Hotels, check-out times

Generally, seven is about the time I begin legging it around the hospital to check none of my patients look likely to die overnight when they're consigned to the tender care of the Hospital at Night con. As the Good Doctor pointed out, the fact that we junior doctors are now theoretically working far fewer hours does indeed mean that patients are put at risk; thankfully, where I am at least, no one has yet been kicked off the premises by management for staying past 5pm. (The downsides of this, of course, is that we routinely work long hours for far, far less money than even our underpaid equivalents of a decade or two received - and we have to pay for the diabolical accommodation - and that it has obliged the expansion of the allied healthcare professionals' roles into what should arguably remain medical).

Anyway, by and large this week has been good. My on-call last night was a bit hideous, as A&E was overflowing with patients, there were no beds in the hospital (thank you, the Department of Health), and it was so bad they were talking today about converting the physio gym into a temporary ward. At one point, I was going to cannulate a lady (Mrs. A) with an incarcerated hernia I'd been seeing and another lady (Mrs. B) opposite exclaimed "doctor!" and then launched into a two-minute tirade about how if she wasn't seen soon she was going to walk out and it was unacceptable. The nurse I was with, bless her, rolled her eyes at me and pulled the curtain round so I could get on with stabbing Mrs. A.

As I left the cubicle, however, a strange thing happened. Mrs. B called "doctor!" again, only this time it was to apologise. She was very sweet, saying things like 'it was uncalled-for' which were extremely surprising from anyone stuck in an A&E close to breaking point, never mind one in a part of the world where people would tell you to fuck off as soon as look at you. Unsurprisingly, this made me like her enormously, and so I told her it was fine, apologised for the wait, and we got along just fine after that.

So even the hellish on-call had its upsides, and Mrs. A had her hernia done late last night.

Tonight, however, amidst writing in the notes that I would prescribe some saline for a chap whose sodium was crashingly low (122, for those of you who get excited by such things) and then very nearly forgetting to do so, and filling in innumerable blood requests for the next morning's phlebotomists' (or "bleeders", as I like to call them) round, I heard a lady with a broad Irish accent address the senior sister (Karen) on the ward. Initially I wasn't listening particularly - she was talking loudly and had an accent uncommon in the area - but then I heard Karen say something like "if you don't want to be on this ward next time you come in, I can make a note of that in the admissions book".

This piqued my interest. Did this woman not realise that the hospital had no beds? This is not an unreasonable assumption - it has been all over the local news for the past two days that there are no hospital beds. The harridan with the woman then proceeded to say - really nastily - "I think we'll change the whole hospital next time. We won't come here again."

My initial reaction you will perhaps have guessed from my title - but the underlying issue is that people don't currently realise how lucky they are to have a national health service at all. Never mind that it's not a hotel, and never mind that treating Karen and hardworking staff like her as if they're shit because you've suffered some minor inconvenience is unacceptable. (As an aside, plenty of the staff here are anything but hardworking - but more on that later). What do these people think the alternative is? Is there a Special Hospital around the corner where their trivial tax payments are magically converted into their own private physician, caterer, and a master of ceremonies who ensures things happen at the moment they snap their fingers?

Given the average intake of narcotics round here, perhaps they do believe this - but they should go get a quote from the nearest private hospital and see how little leverage they'd have there. The worst part about it is, of course, that what you do not appreciate is not valued, and that which you do not value is soon lost.

An Evening with Sir Liam Donaldson!

My Foundation School - the organisation which organises medical training for junior doctors in the region I'm in - has just sent me an invitation to an Evening with Sir Liam Donaldson!

I was very excited, and was about to go to the fridge to leave some vegetables out for the month or so until the event, when I looked more closely. It turns out we are not being invited to put the useless bastard in the stocks and pelt him with decomposing produce - it's "an interactive talk" aimed at "inspiring and empowering junior doctors".

Hold on, Liam. You've just presided over a series of catastrophically stupid reforms which have turned the house officer years into a pale shadow of what they once were. Your spineless failure to oppose these "reforms" has meant that I am paid next to nothing, have to struggle to get the experience I need to become a decent doctor, and have no flexibility in my choice of specialism.

Who the fuck are you to give anyone leadership advice given your craven failure to do any leading of your own over the past decade?

It gets better. The evening isn't even free - it's being organised the "British Association of Medical Managers", who must be the only organisation in the country with "medical" in the name who would want Donaldson anywhere near an evening event. Brilliantly - you really couldn't make this up - it appears that if you are a Medical Manager, your evening starts just before FOUR IN THE AFTERNOON - the event starts at 15:45 and is over by 20:00. Nice work if you can get it.

The whole thing is ridiculous, and it would be ridiculous if it weren't 40 quid to attend. When Sir Liam runs his "resignation advice" evening, I'll be attending. Until then, I want to know why exactly my Foundation School is sending out this bollocks.

I include the full e-mail below for your entertainment. You could play Bullshit Bingo with it - viz "continuing commitment" in the opening line...

For the attention of STFS F1 & F2 Trainees:

BAMMbino

As part of our continuing commitment to present quality training in leadership and management to junior doctors at a price that is affordable and practical and at a level that is educational, inspirational and empowering we are offering the following wonderful opportunity ...

The junior doctor division of The British Association of Medical Managers

presents

An Evening with Sir Liam Donaldson

A session of workshops followed by an interactive talk by the Chief Medical Officer aimed at raising the profile of the clinical leadership agenda and inspiring and empowering junior doctors to become involved in medical management on both a local and a national level.

Wednesday 10th December

15:45 - 20:00

LG Lecture Theatre

Imperial College Business School
Exhibition Road, South Kensington, London SW7 2AZ

Provisional Programme

15:45 - 16:00 - Registration

16:00 - 17:30 - Rotation around 2 workshops of your choice

• How to get involved in local medical workforce issues
• Simple ways to gain medical management experience at your own trust
• Life as a Junior Doctor clinical advisor to the Chief Medical Officer
• So, you're thinking of doing an MBA?

18:00 - 19:00 - Sir Liam Donaldson

19:00 - 20:00 - Drinks and Canapes

Places limited to 88 junior doctors on a first come first served basis. To secure a place fill in the attached booking form, including payment details and return by email to robin@bamm.co.uk, by fax to 0161 474 7167 (FAO Robin Scott) or by post to The British Association of Medical Managers, St Petersgate House, 64 St Petersgate, Stockport, SK1 1HE. If you have any questions please call the office direct on 0161 474 1141.

£20 BAMMbino Members £40 Non Members

Robin Scott

Marketing and Communications Manager

BAMM

'BAMM generates inspired, skilled, creative & enthusiastically energised leaders, everyday'

The joys of e-learning: hospital inductions

I have recently moved hospitals, and before I got there I was required to complete some "e-learning modules". For those fortunate enough not to have had to do these, you need to know only that they are beloved of people who have been to management school because they allow you to pretend to "deliver education" without ever having to meet the people you're educating. In addition, the word "learning" is rather misleading - I learned from the experience that my new employers don't test their own computer systems and that the systems they don't test are designed by GCSE students during their summer holidays - and it looks like all the computer science students were doing proper work again; I reckon this year it was the classical civilization students they got to do it.

Anyway, there were I think eight modules I had to do, covering such revolutionary topics as "Fire Safety Awareness", "Equality and Diversity", and - my favourite - "Manual Handling". At the end of each one was a little test, so I now have eight new imaginary certificates sitting on a computer somewhere! Or at least I would have done had the computer system worked: in fact only two of the certificates loaded, with the others giving 404 messages (page not found), and one test wouldn't register my pass mark at all at first. And none of the links worked, obviously.

I'm not going to describe them beyond that - because they do say a picture is worth a thousand words, so here are just a few of the things my local PCT felt would educate junior doctors with five or six years of university education behind them.

I did find myself wishing at times that I could decide the answer and make it a reality. Who among us, for hasn't wished at times that fire doors really were there to keep patients inside?

CFSMS funding

Well, it appears that money is much easier to come by if you're a barely-competent government department than if you're someone needing nursing care, that's for sure. There's evidence that the CFSMS have received:
19/06/2003 - a suggestion that funding from 1999-2003 was a paltry 20m - "...has produced a financial benefit to the NHS of almost 300m, a 15:1 return on its budget".
??/12/2004 - this notional 15:1 return has dropped to 13:1, with a claimed £478m saving on a budget of £36m "since 1999", suggesting they get about £7m a year...but the following years' accounts state that funding for 2003/2004 was £11.6m. Perhaps the government just doubled the budget that year.
2004/2005 - aha! Annual accounts! They open joyously enough with the touchy-feely, inclusive, it's-not-ours-it's-yours feel of "protecting your NHS" above a picture of a smiling woman, some babies, and bizarrely a handful of pills. Something about the opening page makes me sure they're happy pills. These claim the NHS has now saved £671m, and that funding in 2004-2005 was £18.412m and 2005-2006 reduced to £14.897m.
06/12/2006 - an extra £1.5m for "the Holbein case" (your guess is as good as mine).

So it's all a little confusing, with several mentions of top-up funding to the tune of £100m just in the few articles I could turn up being tactically omitted from the aren't-we-great tubthumping...

The CFSMS: they may be useless, but now they can read your patient records!

The Department of Health have recently issued a code of practice allowing the characteristically catchily-named "NHS Counter Fraud and Security Management Service" to demand 'documents' from doctors. Rumour has it there was a consultation prior to this being made law, but information on who was consulted is thin on the ground.

It appears that what this means is that the CFSMS can oblige any doctor in the country to hand over confidential patient records or risk prosecution, a fine, imprisonment, and a criminal record. Which is obviously a little worrying, as anything which forces us to hand over private information about patients without their express permission risks making them think we're all untrustworthy bastards whose aim in life is not to help them but rather to lull them into a false sense of security before shopping them to the police. And heaven knows we medics don't want to become like MPs.

The CFSMS describe themselves as "a division of the NHS Business Services Authority [with] responsibility for all policy and operational matters relating to the prevention, detection and investigation of fraud and corruption and the management of security in the National Health Service." What this appears to mean in English is that they are responsible for several different things, including:

(1) The NHS Security Management Service (SMS), which tries to stop people assaulting NHS staff. This of course is a perennial problem in hospitals, particularly when the drunks stagger in to A&E after their friday-night beatings looking for softer targets. The SMS took this on in 2003 under the expert guidance of Patsy Hewitt, and their success was evident by 2005, when a national audit showed 2 in 5 clinical staff and 4 in 5 nursing staff had experienced violent or threatening behaviour while at work. The audit in 2006 followed DoH form by seemingly reporting two different things at once - the headline claimed that "the number of NHS staff being physically assaulted has fallen", but the same report stated "despite the overall fall, assaults against staff working in NHS hospitals rose last year". On reflection, this may be thanks to fewer assaults on NHS staff working in community mental health; a cynic might argue that the reduction there could be explained by the ever-smaller number of NHS staff actually working in community mental health. If anyone knows where to find those numbers, it'd make for an interesting analysis...

In 2006/2007 the numbers fell slightly again, but there were still 55,709 physical assaults on NHS staff and the CFSMS managed to prosecute, er, 869 of them. Being a well-trained bunch of unelected DoH / government incompetents, they chose to report this as "a 17 fold increase since 2002-2003". Which is absolutely shameless given that in real terms, after four years of taxpayer funding (including an additional payment of £97 million from Alan Johnson in September 2007), they were managing to prosecute less than 2 assaults per hundred.

The SMS also draw up more of the policy documents which the DoH appear to prefer to, for example, health spending - their summer 2008 newsletter (which has lots of photos of Gillingham FC players, if you're into that sort of thing) announced "a policy template for the management of security in healthcare organisations". While their willingness to use plain english in the document title rather than attempting to stuff as many syllables as possible into it is commendable, it does seem to have taken the NHS Security Management Service four years to draw up a policy document covering, er, the management of security in the NHS. Does anyone know what they were doing for the rest of the time?

(2) And what of the NHS Counter Fraud Service (CFS), you may well ask? Given that they apparently "investigate all cases where there is evidence of corruption involving a public official who is using their public influence for private gain", I was hoping they might have prosecuted that evil old harridan Patsy now she's started using her experience of public healthcare to assist such champions of the private sector as Alliance Boots, the private equity company Cinven (who recently bought BUPA's UK hospitals), and the BT group. Alas not.

Their most recent newsletter announces that they've shopped some fraudulent dentists, which is good although perhaps suggests that all the honest ones left when presented with the new NHS contract. They also got an orthopaedic surgeon who was claiming sick pay from one hospital while working at two others struck off and imprisoned - which while obviously a Good Thing, does beg the question of how exactly the systems in place allowed the same doctor with the same name and the same specialty to claim money from three different places at once. Similarly, 65 dentists claimed more than 2 million over three years for gold teeth, with one bloke claiming 11.4 million over that time. Did no alarm bells go off beforehand about that? Or were they too busy looking for the bolt on the stable door to notice? Perhaps this is overly harsh, as it is obviously good that these people are being brough to task - but how do the systems in place allow this to happen?

They also look at the problem of health tourism, but don't give much information on how they've managed with it.

And this is where the real problem lies. Let's say I as a doctor see someone in A&E in need of urgent treatment. If they're in extremis, I don't have time to ask to see their passport, visa, proof of address, any of that - I'm going to get them fixed up after their car-crash, or stabbing, or get them treated for their chest infection. In most cases, I have no problem with their subsequently being pursued for the cost to the hospital of, say, putting a cast on a broken leg (although I worry that, particularly given the CFSMS' apparent track record, we as taxpayers will end up shelling out far more chasing these guys than they can ever afford to pay.)

There is a twist. Tuberculosis is a rising problem in the UK (as indeed are a large number of other infectious diseases), particularly multi-drug resistant TB. If I get someone coming in to A&E with suspected TB, it is in the national interest to treat them - the healthcare costs alone of treating all the folk they go out and infect are dramatically higher than getting the one person early, and that's before you factor in the economic costs of days lost to work and so on. If word gets around, though, that coming in to A&E with a cough means you get arrested, fined, and deported, your average illegal immigrant won't ever dare to set foot in an A&E department, because they won't trust us as doctors to treat them in confidence.

In that scenario, the trivial costs you recover from some poor bastard who comes in coughing his lungs up before you ship him back home are dwarfed by the increased burden you put on the NHS when his roommate infects a dozen people over the next year because he knows better than to come into a hospital.

There are a number of provisos and specific conditions which the CFSMS need to meet to be able to demand documents - they're outlined in the document itself - but I have grave doubts as to how this will be used in practice. I suspect it'll be used so the CFSMS can give the government a few Illegal Immigrants Sent Home in the press and so justify their own funding, and the upshot will be the left hand taking back 10p while the right hand has to pay out a quid, and a population that trusts doctors that little bit less. We'll see.