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

Tangled Webs

If you think this is just political, stick with it till the end, you may be surprised.

Reading THIS in the Daily Mirror:

DAVID Cameron tried to put a brave face on Tory election results yesterday as his hopes of a landslide failed to materialise.

and THIS in the Soaraway Sun:

DAVID Cameron turned the map blue last night as he showed the Tories are finally back in business. The Conservative leader was celebrating after winning a whopping 875 council seats in the town hall elections.

did make me wonder if the political journalists had been reporting on the same election, though I think the map below probably tells the story (look away if blue isn’t your favourite colour)

And initially I got quite cross, railing internally and occasionally vocally at the Mirror, Guardian, BBC etc.

But consider the following statements:

“I’m afraid you have lung cancer. The prognosis is very bad-most people will live less than a year. The best treaments we have is chemotherapy but that will only add about 8 weeks to your survival time on average (the chemo is a 12 week course) and there is a significant risk of side effects”,

and

“I’m afraid you have lung cancer. Although some people have bad outcomes, many people now live for 2-3 years after the diagnosis. I would suggest you have some drug treatment (chemotherapy). We know that the majority of people will see improvements in their quality of life and symptoms, and a significant minority (probably 30%) will also get a major response to chemotherapy and will live longer as a result”

I use both these sentences (or at least some variation on them-I probably wouldn’t use the first one as it stands) quite often. I use the first when my assessment is that a given patient is not likely to benefit from treatment-for example if they have other major illesses which increase the risk of side effects from treatment. I use the second when I think that people are likely to benefit. Both are true. Both rely on the same data, but it will not surprise you to hear that recipients of statement 1 rarely ask for chemotherapy whereas recipients of statement 2 rarely decline treatment

So now who’s the spin doctor?

What makes a good day?

Well, waking up to THIS, for a start.

Even the rather bizarre BBC reporting doesn’t seem to affect the general aura of well-being. Does make you wonder what would be classified as a good result in BBC-land though!

I suspect even Patricia Hewitt’s parliamentary researcher hates her after Patsy promised to answer any emails with queries or concerns about the health service on Question Time last night. I bet they are having rather a busy day

But I did wonder if she had a hand in introducing the new electoral system in Scotland, after I heard the man from the electoral commission on the Today programme explaining how they had expressly told the government that they should not hold the parliamentary and council elections on the same day as it would inevitably lead to confusion and problems with the new voting system. What did the government do-you guessed it. Result? 100,000 disenfranchised Scots. Are you sure you weren’t involved, Patricia

Down came a spider

Just getting out of the bath this evening after a hard day’s golf when I noticed Lola smuggling something furry into the bed. Never one to miss out on a joke (especially one of Lola’s) I chanced a peek-Imagine my surprise when I saw this little fellow:

Phoneutria nigriventer unless I miss my guess. Can’t imagine what she wants it for.

The Midas Touch?

Curriculum Vitae: The Rt Hon Patricia Hewitt MP

Current position: Secretary of State for Health

Current Salary: 136,677

1948: Born in Australia into a privileged family

Education: Canberra Girls Grammar School, Australian National University, Newnham College Cambridge, Nuffield College Oxford

1971: Press officer, Age Concern

1973: Press Officer, UK National Council for Civil Liberties (Liberty)

1974-83 General Secretary, Liberty

1981: Backs Tony Benn for Labour Deputy Leadership

1981: Tony Benn loses deputy leadership

1983: Stands for parliament in safe labour seat of Leicester East following defection of sitting MP to SDP

1983: Leicester East elects Peter Bruinvels (Conservative) to parliament

1983: Appointed press secretary and chief policy adviser to Neil Kinnock

1992: Neil Kinnock unexpectedly loses general election due to disastrous PR campaign

1989-94 Deputy head of institute of public policy research (leftwing thinktank)

1994-7: Head of research, Andersen Consulting (later Accenture-watch this space)

1997 : Elected MP for Leicester West

1999: Minister of state, DTI

2001: Secretary of State for Trade and Industry

Summary of manufacturing sector in the UK 1995-2003

Year	Number of enterprises	Total turnover	Total employment - average during the year
		(£ million)	(Thousand)
1995	171,518	425,963	..
1996	164,808	450,177	..
1997	169,663	469,787	..
1998	169,376	460,677	4,416
1999	170,196	461,771	4,269
2000	167,289	469,146	4,143
2001	164,718	461,898	3,969
2002	162,212	450,090	3,762
2003	158,528	447,178	3,534

(yes, we were doing all right until she walked into the DTI)

2003: Accenture awarded £1.9 billion contract to provide NHS IT infrastructure

2005: Britain’s last major car manufacturer (MG Rover) goes bust. Hewitt precipitates this by saying company had gone into administration while directors were still trying to work out a rescue deal. First airing of phrase “Hewitt Blewit”

2005 Appointed Secretary of State for Health

2005-6 NHS goes into deficit by £623 million

2006: Loses confidence of nursing profession: Heckled at conference after 7,000 redundancies announced

2006: Accenture pulls out of NPfIT citing losses of 1.1million per day (thanks Patsy)

2006-7: Loses confidence of medical profession: Attacks GPs for daring to hit government targets, hospital consultants for not working hard enough

2007: Creates Debacle in junior doctor training by implementing disastrous MTAS application process

In short she has turned almost everything she has touched to dust. What do you think: would you give her a job? I’m pretty sure she won’t be going back to Accenture

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