Bruce Keogh and doctors' pay freezes

I didn't know much about professor Sir Bruce Keogh until today, but I read his proclamations on doctors' pay and thought I should find out about him. It turns out from his puff-piece on the DoH website that he is NHS medical director.

My reason for looking him up was an article on the BMA website which I'm afraid is subscription only (but see how you get on with that link). In it he says that doctors should consider accepting a pay freeze to help the NHS through the financial crisis, and presciently warns of "tough times ahead" thanks to the "recession's fall-out", presumably while popping down to his local stables to bolt all the doors he left open midway through 2007.

He goes on to say:

"We need to see doctors stepping up to the plate in terms of leadership roles and recognising their financial responsibilities. They need to take control of budgets and accept pay restraint. Doctors have to recognise that they are not above the rest of society. There are all sorts of people out there who are not getting pay rises at the moment, and there would have to be very particular reasons why doctors were [exempt from] that."

Given Prof. Sir Keogh's confusion about the timing of the recession, it's no surprise that he hasn't noticed the phenomenally large amounts of money that other bits of society are paying themselves, and in so doing has aligned himself with such economically-savvy luminaries as the Duke of York and Boris Johnson. Are we quite sure someone who's only just noticed the recession, and hasn't noticed bankers' plans to pay themselves billions of pounds, is genuinely a professor? This isn't some new-Labour reward for brainlessly toeing the party line via statements that appear to have been ghostwritten for him by the Daily Mail, as his knighthood presumably was, is it?

There is a wider point at play here. What we have here is a doctor already in a leadership position, who has by definition presided over the disastrous financial mismanagement of the NHS over the past decade, the leeching of doctors and nurses away from the public sector and the country, and the rock-bottom morale which comes from people like Bruce making imbecilic pronouncements about things they know nothing about. He can afford to take a pay freeze - based on publically available information about what medical directors of individual NHS trusts make, he's might be on 120k or more. But why should I, as one of the thousands of doctors who for years have been telling the leaders of our profession exactly what they should do to save money and have been totally ignored, take a pay cut because the government has screwed things up so royally? If you want me to take a pay cut and to show "leadership", that's fine - but I won't bloody do so until I get some power to affect spending decisions locally so that the same idiots who've got us into this state can't carry on screwing things up.

Let me put this more simply, Bruce: don't witter on about 'leadership' unless you're willing to devolve some actual responsibility with it.

Virtual Learning Environments

This weekend I have had the unbridled joy of preparing for a 2-day course. This has involved a decade of hours plowing through an utterly turgid "virtual learning environment" or "VLE" which makes repeated utterly token attempts at "interactivity". This has made me want to submit examples of genuine multimeejah by e-mailing videos of myself swearing at the course designers to those responsible.

This particular bout of fury was brought on because I dutifully stopped listening to the background music which was keeping me sane because the VLE told me it was very important I had my sound on when I looked at the powerpoint. The sum total of the "multimedia experience" in the presentation was a single ambulance siren on the second slide. That was absolutely the only thing there I needed headphones for.

So. Farewell then Ara Darzi

So. Farewell then
Ara 'Lord' Darzi
Polyclinic-exponent and Grand High Reviewer.

You wanted to put
quality
at the heart of the NHS

and you told us that
as ideas go
this was "radical"
which was
pretty insulting, if you think about it.

Data protection

The hospital trust where I will be working from August has just sent me the reams of paperwork I am required to fill in to demonstrate that I am safe and qualified to do the job. It contains exactly the same questions, and requests all the same paperwork, that I sent in about 12 months ago to demonstrate that I was safe and qualified to do the job this year. Hundreds of people are being paid by the taxpayer to do this.

Best of all, though, was the document on patient confidentiality, which was a mixture of bland statements of the obvious, stern caveats about talking to the media ever, and a wonderful section on "Use of Internal and External Post" which appears to have been written by someone at the department of health purely to remind us of all the ways in which imbecile government officials have sent the personal details of thirty thousand drivers to some organisation in Texas, or left 120 patients' medical records on a train, etc.

I should say at this point that the Trust I'm working for is one I have enormous respect for, and which has not to my knowledge made any such crass fuckups. But again, someone in government has spent time and money writing this patronising nonsense when if I spent my entire career wilfully distributing patients' personal information to as many people as I possibly could, I still wouldn't get near the breaches in confidentiality that a single civil servant can manage after one too many bottles of claret with lunch.

Snake ateronon

I want to know who these unspecified "scientists" are who are besmirching the name of their profession by claiming that some wonder-pill can "stave off" heart disease and stroke? Because whether the drug works or not is so far from being proven I can't begin to explain - but suffice to say that so far as I can make out these snake-oil salesmen have precisely one study of 150 people in which they measured not heart disease or stroke, but instead "the oxidation of harmful fats in the blood".

So a more accurate description of this pill would be something like:
"A new pill is being hawked around to fat, worried people everywhere by a private company looking to make a quick buck. They have demonstrated that it reduces one blood test result at one point in time in a laughably small sample, and are hoping you will pay thirty-five pounds a month just in case it thereby prevents illnesses they haven't demonstrated any reduction in. For thirty-five pounds a month you could buy just under 20kgs of tomatoes at ASDA, or just over 10kgs of organic cherry tomatoes at Tesco. Every month. That way, you'd get lunch as well as the health benefits."

Newsflash, boys and girls: eat sensibly, exercise more, see a doctor if you're worried. Don't buy this crap until and unless someone has proven it'll help you. So far, they're nowhere near.

Here be Swine Flu

It was today reported in the 'ouse of Commons, by none less than the Health Secretary, that there have been twenty-five (25) possible cases of swine flu in the UK since the start of the scare.

One such occurred in my hospital this weekend. Basically, it was total bollocks - the woman in question came in with a straightforward pneumonia, but because she was eight months pregnant the medical team looking after her shipped her on to the obstetricians, on the basis that she was doing reasonably well and at that stage in a pregnancy the priority if she went off would obviously be getting her baby delivered.

As far as I can make out, the obstetricians spent the entire weekend trying to convince the poor lady that she would die and that if she didn't she'd need to be put on a ventilator for them to deliver the baby. In amongst all this they realised that she'd been to Mexico and so called the local Health Protection Agency about her querying swine flu. The only problem, of course, was that she got back more than two months ago - not really consistent with the incubation period - and had a far, far more likely diagnosis already in place.

In the end the weekend team took her away from the panicky obstetricians and put her back on a medical ward, where she is doing just fine, and it looks like despite the hullabaloo that the baby will not be born with a pig's head this time. I wonder how many more of the 25 cases were utter bollocks...?

Saints preserve us....

God bless Jade Goody for what she's done for screening.

But a musical of her life? Spare us that, please - spare me the pound signs in Clifford's weaselly eyes... I feel nauseous just thinking about it.

Occupationals hazards 02, or why ignorance is bliss

Urgh. Today was an 11-hour day (do not believe the government bullshit about the European Working Time Directive - it is code for not paying us for working out of hours), and it ended with my having to aspirate the drain from a pancreatic pseudocyst.

In English, this means attaching a big syringe to a piece of plastic tubing which had been passed through someone's abdominal wall and into the pseudocyst, then left there so that any gunk that built up there would come out through it. A pancreatic pseudocyst, again hopefully in English, is a big collection of the aforementioned gunk which forms near the pancreas, normally after a nasty bout of inflammation of the pancreas.

The patient in question is a charming lady who'd been in and out with this problem for months and months, and was waiting to see the specialists to see if she could have it chopped out (not always a good idea). It was meant to be being flushed regularly, but this was very rarely recorded by our desperately overworked nursing staff and I suspect not done as often as it should be.

On my way to do the procedure, I checked her results, then got my plastic apron and gloves on and got to work. The thing was normally stiff to start with thanks to all the clotted muck in there, and on this occasion it was particularly bad - so I gave an extra syringe-heave...and with awful predictability, the syringe basically exploded, leaving me spattered in stuff the colour and texture of runny dog poo. And smell - god, the smell.

Worst of all, I knew it wasn't poo: it was group C streptococcus sensitive only to clindamicin.

I envied the patient her ignorance.

Occupational hazards 01, or why being a doctor is not comparable to being a banker

Recently, my registrar and I were doing a ward round at quarter to eight on a tuesday morning and discovered that one of our patients had been complaining of bleeding from the "back passage". While in your average man in the street this inspires nothing more sinister than a snigger at the euphemism, to pretty much every doctor in the land it inspires at best a weary shudder.

Obviously, this is because blood in someone's poo means you have to stick your finger up their arse. In medical parlance this is to "perform a PR", and the chances are you'll find something which stinks even worse than usual thanks to the disgusting smell partly-digested blood produces. Unfortunately for us, it's a really good clinical examination - you find out if they're constipated, if there's obvious blood, if it's likely to come from low down the gut or higher up, whether there are any lumps or bumps suggesting anything from haemorrhoids to cancer, you can feel the prostate in men, and you can use it to localise abdominal pain by applying pressure in various different directions which can, for instance, help you identify an appendicitis.

It's also not something you particularly want to do at the best of times: only the dangerously weird actually enjoy it - but before you've had breakfast on a tuesday morning adds that little bit of top-up misery.

Our patient, thankfully, was fine. As we went to wash our hands I shot the reg a mournful look. He replied simply, "Sometimes I envy those city boys." We carried on.

Failing to address the problem 101

Recent weeks have seen a familiar pattern from the government and the Department of Health. Faced with the Staffordshire disaster and the inevitable observations from pretty much all concerned that this was a series of deaths caused by the system they put in place, they have reacted characteristically.

What they've done is:
(1) Blame management.
(2) Ignore completely the issue itself by talking about all the Good Things they have done. Alan Johnson has trotted out the same old lines about reduced waiting times. But, Alan - Staffordshire demonstrated really, really well that the pursuit of targets like this kills people. So that you have some good soundbites to chuck out about the health service in an effort to get re-elected.
(3) Engaging the spin doctors to promulgate these spurious well-done-us messages all over the press. Curiously, the opening line of Alan's pat-self-on-back above has been reproduced on Jim Dowd, MP for Lewisham West's website, Andy Reed's, The Northern Echo's, the Labour North-West's, Ruth Kelly's, Glasgow North-East's, Southall's, Loughborough's, Medway hospital, NHS York and Humber, and even the dailies. That exact phrase "Twelve years ago it was not uncommon for NHS patients to have to wait well over 18 months for an operation" has been used by all of them in some form or another in press releases over the past couple of weeks.

It's testament to just how little this government is interested in fixing the problems it has created, never mind taking responsibility for them. As George Monbiot put it, this is a government that stands for nothing but re-election, even if the price is a few hundred dead in every hospital stupid enough to try to hit the targets the DoH has set them...

On bed crises and their fallout

The hospital at which I am currently working has been struggling over Christmas with the number of people coming in to A&E. Just as those tiresome leaves surprised train bosses every autumn by falling from the trees, so it always seems to surprise hospital management that more people get ill and come through the door of A&E in winter.

Unsurprisingly, the local people already know that waiting times can be bad. They know it not because of the huge waste of money that is NHS Choices, but because they actually live near it and come into it occasionally, and they mentioned long waiting times as a big problem in the survey; the hospital's response is not to look at why wait times are long, not to look at where the process could be improved - instead they just carp on about how much money they're spending on A&E (1.5m quid, if you're interested), and add the fateful "And we never close our doors to admissions."

It seems to me that this is indicative of many of the problems with the way the government and the department of health have gone about changing the NHS. There is almost never a reasoned analysis of why problems exist; those working on the frontline - doctors and nurses - are never consulted, and instead overpaid idiots dream up a way of wasting as much money as possible so they have a bigger headline figure to take to the press. That last point is what has driven government policy on the health service over the last decade - always "we are spending 10m quid on it, so it must be good", and the idea of actually engaging with and supporting the people doing the work never enters their stupid, pompous heads.

It trickles down, too - in my hospital the vogue for frittering money away on consultants resulted in management rounding up some local businessman who is doubtless very successful in the small estuary town in which he works. He came in and told us all about Toyota lean manufacturing; the upshot of this was that patients' notes were moved on some wards from a single trolley at the nurses' station to four or five small trolleys by the bays, the rationale being that they would be closer to the beds and so you would save time.

Before you read on, ask someone who works in a hospital what the commonest cause of spending time looking for notes is, or ask yourself if you work in one yourself. I'd hazard a guess whoever you spoke to said "some bastard leaving them littered around the place". The solution, therefore, is simple - either make the things electronic (difficult if you do it centrally via something like the disastrous National Programme for IT, easier but still costly to do locally) or encourage people to put the things back properly. Not easy - you need to get all the groups who take them out of their appointed slot and leave them places to stop doing so, and everyone does it - but everyone wants it to happen, so doable.

What we have instead is a system where in the past you had to look on one notes trolley plus the desk surfaces which were immediately adjacent to the notes trolley, you now have to look through five different notes trolleys dotted all around the ward, and you still have to check the desk surfaces as well. Genius. As you can imagine, management can't get enough of trumpeting this rather doubtful "best practice".

Similarly, their management of the bed crisis is stupid, although in their defence here it is governed by the unshakeable, immutable stupidity of government policy. In short, the reason that "we never close our doors" is currently that "we" are closing everything else down to create more bed space. The most recent was the closure, without any notice or consultation of staff or parents, of the on-site centre where children with complex disability get rehab. The chief exec turned up on friday and shut it; the builders moved in on monday morning.

Perhaps they thought children in wheelchairs would be less able to fight back? After all, we can't fall foul of DoH rules by saying "sorry, we're full; try somewhere else", because that would cost the trust money. Instead, we'll stop seeing 150 kids a day who desperately need this support in favour of putting 22 people with flu in the same space - and that's not even 22 people a day. The backlash, such as it is, has started, but it's hard to make these people listen.

The really ugly thing about it is that, as the staff working here, we know when we can't take on any more patients, and I'd suggest that when we've run out of beds we are probably at that point. Certainly no one would want to cut vital, careful, developmentally-crucial services to kids in favour of short-term management of illness and what must be a huge locum bill for staff who at best don't know the hospital and at worst are undertrained for the jobs they're being asked to do.

But we don't have a say in it. We just get told when to leave the building.

And in case anyone is reading who has been affected: sorry.