A difficult farewell

One of my longest standing patients came into the hospital last month. He had oesophageal cancer, and has had several courses of chemotherapy, which have given him a very good quality of life for 3 years. When I first met him, I told him that I expected his prognosis to be between 6 months and a year, so he had been lucky. Unfortunately he was now at the stage where his cancer was progressing rapidly and there was nothing more I could do to reverse that process. He was dying.

We had become friends over the last few years , and I found that I could talk to him quite easily about what was going on, and was able in a small way to make his last few days easier. Among other things we discussed a “do not resuscitate” order (he laughed). Although I was not there when he died, I was quite close at hand. His family were with him and he died peacefully and painlessly.

This is what my work should be. I have helped someone with a terminal illness to enjoy 2 years that they would not otherise have had. I had reduced his chemotherapy schedules to minimise the impact on his lifestyle, an experiment with which I was quite uncomfortable at the time , but which was undoubtably the best thing for him. Instead of a protracted deterioration over several months, he was well up until 3 days before he died. Unfortunately things do not always go so well.

His wife wrote me a very kind letter thanking me for my help. So far I have not been able to reply, and I don’t know why. I suppose it is a form of grief reaction-denial. I certainly don’t like to believe that he has died. But I think it’s more than that. I think perhaps he made me believe that I had some power to control the uncontrollable-he gave me a false sense of my own power or ability which has now, inevitably, as it was always going to, gone. Perhaps it is that for which I am truly grieving.

And yet, when I ;ook back on the last 3 year I realise that this was a story with 2 sides. From the start we had an unusually balanced doctor-patient relationship: Whenever I was struggling, he would often offer me solutions. We were both prepared to make compromises to find the best way forward. We had what is politely described as “full and frank exchanges of views” on several occasions, but always with indefatigueable good humour. When he was dying, he made my job easier by laughing. I think perhaps that he gave me more than I gave him, and maybe I’m guilty about that.

But I know that in years to come I will remember him when I am talking to patients about their prognosis, and that his story will give hope to many of them. And that I will remember him when patients are telling me about the impact of their treatments, and I hope I will listen more. And perhaps when it is my turn to die, I will remember him and find the courage to laugh in the face of death, and make life easier for whoever is with me.

And now perhaps I can write that letter

And another thing…

Praguetory and Iain Dale remind me that I missed out one part of the constitutional vandalism inflicted on us: The Prime minister, not content with giving himself effective personal control over the executive and legislature as well as a strong hand in appointing the judiciary has also appointed a toady/crony, elevated to the peerage following substantial donations to the labour party, as the governments senior law officer who would have to decide whether or not to bring charges against him if he were ever caught recommending people be… elevated to the peerage for making, er, substantial donations to the Labour party.

Surely, surely we won’t allow this to happen

And with the quality of members TB has put in the house of Lords isn’t it about time we removed the phrase “elevated to the peerage” from the language-perhaps you have suggestions for a replacement. My starter for ten is “plummeted to the peerage”

Then and now:

“For many, the NHS is part of what it means to be British. It expresses values that are ingrained in the British character - fairness and decency, compassion and a belief in the power of community. Social justice as a legitimate objective for the nation. And yet for all its great strengths - its one million staff, its ethos of public service, the great advances it has brought in public health - the NHS Tony Blair’s Government inherited in 1997 had profound weaknesses. In the fifty years since it was formed the health gap between rich and poor had widened. Too often the poorest services were in the poorest communities. Its centralised top down structure had too often stifled local innovation. It was run like an old-style nationalised industry controlled from an office in Whitehall, even when its sheer scale – now 1.4 million employees – made it impossible to do so. Not surprisingly it felt bureaucratic and monolithic. Staff too often felt disempowered. Local communities felt disengaged. Patients had little say and precious little choice. There were neither means nor incentives to improve services”

Alan Milburn, speaking in 2003 about the NHS in 1997-obviously he went on to say how everything has changed and its now the envy of the world

Lets look at that a bit more closely

the health gap between rich and poor had widened-No change there, as far as I can see

Too often the poorest services were in the poorest communities-yup, as they still are

Its centralised top down structure had too often stifled local innovation. No, you must be talking about another health service

It was run like an old-style nationalised industry controlled from an office in Whitehall, even when its sheer scale – now 1.4 million employees – made it impossible to do so- ring any bells, Patsy?

Not surprisingly it felt bureaucratic and monolithic. Well I’m glad we got rid of that

Staff too often felt disempowered. Local communities felt disengaged. Patients had little say and precious little choice See where I’m going with this?

There were neither means nor incentives to improve services: Well maybe we have a bit more means…

I will spare you the bit about the wonderful new contracts which have changed the way everything works for the better.

In short although there has been a much needed programme of capital investment, on the delivery side, with the exception of reducing waiting lists and waiting times, which must be acknowledged, the government has fundamentally failed to improve almost any of the areas it originally identified as key failings of the system

Not really value for money

Local election question

We haven’t seen any Lib Dems around here, and the Labour Party doesn’t exist-what is the word for a Conservative whitewash?

Blue Rinse doesn’t quite convey the image David Cameron is trying to project

“Carrot = stick” shock

So while sipping a cocktail on the beach at Cannes, Lola found out I had offered her job to Ellee and went off in a strop. Which left me and the laptop and nothing else to do. I found THIS rather troublesome article. Apparently someone has studied brain activity and found that there’s no difference between the carrot and stick. Criminals get the same kick out of avoiding being caught as they do for completing a successful bank job.

Which is troubling…

Because it suggests that those who say that we would be just as effectively managed if we had the threat of losing our job hanging over us as under the current policy of handing over sackfuls of cash might have a point. Maybe I’ll pay more attention to that email I got yesterday about Performance objectives. Not that there’s anything wrong with my performance-just ask Lola

A Different Country…

So having posted about Sir Henry Leach and his comment about living in a different country whose words count for little HERE , I have been thinking about what the legacy of the last 10 years of government will be. I believe the crowning glory of the Blair years will have been to reduce the constitutional governance of this country to that of a banana republic. We are in danger of living in a country where the elections are gerrymandered skewed because of population differences between constituencies so that a government could conceivably win a significant majority in the house of commons with around 1/3 of the national vote and 6% fewer votes than the winner 2nd placed party. This government can appoint the 2nd chamber of parliament and the judiciary, giving it effectively untrammeled power over us. It has abolished the key judicial safeguards of double jeopardy and trial by jury, and would like to remove the 800 year old principle of habeas corpus. We have all seen where this can lead. This is what Churchill had to say about habeas corpus:

“here is a law which is above the King and which even he must not break. This reaffirmation of a supreme law and its expression in a general charter is the great work of Magna Carta; and this alone justifies the respect in which men have held it.“

Tony Blair does not like the idea of a law which is above him.

This would have been unthinkable 10 years ago, and yet it has happened with hardly a voice raised against it.

What do you think Blair’s Legacy will be?

Kicks for free?

As I was getting my morning massage from the lovely Lola before being driven in the Bentley to my Lunch at the club to prepare for a relaxing afternoon’s golf, I hear on the wireless that the NAO has looked at the consultant contract and discovered that NHS consultants are being paid 25% more than they were for rather less work. I was disgusted because I thought my salary had gone up by at least 50%. Still, mustn’t grumble.

Then I heard that nice Mr Humphrys reading out an email from my esteemed colleague Francis Wells, who is a well known cardiothoracic surgeon (cue strains of “holding out for a Hero”) at Papworth Hospital. He seems to think its only right that the NHS pays him something for saving lives in the middle of the night compared to folks like yours truly who only minister to the sick during the day. What rubbish!. Mind you JH said the email was written from the hospital at 2am, which was when I was just staggering out of the Blue Summer Suite (great tip from me old blogosphere pal newmania) with Lola and her friend Marika. Maybe he has a point…

Anyway the Lambo’s back from the garage and I’m off to take it down to Cap Ferrer for the weekend (well it is Thursday). I just want to leave you with this thought: Trotskyist-turned Blairite former health secretary Alan Milburn (where are you now-all is forgiven, please come back) made 2 basic mistakes:

First he assumed that all GPs were stupid and inefficient, so he set their contract with financial incentives (QAFF) to hit certain basic targets, assuming they would achieve about 60-70%. Good GP practices are now hitting 95-100% of their targets, which is a key reason they are making so much money.

Second, He assumed that most consultants are clever, but were abusing the NHS and getting paid for sitting around in the golf club before sauntering down to Harley street to make a few quid on the side. (I fired my secretary for giving my diary to the DoH inspector), so he set consultants’ remuneration based on hours worked rather than any performance target, (was he worried we might hit performance targets?). Unfortunately it turns out that only a few people were abusing the system (and probably still are) and the rest were so incensed by the attitude of the SoS and department that we decided to claim for the hours we actually work rather than what he thought we were doing, but we didn’t have any incentive to work any harder or, critically, to change the way we work. Came as a bit of a shock to old Alan, I hear.

It’s all about giving people the right incentives and understanding what your starting point is and where you want to get to. Well, 0/3 ain’t bad. It’s just about average, in fact.

Au revoir

Not now Lola, can’t you see I’m trying to concentrate

Pouring money down the drain

Dr Grumble points me to THIS post on the informaticopia blog. A mere £72 million down the tubes on a virtual university which was never going to fly.

NHS Direct: about £150 million per annum (but the auditor in 2005-6 made a number of serious qualifications before signing off the accounts, including that it was unable to account for its payroll costs, that it had failed to appoint an internal auditor and that it was unable to provide supporting evidence for 16% of the sample payments examined-so who knows how much it actually costs.) And what this money buys is an unqualified nurse with doubtful insurance sitting on a telephone line advising people whether or not to see a doctor. What a complete waste of money

This is small beer compared to the amount wasted on NPfIT-the national programme for information technology. THESE are the damning conclusions of the committee for public accounts on progress so far. Among the catalogue of incompetent management, the sentence which stands out is this one

“The Department has not sought to maintain a detailed record of overall expenditure on the Programme and estimates of its total cost have ranged from £6.2 billion up to £20 billion”

So I can understand some uncertainty about the actual costs at this stage, but a 14 billion pound range seems incredible. It is beginning to look as though the tangible benefits delivered by this system may amount to zero

I’m afraid these are examples of a widespread lack of financial responsibility and common sense in the entire system. On every level money is literally poured away by the sackful, while in hospitals we are told we cannot afford to buy paper to write letters on, or even printer cartridges to print the letters with.

Perverse Incentives

What is a perverse incentive?

When the system rewards behaviour or policies which are actually detrimental to the service. It has been described as an organisation shooting itself in the foot. Here are 5 obvious examples:

Waiting Lists:

This is the classic perverse incentive. Until quite recently NHS consultants with active private practice had a real incentive to keep their NHS waiting lists long in order to encourage people to go private rather than wait. I am not sure how often consultants conspired to keep lists up, but they certainly had no personal drive to shorten the NHS lists. This situation has effectively ceased to exist as waiting lists have come down, but there are varieties on the theme and isolated cases which I am sure still occur. Dentistry is a classic case in which this sort of practice remains widespread. Furthermore historically hospitals with longer waiting lists were given additional money to help reduce them-thus there was no real incentive to do so

Budgeting

NHS budgeting would not stand up to rigorous scrutiny from industry standard auditors. There are any number of arcane practices, but one of the key perverse incentives is that if you spend less than your budget,it is highly likely that next years budget will be cut, regardless of the reason. If you overspend, there is a good chance your budget will be adjusted upwards, regardless of the reason for the overspend. Everyone from ward managers to senior consultants and managers therefore has a perverse incentive to exceed their budget (the ideal amount is around 5%), so that when taking into account the automatic CRES (cash releasing efficiency savings) which mean that the starting points for all budgets are automatically cut by 2% per annum and a modest inflation of 3%, next year’s budget will be balanced.

Commissioning

We now have a competitive market (sort of) where secondary care (hospitals) are potentially competing with primary care (GPs) for the supply of some services-for example diabetes care and minor surgery. Does it make any sense that the commissioning bodies (Primary care trusts and more recently GP practices themselves) have no representation from secondary care? In effect the GPs have the opportunity to commission certain (possibly more lucrative?) services from themselves, no matter whether or not this provides a better service for the patient

Quality of care

It goes without saying that provision of high quality care is often more expensive than provision of adequate care. Without any real element of competition for patients there is a perverse incentive for trusts to provide the lowest acceptable standard of care rather than seeking to provide excellence, or even to deliver improvements

Targets and monitoring

Although some targets have produced real improvements in the service, many are disruptive to the service and may even be harmful. They consume vast amounts of resource for often little or no benefit. Clearly the vast number of agencies which the government has set up has an incentive to keep issuing targets, as these are the only things which justify their existence. In some ways middle grade hospital managers also have an incentive to encourage the target culture for the same reason

These problems are not new-in many ways they are an inevitable result of the creation of an artificial market, and indeed have been well described in the past-see HERE for an interesting exposition written in 1991 by Steve Harrison discussing gaming, shunting and creaming (boys will be boys). The question is how to avoid them or minimise their impact. The introduction of the market has, remember brought significant efficiency savings. As a junior doctor I remember that one simply did not care what a treatment cost- we all simply prescribed the best treatment for our patients. This nirvana now seems a long way off.

One answer is to abolish the artificial market and create a real market in healthcare. Do we have the courage to consider such a choice. And is it a practical one to maintain a fee at point of service NHS?  On a practical level the best we can do is to minimise the distortions applied to the market.  This would appear to be contrary to gobernment policy

Health Problems

So obviously health is my thing (but hopefully not the only thing) and I want to cover some specific topics over the next few weeks. So far thanks to praguetory I have got as far as

Doctors remuneration

Perverse incentives in the NHS

Dealing with underperforming doctors

Incentivising the NHS to better financial management

I’d also like to touch on how we can afford healthcare in the future

So thats where I’ll start. Any other suggestions as to what needs to change will be gratefully accepte. Or at least considered