HS2: the gravy train

The fron page of today’s “The Times” carries the news that large numbers of employees of the HS2 rail project are on large salaries of over £100,000 per annum.  The thing hasn’t even started building yet and the release of these figures undoubtedly plays into the hands of the naysayers who wish the whole thing would go away, and be replaced by the currently mothballed plans to upgrade the east-west routes in the north of England.  It would be cheaper and of more benefit to the economy, they say, citing “evidence” that the speed of HS2 will not result in any change in passenger numbers or convenience, It would also relieve the pressure on those whose estates are in the way of HS2 who, it must be admitted, have been treated pretty shabbily by the compensation-wallahs.

It all sounds very reasonable.  But haven’t we been here before?  The furore over HS1 is all but forgotten; all the same arguments were raised – poor homeowners forced from their land, those left bordering the line subjected to unbearable noise, shortage of passengers making the whole thing unnecessary, high fares to cover costs will be scorned by travellers.  Well.  All I can say is that it has been an unmitigated success.  I declare an interest, as I use HS1 to get to London from Ashford, but the trains are full, the speed is amazing with a halving of the old journey time, and the only complaints I ever hear are when a train is cancelled or late.

But we have been here even before that.  If we return to 1865 we find that the tunnel on the railway from London Bridge to Chislehurst at Elmstead Woods is only there because the landowner refused permission for access, and refused to allow a cutting, forcing the railway to drive a tunnel which in places is only a metre or so below the surface.  There are numerous examples of major landowners seeking special treatment during railway mania; insisting on diversions or their own stations (or both) and making just as much of a NIMBY noise as today’s complainers.  And a hundred years or so before that exactly the same happened with the canals, and in both cases people were bought off, intimidated or otherwise persuaded to give ground (pun not intended).

That isn’t to say that I lack sympathy for those in the way of HS2.  There is a clear need, though for a reassessment of the comparative costs and benefits of HS2 and HS3.  Whether, given the government’s entrenched position, this will happen is doubtful, but there must come a time when a bold decision to cancel might be wise.  Think planes, and TSR2 (look it up).

 

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Why back pain treatments don’t work

A recent study suggested that many treatments for back pain do not appear to be effective.  I am unsurprised.  The first reason is that the wrong diagnosis has been made.  The second is that the treatment is, actually, ineffective.

Back pain has several causes; pain can come from a number of different structures.  It’s no good treating a disc prolapse with a muscle injection.  If the pain does not arise from a facet joint then injecting that joint will do nothing.  If the issue is a pulled back muscle then manipulation may actually make things worse.  And surgery to remove a bulging disc won’t help if the disc is not the problem.  MRI scans may help, but you can be sure if a disc bulge is on the left, and all the symptoms are on the right, then that disc bulge is irrelevant.  It is difficult, though, to persuade patients that an “abnormality” does not signify.

Thus the first key is – be sure which structure is the source of the pain.  I have an algorithm that helps, but is not infallible.  I failed to diagnose my own disc prolapse for a couple of weeks because the algorithm pointed me the wrong way.  But it’s a start.

The second key is patience.  How do you treat a bruise?  You treat the affected area with a bit of respect (not a lot) and wait for it to get better on its own.  So should you with back pain.  95% get better in four to six weeks – even disc prolapses resolve themselves quite often.  Mine did.  However there are some symptoms that should prompt the seeking of help; severe pain at night, nerve symptoms (loss of sensation or power in the leg); and especially any disturbance of bladder and bowel control.  The worrying causes of back pain are cancer or osteoporosis.  The former produces unremitting pain, the latter may have a sudden onset as a bone collapses.  The history is vital.

Treating cancer in bones is possible.  Treating pain from an osteoporotic fracture is possible, but trying to treat the osteoporosis itself will make no difference.  Time will heal the fracture and the pain will go off; anti-inflammatory drugs will help with the pain meanwhile.

I have had dramatic results from injecting anaesthetic and steroids around facet joints.  Such success may be gratifying not because it works but because it confirms the diagnosis of facet origin pain.  Spinal manipulation is positively dangerous in some circumstances.  I saw a patient who had had his neck manipulated when the cause of the pain was a large cancer deposit in one of the vertebrae which had made it vanish on X-ray; he was lucky that the manipulation did not dislocate the spine and transect the spinal cord.  I have also seen patients whose disc prolapse has been worsened by a quick tweak.  I have also seen a patient who had been diagnosed with polymyalgia (multiple central muscle pains now thought to be due to blood vessel inflammation) whose exacerbations of pain were treated with large increases in their steroid dose.  But the cause of the pain was not polymyalgia, but recurrent osteoporotic crush fractures – which the bursts of steroids were helping to create.  Folk are ever so keen to have an osteopath or chiropractor manipulate them, but there’s an awful lot of them who go back time after time for repeat treatments because they don’t last (or work).

So the first step is to make sure you have the right diagnosis, and the second is to administer the right treatment for it – or none at all.  Nothing can be a treatment.  But it’s not easy to persuade someone that nothing is better than something.  My rule was – if it’s that painful, rest it, but when it starts to improve get moving ASAP.  Bedrest can not only prolong recovery but also lead to chronic problems.  Keeping up muscle strength is vital.

There is a story of an old villager in France who had an astounding reputation for correctly identifying wines.  He could pick types, origins, even years.  Eventually during a tasting competition one of the judges slipped in a glass of water.  The old boy nosed the glass, took a sip, swilled it round and spat.  He looked puzzled.  He had a piece of bread and repeated the process, and then a third time.  Eventually he turned to the judges.  “I have never been wrong, or beaten by something” he said “but I confess that this has defeated me.  I don’t know what it is.  But I do know one thing.  It won’t sell.”

 

Sugar and spice and all things horrible

I may be boring but I have never smoked, eaten or taken cannabis in any form.  It has been around should I have wanted it but I was thoroughly put off by my father, who told terrible tales of street scenes in Bombay (now Mumbai) in his youth in the 1920s.  Men (and it was usually men) were addicted, and sat around in a zombie-like state, and he was convinced that chronic use led to serious mental illness.

Back in the 1960s, when I was a medical student, my friends pooh-poohed his lurid accounts.  “Go on! Try it!” they said.  We were in time of free love, Woodstock, California dreaming and all that.  Everybody did it.  But I never did.

Well.  Hasn’t the worm turned. The appearance of new, highly potent preparations has led to – zombie-like states, chronic addiction and the unmasking, or generation, of serious mental illness such as schizophrenia.  We have been treated to graphic scenes of drug abuse in prisons (BBC – Prison from the inside) showing not only the distressing state of users but the violence surrounding the supply of drugs.  And Spice is the big problem.  For years people have denied that cannabis and its derivatives are harmful.  I cannot believe that any denier could watch these prison scenes and persist in their denial.  Some of the users are clearly vulnerable adults and no-one is looking after them.  Perhaps no-one can.  There’s a lot of money involved so there is no incentive for suppliers to desist.

My father died forty years ago next week, but I bet he is sitting on his cloud wagging his finger and saying “I told you so”  At least it makes a change from me saying it!

 

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 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.

 

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.