claims she was bullied by racists on her course is suing her college for more than £300,000.

Virginia Jibowu, 25, from South Lambeth, says that she was ostracised by white students in an "institutionally racist" environment at London's King's College medical school. She says that while the students she has accused of racism graduated, the college refused to investigate many of her complaints, deliberately failed her and tried to stop her re-sitting the course.

Ms Jibowu is suing the college, which is part of the University of London, at Central London County Court for harassment, race discrimination and victimisation.

In legal papers submitted to the court, she said: "All of the alleged racists are now practising as doctors in the NHS. This can only ingrain the problem of institutional racism within the medical practice." Ms Jibowu is demanding more than £300,000 for loss of earnings, aggravated damages and injury to health and feelings.

But if she fails to finally qualify from the course, she is expected to sue at the High Court for further compensation for the loss of her career, which could run into hundreds of thousands of pounds.

Full story : Evening Standard

Mrs Crippen trained at King’s. We have a lot of friends who trained there. I can state quite categorically that there was no racism of any sort whilst my wife was there. But, before you say it, yes, that was a few years ago. I cannot give evidence as to what the environment is like at King’s College Medical School now. Maybe the Ku Klux Klan has taken over. One thing I will say, though. I do not believe that any London Medical School would “deliberately” fail a student who deserved to pass.

Whilst Ms Jibowu has her day out in the newspapers, King’s College are maintaining a correct and dignified silence.

The college and former students accused of racism strenuously deny all of Ms Jibowu's allegations. The college is vigorously defending her court claim but a spokeswoman said: "We are unable to comment while legal proceedings are ongoing."

Not so Ms Jibowu who has a long catalogue of allegations including:

On a flight to a placement in St Lucia in 2007, another student allegedly booked a seat for Ms Jibowu away from the rest of their group.

I wonder if Ms Jibowu has considered the possibility that the other students did not like her? Not liking people is not racist. It is a matter of taste.

There are complex issues underlying this extraordinary legal case. Dr Crippen has not hesitated to write about the racism that still exists in the NHS, racism that was so well exposed by Dr Sam Everington, who now sits on the GMC.

But there is another kind of racism. A form of racism that few dare mention. It’s called “playing the race card”. It happens in the NHS. It happens in the police force. It happens everywhere. In the NHS, there is a certain sort of poorly performing doctor who, if criticised, immediately instructs his lawyers to issue proceedings for racial discrimination. This phenomenon is just as bad as ordinary racism, but more difficult to write about. It is not politically correct to suggest it happens.

Has Virginia Jibowu been subjected to racial discrimination? Some would say she was in 2002 when she was accepted by the medical school as a EDTP student. Has she now been a victim of negative racial discrimiation? Time will tell. But has there ever before been a case where a student has threatened to sue a University for racial discrimination if she does not pass her final examinations?

+++++++

It will come as no surprise to regular readers to hear that Rita Pal was onto this story ten days ago. Rita is 100% supportive of Virginia Jibowu and provides much more detail about the background, including information from Nigeria. She includes this statement:

She narrates the story: "I applied for the five-year MBBS medical course at King's College London in 2002. I had the right grades for that course but I was sidelined onto a six year experimental 'Extended Medical Programme' (EMDP) because I am black and from a London borough with a high percentage of the ethnic minorities." That was just the beginning.

NHS behind the headlines

For anyone working in the NHS who is concerned about justice and fairness, Rita Pal is essential reading. On this occasion, however, I have to say that I am not convinced by  this post  and, I am afraid, even less by this one.  But please read them both and make up your own mind.

Stafford Hospitals still better than homeopathy

Britain's leading newspaper tells how Stafford Hospital fought to hit New Labour health targets. Put your coffee down before you read the full article or, like Dr Crippen, you will be hairdrying your keyboard for half an hour.

One of [Stafford Hospital's] main innovations was a drive-in morgue which allowed ambulances to deposit live patients directly into the mortuary, sometimes days earlier than would have been the case had they just been left to die in a corridor in line with NHS targets...

The Daily Mash

Sarah Harman jumps on the Jade Goody bandwagon

Sarah Harman, sister of Harriet, and founding partner of solicitors Harman & Harman is someone who believes that there is no such thing as bad publicity. Two days ago, we looked at Sarah Harman’s much publicised gratuitous speculation on the competence of the doctors who have been responsible for Jade Goody’s medical care. Harman does not purport to be acting for Jade Goody and it seems that her speculation is based only on what she has read in the papers. Behaviour like this resulted in Professor David Southall being hauled up in front of the GMC. Maybe the Law Society is more flexible.

One NHS BLOG DOCTOR reader was so outraged that he emailed Sarah Harman the link to the article. This is her reply.

--- On Tue, 17/3/09, harmansarah@talk21.com wrote:

From: harmansarah@talk21.com
Subject: re Jade Goody etc
To: ........@yahoo.co.uk
Date: Tuesday, 17 March, 2009, 9:34 AM

Thank you for showing me the link.

It's very good publicity for me!

Sarah Harman

 Today I notice, under the “breaking news” section of the Harmon & Harmon website, she is reporting the story from the Sun herself. Extraordinary, at a time when even Max Clifford is saying enough is enough.

Feeding the crocodiles

Do you remember that wonderful story told by Desmond Tutu?

Many years ago, the Christian Missionaries arrived in Africa. They had their bibles and we had our land. And they said to us, “Close your eyes, and let us pray.” So we closed our eyes, and we prayed. And when we opened our eyes, we had the bibles and they had the land.

Why can’t the God botherers leave Africa alone? In Barbara Kingsolver’s excellent book “The Poisonwood Bible", the hell fire and damnation missionary preacher tries to persuade the wise local chief to allow his tribe to be immersed and baptised in the crocodile infested river.

And so it goes on. This time it is Obersturmführer Ratzinger who is leading his flock to crocodile infested waters.

Pope Benedict XVI has said that handing out condoms is not the answer in the fight against HIV/Aids, as he makes his first visit to Africa as pontiff.

He said distribution of condoms "increases the problem". The Vatican urges abstinence. HIV/Aids was "a tragedy that cannot be overcome by money alone, that cannot be overcome through the distribution of condoms, which can even increase the problem".

The solution lies in a "spiritual and human awakening" and "friendship for those who suffer", the AFP news agency quotes him as saying.

Baptised Catholics made up 17% of the African population in 2006, compared with 12% in 1978, the Vatican says.

BBC

If 17% of the African population follow his advice rather than the advice of the doctors, nurses, and contraceptive workers who are desperately trying to change the sexual culture by promoting the routine and regular use of condoms, there will be tens of thousands of deaths from HIV/Aids. Deaths that could so easily have been avoided.

Who will rid us of this turbulent priest?

+++++++++++

A reader emails me to draw my attention to this extraordinary Channel 4 interview that I had missed.

It couldn't happen in Britain : Staffordshire General Hospital

Finally, at last, the truth has emerged about the scandals of health care in Mid-Staffordshire NHS Trust. 

A hospital's "appalling" emergency care resulted in patients dying needlessly, the NHS watchdog has said. About 400 more people died at Staffordshire General Hospital between 2005 and 2008 than would be expected, the Healthcare Commission said.

It said there were deficiencies at "virtually every stage" of emergency care and said managers pursued targets at the detriment of patient care.

BBC

There is a much fuller report in today’s Guardian. Please read it all.

• Assessing the priority of care for patients in accident and emergency (A&E) was routinely conducted by unqualified receptionists.

• No all-day, on-call cover by consultants because of shortages meant junior doctors were not adequately supervised.

• The trust had two clinical decision units (CDUs) which staff said were used as dumping grounds to avoid breaching the four-hour target for being treated in A&E

• There were not enough nurses to care properly for emergency patients

• Nurses lacked training

• The shortage of nurses on wards meant call buttons went unanswered…patients were sometimes left for hours in wet or soiled sheets...

• Delays in operations were commonplace

• There was often no experienced surgeon in the hospital after 9pm

• Few patients were given the drug warfarin to help prevent blood clots

• Essential equipment was not always available or working

• The trust board was more concerned with finance, targets and achieving foundation status, with little evidence that poor standards of nursing care were identified or discussed

• The trust was poor at identifying when things went wrong and managing risk

Full report in the Guardian

Every single one of the problems listed above has been covered time, after time, after time, after time by NHS BLOG DOCTOR. I have today received a comment from a regular reader who, perfectly reasonably, says this:

Interesting to see what further developments come out of Staffordshire. One can’t but help wondering if things where so bad why there are no reports of Doctors Complaining. If they did not surely there are grounds for disciplinary procedures, and if they did and were ignored it is even more shocking and the investigation should move further up the food chain.

Joseph K.

I agree with Joseph K. Allowing this appalling lack of care to continue should be grounds for disciplinary proceedings against any doctor who was involved. So why did the Staffordshire doctors not complain? Once upon a time, one of them did.   A courageous doctor then working in a hospital a few miles away in North Staffordshire NHS Trust complained about the appalling medical care she had witnessed in her hospital. Look what happened to her. She was treated by the GMC in the way that Stalin used to treat political dissidents, including being accused of being mentally ill.

I said elderly people were being helped to die - so they tried to say I was mad
HOW GMC TURNED ON BRAVE NHS WHISTLEBLOWER

By TOM WELLS, Sunday Mercury, 06/02/2005

A BRAVE NHS whistleblower could land a record damages pay-out from the General Medical Council - after it branded her 'mentally ill' in a secret smear campaign. Dr Rita Pal went to the watchdog five years ago, claiming seriously ill elderly patients were being helped to die in Midland hospitals. But instead of taking her shocking complaints seriously, the GMC turned on her. Top-ranking staff openly questioned her sanity and even talked of launching a probe into whether she was fit to practise. Now DrPal could sue for huge damages after a judge blasted the controversial doctors' watchdog for acting like a 'totalitarian regime' similar to Stalin's Russia…

Dr Pal, from Sutton Coldfield, recently won a landmark court case which now paves the way for her to sue the GMC. The preliminary hearing - held last summer - had been brought by the [GMC] who wanted to 'strike out' any lawsuit…before it reached full trial. Instead their case - which cost them £84,000 in legal fees - was thrown out…

Full story here.

Perhaps you now understand why doctors in Staffordshire are too frightened to speak out. Or anywhere else for that matter. But do not lose heart, comrades, for already there is good news from Mid-Staffordshire NHS Trust. "Forward together" the front end of their website proudly proclaims.

Good news from Mid-Staffordshire NHS Trust

"We know that coming into hospital can be a stressful time for many people. We aim to make your stay with us as pleasant as possible."

That must be the understatement of the year for people living in Staffordshire. But the new commissar, Comrade Eric Morton, is full of reassurance:

Following the release of the Healthcare Commission (HCC) report today, Wednesday 18th March, Mid Staffordshire NHS Foundation Trust has formally received the report, its conclusions and recommendations

Commenting on the report Eric Morton, Chief Executive of the Mid Staffordshire NHS Foundation Trust, said; “The challenges the Trust has faced since 2005 have been clearly outlined in the comprehensive report from the Healthcare Commission. This report highlights the work that the Trust and its dedicated staff have contributed to transforming Stafford Hospital from one that was failing to one that is already significantly better in many areas and continuing to improve in the key areas highlighted by the Healthcare Commission.

“The report has highlighted instances where care standards fell below those that our patients had a right to expect of their hospital and we regret this. We would like to take this opportunity to offer our very sincere apology. We would like to reassure the local community that our focus is, and will remain, on providing high quality, efficient and safe health care for the people of Staffordshire.

Comrade Eric Morton : Mid-Staffordshire NHS Foundation Trust

Be under no illusion. What went in Staffordshire is probably going on in a hospital near you. It may not be as bad. Yet. Or, it may be just as bad, but even now is being hushed up. Maybe you do not believe it. But one day soon, you (or more likely your elderly mother or father) will be admitted to hospital. Then you will know.

Ben Bradshaw has apologised to the country. Why has he not resigned? Why has Alan Johnson not resigned? What has happened to ministerial responsibility? Can someone please tell me, how big does a health care catastrophe have to be before the politicians in charge resign?

Independent madwives : more allegations of negligence

Deborah Purdue

We have looked before at the activities of Deborah Purdue, an Independent Midwife in Wiltshire.

Why choose Dorset & Wiltshire Independent Midwives?

Frances and Debs share a similar philosophy that women are in the best position to choose the safest and best way for them to give birth. We both have experience with women choosing all kinds of care packages and are keen to support couples to achieve the birth experience they would like.

We both believe that 'less is more'. The less we do - the more we give. We believe that most women can give birth normally with minimal intervention if well prepared and supported, and able to do so in peace. Of course, some women and some babies need assistance, but even if the birth does not go according to plan, the aim is always to keep women involved in decisions regarding their care so that they feel that their choices have been respected.

Dorset & Wiltshire Independent Midwives

Why indeed would you entrust your care to this woman? It seems that "less care" means more trouble and the avoidable death of a baby. Purdue now faces a number of charges relating to the tragic outcome of the home birth for which she took “responsibility”. Full details here. If the facts alleged are proven she should be struck of and then, I hope, there will be a manslaughter charge.

Meanwhile, our dear friends, the Independent Midwives of Kent continue to boast of their management of a home delivery that any doctor, indeed any sensible midwife, would condemn as negligently incompetent. I still shiver when I read of their behaviour and, most of all, their staggering lack of insight. I say any sensible midwife would condemn their management. Is Helen O’Dell a sensible midwife? You would hope so, because she is the Local Supervising Authority Midwifery Officer for the South East Coast. The Kent Midwives say in their pseudo-blog that Helen O’Dell commended their management of this particular birth. Helen O’Dell has not commented nor has she asked the Kent Midwives to stop using her name. Maybe Helen O'Dell she really does approve of Kent Midwives.

When is someone going to stop all these women from plying their dangerous trade? And they are dangerous. So dangerous that no one will insure them. Trouble is, they have no insight. We must again recall the statement from Anne Francis, a spokeswoman for the Independent Midwives’ Association. A statement that still shocks me even though I have read it many times:

Independent midwives tell mothers-to-be verbally and in writing at the first meeting that they are not covered for claims.

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

Anne Francis.
Independent Midwives’ Association.

It looks like negligence is about to be an issue for Deborah Purdue

Dr Crippen and his colleagues will be on important government business until the end of the financial year

The QoF chase is on. The end of the financial year approaches. The government targets must be hit. One of the many simple things that the government wants to know about your private life, is whether or not you smoke cigarettes. They can get most of the data from CCTV but apparently some people smoke at home. They rely on family doctors to provide further information.  Seems a simple question.  Does this patient smoke? Answer "Yes" or "No".  But Gordon Brown does not do "simple" when it come to data collection. There are a huge number of hurdles to be jumped before the data can be entered in a form acceptable to the government. Fortunately, there is a flow chart to help us. 

Best to click on the Full Screen Toggle in the top right hand corner.
Smoking Flowchart March09[1]

Publish at Scribd or explore others: Brochures & Catalogs government bureaucra

If you have not already told your GP about your smoking habits, please phone him immediately. Otherwise, try not to bother him before April. Until then, anyone who feels ill should consult the quacktitioner at their local walk-in centre.

++++++++++

I must put up one of the finest comments NHS BLOG DOCTOR has ever received. This is what 12 years of New Labour has done to the NHS.

New Labour's NHS : and you wondered where the money has gone.

My husband, early 60s, has never been a smoker. He was bemused to receive a letter from his GP, a few days ago, expressing delight that according to their last surgery records, he was recorded as a non smoker and that unless this had changed, they would update his records. But if he did smoke and would like to stop, please would he phone the surgery and ask for their stop smoking service?

If my husband chooses not to contact the surgery to confirm whether or not their last record is still correct how can his GP ascertain what his current smoking status is? And is this a genuine offer of a service for smokers or a data collection exercise? And if it is a data collection exercise, why has he not been informed of this?

I've suggested that he sends the letter back with "Thanks, but I only do skunk."

Ambulance chasing lawyers

Sally Clark was the victim of a monstrous miscarriage of justice when, on the basis of flawed medical evidence, she was jailed for murdering her two children. One of the most extraordinary aspects of the case was the behaviour of Professor David Southall. He had met none of the family but he saw Sally Clark’s husband, David, being interviewed on television. On the basis of that interview he decided that David Clark was a murderer.

Professor Southall said he had been "stunned" by the interview which led him to believe it was Mr Clark, and not his wife, who was responsible for the deaths. But he admitted making the allegation without having met the family or seen their medical records.

Richard Tyson, for the GMC and Mr Clark, said: "This case is about Professor Southall's dogmatic belief in his own expertise which he brought to bear on a case in which he had no professional involvement but in which he intervened in a high-handed fashion largely on the basis of watching a programme on TV.

The Independent

A GMC panel ruled that Professor Southall's actions were "inappropriate", "irresponsible" and "misleading" and he was banned from working in child protection for three years.

Let us turn now to high profile solicitor Sarah Harman, founding partner of Canterbury solicitors, Harman & Harman. There is no suggestion that she has been instructed to act for Jade Goody. But she still feels free to comment on the professional skills of the doctors who have been treating Ms Goody.

'Case for negligence'

Legal advice ... Sarah Harman

A TOP lawyer says Jade appears to have a case for medical negligence.

The star was diagnosed with advanced cervical cancer three years after a series of collapses and episodes of bleeding. Sarah Harman said: “If you are losing blood and collapsing, your cancer is established. It’s strange it wasn’t diagnosed. Jade’s symptoms should have been investigated. If previous biopsies and smears show the same cancer fingerprint as the current one and her chances of survival fall below 50 per cent, she could be in line for a loss-of-earnings payout."

Ms Harman said: “I respect the fact she doesn’t want to sue the NHS, but she has two children to think about.”

The Sun

This is offensive, speculative nonsense. Before we go any further, let us establish one thing. Sarah Harman is a liar. If she respected the fact that Jade Goody does not wish to sue the NHS, she would have said nothing. Now she is by implication accusing Jade Goody of not doing the best she can for her children.

“I respect the fact she doesn’t want to sue the NHS, but she has two children to think about."

How dare this odious woman imply that Jade Goody is not doing everything she can to protect and care for her children? We may not be comfortable with some of the mawkish publicity but it is abundantly clear that, in her own way, Jade is doing everything she can for her children. The only real job that Jade has ever had is that of being a minor celebrity. She does it well. Jade understands publicity, and the media, and she knows how to use them. This is her job. And so, even though critically ill, she is working away openly and honestly at the job she knows best. She is not trawling the gutter for ambulance chasing lawyers. How can one not admire her determination?

Sarah Harman has in any case got her facts wrong. The commonest cause of heavy vaginal blood loss and collapse in a female of Jade Goody’s age is a miscarriage. Or even heavy periods. Cancer of the cervix might cause vaginal bleeding, or bleeding after intercourse, but the bleeding is usually light. Heavy bleeding would be unusual and does not initself mean that there is an underlying cancer. Many women with heavy erratic periods who have read this provocative quote may be unnecessarily distressed.

But we do not need to delve into the medical text books. This is all speculative. You cannot make a gynaecological diagnosis on the basis of a newspaper article. Just like David Southall, none of us know the facts, and thus there is no foundation for accusing Jade Goody’s doctors of professional negligence. Sarah Harman's remarks are defamatory. I hope she gets sued. And, just like David Southall, I hope she gets reported to her professional organisation. 

So who, precisely, is Sarah Harman?

She is the founding partner of the Canterbury solicitor’s firm, Harman & Harman. The first thing you see on her self-promoting website is that she is mentioned in Lawyer Magazine's Top 100 solicitors. Nothing wrong with that. Websites like this are designed to be self-promoting. Unfortunately,  there is another matter that is not prominently displayed on the website. Sarah has “form”, as the lawyers would say, for indulging in shady and disreputable professional practices, and for dishonestly concealing evidence from courts.

Sarah Harman, a leading family lawyer, was last night found guilty of "conduct unbefitting a solicitor" for misleading the court and passing confidential court papers to the solicitor-general.

The solicitors' disciplinary tribunal suspended her from practice for 3 months from January 1 2006. She was found guilty of contempt of court in a high court judgment last year, and ordered to pay £25,000 costs personally in the case of the client whose papers she disclosed. She also resigned as a recorder, a part-time judge.

Oh! Dear!  How distasteful. But it gets worse, for who was the solicitor-general at the time? None other than Harriet Harman, Sarah Harman’s sister.

Sarah Harman hoped her client's case could be reviewed in a trawl through family cases expected to be launched by the then minister for children, Margaret Hodge. The solicitor applied to the high court for permission to put anonymised confidential documents about the case in the public domain. But she omitted to tell the judge she had already passed the anonymised judgment in the case to her sister, who sent it to Mrs Hodge, and sent case summaries to her client's MP and several journalists.

Oh! Dear, Oh! Dear, you may say. But there is still more to come.  Harriet plays the cancer card in her sister’s defence.

Harriet Harman, now a minister in the Department for Constitutional Affairs, told the tribunal her sister had been "very distressed and anxious" at the time because she had been diagnosed with malignant melanoma and had to have two operations.

The Guardian

Pass the sick bag, someone.  Jade Goody has cancer, remember, and she is dying of it. Do you think she wants to read in the paper that she should be suing her doctors for negligence? Is Sarah Harman showing "respect" for her wishes?

This gratuitous speculation by Sarah Harman is unprofessional behavior, as was David Southall’s. Jade Goody does not wish to sue the NHS. It may be she does not wish to sue them because she has had exemplary care. We do not know. Sarah Harman should be reported to the Law Society, just as David Southall was reported to the GMC.

Sarah Harman is a solicitor. She behaved unprofessionally in the past. She knew then that she was breaking the law:

A family lawyer accused of conduct unbefitting a solicitor for passing sensitive court papers to her sister - Harriet Harman, the then Solicitor General - accepted that what she had done was "unlawful but not awful", a tribunal was told yesterday.

Daily Telegraph

What is it about these Harman girls and their attitude to the law of the land? “Unlawful but not awful” says Sarah in the same way as her preposterous sister refers to the "Court of Public Opinion".

I finish by paying tribute to one of my favourite Roald Dahl short stories, The Umbrella Man. No, I am not going off-topic as you will see from Guido’s modern retelling of the tale. Pure joy.

++++++++++

And read Cot Death, Infanticide and Child Protection in which Jonathan Gornall takes a more detailed look at the background to Sarah Harman's decision to break the law.

The tragedy of Jade Goody : would she have had a better outcome in America?

A couple of days ago, we looked at the excellent article on The Tragedy of Jade Goody in the “Blog that ate Manhatten”.  It is well worth taking a look at the comments that the article has generated. Having worked in the USA, I know that there is a general assumption amongst Americans that the NHS is not competent. Americans fear anything with the word “socialist” in it, and the NHS is seen from afar as “socialised” medicine.

There is a theme running through some of the comments in the Blog that ate Manhattan that Jade Goody’s problems are a direct result of the failings of the NHS and a consequent implication that “nothing like this could have happened in the USA”. None us know exactly the circumstances in which Jade Goody rejected medical intervention until it was too late, but all doctors know that such behaviour is not as uncommon as the layman might think. There is a small number of patients who, whatever is on offer, will not seek appropriate medical attention even though they have an obvious serious illness. We have all, for example, seen an elderly lady who finally presents feigning ignorance about an obvious fungating breast cancer.

American medicine at its best is the best that medicine can be. But the Americans do not have a monopoly of wisdom as to how best to provide reasonable health care for the whole population. Far from it. Not all can freely access the "motherhood and apple pie" American dream. Most Americans do not have perfect white teeth and do not live in a little house on the prairie. The poor health care provisions for the uninsured in the USA are a scandal and yet, when an Obama or a Hilary Clinton propose policies to address the problems, policies that must inevitable include some element of so called socialised medicine, the vitriol of the opposition is breathtaking.

God knows, we do not have a monopoly of wisdom in the UK either, but our dumbed down, more thinly spread NHS caters far better for the impoverished than does the American system. If I have an acute medical problem, and I have the cash or the insurance, take me to the Mayo Clinic. But if I am unemployed and have a chronic medical problem like Rheumatoid Arthritis, I will stay in the UK thank you very much.

I do not think Jade Goody was failed by the NHS. Coming from her background, had she lived in America and not been a Big Brother star, she would most likely have been one of the unemployed millions with no medical insurance. It might have taken even longer to diagnose her. And, as someone who is terminally ill, should would not have been able to access the quality of care that most of the terminally ill can access in the UK.

Another threat to British Beer

I worry that Sir Liam Donaldson, our well-meaning chief medical officer, is losing the plot. He is worried about the amount of alcohol consumed in the UK. Alcohol related illness costs the NHS a fortune and is a major cause of a wide spectrum of crime. It is a problem. But Sir Liam has taken leave of his senses. He is going to penalise moderate drinkers from low income families.

Sir Liam is suggesting a price hike on alcohol to a minimum of 50 pence per alcoholic unit. I will leave the DK and his colleagues to give us an analysis of the civil liberty implications, the patronising paternalism and a detailed character analysis of Sir Liam. Sir Liam’s suggestion is an outrage, and will not work. Do you really think that people who already pay £50 or more for a bottle of claret will even notice? The more impoverished hardened drinkers, including the cider and alcopop swilling teenagers, will notice but will continue to drink just as much. Amongst the really hard up, there may even be a Giffen goods effect so that they end up drinking even more. The only people who will suffer will be hard up moderate drinkers, who may think twice about their Sunday lunchtime visit to the pub.

This is the slippery slope to back door prohibition. Sir Liam should open his history book and remind himself as to what his Irish ancestors (and others) got up to in Chicago in the 1920s. I don’t expect Speakeasy’s to open throughout the country to flog illegal cheap hooch, but there is still no doubt that the more you tax something, the more likely there is to be a black market.

What worries me most is that there will be a further influx of those putrid, tasteless, little green bottles of “beer” so beloved in Europe. It is not real beer. Real beer comes from a wooden cask. The French have stopped us using the word “chocolate” to describe Cadbury’s Dairy milk, the greatest chocolate in the world. We should stop them calling their fizzy yellow liquid “beer”. The strength of the Euro has meant a fall off in the numbers of those fat English men with vans who stand in French supermarkets furiously tapping on calculators, frightening the children with their permanently displayed sweaty-crease bottoms. This price hike will be just the fillip they need. They will be back in business. And every time someone in England stays at home to drink from those nasty green bottles that they picked up so cheaply at the car boot sale, that will be another pint of real ale that is not purchased.

The traditional British hostelry is already threatened by the demand for rancid pub grub and fizzy electric lager. The wonderful CAMRA saw off the onslaught of fizzy electric beer led by Watney’s Red Barrel (yes, I am that old, does anyone else remember it?) but I fear that the liberation of the little green bottle purchasing fatties is going to be a more difficult problem.

How the GMC spends our money

All doctors in the UK have to be registered with the GMC.

The GMC currently charges each doctor £390 a year for full registration. According to the GMC there are 232,220 registered doctors in the UK.

232,220 x £390 = £90,565,800

Wow! That’s a lotta dosh. How does the GMC manage to spend nearly £2 million a week? I am grateful to an angry NHS BLOG DOCTOR reader who has pointed me towards the answer. You can find it on the GMC website under the title

Why work for the GMC?

Lots of reasons it would seem. Huge salaries and an indexed linked final salary pension. Index linked not just to the cost of living, but to GMC salaries. Wow! I must get Wat Tyler to provide a costing for purchasing such a pension on the open market. But what makes the NHS BLOG DOCTOR commentator really angry, is this:

Free Private Medical Insurance

All GMC staff are eligible to join the private medical insurance scheme. The GMC has opted for AXA PPP's Corporate Health Plan - Cover Level 2. This is a top of the range plan which includes:

• comprehensive cover for in and out patient services
  
• a stress counselling service
  
• a health information line

Previous medical conditions are covered under the scheme.

The GMC will pay the cost of the premium for your private medical insurance.

Why work for the GMC?

Previous medical conditions are covered under the scheme? What kind of premium do you have to pay to insure your house once the fire had started?

Having stuffed their faces with roast swan and swilled their 1961 clarets, our masters at the GMC must be relieved to know that they can have their heart attacks in a private, HCP free hospital, rather than having to mix it with the common folk in an NHS hospital.

Jade Goody : the lessons to be learnt

Details of the tragedy of Jade Goody have now reached the United States. As so often via Kevin, (and if you ever want a quick overview on what is happening in the USA medical world, Kevin MD should be your first port of call) I arrive at a thoughtful, though in places wildly incorrect, article by Dr Margaret Poplaneczky an American physician and gourmet who lives, works and cooks in New York. She writes the excellent “Blog that ate Manhattan”

Margaret writes sympathetically about Jade.

Whatever you think of Jade, the publicity generated by her illness has led to a 20% upswing in the number of women getting Pap smears in Britain.

And this is a good thing. Because if Jade's story causes even one young woman to get the smear that saves her life, it will mean Jade’s death will not have been in vain.

The tragedy of Jade Goody

Hard to argue with that. The trouble with the cervical cancer screening programme is that those who need smears most are least likely to attend. If the upswing of 20% is drawn from the high-risk population, all well and good. If, on the other hand, this is Miranda and Chloe and their like, who would have a weekly smear if allowed, not much will be achieved. We have to be careful, too, to base our screening programme criteria on science not emotion. Only a couple of week ago, we were told by Professor Mike Baum (and others) that breast cancer screening had got out of control, was doing more harm than good, and instilling unnecessary anxiety in asymptomatic women. It was Age Concern and politicians, not scieintists, who pushed (successefully) for extensions to the previously scientifically determined population that was to be screened.

Now, because of Jade Goody, the media and politicians are pushing for the cerival screening programme to be extended to include younger women:

Ministers are to review the age at which women in England are screened for cervical cancer.

An expert panel will report later this year on whether women aged 20-24 should be offered smear tests, as they are in Scotland, Wales and Northern Ireland.

In 2003, screening in England was moved to start at 25 as it was felt it did more harm than good in younger women.

BBC

Whatever the rights and wrongs, this is an emotional call, made by people who know nothing about screening, made because they are upset by the tragedy of Jade Goody unfolding in the public eye. Jade Goody’s cancer, sad though it may be, is not releveant. Hard cases make bad law.

Margaret then goes on to cover something that is well known within the British medical profession but which has had scant attention in the mainstream media. Jade Goody was warned that she had a potentially life threatening cancer, and ignored medical advice. Medical advice that was repeatedly given.

Jade had more than one pap smear, starting in her teens. At one point, she was even treated for precancerous changes of the cervix. And went on to have more follow up smears after that. But when those follow up smears showed a recurrence of abnormal cells, Jade ignored letters that were sent to her advising her to come in for follow up and treatment.

Why? Because she was scared..

"They had sent a letter to me ages ago, telling that I needed to go in for an operation, but I had been too scared to do anything about it,” Goody confessed.

So Jade put the whole thing out of her mind and pretended it never happened. Until repeated episodes of pain and hemorrhage became symptoms she could no longer ignore. But by then, the tumor had spread beyond the cervix to her uterus. And while a radical hysterectomy and chemotherapy staved the cancer off for awhile, it returned this past month with a vengeance.

And now Jane Goody is going to die.

The Tragedy of Jade Goody

This raises complex ethical questions that need discussion, but first I must correct some wholly inaccurate allegations that Margaret Poplaneczky makes about the UK medical system.

Heck, did Jade even have a source of ongoing care, or, god forbid, a primary physician? I doubt it. This is, after all, a lower class girl from a very rough upbringing - someone, I suspect, whose only contact with the health care system was in public clinics and ERs. She probably bounced around ER’s and hospitals during those years, failing follow up appointments, checking out AMA so she could appear in one or another publicity venue, denying that there was really anything wrong.

The Tragedy of Jady Goody.

No Margaret. You are confusing the UK with the USA. God knows, the NHS is creaking, and we have problems enough, but we do not have “public clinics” for the impoverished poor. In the USA, the impoverished poor, aka the unemployed working class, predominantly black and Latino, may need “public clinics”. In the UK everyone is entitled to a “primary physician” as of right, independent of status and means. Yes, yes, before someone, or no one, or “angry from Tonbridge” writes in, a few people slip through the net, and a few people have incompetent GPs, and there is a difficulty with the homeless who are of no fixed abode, and so on and so forth but by and large most people have a GP. God knows, I do not hold back on criticising the failings of the NHS, but I become amazingly protective when people try to suggest that we have problems akin to those experienced by the medically uninsured in the USA

Around 84.7% of citizens have some form of health insurance; either through their employer or the employer of their spouse or parent (59.3%), purchased individually (8.9%), or provided by government programs (27.8%; there is some overlap in these figures).[34] All government health care programs have restricted eligibility, and there is no national system of health insurance which guarantees that all citizens have access to health care. Americans without health insurance coverage at some time during 2007 totaled about 15.3% of the population, or 45.7 million people.

Health Care in the USA

Whatever happened to Jade, she was not bouncing round American style “public clinics”. Jade had in the past already had medical treatment for abnormal smears, and she was informed of the serious new abnormalities that arose. Sadly, as she admits, she was too frightened to accept the treatment she was offered.

Having disposed of this comparison of the UK and American systems (sorry Margaret, but you pressed the wrong button there) we should look at the much more challenging issue of why Jade did not accept help. Maraget goes on to say:

Maybe, just maybe, there were docs and nurses who tried to help Jade. Folks who personally called, warned, cajoled and hollered at her countless times, until finally, as a last ditch effort, they sent her a certified letter. Health professional who really cared about Jade and wanted to help her, although ultimately she refused their help.

The Tragedy of Jade Goody

That may be what happens in the USA. I do not know. I can tell you what happens in the UK or, at least, what happens in my little part of the UK. At present, if a cervical smear has any significant abonormaliy a letter is sent directly to the patient offering her a free appointment at a gynaecology clinic. Until a couple of years ago, the letter was sent to the GP who then took responsibility for tracking down the patient and making the appropriate referral. I don’t much care for this new system which cuts me out of the process. I preferred to talk with my patients so that I could explain the significance and the seriousness of the smear. A few smears, presumably like Jade Goody’s, show potentially dangerous changes. Most show a bit of this and a bit of that. In this medico-legal day and age all have to be followed up but , frankly, most of the problems are due to over-reporting. Often one can provide a lot of reassurance to a worried patient. I have to accept, though, that impersonal though it is, and despite the additional worry it causes, this direct referral system may mean that fewer patients with abnormal smears slip through the net.

What happens if a women ignores the first letter and does not turn up for the appointment? Both she and her GP get a letter. At this stage, my practice contacts the patient personally and asks her to come in to discuss it. I explain to the patient why it is important to go to the colposcopy clinic for further investigation. I have arrived at this stage on a handul of occasions, and each time the patient has gone for the appointment.

But what happens if, yet again, she does not turn up? How many times do I have to chase the patient? At what stage have I discharged my medico-legal responsibility? At what stage have I discharged my moral responsibility? And does the former cover the latter?

I do not know the answer to these questions, but I do not think I would be going down the American route of being one of the folk who...

…personally called, warned, cajoled and hollered at her countless times, until finally, as a last ditch effort, they sent her a certified letter.

It is a free world, or it used to be. I hate the way that medicine has gone or, more precisely, been taken by the government over the last ten years. I have a handful of patients who have always declined cervical smears and mammograms. I think of one lady in particular whose mother died of breast cancer. “I don’t want to know, doctor. If I get it, I get it. I am not going for a mammogram.” I have offered it to her twice. I have clearly documented in the notes that she does not wish to have a mammogram despite her family history. As far as I am concerned, that is that.

I have patients who will not have their BP taken. I have patients who will not have their cholesterol measured. I have offered. They have declined. I will not warn, cajole, holler and send them registered letters with scary epidemiological data about heart attacks and strokes. As far as I am concerned, that also is that.

I do not know what, if any, pressures were put on Jade Goody to have treatment for her abnormal smears. It is quite clear, though, that she knew she had the abnormalities and declined treatment. Jade Goody is a smart cookie. People don’t often say that, do they? I know, I know, she does not have ten GCSEs, but qualifications are no predicator of rationality. I have patients with university degrees whose approach to medical problems defies all credibility. Few could control the media with the skills that Jade has demonstrated. And good luck to her. I hope she makes a fortune for her family.

Did a doctor sit down with her and explain the significance of the smears? I hope so, though I suspect she probably knew anyway. Could more have been done? I do not know, but I do know that a point is reached at which it would be intrusive and repressive to issue yet more warnings. Whatever happened, it is beyond doubt that it was her decision to ignore the results of the tests. That decision has had tragic consequences but it is not a reason for doctors and, more worryingly, the government to be even more dictatorial.

Another load of balls

It beggars belief. If you made it up, you would be regarded as mad.

Lord Laming's review into services in England found reforms brought in after Victoria Climbie's death in 2000 have not been properly implemented. The peer led the Climbie inquiry and reviewed progress after Baby P's death in the same north London borough. Children's Secretary Ed Balls said he accepted all the new recommendations.

BBC

So far, so good. It sounds promising. What had Lord Laming’s most recent review found?

• There had been an "over-emphasis on process and targets" - resulting in a "loss of confidence" among social workers
  
  
• Progress was being "hampered" by the lack of a centralised computer system and an "over-complicated... tick-box assessment and recording system"
  
  
• There was a lack of communication and joined-up working between agencies
  
  
• A lack of funding made social and child protection work a "Cinderella service"
  
  
• There has been a reduction in child protection posts in police forces since the "initial response" to Victoria Climbie.
  

Yep. That sound’s right. That is New Labour through and through. Poor communication and targets and tick boxes all designed to cover up the cracks in the system. Bit like poor old Mabel, starving to death on a medical ward in a British Hospital, emaciated, covered in shit and pressure sores, dying of malnutrition whilst a whole load of fuck-wit HCPs sit in the office talking about “Productive Ward”. All Mabel needs is for said fuck-wits to roll up their sleeves and get on with some hands-on nursing care.

I digress. Back to child protection. Mr Balls, for it is he, says he accepted all the new recommendations.

No barrier or bureaucracy should get in the way of keeping children safe, he told MPs in the House of Commons.

Balls

So what is Balls going to do? He is going to introduce more barriers, protocols and tick sheets.

All children's services chiefs will be sent for compulsory training in the realities of frontline social work under plans to drive up standards in child protection to be announced today.

A course will be created at the National College for School Leadership to ensure that senior managers are aware of the pressures their staff are under, and are able to do more to address chronic problems of recruitment and retention.

The Times

I’m sorry to lapse into such relatively uncharacteristic bad language, but Balls is an ignorant, arrogant, fuck-wit tosser. What a total prick. This is the blame culture. This is how Stalin did it. If people need "retraining" clearly they got it wrong and must be sent off to the Gulag. What the fuck is the National College for School Leadership going to do to protect children at risk? Come to think about it, what the fuck  is the National College for School Leadership? Does Balls really think that social services chiefs need to go on a course to be “more aware of the pressures their staff are under”? What a complete arsehole this man is.

No one needs to go on a course. We all know why there is a problem.  

There aren't enough social workers. In particular, there aren't enough social workers in child protection.

The reasons that there are not enough social workers in child protection are all too obvious. Obvious, that is, to everyone apart from Balls. Morale is rock bottom in social services because they are grossly understaffed and over-worked. They are underpaid too, not that most of them went into the job for money. Social workers get no respect from anyone. When something goes right, and that is most of the time, they are ignored and taken for granted. When something goes wrong, they are treated like shit. Look at poor old Sharon Shoesmith, currently being publically crucified for the death of Baby P.

No one wants to work in child protection. Why do you think that might be Mr Ballls? And now you are going to demoralise social workers even further by telling them that their directors are piss-ignorant and need to be sent to the Gulag, sorry, the National College for School Leadership, to be  “re-educated.” You are going to take them away from their desks, making the staffing crisis even worse, and send them  on a course to "learn how to prioritise the work."

Who is going to do the work once it is "prioritised", Mr Balls?

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And see Letters from the Graveside from Wat Tyler

The triumph of blogpower : radioactive paedophiles

Finally, Ben Goldacre found a mainstream media platform prepared to let him put foward the science surrounding immunisations, rather then all the prejudice the conventional media usually prefers.  It is unusual, very unusual, for a television company to give a platform to a doctor to put the rational side of the MMR debate. And even then they have to finish with the old chestnut about this being just "one doctor's point of view." I wish they said that every time Dr Wakefield was featured. For the record, Ben Goldacre's views are not in the slightest controversial and accurately represent the views of the medical and scientific community. 

 LBC are still in hiding.

Jeni Barnett's original broadcast was irresponsible. The prejucidical views that she put forward may well cause the avoidable death of a child. I hope she sleeps at night.

There is a fascinating story behind the creation of the video which can be found here on "Be careful what you wish for" - worth reading to get the details of all the legal shenanigans, and also to find out why Ben was not allowed to talk about "radioactive paedophiles."

For those who feel that the excerpt from the Jeni Barnett show featured in the video may not be representative, the full transcript of the show is here:

LBCfulltranscript2

Publish at Scribd or explore others:

The Quacktitioner Royal and the detox fraud

The world sniggers at the heir to the British Throne.

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Let’s face it, the Quacktitioner Royal is not the sharpest knife in the drawer, even in a Royal drawer renowned for bluntness. Mostly, he is a harmless old duffer and his rambling opinions may be dismissed as nothing more than a source of amusement. Now, however, he has gone too far. He has joined the ranks of the pill and vitamin salesmen. Prince Charles has taken his place with Patrick Holford and Gillian MacKeith. Last December, in “The Quacktitioner Royal goes walkabout” we learnt of his visit to Nelson’s. Nelson’s flog overpriced nostrums to people who may be ill. On their company website they say:

Homeopathy today is now widely accepted as an effective treatment for many conditions…

Nelsons

That statement is dishonest. Homeopathy is medically and scientifically unproven.  I challenge Nelson’s, or anyone else, to provide scientific evidence of a homeopathic remedy that effectively treats any medical problem. If they do, I will remove the word dishonest and apologise. Until they do, it stays.

It was whilst the Quacktitioner Royal was at Nelson’s that he referred to his late grandmother:

A lifetime of homeopathy

'When I was very small, I remember so well my grandmother having her wonderful leather pouch with all these homeopathic glass phials in it. It was such a feature of my life and as I got older I became more and more aware of the effectiveness of homeopathy and indeed of complementary medicine generally.'

Quacktitioner Royal

It was Dr Crippen who coined the soubriquet Quacktitioner Royal and it has caught on. A harmless bit of fun. But now Prince Charles has gone beyond fun. He is not just the Quacktitioner Royal. He is the Prince of Wales. He is the heir to the throne. He is the next King of England. People listen to him. People take him seriously. And he has given his name and recommendation to a patent medicine. He is now flogging Duchy Herbals Detox Tincture.

Duchy Herbals Detox Tincture is made from extracts of Artichoke and Dandelion, cleansing and purifying herbs to help support the body’s natural elimination and detoxification processes, and help maintain healthy digestion. Duchy Herbals Detox Tincture can be taken as part of a regular detox program.

Globe artichoke, which has the Latin name Cynara scolymus, is a thistle – like perennial plant originating from Africa. It is easily recognised by its large green leaves and attractive purple flowers. Its is a well known vegetable that can be used in a variety of different dishes, and is also a well known digestive aid.

Dandelion, which has the Latin name Taraxacum officinale, can be found growing throughout the English countryside and is easily recognised by its vibrant yellow flowers. Dandelion leaves can be included in salads, the dried roots can be used as a coffee substitute, and it is also used to flavour herb beers and soft drinks.

We have worked closely with the UK's leading natural healthcare product manufacturer, Nelsons, to bring these 'best in class' herbal tinctures to the market.

The Quacktitioner Royal.

A fifty ml bottle of this rubbish will cost you “only” £10. The recommended dose is 2.5 mls a day. And what does the Prince of Wales say?

Duchy Originals embodies HRH The Prince of Wales's commitment to what he calls a 'virtuous circle' of providing natural, high-quality organic and premium products, while helping to protect and sustain the countryside and wildlife. This in turn helps generate profits for charity rather than for commercial gain.

The Prince of Wales is preying on frail and vulnerable people. He is prostituting the good name of the British Royal family. This is quackery. Duchy Herbals Detox Tincture is fraudulent rubbish. It’s a rip off. Don't waste your money.

Dr Neil Bacon tells lies on Radio 4

Neil Bacon, just back from his skiing holiday it seems, hires a hospital room to promote his website. There is no evidence that Bacon is currently working as a doctor. He likes to style himself as some sort of kidney specialist, but he did not finish the training. He was involved in setting up DNUK but then left that organisation in circumstances which remain unclear. Since then he has been trying to make a living with his new internet venture. It is entirely characteristic of his hypocrisy and duplicity that this promo video is on YouTube with comments disabled. Please feel free to make comments about it here.

Bacon was on Radio 4 at lunchtime today, (soon to be available here) He was once again trying to flog his cynical, disreputable website. Oddly, Hamish Meldrum was cosying up to him, and kept calling him Neil.

Bacon, you will recall, has set up a website which allows people to write in and make defamatory remarks about doctors. You cannot rate Bacon's promo video, and you cannot rate Bacon himself on his own site, because he is not there. But you can look on an independent site called RateMDs where he is still inaccuratele described him as a “nephrologist” (He is not. “Failed nephrologist” would be more accurate. He is not specialist. He is not a family doctor. He is not much at the moment)

The great Rita Pal is, as so often, on the money.

The problem with Dr Neil Bacon is this. He thinks everyone likes him.

Rita Pal

Most doctors do not like Bacon. Most of us think he is a dishonest, internet-spiv. A lot of us wonder why he departed from DNUK. Rita Pal investigated. Essential reading.

On Radio 4 today, Bacon was dishonest. He was saying that doctors enthusiastically welcome his website. Not just a few doctors, but thousands of them. Where does he get that idea from? His mind must be addled. Maybe he hates doctors. Maybe he has never recovered from that thoroughly distasteful picture published by one of his medical colleagues which appeared to show him, semi-naked in a basque, having sexual intercourse with a motor vehicle. Put “Neil Bacon” into Google Images and it is the first hit. Neil Bacon may be dishonest and fraudulent on Radio 4 but that is not a reason for making childish and inaccurate suggestions about his sex life. I fear that every time someone clicks on Neil Bacon in Google Images it will only serve to increase this photograph's  hit rating. We should therefore all refrain from looking at this tawdry composite photograph. If we don't, I fear it will end up on YouTube.

Doctors making fools of themselves

Dr Crippen's favourite : highly recommended

I did not go into medicine to do this, and I agree with this. Nothing more to be said.

Spam, spam, spam, spam, spam...

Over the last three days NHS BLOG DOCTOR has had over two thousand computer-generated comments posted advertising the usual load of drivel. I have therefore turned on comment protection so that only registered users can comment. It only takes a few seconds to sign on and choose a pseudonym. This does not in any way threaten your anonymity if you wish to protect it. I am sorry for the inconvenience. Perhaps there will be one advantage. The ubiquitous "anonymous" will have the opportunity to chose a unique and memorable name.

Dr David Salisbury threatens to sue anti-vaccine web site

Doctors and science bloggers are horrified by the activities of the militant anti-vaccine brigade. Occasionally, we try to discuss, even argue with them. We throw science and evidence at them, and they throw emotion and irrationality at us. But it’s a free world, and life goes on. Mostly, we try to ignore them.

I would never have thought that I would one day write in support of an anti-vaccine web site and yet that is the position in which I now find myself. The One Click Group was set up six years ago by Jane Bryant, who styles herself as a mass communications professional, "to help her sick son."

One Click sets itself a wide-ranging brief, and covers many areas of medical controversy. In my view – and that, for what it is worth, is a view shared by the overwhelming majority of the medical profession - the stance One Click takes on most medical issues is wrong. Utterly, totally, at times dangerously, wrong. One Click is a repository of wibble and is best ignored.

Bill Welsh has a grandson who is autistic. He was convinced that the autism was caused by an immunisation. He campaigns about the "dangers" of MMR immunisations. He submitted a complaint to the GMC against the head of the immunisation programme, Dr David Salisbury. Not surprisingly, the GMC threw the complaint out.

Martin Walker, who styles himself as an investigative journalist, wrote a trenchant article entitled “To encourage the others”. I have read both the complaint and the article. Bill Welsh’s complaint is based on emotion, not science, and in my view has no merit. But I have to admit to a streak of admiration for Bill. This is the true citizen-litigant starting his attack at the top. He does not go for the foot soldiers; he goes for Dr David Salisbury himself. Tilting at windmills, maybe, but that is what democracy is about. Remember Peter Tatchell trying to carry out a citizen’s arrest on Robert Mugabe for crimes against humanity? Wonderful stuff. Makes me proud to live in this country. You wouldn't see that happen in China.

Martin Walker’s article is less stirring. He makes some strong points about the dangers and problems of mass immunisation programmes but his few good points are lost in a deluge of pseudo-science, eclectic self-justifying examples and all pervading vitriol.

One Click has published Bill Welsh’s complaint and Martin Walker’s article. David Salisbury is a well-qualified doctor and immunisation expert. He is a man of integrity. I am a strong supporter of the immunisation schedules he recommends and for which he takes responsibility.

Dr David Salisbury

It seems, however, that his political and PR skills do not match his medical skills for he has just had a hissy fit and threatened legal proceedings for defamation against One Click for publishing details of Bill Welsh’s complaint and Martin Walker’s article. The solicitor's letter is from Elaine Heywood of Blake Lapthorn and contains gems such as:

At page 7 of the essay, Mr Walker refers to an episode of Faulty (sic) Towers and the comic character Basil Fawlty. The essay then states:

“A similar comedy about the JCVI, might begin with David Salisbury reminding everyone not to mention deaths and adverse reactions to anyone, from which a committee meeting moves on to consider a whole host of death and adverse reastions which have in some manner to be ‘talked away’.

Our client is an extremely experienced doctor who trained as a paediatrician and who is a member of expert groups which advise on Vaccine safety and immunisation practice. To compare him to a comedy character and object of ridicule in this manner is clearly defamatory to our client.

Elaine Heywood : Blake Lapthorn

What a load of nonsense. How would Ms Heywood have coped with Hogarth? Are we to sue Guido for publishing pictures of Gordon Brown picking his nose? Are we to sue Dennis Healy for calling Margaret Thatcher Attila the Hen? Or Vince Cable for comparing Gordon Brown to Mr Bean? Or every journalist in the UK for saying that Gordon Brown is incompetently pursuing policies that are damaging the country?

David Salisbury may be a doctor, but he also is a politician in a political role. He is appointed by the government to run the immunisation programme and part of that brief is to demonstrate to the public that immunisations are safe. His head is, by choice, above the parapet and he is fair game for criticism and for satire. He must take the rough with the smooth. Is the government immunisation policy sensible? Yes, it is. Is the government doing a good job convincing the general public of the safety of its immunisation policy? It is not. Is David Salisbury doing a good job in presenting this policy? No, he is not. And yes, before Ms Heywood picks up the phone, I know that remark is defamatory. I am happy to publish a reply from Dr Salisbury if he wishes to make one. (email to nhsblogdocATgmailDOTcom)

David Salisbury does not work on the front line with patients. I do. Like David Salisbury, I am a believer in immunisations. Like David Salisbury, I believe in the importance of herd immunity. Unlike David Salisbury, I spend a lot of face-to-face time trying to persuade young mothers, with babies on their knees, to give the immunisations. The concept of "herd immunity" does not cut much ice with them. And what is the commonest complaint I get from worried middle-class parents?

“We never hear the other side of the story. If any doctor tries to complain, the government silences them. Look what happened to Dr Wakefield.”

Are GMC complaints to be heard in private? Why should we not read the details of Bill Walsh’s complaint? It was dismissed. The GMC felt there was not a scrap of truth in it. Why not say so in public? You do not need to attack Martin Walker’s article with writs. Attack it with science and evidence based medicine. By trying to silence these two people, you only lend strength to their opinions. The English public does not like big government trying to silence small people.

If David Salisbury wants to set the lawyers on someone, why does he not go for Wakefield himself? Why does he not sue the editor of the Lancet who published the original Wakefield paper? Why does he not sue one of Wakefield’s wealthy supporters like well-known pill salesman Patrick Holford? Perhaps because these people are highly intelligent, have good lawyers and are well able and prepared to defend their opinions.

Instead he is going to sue Jane Bryant, the mother of a handicapped child. Precisely what purpose is served by doing that?

I wonder if David Salisbury and his solicitor have read the obituary column in today’s Times, reporting the death of Sir Martin Doughty? Sir David sued the Sunday Times Insight team for defamation when they criticised the way he had managed a council pension fund. The case went to the House of Lords and was thrown out.

The judgment that was handed down in the case shifted the British legal landscape considerably, resulting in a triumph for freedom of expression and the right to report the public’s business to the public. Their lordships quoted with approval the journalists’ case that “any subject is free to express his opinion upon the management of the country’s affairs without fear of legal consequences”. The landmark judgment contained the further, stinging words: “It is of the highest public importance that a democratically elected government body, or indeed any government body, should be open to uninhibited public criticism.”

The Times

Time for David Salisbury to reconsider his position before yet more damage is done.

The death certificate lottery

A call was put through in the middle of the morning surgery. Eric, an 87 year old patient of mine, had just been found dead in his armchair by his son, David. David sounded distraught. This is not the kind of call that will keep until later. I went straight round.

Eric had ischaemic heart disease. He had his first heart attack at the age of 61, long before I knew him. He made a good recovery. His second heart attack was three years ago. This time the recovery was not so good. He was left with heart failure and was taking a cocktail of drugs including ramipril, bisoprolol, frusemide, spironolactone and aspirin. He still got about. He still managed a weekly trip to Sainsburys and, several evenings a week, the short walk to his club. He was on borrowed time, and he knew it. I last saw Eric about three weeks ago. Eighteen days ago, to be precise. He had come down to the surgery for a routine check. All seemed well. So much for routine checks.

His son and daughter-in-law, and his three grandchildren, all live close by. They were a close and attentive family. David spent last Sunday with them, and it was a rare day that one or the other of them did not call. As luck would have it, none of them called on him yesterday.

When I arrived at the house, I found Eric fully dressed, slumped in an armchair, slightly turned to one side. He was icy cold with purple mottling on one side of this face, and on one hand and arm on the same side. His unlit pipe (he still sucked on it, but had not smoked it since the second heart attack) was on the floor. The telephone on the side table was undisturbed.

I’m no forensic pathologist, but I reckon he had died the previous evening. There was nothing suspicious. He had probably had an acute heart attack. Or a stroke. Or a ruptured aortic aneurysm. Or a pulmonary embolus. Maybe he had just died of “old age”. Maybe his family had poisoned him to expedite their inheritance. No, I don’t believe that for a moment. This was an expected unexpected death if that does not sound too contradictory. But should I issue a death certificate? If you are to certificate death, you have to give the cause thereof. I could write “acute myocardial infarction” and “congestive cardiac failure” as reasonable best guess diagnoses and no one would bat an eyelid.

In years gone by, I might have done that. Not any more. I phoned the coroner’s officer. Post mortems are time consuming and expensive. The coroner's officer was curt and business like. She told me that, having informed her of the death, I was perfectly entitled to certificate. I know that. She told me that in view of the history, Eric probably died of a heart attack. I don’t know that for certain, but I agree that statistically it was a likely cause of death. She told me that if I didn’t issue a certificate they would “be forced to carry out an autopsy”. I know that. She told me that families often find autopsies “distressing”. I know that too. She continued to put not too gentle and none too subtle pressure on me to a certificate. Finally, I said, rather curtly I’m afraid, that I was not going issue a best guess certificate. She sighed and said, “well, we will have to do a post mortem then”.

Most GPs are nowadays reluctant to issue death certificates when there is uncertainly so the post mortem rate is climbing. If Dame Janet “girlie-fast-track-oh-look-they made me-a-judge” Smith has her way, soon two doctors will have to sign death certificates. Then the post mortem rate will soar.

I only issue three or four death certificates a year. Occasionally, the diagnosis is obvious and incontrovertible. Often it is not. When a patient of Eric’s age dies the best diagnosis is often “Old Age”. You may be surprised to hear that “Old Age” is a legally acceptable cause of death on a death certificate. It is. When I was younger and knew more, I never gave “Old Age” as a cause of death. It sounded too imprecise. “Bronchopneumonia” is often called the old person’s friend; it certainly used to be the certifying doctor’s friend. I used it frequently. It is precise and scientific. It is also, usually, a fiction. I often put "Old age" now, but only if I have seen the patient regularly and very recently.

The public needs to think very carefully about the precise purpose of death certificates in the elderly. If diagnostic forensic precision is required, then there has to be a post mortem. That means chopping up grandpa. And even when he has been chopped up, as any pathologist will tell you, it is still not always possible to be sure as to the cause of death.

The more realistic approach is to accept that often the best statement that can be made is, “Look, he was 87 and had a lot of medical problems and, though unexpected, his death was neither suspicious nor in the least surprising and was probably caused by a heart attack or a stroke and thus there is no need to subject him, and his family, to the distressing rigours of a post mortem.” Trouble is, there is not room to write all that on a death certificate.

What about Shipman you are all screaming?  Easy. All you do is count the number of death certificates a doctor issues. If there is any sudden change of frequency, or if one doctor issues more certificates than his colleagues, you investigate. You could set a system like that up tomorrow. Such a system would have caught Shipman in a few weeks and would have saved hundreds of lives.

You could also suggest that coroners' officers do not try to brow beat reluctant GPs into issuing certificates against their better judgement. There is not a GP in the country who has not been put under such pressure.

Caring for the mentally ill : you get what you pay for

His desperate plea for help was ignored : click to enlarge

Sad news today about Daniel Gonzales. Daniel suffered from schizophrenia. Unlike most schizophrenics, he was violent and dangerous. I want to stress that last point. Most schizophrenics are sad, isolated, friendless people who are incapable of violence. Most schizophrenics are like my friend Emily. I still miss her. I still feel angry about the appalling lack of psychiatric care she received from the NHS.

So what happened to Daniel Gonzales? Four murders, two attempted murders and then, alone in his room in Broadmoor, he committed suicide. How could this happen? It seems he begged for help but was ignored. Why was he not sectioned and removed to a place of safety earlier? And what sort of complacent, indolent incompetence allowed this poor, sad man to take his own life whilst he was in a psychiatric hospital?  Where were the staff? Having a coffee break? Filling in forms about the latest government targets?

Despite nearly 60 appointments with doctors and psychiatrists and his own pleas to be admitted to a hospital, Gonzales was free to fulfil his ambition of becoming a serial killer resembling the film character Freddy Krueger, from the Nightmare on Elm Street series.

The Times

How can this happen? Well, the facts of this specific case are not yet in the public domain, but I can tell you how it happens in the area in which I work. It is no longer possible for GPs who are worried about patients with severe mental illness to get their patients assessed by trained psychiatrists. The psychiatrists will not even read our referral letters. Our referral letters go to a pot pourrii of dumbed down mental health care workers who decide what should be done. Collectively, they are known as the Community Mental Health Team (as described in Shocking Psychiatry) The word “Team” is, as NHS BLOG DOCTOR readers know, a favourite NHS word used to dilute repsonsibily. The “Team” only speaks in the passive tense. “It was decided that….” and so on. The passive tense is the grammatical refuge of all who wish to avoid putting their name to a decision.

Make no mistake, it is not easy to decide if and when a mental health patient is safe to be released into the community or, conversely, to decide if and when he is so dangerous that he should be removed from the community. The latter decision is particularly challenging. Even if these decisions were to be made by outstanding psychiatrists (and there are not many of those, for the speciality, with one or two notable exceptions, does not attract la crème de la crème of the medical profession) there would be mistakes. But the decisions are not made by psychiatrists. They may be rubber stamped by them, but the face-to-face, front line assessments are often made by people who have not even been to medical school.

You probably think you could have done a better job assessing Daniel Gonzales. You are probably right. So why don't you have a go? A career in mental health is open to all. You don't have to worry about having been to medical school. Or anywhere else for that matter. You don't beleive it? It's true. Any old fool can apply.

If mental health and a stable, happy life are important to you, then you probably value these same aspects in the lives of other people. One interesting career choice you might want to investigate is working as a community mental health worker. The career itself is a broad term that spans many different educational pathways and jobs that all focus on improving a person's mental health, which ultimately improves their personal happiness and participation in society.

The job classification of community mental health worker is such a varied one and it can be used to represent virtually any career that has a focus on the improvement of a person's mental health. The title may be used to mean many different things from one organisation to another. The career itself can be based in a hospital, client's home, agency workplace, private practice or a health clinic.

A career in mental health

Is it any wonder that there are tragedies.

Women in labour to be denied epidurals : official targets introduced

Oh! Dear God, the birth loonies have escaped from the asylum again.

There is a certain sort of health care professional, well known to the readers of NHS BLOG DOCTOR as a madwife, who believes it to be important for women to have as painful and unpleasant an experience as possible during childbirth. Remember this?

“Sue Macdonald, the chairman of the committee, said: "There is quite a lot of research around which suggests that although it is an effective form of pain relief, an epidural means women will spend longer pushing the baby out of the birth canal and are more likely to need some other intervention."

Miss Macdonald said: "Epidurals have become a kind of norm for a lot of women. Sometimes women think, 'I just want to get rid of the pain, how fantastic'. "

British Midwives want mothers to suffer

A while ago, I wrote:

Midwives were the first nurse-specialists I encountered when I trained as a doctor. I developed an immediate antipathy as did most medical students. I hated the way they patronised the patients. I have never understood why, because a woman is trying to deliver a baby, it is assumed by midwives that she can be addressed by her first name. I hated the way women were made to feel guilty if they asked for pain-relief during labour. I hated the way that, if they did ask for pain relief, a pethidine injection was rammed into their thigh without so much as a by-your-leave and without discussion of the pros and cons. I hated the way that women who asked for epidurals were treated disdainfully. Time after time, I saw midwives delaying calling the anaesthetist for the epidural until it was too late. I hated the way that women who did not want to breast feed were treated as second class citizens and branded as failures. On the post-natal ward, there was a “breast feeding room” but no bottle feeding room. I hated the way that, for all their practical skills, the midwives had little understanding of the science behind their practice.

Dr Crippen

Now it seems that egregious madwifery has become part of government policy. Having an epidural is deemed to be abnormal. There is to be a new target.

The targets are contained in a guidance document, Making Normal Birth a Reality, drawn up by the National Childbirth Trust (NCT) with the backing of the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists.

The document argues that mothers and doctors are too ready to resort to medical intervention and that any such procedure brings risks. The guidance was drawn up 15 months ago, and NHS trusts are now striving to follow it - to the dismay of some of their own experts.

The Times

Some of the arguments produced by the madwifery orinientated NCT are so fraudulent and so patronising to women that they make me want to reach for my revolver.

The authors of Making Normal Birth a Reality argue that better facilities and access to dedicated midwives would make women more confident and less likely to request epidurals. In line with NCT teaching, they say that breathing correctly, assuming the right position and pushing at the right time reduce pain and the need for epidurals.

It is not about confidence. It is about analgesia. Having access to a good midwife (not “madwife”) will not reduce the demand for analgesia or epidurals. Good midwives believe in a woman’s right to choose. Good midwives do not promulgate one set of narrow views to the exclusion of all else. They are not like the Madwives of Kent who still promote their wares on the Internet, and continue to advertise their unconventional and dangerous obstetric practices. They even blog about it; except it is not a real blog, because they will not let you comment.

The controversial restrictions, promoted by the “natural childbirth” lobby, aim drastically to reduce the number of women having epidurals, caesareans or other artificial procedures to 40%. In some hospitals the proportion of first-time mothers now having epidurals is far higher at 60%.

How absurd. How intellectually bankrupt. If epidurals are so “bad” why are we comptemplating a “target” of “40%”? We should aim to eliminate then altogether. So why is the government supporting this madwifery? Because it is cheaper. Epidurals need highly trained doctors to set them up. Even this government would not dumb down the task to the midwives. You cannot learn how to set up an epidural by attending a weekend course even with a flip chart and a plate of Bourbon biscuits. The government is making noises about more home births? Why? Because they are cheaper. And, if a few babies die here and there, so what? Think of the money that can be saved.

Please stop comparing childbirth to a sexual climax. Having a baby is not like having an orgasm. Please stop talking about “natural” childbirth. If you want to have a baby naturally, take a break from farming, crawl under a bush, grunt twice, push the brat out, smear the cord with mud, and get back to hoeing turnips. That is "natural" childbirth. Twenty per cent of the babies and five percent of the mothers will die.

If, on the other hand, you want to have your baby in as safe an environment as possible, stay away from the loony-tune brigade and stay away from the madwives. As regards pain relief, it is your right to have an epidural if you want one. Do not let anyone stand in your way.

The Banker, his pension and the deputy leader of the Labour Party

Harriet Harman

I think I may be able to help Harriet Harman. She has said that she is determined that Sir Fred Goodwin is not to keep his pension.

“Who will rid this turbulent banker of his pension?”

Gordon Brown.

The Prime Minister has spoken. Make it so, Number One. But how is it to be done legally?

Ms Harman declined to say how the government would achieve this but made it clear it would not tolerate the award as it stands.

"The prime minister has said that it is not acceptable and therefore it will not be accepted," she added.

"And it might be enforceable in a court of law, this contract, but it is not enforceable in the court of public opinion and that is where the government steps in."

Harriet Harman interview here

I can help. It can be done and it can be done legally. It is straightforward. There is a mechanism that has been used many times in the past. It is called an Act of Attainder. Parliament simply passes legislation confiscating Sir Fred’s pension. No need to bother with the law of contract or those tiresome courts.

The process of attainder was frequently used when a monarch - or Parliament itself - wanted to deal with political foes without the risk of a court trial. The Constitution of the United States of America specifically bans such legislation but what would the USA know of civil rights? The last Act of Attainder was passed as recently as 1798. And why stop at confiscating Sir Fred’s pension? Thomas Cromwell, Queen Katherine Howard, the Duke of Norfolk, the Earl of Surrey, Lord Danby, and the Duke of Monmouth were all executed under an Act of Attainder.

Excellent stuff.

Medical negligence : Robbie Powell update

Robbie Powell

Last week, in “It doesn’t get bleaker than this”,  we looked briefly at the case of Robbie Powell who died at the age of ten from Addison’s disease. I was going to say “undiagnosed” Addision’s disease, but the word “ignored” would be more nearly correct.

The most recent legal hearing was a few days ago. The Powell family have just let me have a summary and update of the continuing case. If you are interested in justice, or in this case in justice denied,  it is essential reading.

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I get a number of emails from patients and families dissatisfied with care provided by the NHS. Some are vexatious. I wish I could say they all are. Time after time after time people say “All we wanted was an apology and a proper explanation”. What starts of as little more than a request for information is so often met with a barrage of prevarication, indifference, and subterfuge that it soon turns into a formal complaint. It is the usual stuff. It is all "pathways" and "journeys", flow-charts and jargon, and of course an expensive website full of computer graphics. This is the appallingly named PALS  (and, yes, it does have a brochure). PALS is staffed by people so low down on the NHS food chain that some of them are barely literate.

Burying the complaint : The PALS labyrinth

The NHS employs over a million staff in thousands of locations. It is a large and complex organisation providing a broad range of services. It is not surprising that sometimes you or a loved one may feel bewildered or concerned when using the NHS. And this can be at times when you are feeling at your most vulnerable and anxious.

So, what should you do if you want on the spot help when using the health service? The NHS expects all members of staff to listen and respond to you to the best of their ability. But sometimes, you may wish to talk to someone employed especially to help you. The Patient Advice and Liaison Service, known as PALS, has been introduced to ensure that the NHS listens to patients, their relatives, carers and friends, and answers their questions and resolves their concerns as quickly as possible.

The PALS sanitised approach to complaints

PALS specialise in mendacious, fraudulent obfuscation designed to fob you off by burying your complaint in so much Stalinist bureaucracy that you will die of natural causes before you get an answer to your questions.

Addison’s Disease is rare and not easy to diagnose. Any doctor could be forgiven for not making an early diagnosis. But in Robbie’s case the diagnosis had been all but made. A vital test was not done. Notes were not read, or they were ignored. And then, when the tragedy occurred, there was an attempted cover up. This attempted cover up was not properly dealt with by the GMC. And the legal process grinds on and on.

There is no excuse for not admitting fault. There is no need not to admit fault. Mrs Crippen and I pay well in excess of £1000 per month out of our own pocket (yes, there is tax relief on that, but it is still out of our own pocket) for medico-legal insurance from the Medical Protection Society. This gives us unlimited liability for medical negligence. Or, to be more correct, it gives our patients unlimited cover should they suffer as a result of our negligence. As yet, and please God, and I do not know what is in tomorrow’s post, neither of us has had to make a claim. But if I do make a serious mistake, I hope I have the courage to own up and apologise. The MPS will then provide financial compensation.

Robbie Powell has been badly served not just by his doctors, but by the GMC and the legal profession.

The nation reels...

A reader emails me to draw my attention to a sensible article in the Daily Mail. Really. "Pity it wasn't original" he concludes. "They obviously nicked it from here."

I couldn't possibly comment.