Stop Press: Mental health services improving

Well, delusion has once again got the better of the Prime Minister as he claims that the NHS is on the right track and that cardiac care, cancer care and mental health services have improved over the last 10 years. Now credit where credit is due, I believe that there have been improvements in cardiac and cancer care, though whether they are in proportion to the money spent is another question-don’t forget this graph from the ONS showing that productivity in the NHS has fallen by 4%, with output increasing by 28%, while costs have increased by nearly 300%: Is this value for money?

But Mental Health? I hope Michelle Tempest has been listening to the PM as I expect she will be able to give a more informed view, but my perspective is that we are seeing terrible problems with mental health at the moment as budgets are cut to feed more glamorous specialties: see HERE, HERE, HERE, HERE, HERE and HERE for a few examples chosen at random from the plethora of stories available. Last year a report by the Sainsbury Centre for Mental Health found that:

“More than half of England’s mental health trusts have seen money diverted away from them to pay for deficits in other local health services.”

So, Tony, in your self delusional world, please tell me how exactly you think mental health services have been improved? No, let me guess, Patsy “The NHS has had it’s best year ever” Halfwitt told you didn’t she?

And just to remind ourselves exactly what Labour has achieved in the NHS in 10 years lets look at this cartoon, originally I think from the Daily Telegraph, now reissued by Dr Rant:

Tony also had this to say:

“I’ve been through this so many times, I just think its really tough while it’s happening. What we’ve just got to do in a sense is hold our nerve,”

Well do it this time Tony: Resign and take Patricia with you!

When doctors don’t perform

What do we do when doctors are underperforming? Historically this was an issue of limited application, as doctors performance was not assessed, so there was no way of knowing how they compared to other doctors in the same field. Now phrases like performance management, appraisal and assessment are beginning to creep into the hospital managers’ dictionaries. Doctors are of course deeply suspicious of this: How would a mere manager (so the saying goes) be able to manage an intellectual and moral titan like me. Pah!

There are 3 major caregories of standard at issue:

Ethical standards. eg Don’t sleep with your patients.

Professional standards: Look after your patients properly and professionally, to a standard that your peers would accept is reasonable

Business standards: Work hard, See lots of patients and generate revenue for the Trust or practice you work in.

For me the interesting aspect of this is what happens when there is a conflict between two sets of standards. In essence as professional and ethical standards should be completely compatible, that means that we are looking at conflicts between business standards and professional/ethical standards. This is easily seen in practice: For instance a hospital might dictate the use of an inferior quality hip replacement to save money. This is fine and will of course happen as part of natural business practice, but when does good value become cheap tat? The doctor has a very important role here as the guardian of standards: only s/he can provide managers with the right information to make the right decision. Or as we saw on Can Gerry Robinson save the NHS?, the case of an eye surgeon who was doing an old-fashioned cataract operation that took an hour instead of 15 minutes. Clearly it is better busines for the trust for him to do more operations with the shorter procedure. It should be better for patients too, but if he is not familiar with this operation, it might be in conflict with his professional standards. This should be a fairly simple matter of continuous professional development, but if not well handled can deteriorate into an ugly stand off.

So how to regulate this.

1) We used to have a body responsible for moral, ethical and professional standards. It was called the GMC. The GMC is now, by all accounts an expensive talking shop which has made some high profile errors (see HERE and HERE, for example). It also has the problem that in cases of serious medical misconduct it is both prosecutor and judge, a problem which Dame Janet Smith alluded to in her recommendations for the GMC following Shipman. So we need to have professional regulation. People say doctors should not be allowed to regulate themselves. I’m not sure that this is right, in the same way that I believe other professional groups are probably in the best position to judge whether or not any given action is acceptable practice. It is interesting that Dame Janet, a lawyer, proposed that a lawyer should be in charge, but she may be right. There does definitely need to be at least an equal representation of non-medics on the GMC to prevent the sort of ‘there there, old chap, could have happened to anyone: See you down the club” approach to regulation. Like many of the beliefs about doctors this was largely a myth, but it needs to be seen to have been slain. In practice I think this means a new regulatory body. Lets call it the Medical Licencing Committee to adjudicate on cases which could be prosecuted by the GMC, or a new watchdog. The GMCs licensing function should be taken over by this body who would have no other role.

2) Trusts need to be more aware of the standards of their doctors. This can only be achieved by trying to develop a culture of openness in medicine. A culture where we admit our mistakes and they are made public. A culture where reviews of doctors performance can be carried out regularly, jointly by senior doctors and hospital managers. These should not be cap-doffing exercises. Neither shuld they be so exhaustive as to waste a huge amount of everybody’s time. But this is done all the time in any company you can think of. In fact I suspect it is rather hard to think of a job in which people earn over £100,000 per annum and do not have some form of serious performance review.

3) I think the career structure of hospital doctors needs to change. At the moment doctors undergo a period of training (in my case about 12 years) and are then, if they make the grade, appointed as consultants. After this there is no promotion or demotion. The pyramid is flat and extremely difficult to fall off. Sure, a few people will go on to be heads of departments or medical directors, but in general these are titular appointments which do not carry any real pay or kudos with them. The appointees are too often the last person to leave the room, or selected by Buggins’ turn rather than merit based criteria. There is thus very little management of consultants, even less management of consultants by consultants, and little incentive for consultants to become involved in management

I would favour a rather more hierarchical structure with pay progression dependent on promotion rather than time served. I also believe consultants’ contracts should be renewable 5-yearly, so that if someone was failing to deliver to the appropriate standard they could be sacked or moved sideways. In practice I doubt this would happen often, but it would focus the mind

4) The thorny issue of business practice. Consultants are inadequately trained in business, and I would make it a core part of their training, with an option for some to specialise in hospital management with an MBA programme and time spent in industries other than healthcare to foster a real understanding of commercial business practice. Only by engaging doctors will we develop sensible safe and ethical business practice, and only by engaging doctors can we set appropriate targets against which people can be measured. But we are talking about perverse incentives here: If the Trust maximises its income, all it is doing is taking money from the commissioning body which could be spent elsewhere. Nevertheless, performance-related pay could be an option for some fields, especially those where performance is easily measured.

But being involved in the business side MUST not absolve us of responsibility to act as advocates for our patients. This is the real test of our mettle

So My prescription is as follows

A new central Medical Licensing Committee to replace the GMC’s function of regulating fitness to practice

A different career structure for hospital doctors with renewable contracts and a more hierarchical structure for senior doctors

Regular and robust performance review on which career and pay progression would depend

Engagement of doctors in hospital management with high quality formal management and business training

Paying for the hours

Unfortunately I have realised that my inflated monolith of a salary will soon be worth no more than a few million Zimbawe dollars thanks to Gordon’s recent discovery that tax and spend policies lead to an end to Tory Boom and Bust increasing inflationary pressure. So I hopped in the Lambo with Lola and hot-footed it down to London to Damien Hirst’s gallery where I was able to pick up a rather tastefully embalmed surgeon for a fraction of the cost of the real thing. I am hoping to put it on the door of my office to discourage any of the squitty juniors from coming to ask my advice.

On the way back we were passing the DCMS when I saw David Lammy deep in thought. I bet he was worrying about THIS problem-how to save the Wardington book of hours for the nation. Thinking it was a book of my hours which my secretary (no doubt jealous of Lola) had sent to Mrs Hewitt, I nearly made him an offer on the spot, but when he explained what it really was, I decided that I didn’t like the idea of opening Sana Towers to the public, so my accountant wouldn’t let me buy it.

But why don’t British museums sell some of their works of art to finance acquisitions. There are hundreds of thousands of pictures and sculptures in this country that never see the light of day. Why not pawn a few to pay for something that the curators are actually prepared to hang. Surely we don’t need to keep them all in case some junior minister wants to hang it on the wall of his grace and favour apartment to impress the chicks.

The Imperial War Museum has got the idea. They recently sold a rare Messerchmitt 163 (German)to pay for an almost unique DeHavilland DH9 (British). This sounds like a good deal especially as it looks like they may have enough parts to make 2 of the DH9s!

Maybe some of our other museums should follow suit. I’m sure this must happen on a small scale, but we never seem to get to hear of it

Speechless

CRETINS

hat-tip ferret fancier

Playing GoD

Today the HFEA issued a decision on pregestational diagnostics or PGD. The press release can be read HERE. In short it says that we should look at the possibility of allowing families with high risk of having children with inherited cancer genes to screen embros to select out those with the abnormal gene. This seems like a very humane and sensible thing to do, and having seen young men and women die of these cancers, and women forced to have bilateral mastectomies and oophorectomies (surgical removal of the breasts and ovaries) at a young age because of their high risk of cancer, I am immediately sympathetic to this decision.

But…on the other hand I wonder. I am inherently and rather uncharacteristically Luddite about this sort of technology. What sort of a world will we move into when we can select particular characteristics for our children? Is it right to be creating embryos and then discarding them? Who will have the rights to these discarded embryos? How do we make a moral difference between selecting for cancer or for cystic fibrosis, or for blondeness, blue eyes or being gay, even (if such a gene is ever found). We are entering a new world with different ethics and values, and with less of the great mystery and magic which makes me glad to be alive.

What joy will there be in the birth of a child we have designed? Will it be the same as the new car we ordered from the catalogue, or the flat we buy off plan? How disappointed will we be when they don’t turn out to be perfect (because they won’t)? Playing with our genetic makeup gives us the illusion of power, but it is just that, an illusion. In the end we will all die, and some will die younger than others. I think perhaps I would prefer the unknown.

But I think if I was a carrier of the BRCA1 or BRCA2 genes, which give a very high lifetime risk of breast cancer (36-85%) and ovarian cancer (16-60%), or the HNPCC gene, which gives an 80% risk of colon cancer, I would probably have the test, and I would probably take up the offer of PGD. Does that make me a hypocrite or a pragmatist?

Both, I suspect

But on a health economic assessment I’m sure this procedure offers value for money, as the cost of PGD will be much less than the cost of treating the subsequent cancers. So on purely economic grounds I can support it unreservedly and leave the moralising to others. So there we are, problem solved. Easy, this ethics business.

If you’ve got IT, you’ve really got IT

Anyone who was in any doubt about the wisdom of letting this government introduce ID cards should read THIS post from Dr Crippen. As those of you who take any medical interest will know the government has recently introduced a computer application system for job applications for junior doctors: MTAS. This has been controversial enough, and the implementation could perhaps most kindly be described as a complete unmitigated disaster. Now we learn that someone in the DoH forgot to password protect the applications. So all the information in them (Address, phone no, sexuality, criminal record etc) was available for anyone to read on the web. Channel 4 have more details . This is what will happen if the ID cards bill goes through. Don’t let them do it

Topping up again

In an interesting new take on the approach to top-up payments in the NHS, reported in the Times HERE, A leading insurer has started a policy in which patients will be able to pay an amount equal to their age per annum, for which they will bee guaranteed access to £50,000 worth of cancer drugs if they are licensed but not available on the NHS. An interesting proposition? Well yes, but lets look at the exclusions. If you have cancer-not eligible. If you are over 65-ditto If any relative has developed cancer under 65 ditto. So in fact I think this is a bit of a loss leader to try and get people to take up their more inclusive policies, when they realise how little advanced cancer treatment is available on the NHS. But of course they have a real incentive to promote the top-up approach as it will potentially save them huge amounts of money compared to wholly private treatment

Including my fees!

Lola-break out the Lafite 61. I think I may need a drink. Speaking of top-ups lets go for a spin. I may have to sell the Bentley

Did he take the truth with him to Gloucester?

The Telegraph today has early publication of the Dr Foster Hospital Guide entitled The NHS: The truth , which has rated every hospital in the country according to a standardised mortality ratio (SMR). While I am delighted to see that my own hospital ranks highest in the region and amongst the best in the country, I have to say I am deeply sceptical that one can read anything into these results. There are so many factors that go into the SMR, many of which are irrelevant to the Hospitals, that they cannot really be said to reflect an individual hospital’s performance. Indeed a cursory review of the Dr Foster database shows that only about half of the consultants in our department are listed, and about half of these have the wrong specialty attributed to them. Only a small thing, but it makes me question the accuracy of their data collection.

SMRs of course are part of the funding formula used to divert money away from areas with healthier populations to those with worse health outcomes such as Birmingham and the Black Country. This formula is probably more responsible for the meltdown in our local health economy even than financial mismanagement by our local PCTs and Trusts, or even the Department of Health. So they are hugely relevant to how our local healthcare is delivered and funded.

But maybe we would be better off having worse outcomes and more money?

But I want to pay…

I would recommend reading THIS short document from Doctors for Reform illustrating a number of ways in which top-up payments are being introduced by stealth into the NHS system, also commented on by the good Dr Crippen. I have experienced several of these in cancer treatment, most notably in relation to the funding of three new drugs, bevacizumab (Avastin), Cetuximab (erbitux) and erlotinib (Tarceva). All are expensive. All are effective in a proportion of patients. None of them are cures. Exhaustive cost-benefit analysis has been applied to each treatment by the National Institute for Health and Clinical Excellence (not-so-NICE), and they have all been found to cost more than the notional threshold of willingness to pay (Currently approximately £30,000 per quality adjusted life year gained (QALY). Their efficacy is not in dispute.

So what are we to do? Here in the real world these treatments, despite being standard practice in Europe and the USA, are not economically affordable by the NHS, though they are all funded by ‘proper’ insurance companies. But why shouldn’t people be allowed to pay for them? At the moment in our region we have received advice from the Department of Health that patients may not pay for top-up care. If they wish to go private, all of their care must be given privately, which means they have to pay consultants’ fees and a 100% markup charged by private pharmacies for dispensing the drugs. Interestingly this opinion is disputed in the Doctors for Reform paper.

And should we tell our NHS patients about these treatments or not (assuming they don’t ask)? I have previously always found it rather difficult to say ‘here is the best treatment, but we’re going to give you the 2nd best’, but now I wonder: shouldn’t everyone know what their options are? probably they should, and I am much more open in my approach to this issue, though I generally try to discourage people from taking the private route unless they have insurance. Unsurprisingly, the Primary Care Trust do not want us to advertise these treatments to patients, but they have recently produced a standard letter explaining the above. But before we get to the stage that we can have a sensible discussion in the clinic, people have to accept the principle that the highest standard of care is not necessarily a right. I don’t think we have reached that point.

They go up diddly-um up

I admit it, I was a great fan of Biggles. Not only that but I am desperately hoping my children will be as well, so that I have an excuse to get them out of storage! So I was very pleased to see THIS amazing story. I don’t remember Biggles flying the DH9, as I’m sure that he preferred the Sopwith Camel, or the occasional foray in an SE5, but I’m sure that he would have been impressed that these guys, having found the aircraft in pieces in a maharajahs elephant shed managed to reconstruct the DeHavilland DH9 bomber, a wooden aeroplane of which no other examples survive, without even the benefit of any technical drawings. I am all the more amazed because I saw pictures of the bits in a display at Duxford before they had been reconstructed and there was no wood there-only the metal parts had survived the years. It did not look like an embryo bomber, and I would have fancied my chances of matching their efforts with the contents of my shed, given enough time and effort.

Rather more worrying they apparently had enough parts left over to build another ‘plane, and this one they’re going to try to fly. I think I’ll let Algy or Bertie go up first. Not that I’m windy of course