A Jolly to the Falklands

The thirtieth anniversary of the Falklands war brings back memories. It was a curious war, and the war that saved Mrs Thatcher. Before it she was way behind in the polls, even with Michael Foot as Labour leader. After it she won a 150 seat majority in parliament, the largest for generations, enabling her to change the fundamentals of the country. It was at the time a very popular war.

I remember as a junior doctor hearing Surgeon Commander Rick Jolly lecturing at St Christophers on his experience as Commanding Medical Officer at the field hospital at Ajax bay. He had spent some of the 1970′s as Battalion medical officer with the Royal Marines in Northern Ireland, spending many hours in the morgues of Belfast studying bullet and blast injuries, and developing ideas on battlefield surgery. His lecture was illustrated with some very gruesome slides, but his studies were well worthwhile. Of the 580 British wounded in action only three died of their wounds, one of the lowest mortality rates of any conflict, and this despite having a makeshift hospital in farm shedsnwith two unexploded Argentinian bombs in the facility. He wrote about his experiences here, and I particularly recommend reading the sections on May 31st, and  June 8th. The proceeds of the book go to support the very worthwhile Charity “Combat Stress”, I have had many patients with Post Traumatic Stress Disorder, even stretching back 70 years.

Surgeon Commander Jolly is a larger than life character, a patriot, marine commando and doctor. In the 1990s he visited Argentina, and enquired of the Argentine government how the Argentinian wounded that he had treated alongside the British had fared. When they looked into this, and saw the compassion and expertise with which the Argentinian wounded were treated by both Jolly and his staff; they awarded him the medal “Order of May”, one of their highest honours. Rick Jolly is unique in modern times by being awarded medals by both sides in the same conflict. He has a special dispensation to wear both medals together on his uniform on any and all occasions.

With tensions being stoked up again in the South Atlantic, and documentaries appearing on our screens critiquing the war, the story of “the Red and Green Life Machine” is perhaps one of the most worthwhile to recall, I am glad there will be a documentary on it . Wars often appear foolish when time has passed, but also produce some genuine heroes, and Rick Jolly is a bone-fide medical hero, I shall raise a glass to him.

Dr Phil

Diversity, Interviews and Joey Barton

Dr Phil is delighted to see that the RCGP presidential election is underway at last. I am not a GP, but the ever entertaining Una Coales is standing. The candidates are listed here. There are six candidates, 4 white men, one white female, as well as the intriguing Una Coales (Korean-American). Two are professors, one designed the QIPP process for the Department of Health, one designed the loathed Revalidation system. So many competing candidates for last position in the STV voting system, at least as a non-member I do not face this difficult choice. This is not a very diverse field, it is the “same old, same old”, with one wild card.

I have done my Diversity Training, it is after all compulsory to do so for the many interview panels that I sit on. We always follow the rules, but do we achieve real diversity? In some ways we do: I am a white male myself, yet now only 25% of British medical students are white males, when 50 years ago it would have been more than 75%. As a state educated white male I am in a minority approaching single figure percentages. Half of our BST and HST Trainees are female, and more than half not ethnically British.

However, appointment committees remain self-perpetuating oligarchies; the purpose of an appointment committee is to select the best person for the post. As the panel consists of the “Great and the Good” of the particular role, so to decide who is the best, they look in the mirror. Cats do not appoint Dogs (hat tip to the Spectator for the cartoon above). It is not now the external stigmata of diversity that are looked for, it is the inner feline. Is the candidate “one of us”? do they buy into the importance of committees? do they support the agenda of the Foundation Trust? do they speak the educationalist gobbledegook that shattered the careers and lives of so many in the MTAS/MMC process? If not then do not pass go, do not collect £200.

Even more telling are the ways that the panels weed out the  ”troublemakers”, those that prefer working independently rather than “team-working”, those with strong challenging personalities, those that challenge the received wisdom of the system. Advice on how to pass interviews always puts the advice to be well but neutrally dressed, not to wear bling, not to argue with the panel, to rehearse the answers that the panel wants to hear. In other words: “do not be yourself”. Conform or die.

Joey Barton being sent off on Sunday

The real art of assembling a unit is getting the mix right: In football terms we need a few creative midfielders, and some who can break up attacks and win the ball, we need a goalkeeper and we need a striker. We need diversity. A truly great manager recognises that the brilliant (if thuggish) Joey Barton is highly talented, with skills that outweigh his extreme behaviour. A medical Joey Barton would be suspended in no time, and we are the poorer for losing their skills. It is not always comfortable to be in the presence of such characters, but they drive change and success. The England Football team needs home-truths like this:

“England did nothing in that World Cup, so why were they bringing books out? ‘We got beat in the quarter-finals. I played like shit. Here’s my book.’ Who wants to read that?” Joey Barton.

Joey Barton is an enigma. One of the few intellectual footballers willing to be interviewed on Newsnight, able to tweet on philosophical and political issues, yet with several convictions for violence.  Joey Barton was not picked by England for the Euro cup team. Like Roy Keane he is too ruthless for the complacent national team, and we are the poorer team as a result. I sense that a grey suit will be picked at the RCGP also, rather than chuck a large UC cat amongst the RCGP pigeons. It would have been entertaining, from the stands.

Dr Phil

Privatisation and Cherry-picking / Journal Club

There has been much discussion about the effect of privatisation on various blogs, but interesting to read here of a serious analysis of the effects. It makes for intriguing reading, and the mathematical analysis appears appropriate.

It does seem that privatisation in this analysis does have net benefit to NHS patients and budgets, but it does filter the middle class patients to the private hospitals, with the sicker and poorer patients disproportionally going to the NHS Trusts. This does seem to increase the length of stay in NHS Trusts (used in the paper as a proxy of costs and efficiency).

I do have one or two observations: The first is that the locations of the private hospitals are not random. The location of private hospitals, such as my very own Little Harley Street, do precede the introduction of a private sector choice in “Choose and Book” by the last Labour government. These locations were chosen very carefully to provide convenient access for private patients. They are inevitably in the wealthier parts of town, tend to have locations with fewer bus routes and better car parking. Even before we get to the stage of cherry picking by ASA codes we do have the other barriers to care. For “Choose and Book” patients to get to these locations they generally need a car or taxi to bring them, thereby skewing the patient social mix.

A second observation is that increased length of stay does not inevitably increase costs. A patient needing very little nursing care and having “Bed and Breakfast only” may be preventing one of my colleagues admitting another patient for expensive treatment. One reason that long stays have not disappeared is that they serve a purpose, of rationing care by limiting access to a set of beds. This ceases to be the case when the number of beds increases, at the NHS Trust site, or elsewhere funded by the NHS.

But where should we go to next?: If the overall effect is to benefit the NHS then how do we prevent the “cherry picking” skewing costs against NHS Trusts, impairing their abilities to provide comprehensive services. The first step was to cut the private sector premium of 10% set by the last Labour government, to a level playing field. I am glad that the Coalition government has made this step in the right direction. It needs to go further, there needs to be a premium on tariff to deal better with co-morbidities, and this is now starting to happen. We also need to have a Training premium of (say 30% above tariff) to cover additional training costs, which I would restrict to cases done by trainees where there are no complications. This would encourage good supervision of Trainees.

Governments of all colours believe that financial incentives alter behaviour. We have proposals for minimum prices for alcohol, taxes on cigarettes and even suggested for trans-fats. All of these are designed to alter behaviour considered by our betters to be undesireable, even though these taxes will fall most on the poor. Financial incentives can be constructed to encourage or discourage almost anything, and are themselves neutral. I have written before on how market forces can help here, but the setting of the objectives is very political: arthroscopy for middle-class sportsmen or good psycho-geriatric care? the choices of our representatives in politics do not reflect well on our society.

Dr Phil

Smoking, the right to be stupid and the loneliness of the long distance runner

An interesting Doctors.net poll has reached the Guardians notice. They did have a recent CIF piece on smoking also. Anna has a thought provoking poem and some musings on the de-normalisation of smoking here. The persistance of smoking gives me much thought.

Quite a few of my patients smoke, and it is often a major contribution to their ill health and early deaths. Some are in denial about this, stating something along the lines of: “My father smoked all his life and lived to 90″. I point out that my Grandfather was in the trenches at Paeschendale and also lived to be 90, but that does not prove that trench warfare is not dangerous! (Indeed as smoking contributes to the early death of 50% of smokers, and around 15% of British troops died in the trenches, trench warfare is arguably considerably safer.)

Mortality in the UK varies greatly by social class and this inequality is increasing. A male in social class 1 (such as myself) has a standardised mortality rate of 66 between the ages of 20-64 compared with an SMR for the same person in social class 5 of 189. In other words the SE5 class man has nearly 3 times the chance of dying before collecting his pension than me. Among men, the dominant factor is smoking, which accounts for over half of the difference in risk of premature death between the social classes. Smoking rates are about 15% in SE group 1, 45% in SE group 5, but in certain groups the rate is higher still, going to 55% in single mothers on income support, and 90% of homeless men. Cigarette taxes are the most regressive of all taxes, taking 15% of income in some groups, and raise £11 billion, smoking related diseases cost the NHS £1.7 billion.

Similar risks,  often partly social class based, such as obesity, binge drinking, and motorcycling are self chosen risks. Is there anyone in the country who does not know that these things are bad for health and longevity? Yet we continue to do these things (though I now only have an occasional crafty ciggy on ward nights out). In part it is the cultural context of various sub-cultures that makes these things acceptable, but in large part they are pleasures freely chosen.

There is an authoritarian, puritanical trend in much of medicine, and in UK health policy, that wishes to make us behave healthily. Yet many of us turn a deaf ear to these new puritans. In part it is the logic quoted by John Mortimer: “There is no pleasure worth forgoing just for an extra three years in the geriatric ward” but I think that there is another reason, one that defines us as human beings, the “right to be stupid”.

Just as the right to free speech requires us to sometimes say offensive things (if we never cause offence then we are censoring ourselves and others), the liberty of the individual is characterised by the right to do something unwise. If I only act as my political, or medical, masters want then where is my existence? Existentialists such as Camus came to the conclusion that suicide was the ultimate defiant act, and what is smoking but a deliberate courting of the angels of death?

In an increasingly controlled and controlling world, the only way to stand up to arbitrary authority, whether from Whitehall or the medical establishment  is to refuse their control.  With revalidation and appraisal on their way what better approach is there than the dumb insolence of getting out fags and lighter?

The smoking classes are often not ones that can express their discontents via the political process, they are those on whom actions are forced, with little purchase on the levers of power. Smoking is often two fingers to their betters.

One film that expresses this desire is “The loneliness of the long distance runner“, running being a good time for thinking. This is the scene where the main character stops running a few yards from the line, to deliberately annoy his Borstal governor, his benefactor:

It is a very British film, and illustrates how little has changed in Britain since 1962, though now the social control of defiant youth is expressed differently.

Dr Phil

Sack the pen-pushers and bring back Matron!

Oh that cry from the message boards! No-one likes the back office staff of the NHS, and all hanker to be chastised by Hattie Jacques.

Our Matron (Barbara)  is five years younger than me, and is more Barbara Windsor than Hattie. I have known her since she was student nurse and I was junior SHO, we have been on both management boards and ward nights out over the years. It amuses me to refer to her by her title of “Matron” in front of patients and meetings with managers in my best Kenneth Williams voice, she retaliates in kind, it being a good natured battle to see who can cause the other to “corpse“. She is a good clinical nurse, who likes to be hands on, but who gets trapped in the office and in meetings.

The cry “bring back matron!” is a cry of the Canutes of the world. The desire to be back in the days of Hattie Jacques and Sir Launcelot Spratt, when senior figures in hospitals could give orders and things would be done. The order is to jump, the only acceptable answer is “how high”. Behaving like that would have me up before the beak in no time, with accusations of bullying, discrimination etc, and a suspension to follow. Ditto goes for my colleague “matron”. If Barbara were to start ordering our privatised cleaners to get their mops out, first she would have to find them, then negotiate a path through the PFI cleaning contract, then suffer the complaints of unreasonable behaviour. So the ward remains dirty unless the nurses do it themselves. I suppose that is how Florence Nightingale started in Scutari, but I rather thought that we should be doing rather better than that now.

The reality of a “modern matron” is not often like my friend Barbara. Much more likely is the figure depicted in Nurse Annes extremely funny blog post “Stupid Bitch Matrons“. I am not capable of the sort of invective that Anne spouts, being an old softie, a lover not a fighter as my mother would say, but I do enjoy ranting as a spectator sport!

The Carry on series of films has many highlights, but are very evocative of times that were fading even when the films were made. These are much darker films than often believed, being about declining institutions, buckling under the influence of modern trends, and filled with sexual frustration. “Carry on at your convenience” is perhaps the ultimate depiction of the decline of British Industry in the 1970′s, and the first financial failure of the series. For the first time the film was lampooning the workers rather than the bosses, but now it is recognised as prescient.

But back to Matron, and Barbara Windsor…

Even in “carry on days” the Matron was on her way off the ward and into the office, a serf to the management, and an instrument of health care policy, and I follow Sir Launcelot into the same fate. We have sacked some of the pen -pushers and over-promoted others. I am rather overpaid to be a secretary, and Barbara is over qualified to purchase supplies, but that is what we have to do. Turkeys do not vote for Christmas, and managers sack the admin staff rather than each other. In the words of the Kings Fund: we are over managed and under administered.

Efficiency and productivity, reducing hospital acquired infections and minimising medical errors are all driven by good planning and logistics. It is all about effective administration and freeing those with clinical skills to do what they are good at. It requires a few well trained clerks and secretaries answerable to me and Barbara, not garbage management from the latest fad from the department of health.

So do not sack the pen-pushers and bring back matron, get rid of matrons like Nurse Annes matron, and hire a few decent secretaries.

Rant over!

Dr Phil

I am just going out, I may be some time…

The famous last words of Captain “Titus” Oates, on the doomed final expedition of Captain Scott, spoken a few days over a 100 years ago, in an attempt to allow his colleagues to make more progress to the next stage. His sacrifice was in vain, and his colleagues died in their tent a 100 years ago tonight.

Scott’s expedition was an example of the British cult of amateurism, embodied by his way of recruiting and planning the journey. Captain Oates was wounded in the Boer war and had one leg shorter than the other. The motor sledges did not work, and the engineer was not present to trouble shoot, the ponies were not bought by an experienced horseman, and were unsuited to the task. The supply depots were not well marked, fuel cans were not properly sealed and the calorie content of the rations were insufficient for the physical effort. Perhaps most damning, despite Captain Scott being a naval officer and Edward Wilson a physician, the party came down with scurvy a hundred and fifty years after the Royal Navy had developed preventative vitamin supplementation.

Amundsen was a less charismatic professional, with experienced companions, experienced in handing Dog sleds, and brought up on skis. The expedition was well equipped and led, and the supply depots well marked, with fuel and food well sealed. It won the race to the pole and came back without incident. The British however love a heroic flawed amateur, the cult of the public school boy.

A century on we have a very intelligent public school boy as prime minister, and the cult of amateurism carries on. The fiasco of pastygate and jerry cans is part and parcel of the same culture. The idea that a talented amateur can wing it when the going gets tough, whether at the antartic or with political public relations, is a large part of why Britain is falling behind other nations.

I am not a public school boy, and while I have ancestors from all four home nations, I have ancestry also from overseas, and have lived and worked abroad. I was brought up in state schools by parents who worked in business, and the culture of negotiating deals is in my blood. I am entering negotiations, both in the private sector, and via Borchester General Hospital with our new commisioners. I cannot believe how amateurish the whole process is. Negotiating parties don’t seem to prepare their negotiating positions in advance, do not understand what they are commissioning, often do not understand finance and expect to wing it on the day.

I relish coming to negotiations with these opponents, they are setting themselves up to fail, and need only a slight push before they collapse. They never seem to learn “fail to prepare, prepare to fail”. With the HSCB now law, we will have even more amateurs to negotiate major contracts. Those that prepare well and negotiate hard will be the Amundsen’s to their Scott’s; the British never learn.

 

Bad weather?

My dear,

Weather is neutral. It’s neither good nor bad. It just is. What’s bad about it is how prepared you are for it.

The snow isn’t bad if you have a warm jacket or house and a cup of hot cocoa. The scorching heat isn’t bad if you have an air conditioned house and a cooler filled with ice cold beer.

There is no such thing as bad weather, only inappropriate clothing.

Same goes for fortune.

There is no such thing as bad fortune. Only inappropriate expectations and reactions.

Sir Ranulph Twisleton-Wykeham-Fiennes

I have as little control over the political weather affecting the health policy in Britain as I do over the metereological weather. February and March were very busy for me, as they so often are, with the conjunction of junior doctors appointments via the deanery, end of financial year targets to be met for Borchester General Hospital , and end of financial year targets for Yerboots Ltd.

I have tidied up most of these now, particularly my own financial affairs ahead of the budget. By creative use of capital allowances, brought forward, I should be able to perfectly legally miss out on the 50% tax band. Low interest rates and the flat economy means that good deals can be struck for equipment and premeses. I am not planning to retire for another 8 years, perhaps not even then, so capital items will need replacing, and now is a good time.

I am not anticipating taking on staff, but as the government intends, shall use my capital equipment to generate wealth for my practice.  This is likely to indirectly provide employment for others. My private practice employs a part share of 7 self employed back room staff (all spend most of their time working for others) as well as providing work for Little Harley Street Hospital. The rewards will be mostly mine, but so are the financial risks. I have therefore carefully constructed my own analyses of how I will generate new profits with my equipment, while providing innovative and efficient care for my patients with the latest techniques. Correct use of capital maximises productivity.

The changes within the health economy are going to overwhelm some, but will allow others room to grow. The existing financial structures within Health Service planning are too slow for this. I have been asked to put in my capital bids for financial year 2013-14 by June this year at BGH, though with the current austerity they may take several more years to be funded. I will do so but the uncertainty over future income will most likely to cause planning blight. In the meantime some will be more bold and fast moving, I do not want to be caught out, but I see why some others just want to walk away into the sunset.

I have often given the advice to junior doctors “fail to prepare, prepare to fail”  There is no such thing as bad weather, just bad planning.

Dr Phil

The Tripartite policy of Privatisation?

A recent post by the Northern Doctor continues to enthral me. The post is about a bail-out fund for NHS hospitals whose financial future is threatened by the Private Finance Initiative. I like his use of “tripartite” policy to describe the drive to privatise the NHS and other parts of the state. This trend is not restricted to the NHS, with a police station in Lincolnshire being farmed out to the private sector today, and welfare to work schemes also being farmed out to the private sector agencies. Private prisons and utilities have been common-place for years. It is clear that this privatisation policy is common to all three major English parties, (I am not sure of the opinions of Plaid, Scottish Nationalists, Ulster parties, or the other minor British parties such as UKIP, BNP and Greens).

Many or most of these policies developed under the New Labour Government of 1997-2010, and the Liberal-Conservative Coalition has merely continued these. It is clear that whatever they say in opposition all three parties agree that privatisation is the way to provide services in the future.

Then Health Secretary (now shadow health secretary) Andy Burnham launching a new PFI project in Teeside.

So why have all three parties come to this conclusion? There are several possibilities.

The first is that this is genuinely a better way to provide services. I am willing to consider that this is at least a possibility, and have posted in the past how this may be done.

A second possibility is that our politicians are under the influence of shadowy health corporations from overseas. But surely the Labour party is at least as open to influence from the trade unions?

A third possibility is that there is no choice when faced with the finances of the welfare state, at least if the party wants to keep the welfare state in existence until the next election. Destruction of the welfare state would be popular with a small minority but is likely to be electorally difficult, and politicians do like to remain in power, it being the point of the game.

If a person, family or organisation is spending more than its income then there are three ways to stay solvent. Earn more money, spend less money or sell assets. Our government struggles to increase income as economic growth is flat, and taxes are high enough to kill it further. Even Ed Balls is asking for tax cuts in the budget. Despite all the hype about “cuts” government spending is going to rise over the course of this parliament. Other than borrowing, which is just taxation deferred to our children, the alternative is asset sales.

And the infrastructure of the NHS is an asset that can be sold off to balance the books, at least in the short term. If you cannot live within your means then you have to sell the family silver.

Del-Boy Brown

I am wondering if one of the paradoxes of this desire by politicians to stave off a major destruction of the welfare state is the part-privatisation of the same. Perhaps the financial lunacy of the PFI scheme is such that no private company would want to take on the liability, and is the protector of the NHS. At least in the short term.

Dr Phil

 

There Stands the Glass / Rehab

Ted Hawkins delivers this country standard with real soul, and the experience of a life often mis-spent.

There stands the glass. Real ale, fine wine, single malts, decent brandy, I enjoy them all. Drinking is an all purpose entertainment, we drink to celebrate, we drink to drown our sorrows, we drink to remember and we drink to forget. Sometimes we just drink. The damage to society from alcohol is undeniable, though the pleasure and relief of alcohol are also manifest.

Alcohol or drugs become a problem when they interfere with physical, psychological or social functioning. I have seen some gross examples of this in my time on the wards. I remember one young woman in her twenties dying of alcohol induced acute pancreatitis particularly vividly, but most casualties have been more insidious. I remember several school friends and junior doctors whose promising abilities fizzled due to drink or drugs. Cannabis and alcohol are a great destroyer of ambition as well as memory.

Recently I got an email from an old friend, a close mutual  friend from school had been found dead in his flat, and the cause was unsurprising. What a waste. Like Whitney Houston or Amy Winehouse his demons had overwhelmed him, having largely been created by himself in a vicious cycle of alcohol induced bad behaviour.

There is a puritanical streak in the government that wishes for minimum pricing to reduce alcohol consumption, and the kill-joys in our own profession are eager to see this implemented. I am not so sure, I think Dr No is right that true alcoholics will drink anyway and financially penalise their families more. There is a class element to all this also: my favourite tipples will be unchanged in price, while the cheaper strong lagers and ciders favoured by the poor are increased in price. The BMA still runs a wine club for its members, named for its founder, but that is OK, as Doctors never over do it do they?…

Ted Hawkins sings the words with the same mixture of  motives as much the rest of western society. The ambivalence towards the relief from psychological pain by alcohol and the psychological pain that alcohol induces is there in his voice. His is an under-recognised talent, honed by many bitter life experiences. Alcohol, like financial debt, provides temporary help but makes the final reckoning worse.

Does even relatively low level drinking cause problems? I follow government guidelines in these things as always , but I am going to try the interesting experiment of getting through Lent without an alcoholic drink. As well as monitoring some health parameters such as weight and BP, I will see whether I become more or less argumentative and anxious. Lent starts next week, but tonight there was Champagne on ice, Valentines day does need to be marked! “Lord, make me good, but not yet…”

Dr Phil

Psoriasis and Psychiatry / The Singing Detective

Dr Phil is glad to be able to re-watch the 1986 Drama “The Singing Detective” on BBC 4. It is a fascinating drama with complex and ambiguous plot. I missed a few episodes when it was first broadcast as I was working as a junior doctor myself, doing a 90 hours per week, and not finding it easy to stay awake studying for exams afterwards. There was not much time to appreciate TV drama.

The hospital scenes that permeate the series were filmed in a closed ward in a London hospital, and based on Dennis Potters own experience of NHS care for his psoriasis and psoriatic arthropathy. This still was from the scene where the nurse removes his pyjama trousers and massages ointments onto his bottom half. The protagonist struggles to keep his mind on the most boring things that he can manage. Some scenes are deliberately reminiscent of hospital based sitcoms of the seventies, and British movies, but enough is familiar to my 1980′s years as a junior doctor.

A large plot element is to explore how his psoriasis is an expression of inner self disgust and repressed childhood guilt. There is a long tradition of this in literature, and skin diseases feature extensively in the Gospels as symbolic of those cast out from society. (While some interpret these stories as “faith healing”, I read Jesus’ cures as symbolic healing of alienation, inner torment and spiritual blindness, rather than physical disease).

The interplay between physical and psychological elements of disease is one that interests me. Does the skin disease cause the depression, or does the depression feed the skin disease? Does the low self-esteem cause the “boob job”, or does the “boob job” cause a further dissatisfication with the body and soul? Or do these all feed on each other in a self defeating spiral of decline?

But for now I shall enjoy the show, and remember the times that nurses wore hats, tea was served from urns, doctors wore white coats, nurses were able to attend ward rounds, and racial stereo-typing of asians and afro-carribeans was considered suitable material for entertainment. The delight is in the detail, and while we may be nostalgic for some of these things, the antique cardiac monitors, the shabby surroundings, the absence of privacy of a nightingale ward do make me realise that many of the things that we take for granted now are very recent. In particular communication skills of doctors have substantially improved.

For those unfamiliar with the show, I recommend this clip of a ward round, not too dis-similar to some that I took part in. Watch until the singing begins at about 6 minutes 30 for the funniest song of the series, following the pathos of the protagonist, and plea for understanding from his doctors and nurses.