Saturday, 12 November 2011

Score one for Sertraline

On the basis of some accumulating evidence of dose dependent QT prolongation with citalopram the manufacturer Lundbeck has issued new guidance on its use. The long and the short of it is that they advise the maximum dose is now 40mg (20mg in the elderly), that it shouldn't be used concomitantly with drugs that also prolong the QT interval (e.g. methadone, tricyclic antidepressants, amiodarone and sotalol), and that it should only be used with caution in those at risk of Torsade de Pointes (CCF, recent MI, bradyarrhythmias, predisposition to hypokalaemia or hpomagnesaemia, including due to medication). This risk also likely applies to escitalopram.

Citalopram is probably the first-line antidepressant in medical practice, partly due to the lower rates of interactions, but give recent evidence that sertraline is more effective, at least compared with straight citalopram (rather than escitalopram), I think sertraline is going to become the go to SSRI of choice now, particularly in the elderly (the maximum dose of 20mg is also the minimum therapeutic dose - so not much scope for increasing it).

Friday, 4 November 2011

Yet more tales of woe from the medical Gestapo

Another affair where the GMC demonstrates how it pisses away the hundreds of pounds in fees paid by doctors to hound those self-same doctors for minor mistakes (highlights below, my emphasis in bold):
The appellant...submitted an application on 8th December 2005 for the post of specialist registrar in plastic surgery in the Oxford and Wessex Deanery. Candidates were required to complete an application form in full.

On 17th May 2011 the panel found that the application form submitted in December 2005 contained seven inaccurate statements which were both dishonest and misleading; that her fitness to practise was therefore impaired; and that she should be suspended from practice for 12 months. She appeals against those findings and the sanction.

Section 6 of the application form required the candidate to list her postgraduate medical qualifications. One of the bullet points states "if you are in the process of working towards a higher degree please say so, indicating expected completion date". [She]..."MD; Leeds University Medical School, UK, Thesis and Viva"; and then, in the final column, which is headed "date passed":
Completion January 2006"
 the panel's finding was as follows:
"...The truth was that far from a VIVA being awaited, your thesis had not even been completed. To imply that is was, applying the test in Ghosh, the Panel is satisfied was dishonest. In reaching its decision the Panel took account of the seriousness of the allegation and your good character. The Panel did not accept your evidence that it could have been worded better. The Panel was satisfied that it was worded in such a way to convey to the reader that your VIVA was expected and by inference your thesis completed and submitted"
Section 7 of the form required the candidate to state what relevant medical or professional courses other than those leading to a post graduate degree or qualification she had attended. [She] listed seven of these. The first was ATLS (advanced trauma life support), which she stated had been attained at the Mayday Hospital, Croydon. Under the heading "date certificate attained" she wrote "2001 C [ie completed] (recertification booked)".

...had in fact successfully completed a 3 day ATLS course at the Mayday Hospital from 13-15 September 2000. The certificate states that it expires on 15 September 2004, that is to say on the fourth anniversary of the last day of the course.

The panel found:
    "...The Panel is satisfied that it was untrue to say that you completed your ATLS course in 2001. In the context of an important job application, truthfulness is expected. You knew this to be untrue. The Panel did not accept your evidence that this was a mistake. This was a certificate relevant to the application. Your application form implied that it was current when it was not. Applying the test in Ghosh, the Panel is satisfied that this was dishonest."
The last entry stated that from August 2004 to December 2005, a period of 17 months, she had worked at Pinderfields Hospital, Wakefield in the speciality of plastic, reconstructive, hand and burns surgery as a "Research Registrar" funded by Action on Plastic Surgery....Section 9 is a single line reading "time in full-time research" and seeking an answer in years and months. The answer [she] gave was 1 year, 5 months. Section 11 asks about "time in plastic surgery (do not include research)". [She] answered that she had spent 24 months as an SHO and 17 months as a registrar. In oral evidence (Day 8, page 378) she said that during this period she spent 50 hours per week on research and her clinical hours were between 40 and 90 per week.

The panel found:
    "...The Panel determined that it was not true that you spent 17 months in a full time research post and spent 17 months in a full time clinical post. That is what your application form conveys to the reader. The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. Applying the test in Ghosh, the Panel is satisfied that this was dishonest."
Paragraph 3(g) of the list of allegations made by the GMC against [her] referred to a statement in the application form "that, during your research project, you had (1) produced 11 publications, (2) produced 21 national and international presentations". This was alleged to be dishonest and misleading. The findings of the panel were as follows [emphasis added]:
    "The period of your research was from August 2004 to December 2005. There were fewer than 11 publications related to your research within that time frame...There were fewer than 21 national and international presentations related to your research within that time frame...The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. Applying the test in Ghosh the Panel is satisfied that this was dishonest."
In a narrative section headed "Other achievements" in the "additional information" section of the application form there were 8 sentences, the fifth of which was "I have produced medical video packages for television which was broadcast internationally on CNN". The charge in relation to this was that it was a dishonest and misleading claim.

The Panel had before it a letter from CNN dated 29th October 2010 which confirmed that [she] "worked as an intern in the medical news department at CNN Atlanta in 1998 and was involved in writing, production and editing of medical news packages produced for CNN Health which were broadcast nationally and internationally." 

In their findings after referring to this letter and the application form the Panel went on:
    "...The Panel determined that it was not true that you had produced medical video packages for television that were broadcast internationally on CNN. It was not true that you were solely responsible for the production of these packages. You were involved in the production with others as part of your internship. The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. Applying the test in Ghosh the Panel is satisfied that this was dishonest." [emphasis added] 
    The findings of the appeal judge were a little more reasonable:
    The above paragraphs of the judgment were circulated to the parties in draft on 1 November 2011. Counsel are agreed that in the light of their contents there would be no reasonable prospect, in the event of remission of the case to the GMC, of a Panel finding that her fitness to practise is impaired, nor of a warning being issued under section 35D(3) of the Medical Act. Accordingly the finding of impairment, the sanction of suspension and the direction for immediate suspension pursuant to section 38(1) of the Act will also be quashed. The GMC must pay the appellant's costs of the appeal, which have been agreed in the sum of £22,000
    What a farce. "Protect, promote and maintain the health and safety of the public" my arse - it's a self-perpetuating and self-interested quango which acts as a tool of the medical and NHS bureaucracy to keep the footsoldiers in line.

    And yet, compare:
    A GUILDFORD doctor who was suspended from medical practice for misconduct last year will be allowed to practise from next month following a case review by the General Medical Council.
    Last year, the GMC found that between 1995 and 2003, Stephen Carr-Bains entered into sexual relationships with two of his patients - both of whom were vulnerable and suffering from mental health problems.

    Dr Carr-Bains, who worked for the Guildowns Group Practice at the University of Surrey, got one of his patients pregnant and then helped her to arrange a termination.
    Following the abortion, the doctor did not put a letter from the British Pregnancy Advisory Service into the woman's records, failed to make any record of the abortion and did not refer her for post-termination counselling.

    Several years later, in 2005 and 2006, the doctor pressurised the woman not to reveal her relationship with him to her counsellor.

    The 56-year-old GP had sex with the other woman while ­‘staying over’ at her university accommodation.
    And contrast:

    The Panel is of the view that you have shown contrition for, and insight into, your actions...the original misconduct took place several years ago in the context of an otherwise unblemished record. Taking into account these matters and all of the public interests at stake, it has, therefore, determined that your fitness to practise is no longer impaired by reason of your misconduct.

    I will leave a comparison of age and ethnicity to the reader. The GMC is not fit for purpose.

    Thursday, 29 September 2011

    Medical students 1 Grumpy old GP 0

    Lovely rant in the Daily Mail about how these new fangled young doctors 'can't diagnose for toffee'. It contains this gem about tactile vocal fremitus:
    If they had pneumonia, and therefore fluid on the lungs, the voice would sound high-pitched, and the vibrations would be reduced. Maybe not infallible, but pretty slick, right

    Oh dear, we'll leave aside that vocal resonance is a better test, and that you wouldn't test for vocal fremitus if the rest of examination was normal anyway, no, the point here is that the vibrations would be increased in pneumonia!* I'd expect my medical students to know this, let alone a GP. What a clown.

    * Don't give me any obfuscatory crap about a parapneumonic effusion - if that's what he meant that's what he'd have said.

    Wednesday, 3 August 2011

    If wishes were horses...

    I've talked about animal experimentation before (e.g. here and here) but I was pointed to this discussion on the Guardian website:

    Dr Sebastien Farnaud of the Dr Hadwen Trust and Prof Roger Lemon of UCL debate the ethics and uses of tests on monkeys

    The opening piece by Dr Farnaud contained so many anti-vivisection tropes I was moved to repeat it here (with my comments):
    "I thank you very much for giving me the opportunity to start this discussion about a very controversial matter, the validity of the use of non-human primates in medical research, a subject in which, as a medical research charity, the Dr Hadwen Trust is particularly interested."
    No, the Dr Hadwen Trust was set up specifically to oppose animal research.
    "The first thing to consider is the aim of the Bateson report, which has just been published, its standpoint and who wrote it.
    This report is an independent review commissioned by all the major research funders in the UK, to assess the quality, outputs and impacts of research carried out on non-human primates, and their benefits to human health. This review follows the publication in 2006 of the Weatherall report by a working group chaired by Sir David Weatherall that recommended that the major funding organisations should undertake a systematic review of the outcome of all their research using non-human primates (NHPs) supported over the last decade.
    Interestingly, whereas the Weatherall report was unambiguously in favour of the use of NHP in medical research, the Bateson report adopts a more challenging position. Professor Bateson, who is emeritus professor of ethology at Cambridge University and president of the Zoological Society of London, is very well respected within the scientific community.
    It is therefore very important that statements in his report, indicating that almost one in 10 research projects that used monkeys in the UK result in no scientific or medical benefit, are not ignored. He also states that the justification for some projects carried out over a 10-year period from 1996 was "inadequate or insufficient" and that future projects involving non-human primates that could not demonstrate plausible medical or social benefits should not be funded."

    I think only 1:10 experiments showing no scientific or medical benefit is a surprisingly high proportion  showing benefit. I'd imagine most scientific research is of minimal use, even medical research, and a figure as high as 90% showing benefit is amazing. Justification for most experiments, when considered outside the narrow question of what people in a particular scientific field think is interesting, is generally poor anyway. So again, I see little to criticise primate experiments over any other area of science.
    "The reviewers also reported the unnecessary and unjustified repetition of work published a decade earlier."
    To be fair, there are plenty of reasons to repeat experiments done a decade earlier, including replicating a study to show that the effect is robust and repeatable, and verifying that you are performing a particular technique correctly by reproducing a know effect so you can then go on to develop that further.
    "These points underline that the issue is not simply an ethical issue but also a scientific one. This simply questions the scientific validity of NHP use in medicine."

    No it doesn't. 10% does not equal 100%.
    "The report recommends the promotion and development of alternatives to the use of NHP in research."
    Well, duh! I imagine 'mom and apple pie' also get a mention.
    "Since most diseases studied in NHP are human diseases that do not naturally occur in NHPs, it seems logical to try to develop models which are from the start human-relevant. Here we have to make clear that nobody is proposing we use invasive methods on human subjects. On the other hand, advanced techniques, which were barely mentioned in the Weatherall report, are highlighted in the Bateson report.. These techniques include, for example, magnetoencephalography (MEG) and transcranial magnetic stimulation (TMS), non-invasive imaging techniques that are already in use to help us understand diseases and the needs of patients who suffer from neurological disorders. Organisations such as the Dr Hadwen Trust have promoted and funded these techniques for over a decade."

    Yeah, because if fMRI doesn't have the anatomical resolution then MEG or TMS are going to do the trick. If wishes were horses...
    "One very important point that the report makes concerns regulation. It emphasises the importance of and the need for a robust system of regulation for animal experiments, at a time when the Home Office is preparing the implementation of the new EU directive for the protection of animals used for scientific purposes."
    Good job UK regulation is the tightest in he world (which is not to say it doesn't focus excessively on process and paperwork rather than welfare).
    "To conclude I would say that although this report will not please everybody, I like to believe that it is a first step towards major changes, a different attitude that will challenge the use of NHPs in medical research."

    Wednesday, 1 June 2011

    FIFA fail

    Ha ha:
    'the head of the Argentinian FA, Julio Grondona.
    "We always have attacks from England which are mostly lies with the support of journalism which is more busy lying than telling the truth. This upsets and disturbs the FIFA family..."
    In an interview with a German press agency yesterday, Grondona called England "pirates" and added:
    "Yes, I voted for Qatar, because a vote for the US would be like a vote for England. And that is not possible. "But with the English bid I said: Let us be brief. If you give back the Falkland Islands, which belong to us, you will get my vote. They then became sad and left."'

    Tuesday, 31 May 2011

    Undercover Care: The Abuse Exposed

    Watch this on the BBC: "Undercover Care: The Abuse Exposed". And then reflect on the failings of the Care Quality Commission in this case* and whether they could detect or act to investigate any similar case in the future**:
    "A specialist residential hospital in Bristol is being investigated by police after secret filming by BBC Panorama found a pattern of serious abuse.

    "During five weeks spent filming undercover, Panorama's reporter captured footage of some of the hospital's most vulnerable patients being repeatedly pinned down, slapped, dragged into showers while fully clothed, taunted and teased.

    "The programme decided to secret film after being approached by a former senior nurse at the hospital who was deeply concerned about the behaviour of some of the support workers caring for patients.

    "Mr Bryan reported his concerns to both management at Winterbourne View and to the government regulator, the Care Quality Commission (CQC) but his complaint was not taken up.
    Ian Biggs, regional direction of the CQC for the southwest, said an opportunity to prevent abuse was missed when Mr Bryan's complaints were not investigated."
    * Headed by the former chief executive of West Midlands strategic health authority (SHA) who presided over the Mid Staffordshire scandal lest we forget, so she has relevant expertise in this area!

    ** Still, at least the unit concerned probably had policies for dealing with dog mess, so it can't have been all bad as far as the CQC are concerned.

    Friday, 20 May 2011

    Some free advice on achieving 'world class NHS productivity' McKinsey style

    Following on from my previous post on McKinsey's recommendations to save money in the NHS, I don't think they've been ambitious enough - where's that blue sky thinking we've come to expect from the cream of Oxford's 20-something PPE graduates?

    As I mentioned before, McKinsey's approach is to list every institution in order of cost/efficiency/whatever and claim that lots of money could be saved if all those 'poor performers' performed at the level of the median. I think this technique can be taken even further, and I'll offer my advice for free!

    The UK spends phenomenal amounts of money per capita on healthcare compared to most countries in the world - using some figures I had leftover from this set of posts on 'The Spirit Level' - we can see that in 2006 the UK spent some $2.5k per capita on healthcare compared to a world median of around $200! That's a potential saving of over £80bn!

    What is that you say, other countries don't necessarily have great healthcare from that $200? Well McKinsey don't deal in trifles like cost-effectiveness and health outcomes, but I suppose I can stretch to looking at that if you insist - I like to think all those years at university were good for something. Using that leftover data I was talking about above we can see what sort of return you get for $200 versus $2.5k. Below is a figure plotting data for life expectancy (in 2007) versus health expenditure per capita (in 2006):

    I've fitted a regression line (which is logarithmic to better reflect the shape of the data). At $2434 the UK gets a life expectancy of 79yrs (versus the predicted 81yrs) while the median spend of $218 would predict a life expectancy of 69yrs (versus a median world life expectancy of 72yrs) - countries spending around $200 include Venezuala (74yrs), Malaysia (74yrs), Kazakhstan (65yrs), Thailand (69yrs), Tunisia (74yrs), Tonga (72yrs), Gabon (60yrs), Fiji (69yrs), Guyana (67yrs), Equatorial Guinea (50yrs), Namibia (60yrs), and Swaziland (45yrs).

    So there you go, save £80bn and 'cut the deficit' or bail out the banks, and it'll only cost you a predicted loss of 10yrs in life expectancy - good value I'm sure you'll agree. No? Maybe that's a bit too radical for you, but there's another approach we could take - look at that figure above again, doesn't seem like you get much of a return for you investment when your expenditure goes past around $1.5k per capita (where the graph flattens out) does it? If we cut our expenditure to $1.5k per capita we would predict a life expectancy of 78yrs and save £36n - thats a reduction of life expectancy of 1-3yrs for billions saved, an absolute billy bargain!.*

    So basically I cannot see how nearly halving UK health expenditure could possibly have any down sides - I've proved it with numbers and graphs and everything! I wonder if McKinsey are recruiting?

    * If you think this proposal is a joke, consider that it is the natural consequence of the putatively 'progressive'  reasoning used in 'The Spirit Level' that increased health expenditure has no beneficial effect on health outcomes like life expectancy for richer countries such as the UK (I disagree) - no wonder David Cameron likes it.

    Thursday, 19 May 2011

    McKinsey save the NHS

    McKinsey in shock discovery that if you put things in numerical order half of them will fall below the median. What tautology will they demonstrate next?

    Via DNUK again - here's a terrifying presentation from McKinsey*:

    In February 2009 McKinsey was instructed by the Department to provide advice on how
    commissioners might achieve world class NHS productivity to inform the second year of the
    world class commissioning assurance system and future commissioner development. The
    advice from McKinsey, in the form of the following slides, was provided in March 2009.

    I recommend having a detailed read to see what a bunch of 20-something Oxford graduates with no experience of the health service can come up with. Basically if everything was done cheaper and more efficiently it'd all be fine - who'd have thought?

    In slide 17 we see how if we just reduced all clinical staffing levels to the median we could save a few billion - no mention of whether staffing levels have an effect on quality of care (another race to the bottom) - indeed they later go on to argue against any attempts to ensure minimum staffing ratios:
    "Some Royal Colleges are recommending introduction of mandatory staffing ratios on safety
    grounds that will lead to increases in staff required above the activity growth e.g ratio of
    1/28 per midwife 

    Certain service reviews are also recommending more staff is required e.g. stroke, children"

    But they argue we should "Limit introduction of mandatory staffing ratios" to save money - they can't be arguing for minimum staffing ratios for any reason, I'm sure it'll all be fine.

    Highlights include slide 28 where they show how you could cut 'bed days' by 10% in mental health if only length of stay could be reduced to the median in the poor performers. I wonder whether those trusts with longer lengths of stays admit more severe patients and don't admit less severe patients, perhaps managing them in the community, and thus have already saved money over the other providers who are admitting less severe patients but getting lower average lengths of stay? Well I'm afraid McKinsey can't tell us because they are analysing data in the same way you would expect someone who has no idea of the context and a money-making axe to grind to do.

    Presumably we could save money by abolishing all those specialist tertiary and quaternary hospitals with their high risk procedures because DGHs get better results for the same procedures. If only these specialist centres could be as good as those small local hospitals, the difference in performance couldn't possibly be because all the really difficult ones get sent to the specialist centres - how are we supposed to show that on our pie charts?

    On slide 53 we can see some of the "procedures with limited clinical benefit" which are "relatively ineffective" or "potentially cosmetic" that we can 'de-commission' to save nearly £1 billion. Femoral hernia repair for instance, as someone on DNUK points out, the risk of strangulation is 45% at 21months in a femoral hernia, this is not a 'cosmetic' procedure!

    A particular highlight is slide 60 where we find out that US physicians who do imaging (e.g. x-rays) in their offices do more investigations than those who need to refer to a radiologist. Presumably this means that we are going to massively increase the training places and consultant jobs for radiologists so we can save a few quid on chest x-rays by running each request past a radiologist first?

    On slide 64 we can see that as digoxin in heart failure doesn't increase life expectancy only improve symptoms we shouldn't fund it at all. Move over NICE and the controversial QALY, if it doesn't stop you dying it isn't worth a penny.

    As someone on DNUK points out, all their reasoning is based on using publicly available data to rank everyone, and then claim that £X million can be saved by making the 'worst performers' as good as the best performers. Conceptually difficult ideas such as figuring out if the factors making worse performers are actually amenable to intervention (e.g. you aren't going to make the people in rural areas all close together and nice and efficient for home visits like in a city however many graphs you draw) are just so much irrelevant detail.

    I wonder how much we could have saved by getting some people who know what they're talking about to do a review instead of McKinsey and their one-size-fits-all Panglossian musings?

    * This isn't new, for instance, the Ferret Fancier reported on it last year, but I think it is timely to revisit what facile idea people like this (yes Lansley, I'm looking at you)have about 'reforming' the NHS.

    Sunday, 8 May 2011


    From BBC 4 - 'Movin' On Up: Pop Hits from 1991' - a look at the early nineties Indie/Dance crossover scene. I have a particular weakness for 'Can You Dig It?' by the Mock Turtles.

    Friday, 6 May 2011

    The GMC is not fit for purpose

    Via (DNUK, the site where doctors go to bitch) I came across this story:
    "A YOUNG doctor who tried to sell her staff pass for free hospital parking can only work as a medic again under strict conditions, watchdogs have ruled.
    "...a foundation year doctor, put her free permit to park at Southampton General Hospital up for sale for £5 on the website Gumtree, the Fitness to Practise Panel of the General Medical Council (GMC) was told.
    NHS fraud investigators found out she later claimed a senior colleague made a sexual advance in exchange for ''looking more favourably'' on the problem.
    "During the meeting, on October 14, 2008, Dr White alleged she was firstly warned she could get the sack by her employers, the Southampton University Hospital NHS Trust. 

    "But the more senior colleague is then alleged to have gone on to say: ''I can ensure that the trust looks on your case more favourably'' and put his hand on her knee before adding: ''What will you do for me?''
    But Brian McCluggage, counsel for the GMC, told the hearing in Manchester the allegation had ''no basis'' and was a ''defence mechanism'' to counteract her difficulty over the parking permit.
    The doctor, who is in her 20s and qualified after completing her medical degree at the University of London in 2007, was not present or legally represented at the hearing.
    She was also accused of breaking a ban on her entering the hospital and failing to attend an examination by a psychiatrist as requested by the GMC." 
    Now obviously what she did was naughty - you shouldn't be selling your free parking permit, even for just £5, but this is a trivial matter that should have been dealt with between employee and employer with a slap on the wrist. This is the consensus amongst the DNUK commenters.

    So what are we to make of her claim that she was sexually propositioned by her educational supervisor? Most of the senior doctors on DNUK think this is highly unlikely and agree with the GMC that this is probably a "defence mechanism". Well I am not so sure. Medicine is stuck in some kind of 1950s time warp where casual racism, sexism, and sexual innuendo are commonplace. Many female junior doctors of my acquaintance have been sexually propositioned by senior doctors (usually their clinical or educational supervisors) and several have been offered inducements (e.g. authorship on publications or attendance at conferences). Even I've been questioned about my sexuality by a consultant on a ward round in front of patients.

    The GMC is commonly used as a tool by hospital trusts and senior doctors to keep juniors in line (paying over £400/yr for the privilege) - how many employees making an allegation of sexual harassment against a senior work colleague are required to to attend a psychiatric evaluation? It wouldn't be possible if this was a simple employer-employee industrial dispute where this kind of punitive action would be illegal, but is just fine when it becomes a 'fitness to practice' issue.

    But compare and contrast:
    "...had all restrictions lifted on his ability to practise after a General Medical Council panel reviewed his case.

    "The former Royal Navy surgeon was convicted at Manchester Crown Court in 2003 of making indecent photographs of children, ordered to sign the sex offenders’ register for five years and given an 18-month community rehabilitation order."
    Or here:
    "...admitted making inaccurate records after the operation and was slammed by the GMC panel yesterday for “significant departures from good medical practice”.

    The panel cleared him, however, of serious misconduct and found that his fitness to practise was not impaired.
    The panel also decided against issuing the surgeon with a warning."

    Friday, 29 April 2011

    Liar, liar, pants on fire!

    Via Dr Grumble:

    Addressing the Royal College of Nursing conference in 2009 according to the New Statesman.

    Wednesday, 20 April 2011

    'Efficiency' is in the eye of the beholder

    From the Guardian:
    One of the big debates around the NHS is whether its budget should be allowed to grow in line with "healthcare inflation", a rate above the national standard that factors in people living longer and demanding more from the service. But Sir John Oldham, the Department of Health's national clinical lead on quality and productivity, has little time for the argument.
    "It's a cop out, is my response," he says. "The challenge we face is one we can't face by doing things as we do now.
    "When people give that challenge to me in a room of clinicians, I ask them each to write down, if they can, one or two things in the last week, in their personal day-to-day frontline experience, with a waste. And I have never walked out of a room without everybody being able to put something down."
    This view is popular with government ministers, who are increasing England's NHS budget by normal inflation and trying to obtain £20bn of annual savings through the Quality, Innovation, Productivity and Prevention (Qipp) programme. It is less popular with many staff and unions, who believe that Qipp means cuts. 
    Unfortunately it isn't these frontline clinicians who get to make the savings, its the managers and bureaucrats and the only way they know to save money is to sack people, they have no idea what is going on at the frontline. This is the absolutely best part of the article:
    All of this would add up to a shift in care for long term conditions equivalent to that which started in mental health a quarter of a century ago, when patients went from institutions to care in the community. He says there are already examples of the openness to change required, such as Tyne, Wear and Esk Valleys mental health foundation trust, which has trained nearly 50 of its staff in use of the Kaizen method for continuous improvement. This involves often simple changes, but made promptly: for example, after staff noticed that nurses were clustering at a station rather than walking around their wards, the trust removed the station the same night. (my emphasis)
    Hah, as a doctor I've already had my office taken away (an office for some six doctors or more) and given to one modern matron to twiddle her thumbs and drink her coffee in (I now have to use the nurses' station), so I'm well aware what a massive time wasting pain in the arse it is to have some moron take away your desk space which you need to complete the tedious reams of paperwork the NHS now requires. Nice efficiency saving geniuses, maybe you could ask why they were all clustering at the nurses' station, probably all filling out  the mandatory risk assessment and care plans that are now required for all patients.

    Monday, 18 April 2011

    Heads I win, tails you lose

    I just learned today that the head of the Care Quality Commission (the health and social care services regulator) is the former chief executive of West Midlands strategic health authority (SHA) on whose watch the Mid Staffordshire affair occurred.

    I suppose you can look at that in two ways, either it is a tacit admission that regulatory authorities cannot be expected to know what is really going on in the organisation they supervise and so bear no culpability for their failings, or, it shows how catastrophic failure is absolutely no bar to career progression for NHS bureaucrats because they take no responsibility for the direct clinical failings of their administrative decisions - heaping all the responsibility onto the front line staff because they can always hide behind the claim that ultimately everything is a 'clinical decision'*.

    * I'll reproduce a comment I made on Neuroskeptic's blog:

    "I love this quote:

    "The Department of Health insists that although Primary Care Trusts can issue guidelines on the amount of drugs GPs prescribe, it is up to the individual GP whether he or she wants to follow them.

    "Hazel's Primary Care Trust, NHS Enfield, admits it changed its guidance to GPs in January but insists doctors were not obliged to follow it."

    Classic administrator response - they will relentlessly hound the GPs who don't follow their guidance to reduce script length yet when they're called out on the negative consequences of their decision they basically say it is all down to the GP and not their fault.

    I'm seeing this behaviour more and more in the NHS - bean counters and other non-clinical staff make decisions that directly affect patient care, usually without any clinical input, and then when the shit hits the fan they blame the clinicians because, after all, they're the ones with clinical responsibility (but no power).

    Heads I win, tails you lose." 

    Not the best doctor in the world

    Now I may not be the best doctor in the world, but I'm pretty sure I can distinguish PEA from VF - you'd think a forensic pathologist would be able to if they're going to declare VF arrest the cause of death:

    "Dr Freddy Patel, the first to conduct a post mortem on Tomlinson's body, said the 47-year-old died of a spontaneous arrhythmic heart attack.
    Patel reached that conclusion through a "process of elimination" after being unable to find the source of internal bleeding into Tomlinson's abdomen.
    "When Tomlinson collapsed, paramedics and, later, an ambulance worker, connected him to a defibrillator. This gave ECG (electrocardiogram) readings (picture the zigzag lines you see on a beeping heartbeat screen).
    Patel's view was that Tomlinson died of an spontaneous arrhythmic heart attack, caused by "ventricular fibrillation" (a fast, irregular wobble of the heart).
    Patel conceded that he was not an expert, but said the ECG readings showed at times "chaotic" activity in the heart, which he said supported his theory.
    The paramedic ECG charts showed Tomlinson had something called "pulseless electrical activity" – meaning electrical activity in the heart, with no pulse and no beating heart[*].
    Another expert, Professor Kevin Channer, from the Royal Hallamshire Hospital in Sheffield, has produced a report on Tomlinson's ECG chart readings.
    He found the ECG readings showed normal activity. Crucially though, Channer said that pulseless electrical activity was inconsistent with ventricular fibrillation (the type of heart attack Tomlinson was said to have died from)."

    * This isn't true, PEA means there is 'normal' electrical activity and no pulse - the heart may still be beating but not pumping around enough blood to give a pulse, this could be due, for example, to loss of blood from massive internal bleeding.

    Wednesday, 13 April 2011

    Nurses have more balls than doctors

    The RCN is usually a pretty spineless union but they've shown more balls than the BMA:

    ...this meeting of the RCN Congress, in the light of Anne Milton's Congress address, has no confidence in Andrew Lansley's management of this Coalition Government's NHS reforms


    For:       98.76% (478)
    Against:  1.24% (6)
    Abstain:    (13)

    Tuesday, 12 April 2011

    Scaring women - easy, profitable, and fun

    According to the Telegraph:
    "Researchers say there might be no safe limit for the amount of alcohol a pregnant woman can drink without endangering her unborn child

    "However, now researchers in Ireland have found evidence that women who drink up to five units a week, equivalent to two 175ml glasses of red wine, could be putting their children at risk of fetal alcohol syndrome.

    "The study found three cases of fetal alcohol syndrome "one each in the low, moderate and high consumption groups". The fact there was one in the low alcohol consumption group led the researchers to question the theory that light drinking had no effect on a baby's health."

    Well this is the paper, in BMC Pregnancy and Childbirth, the abstract sums it up pretty well:
    "A cohort study of 61,241 women who booked for antenatal care and delivered in a large urban maternity hospital between 2000 and 2007. Self-reported alcohol consumption at the booking visit was categorised as low (0-5 units per week), moderate (6-20 units per week) and high (> 20 units per week).

    "Of the 81% of women who reported alcohol consumption during the peri-conceptional period, 71% reported low intake, 9.9% moderate intake and 0.2% high intake.

    "High consumption was associated with very preterm birth (< 32 weeks gestation) even after controlling for socio-demographic factors adjusted OR 3.15 (95% CI 1.26-7.88). Only three cases of Fetal Alcohol Syndrome were recorded (0.05 per 1000 total births), one each in the low, moderate and high consumption groups."
    If we assume all births were single babies (since most will be, and the twins and higher number births will not affect the numbers much) that's rates of foetal alcohol syndrome (FAS) of .0023%, .016%, and .82% in the low, moderate, and high risk groups respectively. That gives a relative risk of FAS in the high alcohol consumption group of over 300x the low consumption group.

    Interestingly the overall FAS rate in the study is 1/10th of the usual estimated rate, probably because this was only those infants detected in the baby check in hospital. So, in conclusion, there were only 3 cases of FAS in this study which is both very low, and also too small to really draw too many conclusions. Any claim about low alcohol consumption causing FAS is basically a case report of one child that occurred with a rate of .0023%.

    Importantly, we have to remember that FAS is believed to be due to heavy drinking throughout pregnancy, and the study did not record this, only alcohol consumption early in pregnancy. If the mother of the FAS child in the low alcohol group was under-reporting her alcohol consumption or went on to drink more heavily throughout pregnancy we have no evidence for a risk of FAS in low alcohol consumption in this study.

    So did the authors really cause such an unnecessary scare by claiming that low alcohol consumption causes FAS as the Telegraph reports? Well here they are in the paper:
    "This suggests that the mothers of the first two infants [the low and moderate alcohol consumption cases of FAS] may have under-reported their alcohol intake at the time of booking as FAS is unlikely to occur at lower levels of alcohol intake" [my emphasis]
    Apparently not. So just another PR/journalist manufactured scare because worrying women about pregnancy, childbirth, and child rearing is easy, profitable, and fun.

    Sunday, 10 April 2011

    Read: 'The Plot Against the NHS'

    Read The Plot Against the NHS which rather nicely details the progressive and deliberate destruction of the NHS under Labour and now the Tories:
    Prices will rise. On the one hand, the cross-subsidisation that is practised inside NHS hospitals will come to an end as the less costly activities are taken out of them, forcing them to charge more for what remains. On the other hand, Monitor will have to ensure that prices are set so that all providers make a profit. To keep the NHS budget down, what is covered by the NHS will decrease. More and more treatments will be ‘decommissioned’ and will become ‘extras’, which you can have if pay for them. This is already happening in one particular way, thanks to another New Labour measure – personal budgets, or lump sums given to patients with chronic illnesses to buy their own care with. If you want more care than the lump sum will cover you can pay for more, if you can afford it. Inequality in health care will be restored.
    If you were to ask me how I thought the NHS could be improved one of the things I would emphasise is that a fundamental priority is to ensure that people brought into hospital as emergencies are treated quickly and effectively - and this means moving away from a 9-5 culture (plus massively scaled down 'on-call' emergency staffing) towards 24hr care where consultant review and radiological investigations don't keep office hours.

    However, government has never been very interested in emergency care, preferring to focus on the 9-5 routine elective operations because they are easy to count and put a price on - paying hospitals fixed tariffs for these. This emphasis has been such that most general hospitals are subsidising their emergency care with routine work like elective surgery or outpatient clinics. After all, it takes a huge number of doctors, nurses, and allied staff to provide even the scaled down 24hr emergency care we have now - getting some money back from this necessary excess capacity by providing elective care is paramount to make ends meet when the remuneration for the emergency care itself doesn't cover the costs.

    Unfortunately the new model of health care, initiated under Labour, and now brought forward by the Tories, envisages that everything will be broken down into its constituent parts and tendered for by various private providers. The Independent Sector Treatment Centres were the start of this - and since elective work is subsidising the huge fixed costs of emergency care there is obviously profit to be made for those who agree to take the routine elective work but don't have the same emergency care commitments. If your patients get complications after your elective surgery and you can just ship them to an NHS hospital ITU without having to cover the cost of that care from the fixed tariff paid for that operation how can you fail to be making a profit over and above the NHS?

    But providing A+E services and receiving unselected acutely ill patients needs more than just A+E staff, it needs the back up of general medics, general surgeons, orthopaedic surgeons, anaesthetists, paediatricians, gynaecologists, radiologists, physiotherapists, ward nurses etc so that once A&E have stabilised and triaged them someone else can actually treat them. That means, at a minimum, all the services of your average District General Hospital - you cannot hive off A&E as an isolated service.

    So what will happen as the DGH revenue streams begin to dry up as more and more of the easy and profitable work is taken over by the private sector? Well since every hospital will now be part of a Foundation Trust they will either have to save money or go bust. Saving money entails cutting services below the already bare bones one we have now - probably a return to the trolleys-in-corridors NHS of the last Tory government - and the rationalisation of services to fewer and fewer centres*.

    Competition isn't going to improve emergency medical care because there can be no market in it - already it is run at a loss because NHS hospitals can cross-subsidise from other revenue streams - they do this because they aren't run to make a profit, they are still, despite Payment By Results and other market 'reforms', trying to deliver good healthcare to the local population. When the NHS becomes just a franchise for private companies to compete for provision it will remain a monopoly provider of local emergency care (if you can't financially sustain one local A+E you're hardly going to open a competing one) so the best the market can deliver is a private company taking over the running of that A+E. But since they won't be able to cross-subsidise emergency care anymore - because other companies will already have cherry-picked the profitable elective work - there will be less money available and standards will have to fall.

    We are moving inevitably to a two-tier NHS where private companies cream off large profits from over inflated centrally determined tariffs for simple elective services like outpatient work and routine operations while complex and difficult or emergency care is provided by an under-resourced remnant of the old public system.

    * For some services, like complex poly-trauma, a rationalisation to fewer centres would improve outcomes as more specialist teams have better results - but this would only be a fortuitous unintended consequence under the Tory plans, and for many other conditions which require less super-specialist provision the extra travel time is likely to prove detrimental.

    Friday, 8 April 2011

    More illness = Good practice

    I have had my attention drawn to this remarkable document distributed to all GP practices in London:

    An Introduction to a Pan London Approach to Improve Quality, Access and Patient Experience in General Practice

    It includes all manner of cunning wheezes to improve General Practice in London. On particular piece of genius includes using predicted* versus the actual GP reported prevalence of various diseases as "an indicator of general practice performance":
    Organisations in the top quartile ranking within London are examples of good practice. Monitoring, intervention and support would be required for those organisations within the bottom quartile ranking in London. Monitoring and support would be beneficial for those organisations within the mid quartiles within London.
    That's right. If you are fortunate enough to have a population with a lower than predicted rate of an illness then you will be judged to be an example of bad practice and failing. But if you happen to have higher rates of illness for some reason, then well done you, you're an example of "good practice"!

    Now I'm no epidemiologist but population level models like this cannot be used to accurately predict the prevalence of disease at a local level** - to tell you what the real burden of disease is that those crappy GPs are failing to detect. A five variable* regression model does not capture all the variation in human disease however much you want it to. The tail is wagging the dog here.

    * "Expected prevalence data are derived using expected prevalence rates provided by ERPHO which take account of age, sex, ethnicity, smoking status and deprivation score at practice level."

    ** They are based, of course, on taking all that local level data and then finding a best fit line between all the real data points - you can't then go back and say that those data points that don't lie on the line are now wrong. What kind of statistically illiterate fool came up with this idea?

    Thursday, 7 April 2011

    Administrators take over the asylum

    I went to visit one of the low level administrators in my trust today. For reasons that are not entirely clear to me she has swipe card access to all clinical areas of the trust including secure units and happily uses it to turn up at inopportune times to bother people (much to the chagrin of the nurses).

    I went to visit her today for a dull administrative reason, turns out trust policy states that doctors aren't allowed access to the administration corridor - we have to ring the person we're visiting and have them let us in.

    Somehow I'm trusted with access to all clinical areas in the local general medical trust (who I don't even work for) such that I could just stroll into the ITU or paediatric ward, yet my own trust won't even let me in to see the woman who arranges leave. They truly have taken over the asylum.

    Sunday, 3 April 2011

    Hyperinjunctions - because not talking about something makes it disappear

    As explained in the Telegraph - our wonderful legal system has a new concept - the hyperinjunction - not the superinjunction where a story can not only not be reported but also the fact that there is an injunction cannot be reported either - this is the next step:
    ...John Hemming, a Liberal Democrat MP, disclosed details of one on the floor of the Commons last week.

    The hyper-injunction goes a step further. Mr Hemming told the Commons that the order, which was obtained at the High Court in 2006, prevents an individual from saying that paint used in water tanks on passenger ships could break down and release potentially toxic chemicals.
    It specifically bars the person from discussing the case with "members of Parliament, journalists and lawyers", along with the US coastguard and any ship owners, and also forbids any speculation linking chemicals in the paint with the illness of any individuals.
    It says: "The defendant must not communicate to the third parties any speculation that the illness of any individual (including without limitation the collapse of H) was, has been or will be brought out by the chemical composition or the chemicals present in the coating of the potable water tanks." 
    According to Mr Hemming, the individual was given a two-week suspended sentence after talking to a lawyer about whether he would take up the case on a no-win, no-fee basis. Mr Hemming said: "What we have, therefore, is passenger vessels trundling around the world with potentially toxic substances being released into the tanks. One of those who worked on the tanks collapsed as a result. 
    Now it may well not be true a true allegation about the paint - but I'm not sure that judges are the ones who should be quashing these things without any public scrutiny - and they certainly shouldn't be able to prevent people getting legal advice after they're granted.

    Saturday, 2 April 2011

    Herbal medicines - because the government thinks you're stupid

    David Colquhoun asks "Why does the MHRA refuse to label herbal products honestly?"

    Basically the EU regulations state that you must have the following on the label of a herbal remedy:
    "Traditional herbal medicinal product for use in [insert baseless medical claim here] exclusively based upon long-standing use."

    And you also get a lovely little kitemark to show that the MHRA has approved your drug:

    They might be broadly safe and manufactured to certain minimum standards but the MHRA refuse to have any requirement to mention on the label that there isn't actually any evidence that this or that herbal remedy can do what the label claims, or even to mention that the evidence shows that it doesn't work at all. And then they boast about how:
    "The growth of the THR scheme means that consumers will have access to a wide choice of over-the-counter herbal medicines made to assured standards.

    "The current signs are that the market will be lively and competitive. The key difference for consumers is that in future they will be in the driving seat and able to make an informed choice when they wish to use these medicines."
    This government (and the last one) and the MHRA think you're stupid. They don't want you to know that these herbal drugs don't work because then you might not buy them. And that would upset their friends in the multibillion pound herbal supplement industry. Because ensuring a 'lively and competitive' market in useless drugs is more important than having a real informed choice. It's just the same story at home as selling useless dowsing rods as explosive detectors abroad.

    Tuesday, 29 March 2011

    NHS reform myths

    Richard Blogger of the torylies blog has a good site addressing some of the 'myths' around the 'reform' of the NHS, here's an excerpt from Myth 10: Private providers will just cherry-pick the easiest cases, undercutting the NHS:
    The Government's Claim:

    The less complex the procedure, the less someone – including in the private sector – will be paid. Unlike Labour, we will not rig the market in favour of the private sector.

    The Rebuttal
    "The less complex the procedure, the less someone – including in the private sector – will be paid"

    This shows a stunning lack of understanding about how Payment by Results works. Each procedure, for example, cataract removal, is paid at the same rate (the tariff). However, not every patient is the same. There will be some cases that are more difficult than others even though they are covered by the same tariff. There is plenty of evidence where this has happened with last government's Independent Sector Treatment Centre programme (ISTC). 
    The problem with the ISTC programme is that the provider was paid for referral, not for treatment. The government says that providers will be paid for treatment, but they do not say that once referred the provider must treat the patient, since there is no such provision in the Health Bill it means that once a private hospital receives a more complicated case they may refer the patient back to the NHS. The NHS has a responsibility to treat patients, private providers will never have this responsibility because they know that the NHS is always there for the more difficult cases.
    This means that if the private providers are cherry picking we will not know about it because such data will be "commercially confidential". There is nothing in the Health Bill to prevent this, indeed, the Health Bill enables private providers to be even more secretive and apply "commercially confidentiality" clauses to their contracts with the NHS.

    The Health Bill will not prevent private providers cherry picking because it does not mandate that once referred the provider must treat the patient. The Health Bill also strengthens the use of commercially confidentiality and so the public will not know whether the private sector are cherry-picking.

    Monday, 28 March 2011

    The fundamental priority of a national health service

    Read this article today from a consultant working in the ill-fated Mid Staffordshire Trust:
    In my opinion a major underlying cause of the ‘Stafford scandal’ was that most of us, including politicians and healthcare professionals, had lost sight of the fundamental priority of a national health service. That is to provide excellent and immediate care to those who become suddenly very unwell. There have been tremendous improvements in many areas such as cardiac, cancer and orthopaedic care.
    However, the importance of the care of sick elderly patients who make up the bulk of our medical ‘takes’ have only rarely grabbed the headlines. Care of these patients is expensive in staff time and resources, it is often difficult and tiring and can only be delivered in a high-quality way by departments which are equipped appropriately, are well staffed by motivated individuals and led by enthusiastic consultants.
    Unfortunately I fear that all these wonderful new innovations in privatised 'integrated care pathways' are going to fragment care and undermine that goal, there may be winners, but it won't be the elderly patient with pneumonia and a hip fracture in A&E.

    Sunday, 27 March 2011

    Politicians and the NHS

    Baroness Murphy blogs on the NHS 'reforms':
    Given the recent Ombudsman’s report about the quality of care for older people, which everyone acknowledges is poor/ disgraceful in many NHS hospitals, and the lack of improvement we have seen with massive investment, I find the idea that the NHS does not need to change difficult to accept.  Could it be that doctors have a vested interest in maintaining the status quo?  (A doctor speaks!)
    This wonderfully highlights the problems with politicians and their view of the NHS (and she's an ex-doctor). First, like so many others who utterly fail to look at the evidence, she makes unsubstantiated claims about how the investment under Labour hasn't translated to increased 'productivity nor outcomes' - this is just untrue in the latter case (and irrelevant in the former case*) - but is a standard trope trotted out to argue against increased funding of the NHS (because, you know, our health expenditure, at the mid-to-low end of the European scale, is clearly so profligate). Secondly she makes the mistake of thinking that because you think something must be done then what you're proposing to do is going to improve things - unfortunately there's just no evidence to say that the governments 'reforms' are going to do any good, and plenty of reasons to believe this thoughtless vandalism of the NHS is going to fuck it up big time, as even the most timid of GPs could tell you.

    Could it be that politicians just don't know what they're talking about when it comes to the NHS?

    * A large part of the increased funding for the NHS went into improving the historically low pay of employees like nurses (which by definition will adversely affect productivity) and in disastrously badly managed GP pay negotiations (which also resulted in less activity for a given amount of money, and thus decreased productivity. 

    Sharing the pain

    Vince Cable:
    ...has confirmed the 50p rate on tax will be abolished

    He told BBC Radio 5 Live: "It moved up to 50p in an emergency because we had to have a sense of solidarity that everybody was bearing some of the pain, and the chancellor said in the budget that we're going to have to move away from that. I agree with him. The Liberal Democrats agree with him.
    I guess solidarity* only goes so far.

    * Talking of solidarity, it looks like MPs have finally agreed to take a pay freeze like the rest of the public sector - I'm sure the increase in their expenses is merely coincidental.

    Friday, 25 March 2011

    Sharing the risk - creaming the profits

    The King's Fund demonstrate their true colours again, according to the GP magazine 'Pulse':
    The King’s Fund has called for entire care pathways to be outsourced to private firms, claiming GPs do not have the time to make the required service re-design in primary care demanded by the NHS reforms.
    What I don't understand is what all this talk of 'risk sharing', e.g.

    ‘GPs can set the standards but consortia will ultimately want to commission organisations to take on the risk.’
    ...a risk sharing model which would see private firms take on service re-design and practice performance management in return for receiving financial incentives
    Now I understand the concept of paying someone for a service, say 'service re-design' or 'practice performance management' but what does it mean to 'share the risk'? It sounds rather asymmetrical, as if you pay a company to take on service commissioning and if it goes badly, well hard luck, you've already paid them, and if it goes well they get a nice big slice of 'performance bonus' to ice the cake - 'heads I win, tails you lose' - and that model's never gone wrong before, and certainly not in the NHS. Good job there will be no financial incentives or conflicts of interest to motivate GPs to adopt that model.

    Of course I have absolutely no idea what these ‘integrated pathway hubs’ even mean:
    ...musculoskeletal, respiratory, and frail and elderly care the first three pathways lined up to go out to tender.
    Does this mean that GPs will no longer be required to know any respiratory or musculoskeletal medicine, or to deal with older patients? The patients will refer themselves to the right 'pathway' presumably ('I've got pain in my chest, I guess that's my lungs, better go to the respiratory pathway hub').

    One wonders how efficient it will seem when all the respiratory or elderly care outpatient work is taken away from the general hospital to be focused in the 'integrated pathway hub' - when suddenly the acute hospital has no money to keep a respiratory team going, no one to put in chest drains, no one to give expert opinion on difficult chest cases - instead they're having to purchase services from these private providers under their 'service level agreement'. What is the ultimate goal - A&E as a glorified NHS call centre referring you to this or that private company and 'care pathway'? Each care pathway 'integrated' with itself but absolutely no flexibility to cover the messy multiple comorbidities that cross the individual pathway boundaries and make up the real cases seen in everyday medicine. Still, at least it will save money.

    Or is it that a 'care pathway' in this case is just one of those referral centres we've seen implemented in areas like musculoskeletal medicine? Staffed with clerical drones who click 'computer says no' and sends the referral back to the GP to ask a physiotherapist to waste their time looking at for six weeks before these moronic box-ticking gate keepers will approve the referral being sent back again - presumably hoping the patient has died or given up in the mean time. For those interested it looks like these care pathways will be like this sort of thing - if my experience is anything to go by they will be vague, inflexible, allow referral centre drones to bounce back anything remotely complicated (because they don't know what the words mean and thus assume it doesn't matter) and ultimately end up with enormously wasted time and duplicated effort. Vive la Revolution!

    Friday, 18 March 2011

    Psychiatry? Orthopaedics? Same difference

    As one wag put it, psychiatry is a recruiting, not a selecting medical speciality. This year there were something like 550 applicants for 480 jobs in core psychiatry training and this was only after extending the recruitment window - locally we had exactly one applicant per job and before extending the window around one applicant for every two jobs. Although it sounds like enough people many of these applicants will be unappointable and many will have applied for psychiatry as a back-up and will get their first choice job (usually general practice, paediatrics, or core medical training) and not take up their psychiatry place. This means that lots of jobs will be filled in 'round 2' where the people who couldn't get in anywhere else and applicants from outside the EU apply (this explains why in one recent year only 6% of people taking the exam for membership of the Royal College of Psychiatrists had trained in the UK for their medical degree).

    But I'm pretty sure stuff like this isn't going to help - the College published the questions to be used at interview in advance this year (although I'm informed that they didn't actually explicitly tell the candidates this) and I'm reproducing the beginning of the 'simulated patient scenario':
    You are an F2 doctor on an orthopaedic ward. Jan Smith has been admitted to hospital this morning as a day case for a knee arthroscopy to be done under general anaesthetic... 
    Presumably recruitment for core medical training included the scenario:
    Imagine you are a consultant neurosurgeon...
    Maybe this is some misguided attempt to be 'fair' to those with no clinical experience of psychiatry but I'm reliably informed that locally there are more F2 jobs in psychiatry than there are in orthopaedics. Maybe the College is afraid to even mention psychiatry in their application - perhaps they think no one applying actually has any interest in psychiatry so there would be no point starting a scenario with:
    You are a CT1 doctor in psychiatry...

    This is not encouraging - I'm also told the psychiatrists on the interview panels had some problems following the ensuing discussions about the management of anaesthetic risks. Do these people have any idea what they are doing?

    Thursday, 17 March 2011

    The future of the NHS

    Duck on the Badscience forums asked me to blog my concerns about the future of the NHS and how what we are about to see is wholesale privatisation.

    What I was saying there is that GPs don't have the time, resources, or infrastructure to suddenly take over all the functions of PCTs next year while carrying on with their day jobs. So, naturally, they will be looking to contract out the commissioning function. But this is just one aspect of the overarching drive towards privatisation.

    Something worth remembering when considering GP consortia is that these are consortia of GP practices, not individual GPs. And GP practices are no longer partnerships of equals but increasingly becoming small businesses which differ from the larger healthcare companies purely in size. The last Labour government introduced the idea that GP practices were not partnerships of GPs by removing the need for a certain number of GP partners for a given number of patients (or rather a given amount of money). Instead they were to be treated as small businesses contracted to provide GP services. This has lead to GP services being increasingly provided by salaried GPs (who are usually more recently qualified GPs) employed by the GP practices which are owned by GP partners (who are usually older GPs). Since these changes were brought in the majority of jobs available for newly qualified GPs are salaried positions and not partnerships.

    So general practice has moved from being an ostensibly private but effectively collectivised system of equals (at least as far as medical staff go, the position of ancillary staff was different) to become a business like any other - the older generation of GPs have taken advantage of the new rules to become small businessmen increasingly acting as employers and screwing profit out of employees rather than acting as traditional family doctors while the newer generation of GPs become wage slaves. It won't be long before the traditional GP practice disappears (as the old partners retire and sell on their stake in the small business they own) as they are swallowed up by larger healthcare businesses - and then who is going to control the NHS budget? It won't be the workaday GPs who will just be employees of these big companies. **Poof** de facto privatisation.

    The words of Liz Kendall (Labour) from the Commons debate on the upcoming NHS cluster-fuck (via Dr Grumble):
    Our health and our NHS are not the same as gas, electricity or the railway. That the Secretary of State believes that they are shows how dangerously out of touch he is. What is the likely result? GPs will be forced to put local services out to tender even if they are delivering good quality care that patients choose and like; hospitals and community services will be pitted against one another when they should work together in patients’ interests; care, which as many hon. Members have said is vital as our population ages and there is an increase in long-term conditions, will become more and not less fragmented; the financial stability of local hospitals will be put at risk, and they will have no ability to manage the consequences of choice and competition in the system; and the whole system will be tied up in the costs of red tape, as GPs and hospitals employ an army of lawyers and accountants to sign contracts and fight the threat of legal challenge, huge fines and the potential of being sued. Let us also be clear that the Bill gives Monitor the same functions as the Office of Fair Trading, so it can fine organisations up to 10% of their turnover.

    The more we see of the Bill, the more the truth becomes clear. The Secretary of State says that he wants clinicians to be more involved, and “no decision about me without me” for patients, but when the Royal College of General Practitioners, the Royal College of Surgeons, the Royal College of Nursing, the Royal College of Midwives, the British Medical Association or anyone else tells him that he should stop, think again and halt his reckless NHS plans, he refuses to listen. When the Alzheimer’s Society, the Stroke Association and Rethink tell him that his proposals will not give patients a stronger voice and improve public accountability, he simply tells them that they are wrong. When health experts such as the King’s Fund warn that driving competition in every part of the NHS will make it more difficult to commission the services that best serve patients’ interests, he simply puts his fingers in his ears and walks away. What makes this Secretary of State think that he is right when professional bodies and patient groups know that he is wrong?

    Doctors and nurses do not support the Government’s plan, patients do not want it, some Conservative Back Benchers and members of the Cabinet do not like it, and the Liberal Democrats hate it. They had the sense last Saturday to see what the hon. Member for St Ives (Andrew George) called the potential catastrophe as far as the future of the NHS is concerned, and to ask for amendments to the Bill. I hope they have the sense to join us in the Lobby tonight.

    Wednesday, 16 March 2011

    A campaign for social science

    Via Church of Rationality I came across this little proposal:
    "...I would set up a campaign for social science.
    This would be a little different from More or Less or Bad Science, great as they are. Very often, they deal with the abuse of statistics. I’m thinking not just of this, but of fact-free hand-waving. What my campaign would do is insist upon more scientific standards of discussion of social affairs. 
    "Now, I don’t know how such a campaign would change politics. I suspect that, very often, it would reveal just how much we don’t know. But it would revolutionize the media. TV and radio would have to drop all those blowhards who just exchange anecdote and hypothesis; in proper science, no-one give a damn abot anyone's opinion - it's the evidence that matters. And it might even reverse the inequality of pay and status between columnists and reporters. "

    Prescribing advice

    Just discovered the 'Prescribing Advice for GPs' blog via Black Triangle, lots of useful stuff for any clinicians out there.

    Placebos in medicine

    Good short response on Comment is Free by Oxford Psychiatry Professor Tom Burns on the use of placebos in medicine and how the media exaggerates the beneficial effects*:
    When researchers write, for example, that 20% of the placebo group recovered in a trial and 60% of the active treatment group did, they are not saying that placebos "have the same effect" in a third as many of the patients. They mean that (for the patients with this condition) 20% will recover in the natural course of events, but with the added treatment 60% will recover. It is this added 40% that matters. The placebo has had no effect on recovery.
    This lead me to a good article he wrote in response to Richard Bentall's tedious criticisms of psychiatry:
    Richard Bentall is right: psychological and social psychiatry research has been a Cinderella to biological and genetic explanations...He is also spot on about the exaggeration and hype of many of their "breakthroughs".
    However, much of his article is so one-sided that those messages risk being lost.

    * The seminal Cochrane review on this topic by Hróbjartsson & Gøtzsche found:
    We found an effect on pain...nausea...asthma...and phobia...
    There was no statistically significant effect of placebo interventions in the seven other clinical conditions investigated in three trials or more: smoking, dementia, depression, obesity, hypertension, insomnia and anxiety, but confidence intervals were wide.

    Tuesday, 15 March 2011

    'Doctor' says screw the NHS

    Via the Jobbing Doctor, according to this BBC story:
    "Dr David Bennett, head of the economic regulator Monitor, has told the BBC he expects to see many more private companies and charities treating NHS patients. If NHS services cannot attract patients they will be allowed to close.

    "BMA chairman Hamish Meldrum said the full implications had been poorly understood."
    As JD points out, 'Dr' Bennett is not a medical doctor*, he's an ex-McKinsey man, and was formerly Chief Policy Advisor to Tony Blair and head of the Number 10 Strategy Unit. Funny how this is not made clear in the article, yet Hamish Meldrum, GP and BMA chairman doesn't seem to warrant the 'doctor' label.

    * I can't find out what his title derives from, e.g. a PhD.

    Friday, 11 March 2011

    Preventing access to psychological therapy?

    Interesting article in the BMJ on the Improving Access to Psychological Therapy (IAPT) initiative started under Labour and continuing under the Tories. It remains unpopular with GPs while being heralded as an outstanding success by central government:
    "The impact assessment on the expansion of the programme, signed off by Mr Burstow, estimates that the cost of providing a course of treatment is £136 for mild mental health problems and £754 for moderate or severe cases. This, the assessment says, is substantially lower than the estimated costs for talking therapies before IAPT, which are quoted as £255 and £1298.

    "Quite where these figures come from is a bit of a mystery because they conflict with those collected by a team led by Professor Glenys Parry of the University of Sheffield, which evaluated the first two pilot sites for the programme, in Doncaster and Newham, comparing them with neighbouring services (Wakefield and Barnsley and City and Hackney). They found that IAPT treatments cost more, not less, than those provided in the neighbouring boroughs, and that it was not possible to say whether the extra costs were justified by better outcomes."
    This accords with the experience of many GPs, mental health professionals, and patients (e.g. see the Shrink here).

    Thursday, 10 March 2011

    Service level agreements in medicine


    All aspects of NHS care for entire diseases are to be put out to tender under radical plans to dramatically expand the role of private companies and charities in running the health service, Pulse can reveal.

    A pilot set to launch across the east of England will put entire NHS care pathways out to tender, starting with musculoskeletal medicine, respiratory care and elderly care.

    As anyone who has seen their local IT services outsourced will be able to identify with, I am wondering what the response time for a chest drain will be under the 'service level agreement'?

    Wednesday, 9 March 2011

    No shit Sherlock

    Saw this paper today:
    Occurrence of depressive disorder was best predicted by a combination of a history of depression and subthreshold symptoms, followed by either one alone. Occurrence of anxiety disorder was best predicted by both a combination of a history of anxiety disorder and subthreshold symptoms and a combination of a history of depression and subthreshold symptoms, followed by any subthreshold symptoms or a history of any disorder alone.
    Now I realise that they were trying to make the point that:
    Past episodes of depressive or anxiety disorders and subthreshold symptoms have both been reported to predict the occurrence of depressive or anxiety disorders. It is unclear to what extent the two factors interact or predict these disorders independently.

    But it did just make me ask whether it was really worth the effort to show that, when all is said and done, people who have had a common mental disorder in the past, and are showing symptoms of it now, are more likely to be diagnosed with it in the future.

    Thursday, 3 March 2011

    Clinical governance

    I've just started working in a new NHS Foundation Trust. Last night I was on-call. During my on-call I got summoned to a ward and told by the nurses to do something - something both illegal and likely to have me up in front of the GMC - 'not bloody likely' I said, 'but it's trust policy they whined'. Eventually they called in the on-call consultant, who wouldn't do it either.

    'Silly nurses' I thought, 'policy indeed!' Now, officially, I'm supposed to have read all 30 of the clinical policies (and the other non-clinical ones too), I've never had the time set aside to do this but the trust have told me to do it so that's their arse covered. They're each 20+ pages long and written in a dreary bureaucratic speak that makes it impossible to easily extract the approximately one line that is actually relevant to clinical practice.

    Having a few minutes of downtime I thought I'd check the relevant policy, and sure enough, there it was, an explicit instruction that in these circumstances a doctor should do something both illegal and likely to get them struck off. I looked at who wrote the policy, a nurse and an admin person (sorry, 'organisational risk lead'), no doctors seem to have been involved.

    So, feeling like a good little boy, I contacted the 'Risk & Clinical Governance Department' to point out this gross oversight - 'oh yeah, someone mentioned something similar in 2008 but the policy isn't up for review until 2012 so we'll take a look at it again then'. Fantastic.

    NHS Whistleblowers

    People often ask me why I spend so much time bitching about how craply run the NHS is in my area rather than submitting incident forms at work and tipping off the local press. The answer is that I want to continue to work in the NHS, and to continue to work as a doctor. The NHS hierarchy, whether that's local management or the people at GMC towers, do no tolerate dissent as seen in this via the Jobbing Doctor:
    Dr Raj Mattu, a consultant cardiologist in Coventry, has finally been dismissed by his Hospital. Dr Mattu made the mistake of criticising the conditions in which patients were being treated in his hospital department.

    Friday, 11 February 2011

    No cuts in frontline services - whiteboards to take up the slack

    We're constantly told by the government that its squeeze on public finances will not affect frontline services in the NHS. We all know this is nonsense. I was at a meeting today where we saw what the cuts, sorry, efficiency savings, actually mean for our trust.

    They have abolished several consultant psychiatrist and junior doctor posts and a great tranche of CPNs, social workers, support workers, and secretarial staff. But fear not, because this will not affect frontline service delivery. How? We all asked. By 'working smarter' we were told by the newly employed 'Team Building Manager', 'Productive Community Champion', and 'Performance Advocate'.

    And what, specifically, does this 'working smarter' entail? We all asked again, because we weren't sure where the extra hours in the day were going to come from to see the same number of patients. And the answer we got was fiendish in its ingenuity. We're going to have a big whiteboard in the reception area of our CMHT community bases. Truly the NHS is safe in their hands.

    The Future of the NHS

    Saturday, 5 February 2011

    Schizophrenia in the Guardian

    A rather nice little piece on a man with schizophrenia and his father who have written a book about the experience:
    "To Patrick Cockburn, it's an illness that has eaten away at his oldest child. To Henry, it has been a revelation. Father and son tell Amanda Mitchison how schizophrenia has changed them both"

    Thursday, 27 January 2011

    Britain: leading the world in fake explosive detectors, because brown people's lives are cheap

    On Newsnight tonight how Britain's military and government promoted selling dowsing rods to third world countries for thousands of pounds. It isn't even like they didn't know about it - they banned their sale to Iraq and Afghanistan but nowhere else:
    "It has been alleged that hundreds of Iraqis died in explosions in Baghdad after ADE651 detectors failed to detect suicide bombers at checkpoints. 
    between 2001 and 2004 a Royal Engineers sales team went around the world demonstrating the GT200, another of the "magic wand" detectors which has been banned for export to Iraq and Afghanistan, at arms fairs around the world even though the British Army did not consider them suitable for its own use.

    The government's Department of Trade and Industry, which has since been superseded by the Department for Business, Innovation and Skills, helped two of the manufacturers sell their products in Mexico and the Philippines."

    The disgusting mandarins of the British government do the security equipment equivalent of letting companies manufacture and export sugar pills to third world countries labelled as antiretroviral drugs for HIV. And they still won't ban their sale because:
    The Department of Business, Innovation and Skills told Newsnight that there was little point: "The impact of any further UK action in preventing the supply of these devices from the UK would be limited if they are available elsewhere"
    It makes me sick.

    Tuesday, 25 January 2011

    The Academic-Medical Establishment

    I was at a talk recently regarding the side-effects of a widely used drug, let us call it 'fictoxetine'. Now fictoxetine has long been thought to cause damage to the body, let us say the retina, leading to progressive visual loss and eventually blindness. Fictoxetine can be used for years, even decades, and so patients need to have their vision screened regularly. This talk reported their findings from a systematic review and meta-analysis that sought to find out whether the evidence actually supported this fear.

    What they presented was data showing that over 1-2yrs of fictoxetine use visual acuity declined by around 10%. They also reported evidence that found that rates of fictoxetine use in people on a register of blind people were around twice those in the general population. They then concluded from this that fictoxetine doesn't really have as much of a major effect on vision as we had thought so we shouldn't be so worried about it and pontificated on how this myth had become so widespread in the medical community.

    The majority of people at that talk took this message at face value and went away with that in their heads, maybe they will change their clinical practice - after all a respected academic in the field of fictoxetine research presented the evidence that showed fictoxetine doesn't have much effect on vision. Didn't he?

    Well no, he didn't, the data I've just described is consistent with fictoxetine having really quite a large and serious effect on vision. If the short-term deficits of 10% in acuity over 1-2yrs continued over 10 years that would be a major loss of 40% of visual acuity. The blind register data is neither here nor there, most people would stop fictoxetine in patients with significant visual loss in the hope that they would never reach complete blindness (conversely, maybe they would be more happy to start it in people who were already completely blind than those with some vision).  So the data doesn't support the narrative being given to it but few people feel qualified or confident to gainsay a big name in the field.

    And this is true throughout academic medicine, and academia in general, powerful personalities are able to shape the discourse in a scientific field not only through the research they perform but also the wider influence their ideas and opinions carry.