Reinventing wheels etc

In the BMJ of 23rd April are listed the finalists for the BMJ Neurology team of the year awards, which include the Multiple Sclerosis team of UCLH for its integrated service.

Reinvention of the wheel? Failure of institutional memory? Left hand not knowing what right hand is doing?  All three possibilities come to mind when I read the nomination which “to everyone’s surprise” showed that urinary infections were the commonest cause of admission in patients with MS.

I am certainly surprised it was a surprise.  Indeed when I read this I was almost speechless.  I have known, and taught this for nearly 30 years.  I took over a Young Disabled Unit in 1985.  Over the next ten years I and my multidisciplinary team turned it from a long-stay unit with 15 residents to a dynamic rehabilitation unit with some 300 clients, the majority of whom had MS.  We provided a regular inpatient respite service, a helpline and regular outpatient review, which was supplemented in later years with bladder ultrasound.  The superb nursing staff were also alert to admissions of our clients to acute beds, from which they would be extracted as soon as possible – or at the very least they would make a trip to the acute ward to advise.  I taught all the trainee doctors that patients presenting to A&E with a sudden deterioration in their MS had an infection (usually urinary, but sometimes chest) until proved otherwise.  While deterioration was rapid, so was recovery if effective treatment was instituted rapidly.  I might add that, as a clinical point that will save some lives if anyone reads this, some patients with an acute infection regularly developed severe hyponatraemia which we attributed to acute adrenal insufficiency, and recovered with hypertonic saline and hydrocortisone; whether this phenomenon was related to previous high dose steroid treatment for relapses we never did determine.

We also provided an effective pressure sore service. Regular physiotherapy helped prevent contractures and maintain mobility.  Occupational therapy home visits were a sine qua non. Our service was entirely integrated.  Our local district nurses involved in home care regularly exchanged information.  If a patient “went off” suddenly then infection testing was arranged at home.  Not infrequently I would write the antibiotic prescription.  Unit emergency admissions were organised not by GPs but by family or the district nurses by direct contact.  In this way we actually kept MS patients out of acute hospital beds.  All of this was done without any input from neurologists.

To return to my opening paragraph it appears to me that the UCLH team have reinvented the wheel.  I regret that my teaching in a suburban district general hospital never permeated to the centre to provide a lasting institutional memory, but perhaps the most damning indictment is that, until relatively recently, it was rehabilitationists who dealt with long-term MS patients and not neurologists, who concentrated on diagnosis (once made, there was little treatment, so many, though not all, lost interest). So the crossover of information from left to right hand was as limited as in a patient whose corpus callosum has been transected.  It is thus encouraging to see the growing interest and enthusiasm of neurologists in integrated long-term management.

Though our model was highly effective, and much appreciated by patients and their families, it was expensive.  The Unit kept afloat as much through my political lobbying as through its care success. Within a year of my retirement it had been closed down.


Never mind the money; it’s better to be wise than foolish

April 2016 has proved a strange month.  Revelations about offshore accounts held in Panama have captured the attention, and hysteria, of the press.  Yes, there have been some interesting disclosures about possible money-laundering by unsavoury individuals, but the dead father of Britain’s Prime Minister has been traduced for being wise.  And his son has unwillingly been subjected to increasingly aggressive attention in respect of how he might have benefited.

I will make my position clear.  I have no offshore accounts (that I know of) and my accountant is scrupulous in ensuring that my income is all identified, and taxed.  I used to do my own accounts until the revenue tripped me up over my expenses (quite simple – I paid my private secretary but did not keep a receipt, so the amount I submitted as secretarial costs was disallowed).  Thereafter I did not wish to fall foul of them again, so I sought professional help.  Even so I failed on one occasion to declare interest on two accounts that I had rolled over into new ones, and HMRC had another little go at me, even though the income was measured in tens of pounds.  But professionals must set a good example.

The furore over Mr Cameron’s finances is senseless.  He earns an income, has unearned income and rent from a house, and was given a lump sum by his mother.  So? It is all declared.  The lump sum may be a will rearrangement that will end up tax free if mum lives seven years, but it is all perfectly legal.  Indeed every finance column in the papers advises that money should be transferred in this way if it is affordable.  I have done it with my children; my mother did it with me, and anyone who does not take advantage of such an opportunity is, quite simply, stupid.  It is perfectly legal, and until it isn’t then there is nothing wrong with it.  Leaving aside whether income should be taxed twice – and inheritance tax is just that – it is sensible.  It is prudent.  Likewise if it is legal to put money offshore, then one cannot criticise those who do it, unless of course the money was ill-gotten in the first place.

So anyway – Mr Cameron has released details of his income, and tax.  His accountant has signed off the information.  Now people are saying the information is inadequate; they want the actual tax return figures.  That is tantamount to accusing both him, and his accountants, of not telling the truth.  Now I know politicians don’t always tell the truth, but I cannot imagine for one moment that a Prime Minister would be so stupid as to provide information that could be proved to be inaccurate.  What’s there is quite good enough for me; indeed it is far more than I either need or want..  So he has share income.  So do I (not a lot). He has rental income.  I have a holiday house which is let out.  Is he, or am I supposed to leave the house empty?  If there are tax breaks should he not take them?  I put money into a perfectly legal tax-free fund – a NISA.  And if I decided to set up an offshore fund should I be obliged to ask permission from my children?  Don’t be so silly.

What Mr Cameron has done is to prove that he is astute in managing his finances.  He is wise.  What of his Labour opponent, Mr Corbyn?  He is so busy trying to get his nose into the business of others that he cannot even submit his own tax return on time! He was fined for that.  What a fool.  What a contrast.  If you wanted someone to manage your money, whom would you choose?