All too predictable

From the Guardian:

"Doctor who criticised NHS reforms is threatened with disciplinary action...
...

Prof John Ashton, county medical officer for Cumbria, received a letter from his PCT last week after he joined 22 other signatories to a letter in a national newspaper criticising Lansley's health and social care bill. The letter read: "You are bound by the NHS code of conduct and as such it is inappropriate for individuals to raise their personal concerns about the proposed government reforms." Ashton will have to "explain and account" for his actions at the hearing."

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.

Liar, liar, pants on fire!

Via Dr Grumble:



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

'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.

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.

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

Result

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

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.

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.

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.

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.

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.

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!

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.

'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.

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).

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

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.

Pay and conditions in the NHS

Our trust has just made a big chunk of people redundant, admin staff, nurses and doctors. Last year my pay was increased 1.5% and this year will get 1% despite a recommendation of 1.5% from the Doctors and Dentists' Pay Review Board. For the next two years doctors and many other NHS staff will have a pay freeze.

Meanwhile MPs get 1.5% as recommended by the Senior Salaries Review Board (we'll see if they decide to vote themselves another 1% next year) and the Chief Executive of my trust got 14% last year and 16% the year before, which is high even for the bloated standards of NHS Chief Execs:

All in this together my arse.

Care clusters: A race to the bottom?

Do you think you've got severe depression? Well you're wrong, you are in 'care cluster 4':

"This group is characterised by severe depression and/or anxiety and/or other increasing complexity of needs. They may experience disruption to function in everyday life and there is an increasing likelihood of significant risks.

Likely to include: F32 Depressive Episode (Non-Psychotic), F40 Phobic Anxiety Disorders, F41 Other Anxiety Disorders, F42 Obsessive-Compulsive Disorder, F43 Stress Reaction/Adjustment Disorder, F44 Dissociative Disorder, F45 Somatoform Disorder, F48 Other Neurotic Disorders, F50 Eating Disorder

Some may experience significant disruption in everyday functioning.

Some may experience moderate risk to self through self-harm or suicidal thoughts or behaviours.

Unlikely to improve without treatment and may deteriorate with long term impact on functioning."

So you're basically the same as someone with OCD or an eating disorder. Care clusters (see Figure 1 below) are the result of the Labour government's payment by results programme. You get allocated to a cluster partly based on 'clinical judgement' and partly automatically by a computer program using scores inputed by clinicians to answer 18 questions.*

Figure 1. The 21 Care Clusters

Unlike 'acute' medical trusts which are paid by 'activity' (e.g. how many operations they do) the mental health trusts will be paid by 'need', and that is defined basically by 'care cluster', which a different local tariff for each cluster. So the local mental health trust will get paid for 20 cluster 1 patients, 30 cluster 2 etc. It isn't entirely clear at this point how that will take into account that many patients only stay on a mental health team's books for a few weeks or months.

As with my local mental health trust care providers are now going to start deciding what services they are prepared to deliver for each care cluster based on that cluster's tariff (i.e. how much they'll get paid for treating that patient) and not by the current combination of supply and need. You are not paid by activity, that is by what care (e.g. therapy sessions or meetings) you deliver, but on what cluster someone comes under - therefore there is going to be a pressure to reduce the amount of care provided within each cluster to maximise profit. You also have to wonder whether patients that seem like they'll require more work, and thus cost, than others (e.g. personality disorders) will get taken on at all.

Locally we're developing care packages for each cluster, but you have to wonder how a cluster that includes major depression, OCD, and eating disorders can really have a generic package that is actually includes the appropriate evidence based treatments for those conditions. And where is the room for a bit of clinical judgement and addressing individual patient needs? 

This might not have happened if it was left to the current model where only a single mental health trust provides services to a given PCT but under the new government proposals for NHS commissioning by GPs they are subject to EU competition law and must commission services from 'any willing provider' based on price. So it seems likely there will be a race to the bottom, I may not want to deny you access to, say, psychological therapy, but if another provider is tendering for work with the GP consortium and they don't offer it they will be able to save money and come in under my quote.

This payment regime hasn't been introduced yet but the tools for implementing it are being put in place in 2010/11 ready to roll it out. Something worth looking out for.


* Bah, who says you can't quantify mental ill-health on a simple 72 point scale, and who says depression can't be nicely quantified on a 4 point scale e.g. 

"Question 7. Problems with depressed mood (current): 
0 No problem associated with depressed mood during the period rated. 
1 Gloomy; or minor changes in mood.
2 Mild but definite depression and distress (eg feelings of guilt; loss of self-esteem). 
3 Depression with inappropriate self-blame; preoccupied with feelings of guilt. 
4 Severe or very severe depression, with guilt or self-accusation."