What’s in a title?

The Times Literary Supplement this week contains a letter from Lydia Davis detailing the struggle she had in translating the title of Proust’s “Du Côté de Chez Swann”.  I had enough trouble with the English title of my book about the origins of modern facial surgery.  No-one has yet suggested it should be translated into French, and I did not, to be truthful, have that as a consideration.

For nearly 15 years its working title was “The Queen’s Hospital and all the King’s Men”, referring of course to the nursery rhyme, which seemed apposite:

Humpty Dumpty sat on a wall,

Humpty Dumpty had a great fall;

All the King’s horses and all the King’s men

Couldn’t put Humpty together again.

Except, of course, that the surgeons did manage to put their 5000 Humpties together pretty well.

But it seemed a bit long.  So I switched to “Faces of War”.  I quick Google revealed several such titles, as did “The Face of War”, which anyway left out 4999 from the equation.  Oh dear.  Then I came up with “Faces from the Front”.  This had no overlaps; if you look now you will find a few sites indicating how to draw faces from the front.  It was short and alliterative.  It resonated both with my diligent editor and daughter, and my publisher.

So “Faces from the Front” it became, although for clarity it had appended a rather long subtitle.  But the book cover makes this suitably sub.  So you can see for yourself and purchase from any number of bookselling sites worldwide.

“Faces from the Front: Harold Gillies, the Queen’s Hospital, Sidcup and the origins of modern plastic surgery” is published by Helion Press (2017).

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Perpetual rediscovery

It was with wry amusement that I read a letter to “The Times” by James Harrison and published in 2003 relating to a “new discovery” about the health of Adolf Hitler, and noting that the conclusion was well-known and previously published. He termed this “perpetual rediscovery”.

During the last week – the first week of 2018 – there have been two responses to an article in the same paper which quoted England’s chief nurse as saying that missed outpatient appointments were a plague, and were costing the National Health Service perhaps as much as £1bn annually.  The subsequent correspondence pointed out that the problem of missed appointments could be resolved very simply – by overbooking.  Thus all slots would be filled, and in the rare event that everyone turned up it would just be rather a busy clinic. In any event, as the NHS did not charge if patients failed to attend, I don’t believe that any money would be lost at all; in fact, because no investigations would be generated, missed appointments might actually save money.

It was a system I used myself.  When managers questioned it, I responded that what was good enough for airlines was good enough for me.  Total rigidity was mad.  Wearing my rehab hat I used to book 45 minute slots for new patients in the multi-disciplinary clinic, because there was always a vast amount of stuff to deal with, including all the physiotherapy, occupational therapy, social work and psychology aspects of long-term severe disability.  A no-show left us all sitting doing not a lot for a long period.  Crazy – not least as for these patients the major cause of a no-show was a transport failure.

I write to “The Times” a lot.  I had four letters published in 2017, taking my total to around 70 which I reckon is a hit rate of about one in eight.  I keep a copy out of vanity.  Thus is was that I was able to recall a previous article about missed appointments, in which it had been suggested that “no-show” patients should effectively be fined (the idea was that a refundable deposit would be forfeited for a non-attendance).  In my response I said:

“…about half of missed appointments are missed because of administrative error – the appointment is sent to the wrong address, for instance… Overbooking ensures the doctor works at full efficiency.”

I annotate all my scanned letters by date, and was thus able to see that I had written this 28 years ago.

Perpetual rediscovery is, in part, a failure of institutional memory.  There is another “perpetual” in the arcane art of outpatient booking – a curious issue which I call the endless loop syndrome. Let’s suppose a patient cancels and the clinic doesn’t know. What happens next is as follows:

• Let’s say the patient rings to cancel the day before the appointment (January 30^th), and is re-booked by central appointments for 5^th March
• The patient doesn’t appear in clinic, so the clinician, not knowing of the cancellation, completes a “did not attend” (DNA) form, which generates another appointment booking through the local clinic desk. However this takes a day to process, so this re-book is for 12^th March as the 5^th is full
• Patient receives the letter confirming their own rebooking for 5^th March
• Two days later they receive a second letter generated through the DNA, for 12^th March. The letter says “Due to unforeseen circumstances your appointment with Dr Bamji has been changed to the 12^th March”
• The patient thinks this change refers to the appointment they made for the 5^th, but this of course remains on the system
• On 5^th March the patient doesn’t appear in clinic, so the clinician completes a DNA form, which generates another appointment booking. However this takes a day to process, and is for 27^th April
• The letter confirming this is received by the patient on the 11^th March, and they assume it refers to the appointment the following day, so they don’t turn up
• On 12th March the patient doesn’t appear in clinic, so the clinician completes a DNA form, which generates another appointment booking. However this takes a day to process, and is for 9^th May

And so on ad infinitum, potentially.  Actually it usually stopped after three our four iterations, because the irate patient would ring my secretary to ask what the hell was going on, and she would untangle the mess.

I monitored my DNA rate over several years.  It remained quite steady at between 10 to 15% of new appointments, and slightly less for follow-ups.  If I enquired of one of my “regulars” why they had missed, there was a reasonable excuse 90% of the time; they were ill, a relative was ill, transport had failed to collect them, snow had confined them to the house etc.  Just 10% forgot.  Text message reminders are all very well but, if generated the day before, leave no time for an empty slot to be re-filled.  And occasionally the patient had died so they were unlikely to respond – or their relatives were so devastated, and busy with arrangements, that cancelling an outpatient appointment, if indeed they knew of it, was the last thing on their mind.

So I was amused to read someone else’s solution of overbooking.  Twice.  I wonder if either of them had attended any of my trainee lectures on how to run outpatients – or indeed read my letter from 1989.  I doubt it.  Nihil novi sub sole (Ecclesiastes 1:9).

Time heals – slowly

When I retired from the NHS having worked at Queen Mary’s Hospital, Sidcup for 28 years it was with some bitterness.  During the last two years the hospital had been threatened with a merger and the likelihood of losing its A&E and maternity departments.  I was quite sure that the merger would not solve the financial problems it was supposed to, and said so in fairly forthright terms, but was ignored.  Thereafter I was threatened with disciplinary action for speaking out, and had to deal with several mischievous attempts to interfere with my clinical practice and make my working life difficult.  Despite having workload figures far in excess of any of my colleagues in the merged Trust I was told, under the counter, that I was about to be investigated for cutting sessions.  Being 60 enough was enough. In one way life was great, but I could not help feeling that my retirement was engineered.  Within six months of mt leaving my rehabilitation unit had been closed, and my sessions in the rheumatology department remained covered by locums for over three years.  So much for any legacy.

As I had predicted the new merged Trust fell to pieces – for exactly the reasons I had stated.  So schadenfreude was the order of the day,, but I failed to get the General Medical Council to deal with one medical manager whose conduct I felt had breached professional guidelines.  I also expected Queen Mary’s, now bereft of acute services, to curl up and die.

My pessimism was misplaced.  Although the hospital is managed by one Trust and has clinical services from another two, in bits, there has been what appears to be a successful and remarkable transformation.  My previous experience of acute hospitals losing their acute services was dire, with almost inevitable closure.  But somehow Queen Mary’s has reinvented itself – admittedly with the help of £30m in investment, but it now possesses a large renal dialysis unit, and spanking new and completely up to date Cancer Centre, new outpatient facilities, a splendidly redesigned front entrance, and it looks set for a long future.  More to the point the staff that I left demoralised appear to have been re-energised, and when I returned for the celebrations to re-dedicate the hospital, and also its 100 years of existence, I came home feeling that my negative attitude was now quite unnecessary; the hospital had moved on, and so would I.  It was a great pleasure to meet up with the various dinosaurs of my era and agree that everything looked pretty good.

That’s not to say that one should forget the past; there are lessons to be learned, not least in how to do things so as not to upset and irritate people, as I have described in previous essays.  It has perhaps also helped that after 25 years of trying my book “Faces from the Front” has finally come to fruition!  You can find details at http://blog.helion.co.uk/tag/faces-from-the-front/. (A great gift for anyone with an interest in plastic surgery, the First World War, facial injury etc).

So time has passed and healing has occurred.  Nonetheless I am reminded of a poem I wrote that relates to experience:

When appointed consultants, we all seemed quite young –

Looked up to our elders and betters;

But time passes by, and we cease to give tongue

Or write all those Young Turk-like letters.

And then we all find that the new ones around

Are the ones now creating the fuss –

For they carry the torch of the bright and the bold

And the elders and betters are us.

Don’t bank on it being a good idea…

The run-up to the 2017 General Election has begun, with interesting promises already being made (or in some cases, not being made) by the politicians.

Notable among the pledges is Labour’s proposal to have four new Bank Holidays.  Labour has already trumpeted its commitment to the lower-paid by suggesting an increase in the minimum wage to £10 an hour (which may mean that businesses will lay people off) but let’s look at the economics of these extra holidays…

• Those workers paid hourly, but working an 8 hour day they will lose four days of pay, or £320.  Thus those with the owrst employment arrangements will be worse off.
• Those businesses paying a salary will lose four days of production but still have to pay their workers the same.

Have I missed something here, or is this an oxymoronic plan?  What is the point of a holiday you end up paying for, but have to take whether you like it or not?  Of course there is, on top of this, the disruption that will occur in the NHS, which Labour pledges to protect.  Bank Holidays are already a nightmare.  All non-emergency services shut down; no cold surgery, no outpatients.  There will be a rapid increase in waits.  Think about it.  Senior doctors have six weeks leave and two weeks of study leave, which means that at most they work a 44 week year.  Those who have commitments on Mondays lose six this year to Bank Holidays (in England) so are now down to 36 weeks.  Another two weekdays go for Christmas.  Then we are to lose another four days – which is nearly another whole week (OK, they won’t all be Mondays but a week is a week).

Would you trust the originators of this madcap scheme with your money?  Leave aside that they will take even more of it to fund all their other crackpot plans.

I have a rule for plans.  Look at an idea, and work out whether there is anything that could possibly go wrong with it.  Look at every angle; assess the pros, but search for the cons.  In this case it is one big con, in every sense of the word.

 

Elections, democracy and making the best of it

On 18th April 2017 the Prime Minister indicated that she wished to call a general election.  Today it is likely that she will obtain the two-thirds parliamentary majority that she needs.  It doesn’t seem to matter what decision is taken, or why, but someone will always argue that it is wrong.  In this case Mrs May will be accused of opportunism, given the disarray in the Labour Party, which has agreed to an election even though its prospects are currently grim.  Of course when she became PM Mrs May was pilloried for not holding an immediate election to consolidate her position as an unelected (by the country) leader.  Now people are asking why she needs one; she has a parliamentary majority, after all.

It all comes down to Brexit.  As she put it, the country has decided on Brexit but at Westminster many people are intent on derailing the process.  A larger majority will dispose of any problems with votes.  But it will be interesting to see what the final result will be.  There are numerous imponderables.

• The process of Brexit has begun, so UKIP is irrelevant; it has achieved its aim, and has no other policy to fall back on.  Where will their votes go in the Brexit-strong areas that were once Labour heartlands?
• The Liberal Democrats remain Remainers (and remoaners).  Will they pick up votes from the Tories in their Remainer strongholds?
• The prospect of the present Labour Party leadership making a fist of Brexit negotiations is so alarming that it cannot possibly happen.  Except everyone said that Trump was unelectable in the USA, and look what happened there
• The Scottish Nationalists have made a great play about Scotland having voted to remain, and threatened another independence referendum so they can make their own way within Europe.  Except they have no money, as the oil revenues they trumpeted as the country’s resources have diminished substantially.  And so the Scots really want another referendum? Probably not.  So if the Scot Nats are remainers, and the Tories are the party of Brexit, where will Scottish votes go?

But the key to this is what democracy means.  The nation voted for Brexit.  OK, so bits of it did not, but in a democracy the minority must abide by the decision of the majority and not threaten to secede.  My household (of two) voted to remain, but we are not currently agitating to set up the Independent Republic of Norman House, Rye, but thinking about how to make Brexit work for the best (or the least bad).  The more divisions there are, the worse the nation’s negotiating position will be.

So my solutions to the questions above are as follows:

• UKIP voters should vote Conservative so that Brexit will mean Brexit, to coin a phrase
• People thinking of voting Lib Dem should not prejudice Brexit by undermining Tory MPs, but might consider the Lib Dems in Labour areas if they simply cannot countenance voting Tory
• Trump at least managed to upset people and obviously was able enough to make lots of money.  It seems that Jeremy Corbyn is simply incompetent.  Also it is clear that he has a very short fuse.  Patience is a virtue, and simply losing one’s temper in public is not a good starting point for diplomacy.  So Labour voters should arrange his defenestration and if they can’t swallow their longstanding devotion to the Labour Party, they should not vote at all
• I hesitate to advise my friends across the Scottish border how to vote, else the fish lady will come down on me like a ton of bricks.  But I think Scotland would be taking a huge risk in trying to leave the UK – a far greater risk than that of the UK leaving Europe.  So common sense dictates, remain or leave the EU, that they accept the majority decision and work to make it work, rather than bleat from the sidelines.  There are some very able politicians up there, and they would be better inside the tent pissing out than vice-versa.

It’s all rather exciting…

Saying sorry

In medicine people don’t say sorry enough.  Every month there is a new press report of some disaster where there has been a cover-up, a failure of communication, an attempt to move blame, a guilty silence accompanied by a shifting of feet.  It is stupid because it aggravates the situation and leaves those affected more distressed an angry than they would have been otherwise.  A quick and appropriate apology cools the situation as people respect honesty.  The most potent example I have of this is a patient whose sight was severely affected by a prescription change in my department which I (and the patient’s GP) failed to notice.  When the problem came to light she asked what she should do, and I not only apologised but told her to consult a lawyer.  Rather diffidently she asked that, if she did and there was a case, would I continue to see her.  This was trust based on honesty.  Although there was a bit of an argy-bargy over responsibility there was none over liability, and she eventually received a six-figure settlement.  And I continued to see her.

How different Hillsborough would have been if the police had not tried to cover their backs, but admitted their failings.  On an international basis the same rules should apply.  If a civilian airliner is by mistake brought down by a missile, and all aboard perish, and there is incontrovertible evidence of the perpetrator, then that perpetrator will only be despised if they try to dodge the blame, not least if they change their story all the time.  Likewise, if nerve gas is dropped on a civilian target, and there is indisputable evidence of who did it, and equally indisputable evidence of an attempt at a cover-up (with attempted changes of story to try and adjust to emerging facts) no-one could ever trust them again.  So why do they do it?  Holding up your hands may be very painful, but there then is an end to it instead of continuing recriminations which poison things indefinitely.

So, in fact, medicine mirrors the rest of society.  What a pity.

Why have we forgotten the past?

February 21st 2017 and another report emerges in the press suggesting that the NHS provider sector can only be saved by closing hospitals.  True, the potential to develop centres of excellence is enhanced by having larger centres.  However, given the impossible-to-cope-with levels of bed occupancy (85% is considered the maximum sustainable, while it is currently running at 95% in many places) cutting the numbers of hospitals will only work if the numbers of beds in each is increased, and this does not appear to be on anyone’s agenda.  Despite the fact that the UK has fewer hospital beds per head of population than anywhere in Europe people seem to believe that simply speeding discharges into enhanced social care facilities, or even “step-down” hospitals, will solve the bed crisis.  Would it not also be possible, it is argued, for such facilities to take in those who do not really need an acute hospital bed, but something somewhat less acute, thus reducing the load on A&E departments?

There are several flaws in this.  First, the pressure to discharge patients in haste will not be reduced, because fewer A&E departments admitting the same numbers of patients keeps up the pressure on the front door.  Too soon a discharge leads to patients bouncing back.  Second, “Care in the community” is not cheap.  Third, it seems counter-intuitive to reduce costs by concentrating resources in larger units (otherwise known as economies of scale) while at the same time promoting the establishment of small ones.

And this is where the past comes in.  When the NHS began it assimilated voluntary hospital (which were largely broke) local authority hospitals and a vast network of small cottage hospitals.  During the 1970s and 1980s it became increasingly obvious that these small unites, with disproportionate overheads, were unaffordable.  So they were shut, or if bits such as outpatients somehow survived, the beds were close.  In my own area a thriving cottage hospital in Erith, taking GP admissions and step-down patients and even doing major surgery, fell foul of this and the need to meet ever more stringent health and safety rules.  The hip replacements done there were displaced to the district hospital.  In Greenwich, when I arrived there in 1983, the hospital stock included Greenwich District Hospital, the Brook Hospital, Woolwich, St Nicholas’ Plumstead, the Memorial Hospital on Shooters Hill, Eltham Hospital, the British Home for Mothers and Babies and the Dreadnought Seamen’s Hospital.  Well before I retired from the NHS in 2011 all were shut, and services confined to the Queen Elizabeth Hospital, which had started life as a military hospital but took civilian patients.  So eight went into one.

Why were they closed?  They were unaffordable. But all the people who agonised over those decisions are retired, or dead.  There is no institutional memory.  Instead the new ones on the block reinvent the wheel.  Medical advances have meant we can do more (which costs more), and keep people alive longer into frail old age when medical problems compound themselves.  But the basic financial rules underpinning it all have not changed.  Lots of small units accrue more costs than few, larger ones.  Domiciliary care requires more staff to cover the same workload, and travelling times make it inefficient in comparison to care in institutions.  You cannot close a hospital with 300 beds and expect to do the same amount of inpatient work in the one next door of the same size without increasing the bed numbers and staff there; keeping people out, using low-key facilities, may be just as expensive as keeping two hospitals open.

And did closing all those hospitals in Greenwich solve the financial problems?  A question to which the answer is no.  It is interesting to see the Sustainability and Transformation Plans being developed now.  My reading of most of them is

• This is what we want to do
• This is how much it will cost to do it
• Oops!  We can’t

In the early 1980s when I was a clinical manager we did something very similar to an STP in one of my hospitals – except it was called a zero-based budgeting exercise.  Guess what? Exactly the same thing transpired.  The past seems to be a long-forgotten place…

Rather than fiddle with an increasingly broken system we need to grasp the nettle and go back to the drawing board.   I wonder whether, in 50 years’ time, people will wonder why it took so long to do that.  The NHS needs to cater for medicine of the 21st Century, not that of 1948.