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.