Don’t let wool be pulled over your eyes

…or maybe not.

Our Trust decided it was going to have another round of back-office cuts to try and meet its deficit, so it set off by telling all the over-65 staff that they were to have their contracts terminated (there was a bit of a rush with this, as the law was to be changed to forbid this, to be enacted some 6 months later). We lost a senior orthopaedic surgeon, some of whose patients were so angry they followed him into the private sector, but we also lost two of our valued and hard-working clinic receptionists, who had spent the last 15 years or so manning the desk for the rheumatology and orthopaedic clinics.

I was sad at the manner of their exit, but returned the following week to discover that the reception desk was empty, and that my patients (many quite disabled) had to walk 60 yards round to main outpatients, queue for ages and then return to the rheumatology waiting area. It transpired that the reception staff had been cut by four. Two desks had been abandoned, and the remaining staff were tearing their hair out trying to cope with the large numbers of patients, who at peak times would be queueing almost 50 yards down the main hospital corridor.

I complained to our Medical Director who, Pilate-like, washed his hands of the matter. Well – I suppose the hand-washing set a good example on the C.Diff. front. After several other complaints directed at those to whom he had directed me I finally got an answer – which was that the restructuring had only lost one full-time equivalent post, and implying that the reception manager was falling down on the job. Having seen her, in tears, trying to cope a week before, I was not impressed so summoned her to ask if the figures were true.

She told me they were. However, they included two receptionists based at the cottage hospital, and one member of the pre-admission team, who could hardly be classed as main hospital receptionists either because they worked somewhere else or because they did another job entirely. None of them had previously been in the reception staff budget.

It got worse. My secretary was suddenly phoned by an anxious senior manager, telling her that she now had to collect a huge pile of outpatient outcome forms (the ones in colour), book the follow-up appointments and code the details. Otherwise, she was told, the hospital would lose oodles of money because it couldn’t claim for the work done. Guess who normally did this work. The receptionists they had just disposed of.

It is very sad when managers not only try to delude others, but appear to delude themselves. If you are faced with an improbable scenario, or offered some rumour, check it out and get the facts. Preferably in print. Then you can screw the bastards back.

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History matters

The PCT decided it was going to build a new Child Development Centre on our cottage hospital site in Erith. The outpatient consultants got wind of the plan. It required demolition of the existing 1960s department (which instantly raised questions about where outpatients might be seen during the rebuilding, as spare capacity in the DGH was non-existent).

However the proposal also demanded the demolition of the X-ray department. This is opened yearly under the London Open House scheme which allows public access to interesting buildings that are usually inaccessible; the department is housed in the only surviving underground hospital in the UK built in case of major attack from the air and was completed just before the outbreak of the Second World War.

Those planning its demolition were unaware of its significance. I assumed that it was a listed building, which would have knocked the whole plan on the head (car park spaces sufficient for the new proposal could not be provided without flattening it). I did some homework, and found it wasn’t. So I asked the Department of Culture, Media and Sport (once known as the Department of the Environment), by way of a detailed submission, which ran to a dozen or so pages, with pictures, to spot-list it.

It did. Curiously the CDC planners, once hell-bent on destruction, suddenly became enthused by this historic building they now had to care for and cherish.

But a sense of history is important – likewise joined-up thinking. Some while earlier a proposal to consolidate three Bromley hospitals picked a site on Green Belt land. The outline plan cost about £8m. Perhaps unsurprisingly (for it appeared that no-one had thought to run it past the DoE as it then was) that department turned it down.

When my rehab unit was being constructed there was a delay, as the builders struck water unexpectedly while digging out the foundations. Ah, I said, that’s because you are building over the old ice pond that belonged to the big house in whose grounds the hospital sat. They knew I had the estate plans in the archives, but nobody thought to consult them.

In all of these cases you might detect a sense of schadenfreude on my part. However each one underlines the fact that doctors are trained in analysis and if their analysis is better than anyone else’s then they will win. It is likely to be the case in many such instances (I confess the planning rules are well-known to me because my wife and I are serial NIMBYs who have objected to numerous planning applications near our various houses – not all of which we have won). But the principles are – know your facts, rely on your experience, look for every possible fault and consequence of any particular action and think not about what is necessarily best, but what is least bad.

There may be some managers reading this. I have met many good ones, though too many of those have become disillusioned by the constraints and bureaucracy and have left. But there is a rule for you, too. By all means pursue a firm agenda, be it related to service change, cost or political direction. But do not under any circumstances forget that if you do not carry your troops along with you, then you are lost. Too many plans and diktats are imposed without proper consultation and those who feel they should have been consulted will be those who will try to undermine you and even bring you down. Doctors, particularly consultants in the hospital setting, have longevity. Although there is increasing mobility many consultants will stay for 20-30 years. Managers, in comparison, are here today and gone tomorrow. You may resent the inertia of such a system but the only way to change things is to ensure that no-one will feel excluded from the decision-making (or worse, come up with an immutable reason for no change). So. Consult. Then, if you must, make the decision you were going to make anyway.

Now I am out of it all I can let you into a secret I was entrusted with by a friend. I was always impressed when, in meetings, he would preface a plan by saying “I have consulted with a number of people”. How thorough, I thought. Then one day he came out with a comment about something that would have involved him consulting me, but he hadn’t. After the meeting I asked who he had consulted. He winked. “Andrew” he said “zero is a number”.

As a corollary to this, sometimes you can achieve results by frightening people. Write a letter, and cc various influential folk (Chairmen, MPs and the like). There’s no need to send the copies.

Who is in charge – Doctor or Manager?

This is a long essay.  Sorry.

Once it was the case that clinicians decided how to run their service and managers facilitated; now doctors find ways to meet management targets set by the managers (or politicians). What surprises me is how the new generation of doctors do not seem to have a problem with this; they obey like sheep. My failure to persuade colleagues that they must stand up was one of the reasons I left the NHS early.

Ponder for a moment, and recall what I said earlier. How long is the average senior doctor in a single place? And how long is a manager? (And to that add – how long is a politician?) So where resides the institutional memory?

No doubt it will be said that as a geriatric with a bus pass I am the last person to be pontificating, as times have changed, I am an old stick-in-the-mud, poor old chap can’t keep up with the times etc. But you should remember – I was young once and I don’t think I have changed greatly, except that when I pontificate I do so from a position of experience.

How many times have the keen and thrusting new generation come up to me and my fellow old farts with a new plan to save the NHS? Reform, modernisation, I have seen it all before. I am likely to say gently that we tried that 25 years ago, and it didn’t work then, and I am not clear what has changed that will make it work now.

It’s not always the managers’ fault. Sometimes they are driven by political pressures but doctors must be prepared to embrace change if it’s good, but be equally prepared to resist it if it isn’t. And, as I have said before, that requires doctors to step outside the evidence-based culture of clinical practice and consider finances, common sense and history.

Consider the plan. Be prepared to raise Cain if you have not been consulted at the right time. Do a proper SWOT analysis on it if you must. Look for unforeseen consequences. Think of the cost of doing it compared to the cost of not doing it. Check it hasn’t been tried before somewhere, and failed. Have your arguments ready marshalled for the showdown. Be prepared to concede if you have missed a trick but be prepared to enlist support from without if you cannot find any flaws in your own argument.

Let’s look at some global and parochial examples.

 

The Lancashire/Cumbria ISTC debacle

While I was President of the British Society for Rheumatology (2006-8) a grand design was developed in the north-west of England to construct a series of independent sector treatment centres for musculoskeletal services (ie orthopaedics, rheumatology, physiotherapy etc. A detailed proposal was drawn up showing where these new centres would be, and indicating how much more convenient they would be to a large part of the population.

There had been no consultation with people providing the existing services in District General Hospitals. Cain was therefore raised. It became apparent on careful review of the plan that it would be funded by a transfer of work from existing centres to the new ones – there was no new money that would allow both to co-exist. So the SWOT revealed an unforeseen consequence. A quick calculation indicated that the existing centres would lose so much elective work that one-third to one-half would have to close as they would be uneconomic. This had a further knock-on effect as emergency services would immediately be threatened. On this basis, although the new centres would provide better elective access to some of the population, the loss of existing centres would mean that other parts would have worse access.

The local consultants enlisted the support of colleagues nationwide, and of their local MPs. Backed up by a firm medical opinion, the trade unions started to kick up. The plan was abandoned. As the government had paid a private company on the basis that it would be the preferred bidder a considerable sum of money was irretrievably lost.

If only they had consulted with the locals, and worked with them instead of behind their backs…

 

Choose & Book

The rheumatologists in SE London were approached by the clinical lead for the Choose and Book project to be briefed on its introduction. We looked at the system and realised that, while it had been extensively consulted on at the consumer end (ie with GPs) it had not been consulted on at all with the providers of outpatient services (ie the consultants). So we wrote our own analysis pointing out all the likely difficulties and flaws, and duly turned up for the meeting. The team were quite taken aback by our negativity. When challenged on why they had not sought specialists’ advice they retorted that there were too many specialist organisations to consult. The meeting ended with dissatisfaction on both sides. A month or so later the Royal Colleges and specialist societies were circulated with a request for their input to the provider side of the scheme…

In fact there has been widespread dissatisfaction with the system on all levels. Getting the first available appointment may be good in some ways, but may lead to the division of care between hospitals and there is risk in that. Anyway, the waiting time may be a poor indicator of quality. Consider the following fable.

Pestonjee Bomonjee sat under a palm tree, wearing his hat, from which the rays of the sun were reflected in more-than-oriental splendour. Beside him was the cooking stove but, O Best-Beloved, I wouldn’t ask about that if I were you. Word of the cake-crumbs had got about, and them that could sort out thieving rhinoceroses were in demand. So it was no surprise when a little old man appeared from the Almost Undoctored Exterior (which abuts on the islands of Tobacco, Sago and Tapioca, and the promontories of Salmonella), and stood before him, and bowed ‘scrutiatingly deep.

“Oh Sage,” quoth he, and pitiful it was to hear the tremble in his voice, “Oh Sage, I am needful of your superior advice on a matter of the Utmost Importance. My water is stopped up, and something must be done.”

“Might I assume that this is not a problem of the mains supply to your accommodation that has been obstructed on account of an overloaded articulated lorry squashing the main, or more likely of you not paying your water rate?” said P.B., “but that of which you complain is a personal affliction caused by the benign enlargement of the prostate gland and resulting in Hesitance, Penitence and Dribbling?” And, on a sign of assent, he continued: “Why, then, you must find a urologist (or a general surgeon if you are less particular) to whom you may submit yourself for surgery.”

The old man nodded gravely. “I have myself reached the same conclusion,” he said, and added rapidly, “That itself is not the problem. But I have been told that there are many who will perform the operation, yet I may wait for years before it can be done. I have consulted the Great Wise Minister, K, Neth Clariq, second only in the land to Queen Tat Cha, and he said (or at least he has written on a White Paper that this is what will come to pass) that I must travel to the Uttermost Ends of the Earth to find him that has the Shortest Waiting List. He has told me that my personal physician, Dr Geepi, will herself conduct the search using a Fabulous Machine, which some call a Computer.”

Pestonjee Bomonjee, whose face had darkened at the mention of K. Neth Clariq, was silent for a moment. Then he smiled, kindly.

“Pay no attention to the words of Clariq.” he said. “I advise you to seek out the surgeon with the longest waiting list, and apply to him (or her) for attention.”

But why should this be?” exclaimed the Pensioner. “Your advice makes no sense! If the operation is required, it must be done with all haste!”

“That is but one of the factors involved in your case;” said P.B., “there are others. In the Old Days your Doctor Geepi would have sent you to the surgeon whose bedside manner was politest, whose scar was neatest, whose postoperative complication rate was lowest, and whose hospital was cleanest. Naturally, then, the waiting list will be long. The surgeon that might hack you about, let you bleed pints postoperatively, and discharge you with wound abscess will no doubt be well known as a butcher, and no-one will send him patients. Naturally, then his waiting list will be short. If you are that desperate then take Slasher Harry with alacrity, but blame not me if you end up in trouble.”

The old man nodded. “I understand and can see what you say is true. But why should Clariq not see this?”

“He might,” said P.B., “when he needs what you need. But he is ignorant of the First Law of Audit. Facts may be Facts, but there is always more than one explanation for why the facts are Just-So.”

“Clariq that dictates and cuts the docs’ rates makes dreadful mistakes.”

And there was a great deal more in that than you might think.[1]

 

Data, data, don’t compare a rosy apple with a pear; the new and follow-up game

The funding system of Payment by Results (PbR – perhaps more aptly termed payment by activity) has been responsible for the development of a new game. My local Primary Care Trust sent down an instruction (not a request, mind) that my department reduced its follow-up appointments because the ratio of new to follow-ups was too high (we averaged 1:4.2 and they wanted 1:2.1). We refused and they sought a meeting to discuss the issue. We were informed that we “had to” reduce our follow-ups because our ratio was much higher than the comparator hospital – which was not in fact far away. We had done some homework and identified that our casemix was substantially different from theirs, largely because we had a back pain triage service that creamed off a large percentage of patients who would by the nature of things be seen only once and then in the main sent on to physiotherapy. The other hospital counted all such patients under rheumatology. Inflammatory joint disease required ongoing specialist review (as it turned out, later NICE guidelines underpinned this). We pointed out that if we discharged the numbers needed we would have to discharge over two-thirds of our rheumatoid arthritis patients. Would the GPs be happy to monitor their disease-modifying therapy? What about review of biologics patients? What would happen to emergency flare-ups? Our own Trust managers were quite happy that we should discharge patients, on the basis that they would have to be re-referred and then attract a new patient rather than a follow-up tariff. We thought that was, simply, stupid. We also thought our GP colleagues would agree, not least because of all the time they would waste making the re-referrals (of course, under C&B there was no guarantee they would see the same consultant or even be able to get the patients back to the same hospital).

We had not at this stage raised the casemix issue; its time had come. I suggested that we did not need to discharge our follow-up rheumatoid arthritis patients at all; there was another way of reducing our new:follow-up ratio which would actually make it better than the comparator hospital. Interest was immediate. I explained the casemix difference and said that if we included under rheumatology all the back pain patients going through our (physiotherapy led) triage service we would add another 1500 new appointments to the caseload – but of course these would all be charged under Payment by Results and add an overall cost to the PCT budget of nearly £250,000.

No further interest was taken in trying to reduce our follow-ups. At least at first. Another attempt has just been made (and there is an intention to reduce new patients also, which will of course require an even larger reduction in follow-ups to achieve the magic ratio – there is a new manager on the PCT block (and all ours changed after major reorganisation), so the institutional memory on both sides has been lost. This time round the required ratio is 1:1.88. This was, it transpires, signed up to by our Trust! Indeed the Chief Executive indicated to me that he would look unfavourably on me if I do not obey. I must not do work for which the Trust will not be paid. I was told that the responsibility for my patients lies with the GP, not me. I might add that he promulgated quality as the first priority of our service. Here we go again!

I actually tried to find out where this new to follow-up nonsense had come from. Rather like Athene springing fully armed from the breast of Zeus it appears to have been a thought process with the Department of Health (based, of course, on surgery, which is what so many department-wallahs seem to think hospitals are exclusively for) and then sent out as a policy document. It is predicated on the assumption that once a patient is discharged from follow-up they will never need to be seen again. It also suggests that all hospitals should aspire to achieving the 25th centile. So – if we all do, then the mean moves, so we all have to reduce further, ad infinitum et ad absurdum. I think it was Estelle Morris who famously said, while Education Secretary, that it was a disgrace that half the population were below average intelligence but this has been variously attributed to Lyndon B Johnson and George W Bush among others. It would help if the top team understood statistics (in case you don’t, just recall that the mean is the midpoint of a population so by definition half are above and half below). But then, as my good friend Wolfgang Gaissmeyer points out, even medics don’t understand statistics. A test for you. What percentage is one in a thousand? Most people come up with 0.01%. Wrong.

Perhaps common sense will prevail, but why does it take such effort? Following on from my 2008 audit a large chunk of the Midlands decided to do something similar, and over a dozen units repeated our work. They found an average ration of 1:4.9 and, like us, found that casemix differences were the main determinant of whether a unit was above or below the mean. However when one hears of managers suggesting that improvements must be made so that less than 30% will be below the mean you do wonder whether any of them have even a GCSE in elementary maths (just in case you have already forgotten what I wrote in the last paragraph, the mean is halfway so 50% will be below and 50% above – always! And so, moving everyone closer to the end centiles alters the mean, and thus the centile points, and off we go again).

What might be sensible (and interesting) is if the managers made an investigation into both ends of the normal distribution to discover why some ratios were as low as they are as well as why some are so high. With all the pressure to stop GP referrals, and threats of extreme sanction if GPs over-refer, I think an investigation should be made into why some under-refer. Patients are more at risk from that than from being sent to hospital too quickly.

There is of course a serious side to this farce. On the one hand we have PCTs suborned into taking out block contracts with private suppliers that are then underused (like the MRI scanning contract referred to earlier). On the other they refuse to pay for NHS provision that is not only necessary but is best practice according to national guidelines. If consultants have heavily overbooked clinics (like me) do we really have an interest in seeing people unnecessarily? But cutting hospital outpatients will effectively lose us large chunks of profitable business (unless, of course, we are not paid for it). Thus it is not only in the patients’ worst interests to be discharged but it is actually in the hospital’s worst financial interests not to challenge the figures! Unless, of course, they return as new patients and are charged as such – wondrous effect on the ratio, but increasing the cost to the PCT by at least 40%!

What amazes me is that some consultants are actually putting down on their CVs how they have succeeded in these aims, and appear proud of it.

There is yet another twist to this. Although we are being “ordered” to see less new patients our clinics are full (through Choose & Book referrals from out-of-area) and even over-full because a large number of local GPs are not using C&B on the basis that (1) they want their patient to see a particular consultant and (2) the patient actually agrees that their GP’s advice is reasonable and is prepared to wait. I had one such recently; every page contained a header in capitals saying “Dr Bamji only”. But there is a “breach” target for new referrals. It doesn’t matter how many thousands come through the letterbox but we have to see them in 6 weeks or the hospital is fined. So we run extra clinics (for which we might personally get paid extra – cheaper than the fine) to see the patients that the GPs want us to see. But the PCT then says we are seeing too many and refuses to pay the hospital.

Of course the PCT had got partly wise to this, and so forced GPs to submit to a vetting system for referrals. It’s as if they are not trusted. What happens if they are browbeaten into not making a referral and something goes wrong may be a matter for the courts.

But where is patient choice in all this? I had lots who, when I suggested discharge, expressed both horror and fear – horror that there will be no-one who has time to listen to them and fear that their GP will be unable to look after them properly.

Managers lose their heads when targets, however mad, are threatened with breaches. One of our neurologists, a long-term locum, left recently. The secretary, who happened also to be mine, was ordered to cancel all the follow-up appointments – but continue with the new ones. She very reasonably pointed out that many of the follow-ups were awaiting the results of tests done after the initial consultation, and they would get very agitated if they were suddenly told that no-one was going to let them know if they had a brain tumour, MS, motor neurone disease or whatever else they feared. This cut no ice. Is this mad, or what? It’s time to abandon the “target” of new to follow-up ratios for the lunacy that it is.[2]

 

“Internal referrals”

It amazes me that, if a specialist sees a patient and decides they need to see another, that they are being inhibited or even prevented from making a direct referral but are being ordered to send the patient back to their GP for them to make the second referral. This demeans the specialist, wastes everybody’s time and is I think an arrogant and conceited view. The specialist may be far better placed to refer on appropriately (especially as they know who they would be happy to be referred to, or more importantly whom they would not wish to see, which is expressed in the fable above). Forbidding the practice is childish, petty power-play and completely contrary to patients’ interests. It also adds to GP workload, quite unnecessarily. However, as the irritation was minor, I played along. When it was least inappropriate. Which was not often.

 

Contracts and PAs

Our managers decided to make everybody’s contracts the same. PAs are Professional Activities, in case you didn’t know.

Pity this did not take into account the fact that some of us see twice as many patients as others (so earning the Trust twice as much income, assuming the PCT actually pays). We had a splendid calculating program which worked out our sessional time to the second decimal place. In fact it made even more explicit that most consultants actually put in more time than they are paid for. So cutting sessions (which could mean a pay cut of 20% for some) should produce an immediate response of “Which clinical commitment shall we drop?” This will not increase productivity, which is another aim of government.

 

Bed-stealing

My rehabilitation unit was built for a 3 district population with 20 beds, but with the perennial shortfalls only 14 could be staffed. Periodically there were pressures from the acute hospital to use our empty beds as an overflow. To avoid major problems for our own patients we set strict criteria for use – no significant infection (C.Diff or MRSA), no dementia (the unit has automatic doors which lead to the hospital back road, which is a bus route) and no incontinence (disabled folk who cannot see very well will either trip on the wet patch or scoot gaily through on their wheelchairs and spread it about a bit).

You can guess what came next. As pressures grew, protocols went out of the window, so we ended up on one occasion with 12 medical patients of whom all were in one or more ways in breach of our rules.

When this happened I made a fuss; it often seemed to occur when my unit manager was off duty, or at weekends. On one occasion I forbad the bed manager to admit a medical patient, not least as one of my seriously disturbed and depressed patients, who we had only just got settled in a side-room, was going to be moved out of it. The following morning I arrived to find the medical patient ensconced.

Now much of the time we could cope – except that it was rare for all the extra staff needed for the 6 beds to turn up, so the permanent staff ran around at double speed (if bank and agency staff did appear, we were subsequently accused of overspending). But ignoring the clinical rules has itself become a rule.

As a result we had to cancel some of our booked admissions. One such was Mrs Smith, an MS patient who was already in a state because she had just buried her best friend. The dog had been boarded out (cost £140) with a couple who had changed their holiday dates to oblige. Mrs Smith sat on the unit all day hoping one of the medical patients who was supposed to go home actually did, but they didn’t. She was offered a night on an acute ward, but previous experience of care led her to turn this down, so at 8pm she went home. The ambulance crew kindly drew her curtains. The next day she was stuck. She couldn’t open the curtains, her telephone was not within reach and so she couldn’t contact her family who, thinking she was on the Unit, had gone away.

Need I say more?

Actually, I need. A year and a month after I retired my erstwhile Unit Manager informed me that the Unit – a purpose-built unit, designed for (and partly by) heavily disabled patients – was to be moved to an ordinary, unconverted ward so the space could be used for something else. I suppose you could argue that in the last 25 years all the other units that worked like ours had gradually been closed down, and that ours was an anachronism. However, it had provided substantial care and support, on both an in- and outpatient basis, to well over 300 patients. Of course it was expensive; looking after severely dependent people is staff-intensive, but to run “standard” ward levels was impossible. If a heavy quadriplegic patient requires three people to move them you cannot have just two nurses, and if all your patients are in wheelchairs then they need lots of room to move about. When I started, the Unit was in an unconverted ward and we got moved out to our new premises precisely because the old ones were inadequate.

The wheel turns. Once again pennies come before patients. The large numbers of severely disabled folk we looked after included patients with multiple sclerosis, spinal cord injuries (who had often been discharged from the big centres with no backup, so couldn’t cope) and young patients with muscular dystrophy. It was thus ironic that a report appeared the same week of the closure decrying the lack of support for disabled children entering adulthood. That was one of the things we did, and now it has gone.[3]

 

[1] Bamji AN. How the NHS waiting list got its length. Hospital Doctor, 6/4/89. Read this in 2014 and you will wonder at its acute relevance. You are correct to identify the tale derives from “How the Rhinoceros got his Skin” by Kipling. I have a soft spot for it, not least as my great-grandfather was hakim to the Maharajah of Baroda, whom Kipling would have encountered. That his name was Pestonji Bamji (of which Bomonjee is an alternative spelling) may thus be more than coincidence.

[2] A much condensed version of this (I think it was Mark Twain who apologised for the length of a letter on the basis that he had not had time to write a shorter one) is Bamji A. We should scrap targets for outpatient follow-up ratios. BMJ 2011; 342: c7450. Actually I learned, at the end of 2012, that the target had been abandoned “because it didn’t make any sense”. Fancy that.

[3] Following reorganisation of the reorganisation that created the South London Healthcare Trust (and failed), my unit has now been closed. The senior staff have been relocated to a major teaching centre which is taking over one of the constituent hospitals – not mine – and intends to open a similar unit in it. So a purpose-built unit will be replaced, four miles down the road, by another, although I suspect it will be less purpose-built. Such is NHS progress.

Single bedded wards and the nursing crisis

When our new rehab unit was built in 1998-9 we designed it to be fully wheelchair accessible and as safe as we could manage. Unfortunately our best efforts were obstructed by the politically correct who wanted to pursue their ideal of single-bedded rooms for all.

Sometimes I despair of policymakers who have no common sense and no ability to see past the end of their short book of dogma and commandments. I doubt many have been in hospital themselves; if they have, the have failed in one of my commandments – look not only at the action but its possible consequence – and indeed another – weigh the risk, and benefit, of doing something against not doing it.

Single rooms are lovely and private, and can have their own washing facilities so people don’t have to share toilets – nice when there’s a lot of diarrhoea about and not many cleaners. But – they are lonely places and unsuitable for the really ill. Wards of single rooms require many more nurses to supervise them; bells and buzzers are fine if they are answered, but you cannot see when a patient collapses and neither can anyone else. If a patient on a Nightingale ward “went off” then all the other patients would raise the alarm. If a severely disabled patient was assaulted by a demented neighbour (this happened on my unit once) then help could be summoned. Suppose I shut you up in a single and featureless room, and the TV didn’t work, you would rapidly go crazy; in a bay, or large ward, there is someone to talk to. Patients can help each other, even do things for each other. And they can make carping comments about staff hygiene, as they can watch whether handwashing takes place.

All of these arguments were raised by our own patient group who were very unhappy, given their heavily dependent state, to be confined to single rooms. Shouldn’t they know best? But worst is the apparent assumption that a ward of 20 beds requires the same number of staff to manage safely irrespective of its configuration – an assumption that is patently untrue. And in these financially straightened times it is nonsense to design single-bedded wards when it will then be impossible to run them because the staff cost is unaffordable. Once more the economic argument must be deployed. Can we afford to be fully touchy-feely and if not, how will we compromise?

Another aspect of the strain in hospitals is the feeding issue. For years there have been stories of disabled patients who have had their food put in front of them and either been unable to eat it (because they cannot reach or see it, or are very slow). Nurses’ patience seems to be shorter, so the trays are removed, usually with a comment such as “Don’t you want it, dear?” and the patients gradually starve.

Recently a government spokesman suggested that if relatives were concerned about the nutritional state of inmates then they should come in and do the feeding themselves. If this does nothing else, it underpins the staff shortages in hospitals. Of course such practices are common in Europe, but two problems are immediately apparent.

The first is that many if not all wards have a notice on the door banning visiting during mealtimes.

The second is that if a relative does manage to slip through and do some feeding, the reaction of the nursing staff is not to say thank you but to suggest, often with a gay laugh, that perhaps they would like to help with some of the other unfed patients.

Oxymoron!!! This is not good.

 

Duh-duh-duh-duh Duh-duh-duh-duh – VAT man!

In July 2013 it became apparent that there was a problem with the transfer of NHS property (transferred from parts of the organisation that “disappeared” under the Health and Social Care Act 2012) to a company called – unsurprisingly – NHS Property Services. It is in fact a state-owned company. This company is supposed to collect rents from the various users, but because of the way it has been set up it will have to charge VAT on the rents.

So the NHS, which is state funded, pays an extra 20% back to the government! Those who have to pay will have to trim expenditure elsewhere (ie make cuts).

I suppose you could adjust all the rents downwards so that the overall bill remains the same. But wouldn’t it be easier not to pay the tax? After all it requires an army to collect it.

I expect the government will simply increase allocation to compensate. Then of course it will say that it is pouring even more money into the NHS, but will forget to add that it is all pouring straight back out without any benefit to patients whatever.

 

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 ccould be admitted without being screened first – not that our bed managers cared, and we had frequent occasion to complain when unscreened patients were dumped on the unit so that A&E patients could 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 had 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 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…

[1] Bamji A Tackling MRSA. Hospital Doctor, 22nd April 2004

[2] Alex Wafer. A&E Targets damage MRSA safeguards. November 13th 2004

The cost of capacity: MRI

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 decided 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:

Patient develops symptoms

  • Patient goes to GP
  • GP fixes X-ray or scan, writing brief and usually unhelpful clinical details on the request form (sometimes without taking a full history or examining the patient)
  • Radiologist looks at film with only half a sentence to go on and reports film accordingly (Question – ?fracture; answer: no fracture seen – never mind the other maybe important things such as arthritis, deformity).
  • GP tells patient investigation is normal
  • Patient still has symptoms

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?