A dangerous trick of the mind…

The Medical Protection Society Casebook publication has a fascinating article today on Involuntary Automaticity (IA). This is what happens when the involuntary side of the brain takes over something that you do in the same way repeatedly, like driving. It may also account for why some medical errors are made, when we have fixed protocols for everything and IA takes over from the conscious checking mechanism. It’s also more likely to happen (to both parties) when 2 people are following a protocol which requires them both to check it, as they both involuntarily assume that the other person has done whatever it is they are supposed to check. So in a rather bizarre twist it means that changing a medical protocol from something which an individual has to make a conscious effort to think about and do into one which has pathways and guidelines which tell us what to do, with built in checks, may actually lead to more errors being made. This, rather worryingly is what pilots do on landing and take off.

It is also a particular issue in oncology where the driver is for ever more tightly controlled policies and guidelines, and is thought to have been a factor in the recent tragic case in Glasgow of a 16 year old girl who received a huge overdose of radiotherapy for a brain tumour last year. I can certainly think of occasions when I could have sworn I had checked something, but when I have double checked it it is clear that I can not have done.

Maybe it’s time to get rid of all the protocols and guidelines and go back to properly trained doctors taking responsibility for what they do, rather than expecting half-trained sub-consultants to get by through rigid adherence to defined procedures…

UPDATE

By a bizarre twist of fate at our clinical governance meeting we have just discussed a case where radiotherapy was given to the wrong area because a single mistake was made in annotation at the beginning of a patients journey.Despite (or because of) rigid adherence to protocol and an inbuilt check system, the mistake was not detected and ultimately led to this error, which thankfully should have no long-term sequelae. In retrospect this is quite a clear case of IA.  I was able to sound surprisingly knowledgeable about systems theory.  The Casebook article suggests the following remedies for IA:

Teaching doctors about systems theory

Adapting protocols to generate tactile and oral responses

Creating effective relationships between managers and clinicians

Using independent checkers

Developing different checklists to keep clinicians alert

Involving patients in their consultations more effectively

Minimising stress levels

Reducing distractions

Although I believe there is no substitute for good training and individual (rather than collective) responsibility, I think most of these sound very sensible, and especially the last three.  The patient in question knew the correct information which would have prevented him from getting the wrong treatment.  If only he had been asked…

Brainless Myopic Anencephalic

What is the BMA for?

I am a member of the BMA. It costs me nearly £400 per annum. I like the magazine, and I like to know what jobs are being advertised. Those are about the only benefits it brings me.

The thing is that as I’ve already said, I don’t believe that consultants should need a trade union. We are professionals and experienced and can speak up and negotiate for ourselves. There are doctors who may benefit from a trade union, as they can be more easily exploited by the system. They are called junior doctors and they have just been completely shafted by the new MTAS system introduced by my favourite health secretary. What does the BMA do? nothing. In fact James Johnson wrote THIS letter to the Times today supporting the process.

Now if I was the head of a trade union in which half my members were effectively threatened with random dismissal by a computer system which hadn’t even been through Beta testing, I think on the whole I would side with my members, and try to find a workable solution. JJ doesn’t see it that way and is presumably toeing the government line in the hope of being Sir James at some time in the future.

Spineless, useless, worthless

So back to my original question-what is the BMA for, and whose interests does it serve?

Bread for the masses

I am all for freedom of choice, but for the life of me I can’t see what’s wrong with THIS

Dogma dogma

Grammar schools are an odd thing to get hung up on.

What we should be getting hung up on is these three facts

1) There is less social mobility in this country now than there was 50 years ago, and less in Britain than in almost every developed nation It has even got worse (amazingly) despite 10 years of a Labour government

2) 50% of children leave primary school unable to perform at a basic level in reading, writing and arithmetic.. This may not be surprising as many primary school teachers are now unable to pass basic literacy and numeracy tests

3) Our universities are unable to differentiate between the bright and the average student when selecting because of the ridiculous number of people achieving straight ‘A’ grades

My position is very clear, Academic selection and streaming are essential if we are to allow the brightest children in our schools to flourish. They are the future leaders of our country, our innovators, our scientists, our financiers, our doctors, our business champions, our civil servants. We NEED them to achieve their potential if we are to do so as a country. I do not think selective entry to school is necessary if schools have sufficient numbers of pupils and resources to provide a truly intellectually stimulating environment for the brightest children. If we are unable to provide that environment then we need selective schools.

The corollary to that is that most of our children are not the brightest, and they need to be given the opportunity to thrive as well. This is where the Grammar school system let us down, or rather the secondary moderns did. Secondary schools should all be able to educate children to a university standard (whatever that is these days). If there is a selective school in the area then it needs to work in partnership with the local non-selected school to identify late developers and include them.

I do not believe that binary selection at 11 is an appropriate way to sift our children, and late developers have to be given the same educational opportunities as precocious children (see above).

But my major problem with education in this country is that too many state schools are simply too unambitious for their children. No matter how well they are educated, they are not given the ambition to succeed, the belief that they can be captains of industry or prime minister. The best they can hope for is to be a ‘B’-list celebrity. That is what is missing. That is what I hope City Technology Colleges and other secondary schools in the future will provide. But we have to prioritise the brightest children

Into the ears of babes and sucklings…

I went to a football match on Sunday. I took my 7 year old son. I haven’t been to a live footie match for several years-in fact since I became a father. There was a moving moment of solidarity with the McCann family. After that, the singing started. Here’s a sample of what the Chelsea fans were singing to their Everton visitors.  (Those of a tender disposition do not read on)

In your Liverpool slums
In your Liverpool slums
You look in the dustbin for something to eat
You find a dead rat and you think it’s a treat
In your Liverpool slums

In your Liverpool slums
In your Liverpool slums
You s**t on the carpet, you p**s in the bath
You finger your grandma, and think it’s a laugh
In your Liverpool slums…

It goes on and it doesn’t get any better. Now I know that I wasn’t in the family enclosure, although I was surrounded by children. I know that football is an emotive part of may peoples lives. I think I have a sense of humour which is not especially delicate, and I have a more or less complete mastery of Anglo-Saxon vernacular, which I use regularly. But I don’t want my children or anyone else’s growing up learning to hurl ritual abuse at people. I don’t like them thinking it’s normal to be so tribal. I want them to be able to think as individuals, not as part of a baying mob. I also don’t see how it is very different from racist abuse. Not of course that I particularly like Liverpool myself!

Maybe that’s my prudish middle class background. I certainly don’t remember having the same objections 20 years ago. But I’m not sure I will take my son back to Stamford Bridge, at least not for another 5-10 years

Which is a shame because he absolutely loves football

A Tale of three drugs

Non-medics may care not to read this!

Dr Crippen has THIS post today about the lack of availability of Tarceva (erlotinib), a drug about which he has strong views and has previously posted. I think it may be helpful to consider the case of this drug in a little more detail. Tarceva is a drug which is licensed for the treatment of lung cancer after previous chemotherapy. It is no available on the NHS as it is deemed by NICE not to be cost-effective (though interestingly it is cost-effective in scotland-work that one out if you can!)

There are 2 other drugs licensed in this situation, namely docetaxel and pemetrexed. Only docetaxel is available in the NHS. The following are 3 graphs showing the survival figures for 1) tarceva vs placebo, 2) docetaxel vs supportive care and 3) docetaxel vs pemetrexed

1)

2)

3)

They show (to me, anyway) that both docetaxel and tarceva give a survival advantage over supportive care alone, amounting to an approximately 10% absolute survival advantage at 1 year. The third graph shows that pemetrexed is as effective as docetaxel.

The costs of these drugs (approximately) are as follows:

Tarceva £1,800 per month (average course will be around 3 months, may go up to 18 months)

Docetaxel £6600 per course

Pemetrexed £8000 per course

These drugs have different side effects, different risks, one may be more suitable for one patient than another. I believe they all have a role, and in the private sector I am able to discuss with patients the pros and cons of each and come to a decision as to which is better for an individual patient. Why am I not allowed to do the same in the NHS, where the choice is docetaxel or nothing? Just because it is the cheapest does not make it the best choice. Indeed for a patient who is likely to have side effects from docetaxel, tarceva may be more cost-effective. The only people who will be on the treatment fo more than 6 months will be those who are benefiting, and in those patients the drug is cost-effective. The people in the best position to make these decisions are the oncologist and the patient, NOT the DoH. If they had their way, oncology could be practised by automatons.

Now, that said there has to be rationing in the NHS. There will be drugs and treatments that we cannot afford. I feel, however that if these treatments are available in every other developed country but not the UK, then we have set the cost limit too low, and this is reflected in the fact that our cancer outcomes are amongst the worst in the developed world. It might be that we decide that this is acceptable and we will not devote resources to treating cancer as it is not cost-effective. If so, I will look for a new job.

Its really true…

He’s really going

*Sniff*

Miss him already

(Good to see George W believes in wearing a condom, though its not a brand I recognise!  And I like the merkin, too)

Its true…

Britain is one of the worst places in the developed world to be if you get cancer, researchers from Sweden’s Kaolinska Institute have shown HERE . But bizarrely one of the leading nations in the world in research against cancer. I am afraid that this will come as no surprise to those of us who treat Cancer for a living.

However I was interested to hear Karol Sikora, a well known UK oncologist on radio 4 this morning. He says he wants rationing by NICE to be explicit and timely so that the NHS can provide a “core service”, with the implication that people would have to pay for anything over and above the core service. This is not, of course, what Patsy and the DoH want us to believe. You can hear the interview HERE

But speaking as I was previously of perverse incentives and conflict of interest, I wondered whether Dr Sikora might have mentioned that he is the leading light behind CancerpartnersUK, a private venture providing oncology services to NHS and private patients, and centres where people will be offered a basic “NHS” package with the opportunity to pay extra (to Dr Sikora’s dispensary) for additional drugs like erlotinib or bevacizumab which are not available on the NHS. So, to look at it cynically, he has an incentive for the basic NHS package to be as basic as possible to encourage his own business.

Now I think this is a model which may well work and may have benefits, but I think Dr Sikora would be well advised to declare his interest in this organisation, which is more significant than his NHS commitment, which I understand to be minimal.

It’s a lie…

THIS can’t be true. If it is we have to keep it very quiet. I’m certainly not telling Lola!

Bloody Mediocre Actually

Let me start by saying that I am deeply suspicious of professional trade unions. I do not regard myself as a disenfranchised working man who needs the resources of a trade organization to negotiate on my behalf, and I don’t believe in a number of things that my own trade union, the BMA, woud regard as sacrosanct (eg national terms and conditions of service for consultants). I am not convinced that the BMA serves the interests of its members, let alone the general public, and I often ask “what is it for?”

The BMA has issued a document called A rational way forward for the NHS in England, which I read today with a mixture of sage nods and spluttering in the style of an HM Bateman cartoon

Here’s a synopsis of the main themes:

1.) NHS to be taken out of day to day political control and put in the hands of a board of governors

Well, fine but is it realistic to think the NHS can have access to £90 billion without accountability to the treasury and the taxpayer. I’m pretty sure Gordon won’t go for it unless he has a ’stealth’ hand on the purse-strings

2) Explicit acknowledgement of and discussion of rationing

Absolutely-and about time too

3) Increased Autonomy for local health economies

Leaving aside whether an economy can have autonomy, I know what they are saying and this is devolution of decision making to a local level. This has to be good, too.

4) National quality standards to “underpin local management and provision of services”

I can buy into this, but the language is getting more obscure which suggests catastrophe looming

5) “A more mature form of commissioning would diminish the need for a purchaser-provider split. Commissioning should be clinically led, based upon collaborative relationships between primary and secondary care, and seek to develop integrated care systems. Commissioning must be led by the public sector.”

Now they are beginning to lose me altogether. How can you have commissioning without a purchaser-provider split? It may be that they are saying that commissioning bodies should have representation form both primary and secondary care, which I would entirely agree with.  I’m all for collaborative relationships but I think we’re getting into motherhood, apple pie and management jargon

6) Private sector provision should only be commissioned where there is no NHS capacity to provide the service. There is no evidence that the private sector offers improved services or better value for money than the NHS. There should be no further central procurement of private sector provision. The private sector should support the NHS rather than be seen to be supplanting it

No NHS capacity? This has to be wrong. I’m not a fan of central commissioning of private sector services, but it does drive down costs, and may be appropriate in some instances. Why should the private sector support the NHS? Surely both should work, together where necessary, for the improvement of patient care. This doesn’t mean the private sector “supporting” the NHS

7) In order to enable the development of integrated care systems, clinical networks need to be established. This requires a commitment by the service to make protected time available for clinicians to plan service development.

hmmmm

8.) Areas should be encouraged to move toward single-system working, as exists in Scotland, where commissioners and providers work within a single structure. This is because efforts to move towards a different form of commissioning and the development of clinical networks may be frustrated by the formal existence of a
purchaser-provider split. We believe that a HEFT model could achieve this. Boards would include provider and commissioner representation from hospitals, general practice, community providers and public health.

This is unquestionably (to my mind) the right way to develop commissioning-but no mention of patients here

9) Clinical networks should have patient, carer and user involvement at their centre.

stating the bleedin’ obvious

10) We recommend the formation of local health councils to provide a link between the community and health professionals/managers who are shaping local services. Their membership will be elected.

Great idea. These were called community health councils. New Labour abolished them

11) Commissioners must be given freedom to make investments without showing a return within the financial year… greater financial flexibility is needed.

Common sense

12) A new agreement is needed for managers’ relationships with clinicians, together with a new agreement between the government and the NHS, and between the NHS and its constituent parts. This will involve devolving responsibility for the management of care to clinicians and a shift in managers’ priorities. Primarily this will mean a move away from an obsession with external political expectations and towards a focus on clinical quality and service development.

This is true, but see below

etc etc. There were 24 recommendations in all. Some of them were sensible, some of them were stating the obvious. What was said was considered and generally sound.

BUT…

There was no mention of other critical reforms that need to happen: Giving patients information about their health service and doctors, and the choice of which doctor to see and which hospital to be seen in. No mention that if doctors are to take responsibility for the innovation and development they need to be trained to do so. And, by the way, that they need also to take responsibility for the failings of the system as well. No mention either of improving doctors’ productivity with incentives and financial or other penalties.

In short no mention of fundamental reform of the way in which patients interact with their doctors. Only limited mention of empowering the patient in this discussion. No mention of managing doctors’ performance.

Just what you would expect from a trade union, perhaps. Not necessarily what I want to hear from my professions’ “leaders”

Having said all that, if you add in some of the above details, and read it in the knowledge that it is written by a doctors’ trade union, it is a reasonable document with some well considered points, and may form the basis for sensible discussion. Myself I do not believe that it goes far enough. Root and branch reform is needed in the NHS, which is now performing incredibly badly compared with other international comparators. But the point that is made in the report is that the NHS needs to change by evolution rather than revolution. I believe that we need some genetic modification to speed up the process, though