Letters & Lessons of a Career Consultant
Now retired from the NHS I have a little time to collect some of my thoughts and experiences of it. That is, a little time in between unpacking, cleaning and planning, as we have just moved to East Sussex (Rye to be precise and this is the view down Mermaid Street that we have from the top floor).
One day this may turn into a book. New essays will be added from time to time. The views expressed are my own.
Andrew Bamji
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This series of essays and anecdotes is based on my experience at a small District General Hospital as an NHS consultant. I am no great researcher but I have written a lot; review articles; around 500 letters to “The Times” (59 published); letters, Rapid Responses and Personal Views to the British Medical Journal; two memoranda to the House of Commons Select Committee on Health and a monthly comment column for five years in the British Society for Rheumatology’s journal under a pen name amongst others. If you have a point of view, then express it. If others find something in it then it may be aired widely.
If you are a doctor, some of the lessons may help you to be a better doctor. If not they may provide some unexpected insights into the NHS. Not much of it relates to medicine as it is taught. Some lessons are clinical. Most are common sense. However as time has gone by I have become increasingly aware that the majority of doctors think in a medical way. That needs to be adapted so that one can deal with non-doctors (other, that is, than patients, although there may be some branches of the profession, and some individuals, that need lessons in that too).
There are some simple principles and parables. If you detect repetition it is for a reason. If you don’t understand then you should go to some of the recommended background reading.
Working in a small place can lead to professional isolation. In my case the closure of my hospital’s A&E department, and the relocation of most of my acute side colleagues to other sites for much of the time, has worsened this markedly. However one can still learn what’s going on around the country by talking to friends at meetings, and learn about the systems in other countries from passing colleagues from abroad. Thus it remains a sad and salutary fact that many of the “reforms” proposed for the NHS over the last 30 years have come from the United States – about 10 years later, and all too often introduced just as the USA is learning that theirs have failed. One must never stop asking “Why?” It will irritate people but is the only way to learn – and may be the only way to stop the introduction of useless or poorly researched ideas.
Why the wry observer? I have found that cynicism and pragmatism are sometimes lacking in decision making and strategic planning; some of my prophecies have come true, and I cannot therefore resist a dig at those who pooh-poohed my projections; and it is a rather feeble pun on the name of our local paper.
There are many myths in healthcare. The first is that the Labour government of 1948 invented the NHS. It didn’t. The basic principles were put together by the Socialist Medical Association some 10 years previously, and the first official stab at an NHS was laid down in a British Medical Association report of 1942(1). Bevan’s difficulty in getting it through (exemplified by his oft-quoted statement that he had had to stuff consultants’ mouths with gold) was not really a problem of principle, but of detail.
An analysis of healthcare in the era between 1930 and 1945 reveals a split hospital service that was largely bankrupt. Large teaching hospitals were cushioned by their endowments. The local authority hospitals were run on a shoestring, while the voluntary hospitals were under severe financial pressure and, if they had not been subsumed by the NHS, many would have had to close. Bevan fondly believed that the NHS would so improve public health that the cost of provision would fall, failing to see that the eradication of some diseases such as TB and diphtheria would prolong lives. New conditions would then rise up (heart disease, cancer, diabetes); treatment of these would negate any saving, and so it proved – and proves today.
I have little doubt that despite all of the inefficiencies of a state monopoly the NHS is a fundamentally sound idea. However successive governments, in seeing the problems and costs, have chosen to think that they can be swept away by reform. I have lived through too many, going back to Kenneth Robinson in the 1960s (I remember several meetings of north London GPs at my parents’ flat, which he attended (not a likely scenario today), through the abolition of health boards, the establishment of district and area health authorities, the purchaser-provider split, fundholding, the development of Trusts and then Foundation Trusts, the introduction of the Private Finance Initiative and most recently the idea that GP consortia should and could run the NHS.
Undoubtedly there have been changes in what we can do for people, and the cost of it, but none of the reorganisations or reforms has solved the underlying problems. I do not believe they ever will. Is this an implementation failure, or is it an indication that it’s the wrong thing to do?
One thing that I have learned from experience is that the NHS is not good at reflection. The plans for reform came up at fairly regular intervals, and were introduced with great fanfare. Some were carefully thought through; others (notably the Thatcher reforms of the 1980s) were sketched on the back of an envelope (literally) and then worked up on the hoof. However, analysis of the benefits of each reform is superficial – except that it is deep enough to force realisation that the last one did not work. So another is dreamed up. It seems odd to me that, as each reform fails in its turn, we spend all our time on yet more reform, as if we seek ceaselessly for the Holy Grail. There is an old saying that a surgeon is a blind man looking for something, a physician is a blind man in a dark room looking for something, and a metaphysician is a blind man in a dark room looking for something that isn’t there.
Medicine is science, not metaphysics. There are various reasons for reform failure. Sometimes it is because the change is impractical. On occasion it is too expensive, and distracts effort, and money, from the real business of patient care (the PFI initiative is a good example – see below). Sometimes it is because science moves on and the world has evolved; the classic example is Bevan’s firm belief, in 1948, that providing a national service would reduce costs as the people’s health improved, not understanding that the costs of medical advances would more than wipe out such savings.
Reform, from experience, merely shuffles the pieces on the board. It is rare for any to be added or removed unless costs dictate it. Reform is destabilising and demoralising. If it doesn’t work, we should understand that the only way to save costs is to ration care, and plan sensibly how we do this. It is a pity that politicians fail to understand that much of the resistance to reform by the medical profession is not stick-in-the-mud stuff, but based on experience. We are here today and tomorrow; they are gone tomorrow.
It is also a pity that modern politicians, managers and to some extent the public have developed their ideas for the NHS from the wrong starting point. If you look carefully at the proposals of the last ten years you will find that they have a common theme – that care in the NHS consists of discrete packages. People become patients; they consult their GP; they may be referred to a specialist; they have an operation; they are discharged. Alternatively they get suddenly sick and are admitted to hospital through the emergency department; they get better; they are discharged. Some, of course, die, but if you predicate the whole of healthcare on such a simplistic pathway you omit great swathes of the medical spectrum that do not fit into it. It is bad enough doing rheumatology, where a proportion of patients do not “get better” in the way those outside medicine perceive “getting better” (in other words, they revert to normal); it is worse being a rehabilitation specialist, where a large proportion of patients inevitably and inexorably get worse.
There is a nice set of posters reproduced from the Second World War by the London Transport Museum. These show a series of reconstructive processes required after damage from enemy action. The strapline reads “Rehabilitation Takes Time” and so does good clinical care. Time and again my clinics overrun because I talk to my (chronic) patients. Time and again they tell me that they do not get such time with their general practitioner – that is, if they can actually see their own GP and are not given whoever is free that day. I have had patients who tell me that if they try to introduce a second problem they are told to go away and book another appointment. So much for holistic care, not least if each system problem (and with rheumatoid arthritis patients develop all sorts of other problems ranging from heart disease to skin ulcers) then gets managed by a different doctor. But such stories stem both from growing pressures on time and from a spreading trait in doctors – that they must do as politicians and managers ask. Do these folk really know what is best for patients? If so, how? What qualifications have they got to make decisions on medical management? It is a sad day when medicine is planned by focus groups of the middle-class well who do not understand some of the consequences of their aspirations.
I fear that many doctors have lost the skill (or will, perhaps) to ask “Why?” I ask why I have to discharge follow-up patients to meet a ratio target (see below), among many other things, and I am not popular for doing so.
The concept of institutional memory is also important to understand, and respect. It derives from those who have been around a long time. It is useful (like that mythical medical instrument, the retrospectoscope) and should rarely be ignored. Often the guardians of institutional memory can point out that the “reform” has been tried before. Beethoven tried, in one famous example, to reform a sonata by pasting pieces of paper over lines he didn’t like. When musicologists unstuck the amendments they found the first draft was identical to the last. A “modern” colour scheme for Paddington Station turned out, after dozens of layers of old paint had been burnt off, to be almost identical to the original. So it would be helpful to stop talking about reform as if it will improve things.
That said we doctors must be honest in setting our relative priorities, and accept that the common good may downgrade us. Richard Smith expressed this beautifully in the introduction to an editorial in the British Medical Journal:
“The BMJ never publishes anything useful to leechologists. You haven't got a single leechologist on your editorial board. Once in a blue moon you publish a leechology paper, and it's always bloody awful. I don't know who you get to review them. What you don't seem to understand is that leechology is one of the most important specialties in medicine. There aren't enough of us, we're overworked, and general practitioners don't seem to know even the basics. Everyday we're dealing with dreadful cock ups. It's time your journal taught ordinary doctors the rudiments of leechology.”(2)
He reminded me of this when I asked for space for a special plea for rheumatology nearly 10 years later. Fair comment.
Management-speak is a joke in the NHS. New phrases assail us every month as the change-drivers hear what we say. Doctors have a number of defence mechanisms, ranging from passive acceptance to cynical subversion – into which latter category fall the players of “Bullshit Bingo” (take your grid of management words and phrases, tick them off as they are used and shout “Bullshit!” when you complete a line in any direction. There is also a perverse reverse variant, in which participants have to use words in the grid appropriately.)
“Reform” is on the grid. “Modernisation” is another. In the NHS context they set the background for politically driven change and, if ministers are correct, the NHS cannot move forward (and that’s on the grid) until it has reformed and modernised.
Modernisation likewise is a synonym for doings things differently, but with an outcome that may be better, the same or worse. A modern hospital may perform better in some functions because it has smooth surfaces and piped oxygen, for instance, but if it starts to fall down after twenty years, or the flat roof develops a terminal leak, then it may, overall, be no better than a soundly built Edwardian voluntary hospital. If I am tied to paperless records, a server failure, generator test or power cut makes them inaccessible. My analogy is of a clock. Why should I “modernise” my timekeeping by replacing a serviceable and decorative 17th Century grandfather clock with a digital version that automatically updates itself via a satellite link to an atomic clock? Assuming I remember to wind it up it tells the same time to an acceptable precision, and a satellite clock won’t run without a battery.
So “modernisation” is a smokescreen. Keep people modernising and it distracts them from their real jobs. That’s not to say we must set things in aspic; lateral thinking may achieve huge benefits. Our managers call that “thinking outside the box”, or “blue-sky thinking” and, of course, moves to take down local Chinese walls between health and social services will promote joined-up thinking. (My God, I’ve got a line! Bullshit!)
We have all become preoccupied with getting what is best. We cannot afford perfection and so must look at planning what is least bad. I believe we should consider changing the R-word from Reform (including Reconfiguration) to Rationing.
Experience is one of the benefits of getting older. Then you learn from experience that once you have learned from experience, no-one listens to you.
Posted 17th August 2011
No doubt this essay will raise hackles but I have often said that I am prepared to say things that other folk do not dare to think. I have been appalled in the last two years at how the hospital side of the NHS (I cannot speak for the primary care side of the fence except in generalities) has become obsessed with money. In financial terms money is supposed to follow the patient, but in reality the patients will get whatever the money can buy (or, in hard times, cannot buy). A large number of my colleagues have become infected with the virulent plague that turns them from caring for people into ruthless money-saving machines, and so interfere with all sorts of clinical necessities, like seeing follow-up patients, prescribing drugs and treating patients as people and not as diseases. I understand the temptation; I have nearly fallen for it myself, when trying to wear a management hat. But let us then pursue this approach in a logical and complete way, and see where we end up.
Much money is expended on very old, very sick and very demented people who get acute illnesses and end up in hospital beds being made “better”. If one asks “For what purpose?” there is no good answer; often these poor husks of people will be sent back to the care home they were admitted from (or transferred to one because the home situation is unsupportable). There has developed what perhaps is an unhealthy obsession with making sure that anything treatable is treated. Thus an 89 year old with a urinary tract infection who does not really want to go on living, confused and in renal failure, is given large doses of gentamicin as the infecting organism is only sensitive to that, and ends up with worse renal failure and possibly deafness to boot. Even if the doctors have agreed that all is hopeless the patient is then left to die by natural decay, which may take days or longer. Pain relief is kept to a minimum because great care is taken not to do anything that might actually cause death. So patient, relatives and staff all hover, waiting. It is a most unpleasant business (I know; this happened to my mother). Inevitable unconsciousness develops and still they linger on.
How much kinder it would be in this situation to do something positive to advance the inevitable outcome. And this is what we should do to save bed days, care costs and so on. It is actually the best answer to saving money in the NHS (except, perhaps, for giving chemotherapy at £60,000 a pop to prolong life by two or three months). But we cannot; Harold Shipman perhaps must carry some of the blame. My mother’s death was slower than I would have liked; her actual death was in the middle of the night, so we were not there, and I would have preferred it if we had been. Planning the time of death would have saved much distress and sadness. But at least it was quiet and painfree, unlike that of the mother of one of my colleagues left screaming in pain during her last days (I might add in her own hospital) for whom the excuse was that the syringe driver medication had been written up – except that it had not actually been given).
We should not prolong the horrible existence of many folk, in my view, but certainly once death is clearly inevitable then we should certainly not prolong its process.
“In that direction,” the cat said, waving its right paw around, “lives a Hatter: and in that direction,” waving the other paw, “lives a March Hare. Visit either if you like: they’re both mad.”
“But I don’t want to go around among mad people,” Alice remarked.
“Oh, you can’t help that,” said the cat: “we’re all mad here. I’m mad. You’re mad.”
“How do you know I’m mad?” said Alice.
“You must be,” said the Cat, “or you wouldn’t have come here.”(2)
The National Health Service is Wonderland. Whether it is run by the Hatter on the right or the March Hare on the left it has always been underfunded. The Fourth Annual Report of the Sidcup and Swanley Hospital Management committee in 1952 stated:
The year under review was again difficult, owing to the ceiling placed on expenditure... and it was apparent from the outset that it would not be possible to provide adequate services within the sum allotted... In response to the appeal of the Minister of Health for economy, all demands for expenditure have been strictly scrutinised and many economies have been effected.
If every demand is met, the pit of resources needs to be bottomless, so it comes as something of an irritation to be told by outsiders that more and more can be done without more and more cash. There is much pontification by those that don’t know and won’t listen. When things do go wrong (and the lack of neurosurgical intensive care beds in London so that a Sidcup patient was once flown to Leeds is an example) politicians move with unbelievable speed to blame the doctors.
Doctors are expected to be perfect, but are not given the wherewithal so to be. The new NHS has failed to free hospitals from any of the old constraints on development. Indeed in many respects it has made things worse. The rise of a new management bureaucracy has failed to streamline or speed up decision making and decisions are still made, (or as is more often the case not made) as a result of political expediency. All planning is based on yearly contracts and the NHS is supposed to run as a business. It cannot. The catchphrase is “money follows the patient”; so no patient, no money. But if there is no money, there can be no patient. Someone somewhere has forgotten that new businesses need money up front.
Suppose then that I, as a clinician, wish to develop a new service. I start by defining
the clinical need— in my case the absence of facilities for brain injury rehabilitation
in South East London and Kent. The service is specialised, and no single small district could justify a single unit for itself, so a unit to serve a wider area is planned. The combination of physical and psychological disturbance in patients with head injuries requires a labour-intensive approach, so staff costs are very high for small numbers of patients. In other words, this is a high-cost, low-volume service.
Models of care at home and abroad are examined. The unit can serve also as a base for research and education of NHS staff; these costs are included. Direct estimates of need are prepared by consulting clinicians who receive such patients— neurosurgeons, orthopaedic surgeons and rehabilitation specialists. The final capital and revenue costs are identified and the business case finalised.
But there it stops. The proposal is aired before the several Commissioning Agencies. They accept the projections of the numbers of patients likely to need the service. “But” they say, “we cannot commit ourselves to buying this service, because we can’t see what you are offering. And of course we would only meet the service costs, not the costs of education and research.”
“But,” I say, “money follows the patient. So without the money I can’t offer the service in the first place. And proper education and research will help us all to develop.”
“Well, we’re very sorry” they say, “but we won’t buy a service sight unseen.”
“But there isn’t any service at all anywhere and if you don’t commit the money there
never will be a service.”
Gallic shrugs. And you can hear them counting the number of hip replacements they won’t have to leave unfunded. “That’s your problem, not ours.”
Which it is, of course.(3) I would be mad to set up a costly service without a commitment to use it. Managers are of course immune from this Cheshire Cat Catch-22; several dozen millions of pounds followed Wessex Regional Health Authority’s computers down the plughole.
The government has made an effort to bring in pump-priming money to solve this
sort of problem with an exercise called the Private Finance Initiative. Its first impact was to blight several projects already in the pipeline, as they had to be held up while they went through the new procedure. I had high hopes of priming the brain injury rehabilitation project this way, until Mrs Margaret Beckett announced in the House that companies committing their assets to this kind of scheme might, under a Labour government, have them confiscated (4). Hands up those who think the next government won’t be a Labour government. So private investors run a mile, given such a friendly guarantee, and the system is itself Catch-22— damned if you don’t use private funds, and potentially damned if you do.
A further perturbation is introduced by the rise and rise of General Practitioner fundholding (5) . The commissioning of specialist low-volume services on behalf of small populations results in wild and unpredictable fluctuations in contract demand. Add to that the possibility that contracts may be moved between providers on a yearly basis and any possibility of strategic planning vanishes. The uncertainty of the contracting process makes it difficult to reassure staff that their future is secure; a workforce that is constantly on the hop is a deeply unhappy workforce, and becomes uncommitted and unproductive (6) . Certainly much of the unrest in the NHS today is engendered by the fickle, almost ephemeral nature of the purchaser- provider system with contracts that may be here today and gone tomorrow. Patients with chronic diseases do not have sell-by dates and to encourage a system that jumps their care from place to place is as unkind as it is absurd.
The commissioning of new services is caught by Catch-22, but even the development of existing services is constrained. My department receives more outpatient referrals weekly than there are clinic slots. I do more clinics than the national average already, so to meet the demand extra staff are needed. The situation has been exacerbated temporarily by the closure of the Queen Elizabeth Military Hospital, which has been providing a rheumatology service to the locality for years at no cost to the NHS; all the patients under regular review with chronic arthritis are being discharged to have follow-up elsewhere, and we expect about a hundred complex patients all at once. No money comes with them, let alone follows them. To accommodate them, other referrals have to be put off. The waiting time for a new appointment lengthens and Patients’ Charter goes through the window. A business case for a new consultant is put, but the Commissioning Agency has no money to fund the extra work, unless it takes it from another area. So, on the one hand we are faced with a demand for appointments that we cannot meet, while on the other we are denied the funds to meet them (and the redundant consultants from the Military Hospital are still out of a job).
What then is the answer? Overt or covert rationing will not go away. Neither will gratuitous waste. Wessex’s computers apart, I am told that £6 million would have been saved if the Department of Health had spoken to the Department of the Environment before forging ahead with plans for a new hospital for Bromley on a Green Belt site— which the DoE turned down; half a million was blown at the Brook Hospital in Greenwich on a magnetic resonance imaging scanner that never worked (7) . It’s well to remember that these expenditures were never sanctioned by doctors.
Firstly it is up to government to concede that its financial commitment to the NHS never has met and never will meet the demand, and stop playing the game of the Emperor’s clothes (8) . Secondly the contracting system must be stabilised so that long- term strategic planning is not blighted; and the wasteful duplication of the contracting bureaucracy, with negotiators in every hospital and General Practice, must be abolished. Thirdly a sensible pump-priming system for new developments must be introduced— one which is not prey to political dogma. Fourthly, it’s time to stop knocking doctors, and time to listen to what they say. I believe that the patience of the medical profession, and its steadfast attempt to continue to be positive in the face of constant sniping and senseless change, caught between the rock of patient demand and the hard place of underfunding, is little short of miraculous. But then, like the Cheshire Cat, we are all mad here.
1. I include this essay as an example of several phenomena – the enduring nature of politicians’ desires to fiddle with the NHS, their deceit (by making statements they abandon), the innate immovability of an over-bureaucratised system, and censorship. I was asked to write the piece by a magazine for MPs called “The Parliamentarian”, which offered me a fee, accepted the article and then not only refused to publish it, without giving any reasons, but didn’t pay either. It may seem a little dated now, but it was written in 1994. I reworked it for a Personal View which did appear in the British Medical Journal (Bamji AN. Brain injury rehabilitation: jaw-jaw not war-war, BMJ 1996; 312: 916-7)
3. And remains so; 17 years later there is still no specialised brain injury unit provided by the NHS in South London
4. Two points here; I didn’t at this time realise how PFIs would be set up, so thought they would be like decent house mortgages; and Mrs Beckett’s threat was not only not carried out but positively reversed, as the incoming Labour government saw a great opportunity to expand the NHS on the never-never, in a completely unaffordable way as we shall see, and yet keep the expenditure off the government balance sheet.
5. Later abolished, but resurrected in a slightly different form by the Coalition government of 2010
6. This is exactly what happened – again – in 2010 as the result of financial cuts, outsourcing and tendering. Plus ça change…
7. It was designed to go into a temporary building, which was not solid enough to damp out the vibrations generated during the scanning process as the magnet switched on and off. Furthermore it was purchased from the USA second-hand; it was assumed that its previous usage pattern was what it would have been in the UK (about 6 hours per day) but it had in fact been used regularly for over 20 hours a day, so was pretty clapped out.
Talk to many doctors and you will hear then say that their crumbling Victorian buildings had a charm and ambience (feng shui if you will) that is unmatched by a modern glass tower. But is the new building actually better? It may be filled with labour-saving and energy efficient devices but if the glass windows face into the midday sun it will get unbearably hot. And as it is air-conditioned you cannot open the windows. And maybe the air-conditioning cannot be used because the water cooling tanks harbour legionella. This may be why so many modern hospital wards stink – made worse because there are not enough nurses to wash the decrepit patients.
On a personal note I will exempt Torbay Hospital from this diatribe, because the personal care my mother received during her terminal illness was exemplary and gave me hope that if the NHS can return to standards like theirs, all could be well.
The Victorians knew a lot about cross-infection, which is why they built serried ranks of wards separated by open corridors to prevent transport of infectious agents across the whole hospital. Lots of nurses kept the patients clean. Any floating microbes would drift through the ward to the centre, where a coal fire burned constantly, so that air was sucked into the tall chimney and the bugs were incinerated as they followed the air flow. Of course there were side-wards for highly infectious folk and the windows were often left open (or more recently extractor fans maintained flow; one has of course to remember that if the sideroom contains the infection and the main ward holds the immunocompromised then the fan must suck out, not in (1) , while if the patient with no white cells is in the sideroom for their own safety…).
I like the idea of burning bugs. So let’s redesign all hospitals to include a gas or coal heating system, complete with tall chimneys, so the MRSA, C. Diff and other such can be massacred.
The rise, fall, rise and fall of the community hospital; or, small is not always beautiful
Once upon a time every small town supported a cottage hospital. Usually they were funded by subscription or by company and charitable donations and bequests (it’s interesting how many War Memorial hospitals there are) and when subsumed into the NHS in 1948 they became satellite outpatient services, sometimes with inpatient beds for surgery or convalescence and often with a physiotherapy service and diagnostic facilities such as X-ray. When I worked in Bath I did satellite clinics for my various bosses in Bradford-on-Avon (excellent toys in the OT department), Frome (good cakes), Warminster, Trowbridge (sandwiches), Chippenham, Calne, Radstock and Devizes – and there were others). My own cottage hospital in the grimy South-East corner of London, near the Thames, was another such. Postcards were made of it; orthopaedic surgeons did hip replacements there; the X-ray department was in a WW2 underground hospital (the subject of another chapter); the outpatients department was a typical 1960s cottage hospital design with rabbit warrens of consulting suites and a WRVS canteen down the end. The hospital opened on its present site in 1928 and was opened by the Prince of Wales; a photograph includes the grandfather of one of my retired orthopaedic colleagues. Its activities were regularly and fully reported in the local paper (making a mockery of the partly closed modern hospital Trust Board public meetings). It raised money by raffles and fetes, where a tug-of-war competition between the local large armaments companies (and the police) was rewarded with a 16oz silver cup (Mappin & Webb) presented by Vickers in 1898, which we still possess.
In the 1980s cost-cutting by rationalisation began. Small units such as ours became expensive, and just as the rise of Tesco killed the corner shop and high street by undercutting, so the cottage hospitals became uneconomic to maintain as standalone units, especially when new health and safety regulations effectively condemned the operating theatres (never mind that the infection rate was almost zero). Lengths of stay also diminished and the need for convalescence did likewise as it became apparent that rapid post-op mobilisation reduced complication rates. So Erith lost its inpatients wing to the mental health service (which later showed its ignorance by re-signing the site with large direction arrows to “Outpatience”). We watched as around the country numbers of similar units, including many I worked in around Bath, closed their doors and left their communities reliant on the big DGH miles away, thankful that at least a lack of outpatient capacity at the main hospital made our cottage hospital’s closure almost impossible. It was sad but an inevitable consequence of trying to save money.
In the late 1990s and Noughties the new New Labour government decided it would bring care closer to home. Part of this was stimulated by Fabian Society policy driven by a local MP (and GP) who wrote a pamphlet with the provocative title “Challenging the Citadel: Breaking the hospitals’ grip on the NHS” (1) . This was to involve the diversion of hospital outpatients “into the community”. Among other things it would require the building of a network of community hospitals where patients could be seen as outpatients, have tests done and receive things like physiotherapy. This new philosophy really took off, and when the government decided it was to launch an NHS Constitution the head of the NHS, David Nicholson, announced at the inaugural meeting, in 2008, how pleased he was that in his own little town (one of the Chippings, but whether it was Camden, Norton or Sodbury I cannot recall and don’t care anyway) had a brand new community hospital, and it was wonderful and the way forward.
It was all I could do not to stand up and say “HANG ON! We have spent the last 10 years closing cottage hospitals because they are uneconomic, and now you are talking about opening them all again! WHERE IS THE MONEY COMING FROM?” Actually I knew the answer to the last bit. More on that elsewhere. But the moral of this tale is that things may be nice and patient-friendly and touchy-feely, but in times of trouble Uncle Andrew thinks that financial prudence might be a Good Thing. Tesco knows best. Small may be beautiful, but not if it’s unaffordable (and it’s interesting to note that Tesco’s local “One-stop” shops charge 18% more than the supermarket price).
Our cottage hospital suddenly became the focus for a re-profiling exercise of the “move care into the community” type. Two meetings were held to brainstorm plans. These were organised by the local Primary Care Trust (PCT). It was only after the second meeting that I discovered all of this. Perhaps it was unreasonable to expect the PCT to be interested in the views of the (many) consultants who have, and still, provide an outpatient service there. After all I have only worked there for 27 years. But even this initiative may come to nought, as we have a new government and PCTs are to be abolished. This raises another issue – or system fault. You can negotiate all you like but if someone changes the system, or the finance, then you have to start all over again. Old lags like me who have been around a bit have spent a lot of time trying to plan the same services with literally dozens of different people, which become tedious. If you compare some of my discussion papers from 1985 with those twenty years later it is disconcerting to realise how similar they are (except that the early ones are printed with a dot-matrix printer and the stored version is on an unreadable floppy disc, unless you happen to have an old BBC B computer knocking about…)
As a corollary, one should bear in mind that the affordability issue is stealthily rearing its head again. The Labour government of Gordon Brown created some new peers so it could boast it was a government of the talents. None of them lasted very long, but Ara Darzi, a teaching hospital surgeon, took on the total reorganisation of the NHS, general practice included, and reinvented the polyclinic concept. I remember seeing the trailer to this where he was meandering down a hospital ward, and stopped to talk to a lady who had rheumatoid arthritis; he asked her how long she had been in, and hearing it had been for some weeks expounded at length on how such hospital stays were avoidable. Had he talked to me he would have found that such admissions are so rare that they are remembered for years; we hardly admit a soul these days, so it was a very bad example. I also recall that he brought over some enthusiast from Berlin to support the polyclinic cause, and remember thinking, as this chap was wheeled out all over the place, that one could not build a nationwide system based on a single example. Where were other successful models? Why were people from these not speaking also? Perhaps there weren’t any.
I have some sympathy (or synergy?) with the polyclinic concept. A couple were built in London, and opened to the blast of many trumpets. Two years on, and they are closing – because they are too expensive to run.
Told you.
Posted 18th August 2011
If doctors are to be credible they must not only say what they want to do for patients and why, but they must employ economic arguments as well as medical ones to make their case.
Take MRI. It’s an amazing modality of investigation, not least to those of us old enough to remember neurology and oncology pre-MRI, when one relied on careful physical examination, intuition and guesswork, with a bit of diagnostic surgery thrown in. No longer the risky and inexact myelogram for diagnosing disc prolapses, just a quick if claustrophobic run through a magnet.
So our dear government decides to get in on the act. If MRI is good then everyone should have one whenever they want. For anything. Bit of backache, neck pain, knee pain, whatever. But the hospital waits are too long! So let’s provide scanners all over the place – in large general practices, polyclinics, allow access to private scans…
Wait a mo. Let’s look briefly at the medical issues and principles. We should do a scan if it’s likely to change our management. If a patient has back pain then (a) it is likely to get better within 6 weeks (b) a scan in a patient without root compression signs is unlikely to be helpful in planning treatment (c) a minor abnormality (eg a disc bulge) may be quite immaterial but may alarm the patient and (d) if the patient then goes to a specialist who cannot see the scan itself it wastes time. Indeed what is the process of radiological investigation? It is as follows:
It’s actually a game of Chinese Whispers unless the clinician can see the film and interpret it (which many non-radiologists cannot anyway) in the light of the considerable clinical background.
But I ramble. Let’s suppose a hospital MRI unit is open 9 to 5 and has a waiting time of 12 weeks. The cost of reducing that to zero is the cost of staffing it from 7 to 9 – six hours of radiographer cover as overtime daily, which equates to perhaps £90,000 per annum. Now consider the cost of providing a new scanner “in the community” – capital cost £1.5-2m, revenue consequence 10% annual capital writedown, staff costs (at least 4 radiographers to cover, plus cost of radiologists’ time). At an annual cost of £200,000+ we now have two MRI scanners, neither of which will have enough business to work at full capacity. Or the Primary Care Trust contracts with a private scanner on a fixed contract basis and pays for more scans than it needs (many of which are not necessary) but is happy because it is doing the contracting rather than leaving scan decisions to expensive specialists. This is not cost-effective. Specialists don’t do scans because patients want them and do do them because the result may alter management. So we are cheaper. Why is this not obvious?
Ward infections: acquired or identified?
My musings on the value of old-fashioned techniques for sterilisation reminded me that there is another myth, sadly believed by politicians, that there is an important problem called hospital-acquired infection. There is a problem with hospital infections, but is it rightly named and if we changed a word might it take some of the hysteria out of MRSA?
Let me make it clear that I have no doubt that patients may acquire MRSA or Clostridium Difficile during a hospital admission. That’s why we had a policy on my rehabilitation unit that no patient can be admitted without being screened first – not that our bed managers care, and we have had frequent occasion to complain when unscreened patients are dumped on the unit so that A&E patients can be decanted within the four hour target time (1) . Indeed I got into trouble when our experience was reported in “BMA News Review” in 2004 (2) and I was threatened with disciplinary action for breaching the hospital’s whistleblowing policy, which I hadn’t (and it was unedifying to see managers lying about the issue). But MRSA doesn’t spontaneously appear like magic on a hospital ward, does it? I was seized with schadenfreude when, in a letter of response to my resignation, our Chief Executive told me how wonderful the Trust’s success has been in reducing hospital infection – when all he has done is introduce my seven-year-old plan which he had never read!
One of the good things to come from targets (and the target is to reduce MRSA septicaemia, not actual surface infection) is that our microbiologist had to develop a good data set both to look at numbers of MRSA infections on wards and where in each case it had come from. Analysis over several months in 2009 revealed an interesting but perhaps unsurprising conclusion; the vast majority of MRSA came from the community. Patients did not acquire it after hospital admission. They came in with it. Of course we all know that out there in the community the district nurses carry it about and the care homes let it spread among their inmates – or that’s how it seems to me when I compare the lazy, laissez-faire attitude to MRSA colonisation with the stringent curative and preventative measures on my rehab unit. But it underlines the truth – that most MRSA is not hospital-acquired, it is hospital identified. How then it is government writ that a hospital can be penalised for high MRSA rates is beyond me, when its only “fault” is that is admitting unscreened patients who are ill, and then testing them! So let’s have a campaign to distinguish acquired from identified, realise the scale of the problem is not that great, and concentrate on dealing with the source – the place where everything is better – the community!
Politicians like to pretend that they have fixed things and I was particularly amused by a report in the “Sunday Times” in mid-April 2010 in which the Health Secretary, Andy Burnham, trumpeted the news that good ideas from the NHS were to be exported worldwide – including how to manage MRSA! I found this rich coming from a government that, when my experience on how to manage MRSA was reported, threatened my managers; it was this that resulted in the attempt to silence me with disciplinary threats when all I had done was describe my unit’s good practice.
I went to Venice recently for a long weekend. It was tempting to visit of the many shops catering for Carnival and purchase a Venetian cloak and hat together with a plague doctor’s mask, and wear this into the hospital during the next norovirus outbreak…
Posted 7th September 2011