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 30th), and is re-booked by central appointments for 5th 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 12th March as the 5th is full
  • Patient receives the letter confirming their own rebooking for 5th March
  • Two days later they receive a second letter generated through the DNA, for 12th March. The letter says “Due to unforeseen circumstances your appointment with Dr Bamji has been changed to the 12th March”
  • The patient thinks this change refers to the appointment they made for the 5th, but this of course remains on the system
  • On 5th 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 27th April
  • The letter confirming this is received by the patient on the 11th 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 9th 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 (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.


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.

New government department to be established

Today (Friday 13th January 2017)  “The Times” published my letter in response to their article describing how the government had decided to attack the head of the NHS, Simon Stevens, and blame him for all its failings.  In the edit a little bit was lost, so I quote the whole thing here:

“For the government to blame Simon Stevens for the crisis engulfing the NHS is akin to the Dutch public of old attempting to blame the little boy who stuck his finger in the dyke.  As for not following the government’s “direction of travel” – well, there isn’t one.  All credit therefore to Mr Stevens for trying to find it.  The government may not like what he says, but at least he is thinking outside the box which, as thinking inside it has manifestly failed to sort things out over the last 30 years, can only be a sensible thing.  That said, it doesn’t matter how brilliant a manager is if the business he is trying to run is terminally bankrupt.  The NHS as constituted cannot work and it is time to seek radical alternatives.”

I trust that Mr Stevens, should he read the letter, take some comfort from my support. Doctors traditionally bash managers; managers refer to the control of doctors as like herding cats.  But successive governments have spent untold time, and money, trying to “fix” the NHS almost from its beginning, and yet successive quotes in newspapers from the 1950s onwards have wanred of impending or exisiting crisis.

Things are very different from 1948.  Then, infectious diseases still killed thousands; heart attacks were untreatable, gastric and duodenal ulcers were rife, investigations were primitive and cheap; cancer simply killed.  Now antibiotics have saved thousands, heart attacks are treatable, if not always preventable; drugs have almost eliminated stomach ulcers and cancer can be treated.  All of this comes at a cost.  Investigations that are now routine, such as CT and MRI scanning, are not cheap and drugs that limit disease and extend life are exorbitant.  People live longer as they don’t die early from the aforementioned conditions, but live into old age with multiple, life-threatening pathology and often dementia on top.  Take such a person and admit them and it will cost thousands.If it’s a different set of health issues then I argue it needs a service designed to fit it.

Tinkering has failed us.  We labour under the illusion that the NHS is a business.  We have a so-called purchaser-provider system where the purchaser’s outlay is limited because it is constrained by what it gets from government, and the provider side limited because government sets the pay rates for procedures.  How such an arrangement can provide, or be expected to provide a surplus is beyond economic comprehension.  If government gives too much money to an organisation, all it has done is just that; if it gives too little then the organisation will be in so-called deficit.  To make savings it then has to make cuts in service, so it then gets even less money and the spiral continues.

Phillip Collins in “The Times” today argues that the age of the general hospital is over, suggesting that orthopaedic surgery can safely be conducted in small (and he presumes cheaper) units. He is completely wrong because he has looked only at one side of the argument.  A small unit may be cheaper (though there is a vast pool of evidence to suggest the opposite) but to divorce specialties from each other runs the risk of serious clinical failure.  If there is some unforeseen problem, where is the physician to solve the coronary episode or pulmonary embolus, the sudden loss of diabetic control, the acute hot joint?  Where is the vascular surgeon to deal with the postoperative unstoppable haemorrhage?  Where are the opportunities to exchange cross-specialty experience, or to train trainees in complication management? What is the cost of providing small intensive care units to rescue the patient who suddenly collapses and requires ventilation?  It is the availability of multiple specialties that maintains the safety of medicine. Collins hadn’t thought of that.

This all leads me to the expected announcement that the government will change its planning processes.  As well as coming up with ideas it will also test them to destruction in a new departmental analysis system.  In the NHS and elsewhere we have been belaboured and bewitched by policy initiatives that have fallen over because no-one has looked at the possible bad outcomes of change alongside the good ones.  Take Jeremy Corbyn’s recent idea to limit top wages.  Sounds great – economic madness and probably impossible to implement (and top earners will leave the country – pay peanuts, get monkeys, not a good idea.  So watch out for the new Department of Alternative Orthodoxy, which will contain a new committee called OfWhat (the Office of “What if?” or the Null Hypothesis Office). All plans would pass through a scrutiny committee whose only role would be to find something that would make the scheme fail.  Then there would be no egg on face when some smartass like me pointed out post-hoc why it wouldn’t work, and no need for the enthusiasts to slink away, red-faced with embarrassment at their simple and stupid errors of omission.

Let me give another example.  Some years back the NHS became intensely interested in the American system of Health Maintenance Organisations (HMOs).  My hospital was approached to consider the system.  It was decided that a working group of managers and consultants should go to the States for a week to see the system first hand.  There was great excitement.  There was no doubt that such a trip would be a good learning exercise and would help us to make a decision on whether an HMO system might work fir us, but I pointed out that if the public got to learn of it, given the parlous financial situation at the time, there would be the most frightful reaction and those that went would be pilloried for wasting resources by going on an expensive junket.  The press would have a field day.  Somehow no-one had thought of that. They had all looked at the plus side of the equation alone.  The proposal was abandoned.

Actually no such department will be established because it is too bold a step.  It would tacitly acknowledge the recurrent failures in the present system and no politician would be prepared to do that.  Would they?

Oxymorons and unintended consequences

I receive a daily digest of articles from the HSJ, or Health Service Journal in full. Today there are two headlines:

More trusts considered for ‘financial special measures’

All trusts given new targets to achieve provider sector surplus

Now Trusts considered for special measures are, basically, in financial trouble, in other words in deficit.  Many such Trusts have been unable to solve their deficit problem, and have had a succession of managers who have come and gone as the impossibility of balancing the books and maintaining safe clinical services becomes apparent.  As I have commented before, reducing deficits means cutting services, while maintaining these with adequate staff means increasing the deficits; there is a limit to how long the pips can squeak for.  The disastrous failure of clinical safety in Stafford will almost certainly be accepted to have been due to the cutting of corners, but the Care Quality Commission can put a Trust into special measures if its finances are wrong (even if its clinical services are fine) or if its clinical services are wrong (but its finances are fine). Heads I win, tails you lose.

To achieve a provider sector surplus requires Trusts to save more money still.  If they cannot do it now, how will they possible do it tomorrow? And what will be the effect on their clinical services if they succeed?

So these two juxtaposed headlines are, effectively, mutually exclusive.  The irony of the juxtaposition appears to have escaped the HSJ.  However there is another ingredient to this toxic mix. Jeremy Hunt,  the Rachman landlord of the NHS, has spoken at the Conservative party conference to announce that he intends to force trainees to stay in the country after qualification for four years, because too many are leaving and abandoning patients to foreign doctors who can’t speak good English.  He also intends to increase medical school entry to make it less necessary to recruit NHS medics from abroad, but also fill the unfilled posts currently washing around the system.

But herein lies a problem.  If Trusts are bust then how will they be able to employ more doctors?  It won’t help the provider sector surplus, will it? Cutting deficits means shedding staff, not employing more.

Of course what Mr head-in-the-sand Hunt has failed to realise, or chooses to ignore if he has realised, is that doctors are voting with their feet because life as an NHS doctor employee is becoming intolerable.  He won’t fill medical school places when all the prospective students are being put off by their medical friends, parents and relatives.  So before trying to induct more people into this uncomfortable and failing system he should first address the concerns of doctors over workloads, continuing education, regulation and bullying (viz the attempt to enforce a new contract).  Then we might get somewhere.  But he will never produce results from a sullen and rebellious workforce.