Friday, 31 October 2008

GMC referral and more

"We have requested that some of the senior doctors be investigated for their role as managers integrally involved in the introduction of this. We have asked the GMC to investigate whether their professional and managerial actions and conduct in relation to SSR/MTAS fell seriously below the high standards that are expected by the profession, as laid out in ‘Management for Doctors’ and elsewhere, and whether their deficient performance, and their failure to meet the published GMC Guidance for Doctors in management roles, was so significant that their actions would amount to misconduct and/or deficient professional performance and would impair their fitness to practice in this managerial field of work under section 35C of the Medical Act 1983 (“the 1983 Act”)."

Remedy UK have written to the GMC to request that the senior doctors involved in MTAS, SSR and MMC be investigated for their actions. The full details of the request can be read at the Remedy UK website in full here.

I can only say 'hear, hear' in response, it's not about being vindictive, it's about ensuring that those in charge of the big schemes and reforms are aware that they must behave properly in their roles, it is simply not good enough to say 'lessons have been learnt' and for nothing else to happen.

Those who failed so many people so very badly with MMC and MTAS must be held to account, not only to restore people's faith in the system but in order to go about preventing more disasters like this happening in the future. It does seem that some lessons have been learnt, however it is also abundantly clear that other have not, for example the woeful application system for the Foundation job schemes does look rather similar to the failed MTAS methods.

Whether the GMC will do anything about this is another matter altogether. Many have rumoured just how close the GMC bigwigs are to certain members of the medicopolitical establishement, and for this reason it would appear unlikely that someone living in the house of cards would start blowing a gale. Stranger things have happened though.

Monday, 27 October 2008

PCT referral schemes scrapped but fishy smell lingers

It appears that despite the best attempts of several PCTs to introduce sick cash incentives for GPs to refer less patients to hospital, they have been thwarted by the government who have come out against these schemes:

"It is clearly essential that they do not in any way undermine - or be constructed in a way that could be perceived as undermining - the GP's overriding clinical and professional duty to provide the best care for each individual patient."

The DoH has said something sensible for once. It seems that the government had come under pressure as a result of a Telegraph investigation into these PCT schemes, however I did break the details of the Torbay scheme myself in the middle of last week, every little helps I guess.

One thing that should be emphasised though is the reaction to these schemes from GPs. Although a lot of GPs were concerned about the unethical incentives contained in these schemes, a lot of GPs did quickly sign up. In fact the Oxford LMC (Local Medical Committee) signed off on the scheme despite predicting the negative press coverage, while the Hampshire LMC passed it by 14 to 11 votes. I am slightly disappointed that more GPs didn't tell their PCTs to stick their unethical cash where the sun don't shine.

Another strange aspect to all this is the fact that Mark Britnell, the NHS' director of commissioning, made it appear that he and the DoH knew nothing of these schemes until the Telegraph had alerted them:

"We are grateful to The Sunday Telegraph for raising these three incidents and we have asked strategic health authorities to look at their local incentive schemes with PCTs, to make sure patients are getting the most appropriate care, and to make sure the relationship between the GP and patient is not undermined."

It seems strange that PCTs up and down the country were all rolling out these incentivised referral schemes at exactly the same time without the DoH or Mark Britnell's knowledge, it would be a wonderful coincidence if they had all thought up such similar schemes independently wouldn't it? It all smells very fishy to me.

Thursday, 23 October 2008

Sick PCTs incentivising patient death

The ferret has just found of one PCT that is sinking to new unethical depths in the incentivisation of medicine, it certainly would not surprise me if more than one PCT was indulging in this depraved behaviour. The national media has already noticed the unethical incentives offered by numerous PCTs in trying to get GPs to refer less to hospitals, clinical need is being thrown out of the window as the bean counters take over the NHS. In a new PBC scheme in one PCT the following are allegedly 'indicators of access to personalised and effective care', and GPs are being paid to reduce emergency beds, emergency admissions, out-patient referrals and alcohol related admissions, while they are being paid to let more patients die at home. These are the PCT's 'vital signs' that it intends to pay GPs for fiddling, amazingly the fools at Torbay have left the full document on their website, it may not be there for too much longer:

-Emergency bed days per 1000 patients
-Admissions for ambulatory case sensitive conditions per 1,000 patients
-Proportion of all deaths that occur at home
-GP referrals per 1,000 patients
-Rates of admission for alcohol related harm per 1,000 patients

(note- ACS conditions include life threatening problems such as angina, COPD, gangrene, perforated or bleeding ulcer, asthma and many more killers)

I find it hard to comment on this scheme without swearing but I shall nonetheless try. PCTs have already unethically started schemes up and down the country that reward GPs for reducing referrals, irrelevant of clinical need. The Mail calls the PCTs 'sick' and I am inclined to agree with them on this. The new incentivised vital signs detailed above reward GPs financially for reducing referrals irrelevant of clinical need, for reducing hospital admissions for life threatening conditions and for ensuring that more patients die at home. This is not just unethical, I think the PCTs are encouraging GPs to break the GMC's clear guidance on the duties of a doctor, there could be severe consequences for both the PCTs and the GPs if they accept these sick schemes:

"-You must make sure that your conduct at all times justifies your patients’ trust in you and the public’s trust in the profession.

-You must act in your patients’ best interests when making referrals and when providing or arranging treatment or care. You must not ask for or accept any inducement, gift or hospitality which may affect or be seen to affect the way you prescribe for, treat or refer patients. You must not offer such inducements to colleagues."

These PCT schemes are an utter disgrace. They demonstrate that the health service is being run by bean counters who have no understanding of the role and responsibility of being a doctor. Any doctor taking part in these schemes should be ashamed and could well be in grave trouble with the GMC, interestingly I wonder whether anyone with a medical degree has been involved in coming up with these ideas at the DoH or in the SHAs? It does emphasise the way in which doctors can be accountable for taking part in sick schemes like this, while medical managers are seemingly immune from ethics and codes of conduct, they can encourage bad clinical practice and they just don't care for the potential consequences in terms of patient harm.

Modernising Scientific Careers

Amazingly enough this is no joke, MSC (Modernising Scientific Careers) is upon us, so what exactly is MSC?

"The Department of Health's Modernising Scientific Careers (MSC) workforce programme is designed to ensure flexibility, sustainability and modern career pathways to address the needs of the future NHS."

In government speak this means 'unflexible, unsustainable and dumbed down pile of manure' and it deems a bit similar to the ideas behind the disastrous top down failure that has been Modernising Medical Careers (MMC). There is emphasis on a framework that appears to focus on competencies and centralisation, the government seems to be obsessed with these ideas despite the fact that their track record with them is of Eddie the Eagle quality:
  • introduce an integrated career framework encompassing all disciplines and employment groups within the workforce based on roles and function and linked to transferable skills and competences
  • clearly identify pathways for progression and transfer, supported by learning and development providing enhanced opportunities
  • provide national consistency and maximum flexibility to support local service delivery, the expansion and extension of current roles and the emergence of new roles.
Guess who is MSC's Programme Director? None other than the larger than life Shelley Heard, one of the key figures behind MMC, and my, what a success she made of that. NHS Employers must have had their work cut out to fight off the competition for her signature, well that or maybe they bribed her with a lifetime's supply of Ginsters. One wonders precisely what qualifies Shelley Heard for her position, is it her compliance with government ideology that has been proven by her years as a postgraduate Dean or is it her rank incompetence?

This government is pursuing the very opposite of excellence, their obsession with top down control and centralising everything in sight is so destructive that it's hard to put into words, they are completely unwilling to trust anyone to get on with their own jobs, hence more and more is run from the centre by corrupt government friendly numpties who will do anything the government says in order to hang onto their job or get their OBE. Hence the long term interests of the country are ignored time and time again, as the short term interests of brain dead politicians and their hangers on are served. The compliant incompetent are put in charge, while the educated experts are dis empowered as they may dare to disagree with the government's Stalinist approach, no wonder everything is turning to turd brown.

Wednesday, 22 October 2008

GPs sailing close to the wind

The screening for certain disease has had massive impacts upon our health, for example cervical cancer, however screening is only appropriate should certain criteria be satisfied. A number of factors should be considered before screening for a particular disease, they are nicely summarised by the WHO here. For an example of a cancer that it is pointless, arguably dangerous, to routinely screen people for, then take Ovarian cancer.

Firstly the blood test for the tumour market Ca-125 is a waste of time, it is not particularly sensitive and very non specific. Secondly screening with ultrasound scans is also dangerous, as for every cancer detected several women will undergo pointless diagnostic surgery which has obvious risks attached (estimates of this number are 2.5 to 60 women needing surgery for every cancer detected). There is also no decent evidence that early detection of the cancer will reduce mortality. Interestingly even in the high risk groups there is no evidence that screening is of benefit in terms of median survival and overall mortality:

"Although there is interest in identifying and screening these very high-risk women, there is no evidence that screening benefits this group in terms of median survival or overall mortality."

So overall screening for ovarian cancer appears foolish at best, unethical and reckless at worst. So when I hear that some GP practices are sending letters to their older female patients to advertise the screening for ovarian cancer by a certain private health firm (Health Screen Clinic or Health Screen First Limited as they are technically known) I get a little hot under the collar. This is unethical at best and given that they are sending out the private health firm's propaganda with their letter, it is sailing very close to the wind indeed. This has already recieved coverage in the national press, so why are some GPs still pestering their patients with this private firm's propaganda against the advice of the BMA?

In fact the private health firm recommend screening for people with only one first degree relative who has been affected, they are also using the rather useless Ca-125 blood test which costs the patient are rather significant amount of money. I see this behaviour from the private health firm as scaremongering, they are trying to scare a vulnerable group of patients into spending their money on screening themselves for a disease, that even if detected may not result in any improved survival. The GPs are complicit in this. In the GMC's duties of a doctor it states in the probity section:

-you must not put pressure on patients to accept private treatment
-you must not exploit patients' vulnerability or lack of medical knowledge when making charges for treatment or services

These GPs would struggle to defend their position in front of the GMC. Not only do they stand to gain financially by leasing their rooms to this private firm, but also they are distributing this firm's factually inaccurate propaganda to their patients. I am not sure if this is an isolated example, it may well be going on in many other areas, and I would be very keen to know if this is the case. Interestingly the BMA's advice makes it clear that GPs know that they should be steering well clear of this particular firm, the wind is indeed close, maybe too close for comfort:

"The GPC has asked LMCs to warn all practices in their area of the significant risks they take should they involve themselves with this company and its current business model.

  1. The practices could be deemed in breach of their GMS or PMS contract for breaking regulation 24 in relation to fees and charges, as they are receiving an indirect fee for their involvement in letting this private company screen their patients. The level of involvement in the company’s operations and the payment of a fee for rent, means that this goes beyond any allowance to rent practice space to an individual practitioner or company as permitted in the Premises Directions.
  1. The practices are in breach of the Data Protection Act. They hold patient data as part of their NHS contract. It was never intended, and patients are not aware or indeed have consented to their personal data being utilised for the purpose of advertising private services.
  1. The practices could be deemed to be in breach of the GMC’s Good Medical Practice (probity guidance) and therefore may be open to ‘fitness to practice’ procedures."

Monday, 20 October 2008

Unethical, scandalous and downright dangerous

It always amazed me just how poor the national press are at picking up on the rank mismanagement of the health service by the various organisations that are so good at getting most things so very wrong. It's no surprise that the NHS is so badly organised because the management structure is virtually incomprehensible to even those that work within it, consequently no one is in charge and no one takes responsibility for anything; the structure is also subject to incessant politically motivated tinkering, so that even when people have become accustomed to one dysfunctional structure, it is changed to yet another.

Primary Care Trusts (PCTs) are great examples of this rank waste and routine incompetence. They began as small and actually reasonably functional organisations that worked closely with local clinicians, however what they have matured into would make even Frankenstein's mother ashamed. They are now huge bureaucratic disasters, frequently there are more PCT managers than local GPs, and the job titles that are on offer at the local PCT would shock even the mighty Kafka. For example the Oxfordshire PCT started as six people, it has now proliferated into a monster that employs more than 2,500 people.

You would think that a body that employs so many people and that controls so much tax payer's money would employ a few highly trained experts in public health, so that they could efficiently go about spending their money in evidence based manner. You would be wrong, the PCT is made up of numerous people who have very little understanding of medicine and certainly no qualifications in public health. Have a look at some of the useful 'world class commissioning' posts on offer here.

Sadly PCTs do not work alongside hospitals and clinicians to try to improve health care for patients, they expand their own monstrous bureaucracies because they can, while the money that funds their expansion has to be cut from other budgets that fund essential local services such as hospitals. Hence as the PCT proliferates, more and more short sighted managers are employed to run schemes that are set up to deliberately starve good local health care services of cash. This vicious cycle continues, PCTs expand as local services are cut, that's the good old NHS for you, power to the uneducated and minimally trained PCT manager, and this is power without any accountability or responsibility.

A cracking example of the PCTs continued drive to stop paying hospitals for work that needs to be done is demonstrated by this scheme that actually pays GPs not to refer patients to hospitals, I kid you not. Unsurprisingly this scheme has been slated by local clinicians and patient groups, so what did the PCT have to say on this, something convincing? hardly:

"We have got significantly increasing rates of referral into secondary care providers. We're not sure why, so we're trying to understand why."

So referral rates are going up, so rather than trying to work out why this is happening, the ingenious PCT managers have decided to encourage GPs to refer less, they don't seem to care that the vast majority of these referrals are likely to be clinically necessary, they just want to reduce referrals and don't care if patients die in the process. I also understand that the PCT is so poorly run that they don't actually know what the correct referral figures are, a little birdie told me that the PCT's figures are laughably inaccurate. So not only is the PCT threatening patient safety by ignoring the clinical need of patients, but their dodgy decision making is based on the most dubious of figures that are being interpreted by people with no detailed understanding of clinical medicine. Lunatics taking over the asylum I hear you say, personally I think that's a little harsh on the lunatics.

Sunday, 12 October 2008

The dustbin of training

Whatever one chooses to prioritise can have massive knock on effects on other things, many of which are completely unforeseen. It's similar to engineering, when you change a certain property of something deliberately, it may alter other properties that you did not expect and it may have a quite catastrophic effect. The Titanic is a great example, supposedly unsinkable, however as we know it's design left it open to massive disaster.

The government's butchering of the health service to satisfy short termist political demands has had so many devastating knock on effects. Few politicians would have predicted the untold damage that the blanket Accident and Emergency 4 hour wait target would have had. AE is now no more than a glorified triage service thanks to the 4 hour target. The best way to improve AE care would have been to increase AE capacity so that a high quality service could have been developed to attract more talented doctors and nurses. Instead the 4 hour target has created a triage service that drives the best staff away and that has no incentive to sort out patients properly. The 4 hour target and the unnecessary excessively rapid movement of patients has also been a rather key driver in the rise in certain Hospital Acquired Infections (HAIs).

Likewise the current top down bullying from the DH to enforce the 18 week target. Superficially it seems like a sensible idea, however when one learns of the unforeseen side effects in does not seem too clever. A lot of patients simply do not need to be turned around in 18 weeks, they have minor problems that are causing them only minor symptoms, often a bit more time waiting is good for some conditions, it can result in a lot of them going away during the waiting period. The worst aspect of this target is that it is not clinically driven, for example the patient who is living in agony and needs a joint replacement quickly cannot be prioritised as well as they should be, as there are numerous other patients with much milder symptoms who have to be turned around within the 18 weeks. The 18 week target has also led to a culture of fiddling the statistics, as if there is no increase in capacity then no more work can be done anyway.

The long term sustainability of the health service has never been at the top of the government's agenda, they only care for the next election, much like our economy, it's no surprise that we meandering down sh*t creek without a paddle in this regard. Our economy has been run in an incredibly unsustainable short termist manner, we are now seeing the rather significant side effects of this stupid policy.

Training is a key if one hopes to sustain a high quality health service, no wonder the government has completely ignored training in recent years, all the policy has been directed at improving superficially gimmicky statistics to spin their network of dishonest propaganda. The current thrust at increasing output has seen trainees struggle to get the experience that they so desperately need to become the high quality doctors that they want to be. In surgery for example Trusts are under so much pressure to increase output that the training of tomorrow's surgeons is no priority at all, trying to get operative experience in this climate is not easy at all.

The government has also taken power away from the independent professional bodies, the Royal Colleges, and handed a lot of unaccountable power to useless organisations like PMETB and the GMC. Training posts are now ten a penny, the training content of jobs is not regulated properly, meaning that trainees are woefully inexperienced for their grade. Medicine is no longer the apprenticeship that it once was, the educationalists and politicos have far too much say in the training process, their emphasis on waffle and paper chasing have done nothing to improve training. Nursing training has also been subject to a same ridiculous politically correct forces, the loss of the apprenticeship has seen standards in training plummet.

The emphasis is also not changing. The short termist policies are the drivers, and training is still being left to rot. Darzi's review does nothing for training, the establishment of NHS MEE is just a token gesture, it is simply a powerless advisory body that will be made up of the same old government friendly cronies who have overseen the disasters of MMC and MTAS. Hospitals are invariably run by jumped up morons with clip boards who care nothing for the quality of care provided, they simply have certain top down government objectives to satisfy or else, and if the quality of care and good training get in the Trust's Stasi's way then they will trample over them. There are rumours this week that first year doctors are not being allowed to put in IV lines due to 'infection control' concerns, if there was an example of the lack of joined up thinking that our short termist politicos have forced upon us then this is it. The economy is crumbling, as is medical training, and this is because the politicians care only for today and never tomorrow.

Saturday, 4 October 2008

A system built by lunatics

I am possibly being a little kind in describing those that continue to tinker with the structure of the NHS as 'lunatics', there are other words that better fit their misguided actions. It is tricky to get across the sheer stupidity of the way the system is run to people who peer into the goldfish bowl from the outside. Although I reside within the bowl I shall try to describe it for someone who is looking in.

Lord Darzi's recent NHS review talked a lot about improving quality, and we know when the government talk a lot about something they invariably are about to do the exact opposite, just like the NHS constitution in fact. This NHS Review also talked a lot about reform being locally driven and patient centred, this was just as central government ordered Lord Darzi's portacabins to be erected in every PCT so that the old and vulnerable would have to walk that bit further to see their varying not so local doctor; in fact they may no longer be able to see a doctor, this government seems intent on empowering anyone to do jobs that used to be done by people with lots more training and medical degrees, quality, err, anyway that's another story.

In surgery the government pays hospitals for the operations that they perform, this initially sounds sensible, however when one probes beneath the surface it is far from sensible. This is because the tariff system was not thought through, they forgot about numerous surgical procedures, meaning that the most complicated and specialist surgical procedures frequently result in the same remuneration as the most simple and straightforward procedures. This is results in the big specialist surgical centres routinely losing money as they are taking on the most complicated, expensive and unrewarded work. These big centres of excellence dared to point out to the hair brained managers that the payment system was stupid, the managers just said that the specialist centres were inefficient.

Meanwhile ISTCs are paid for work they don't even carry out, and a lot of their work appears to be slightly shoddy to say the least. The tariff based system doesn't even work for the NHS alone, as centres that carry out lots of bad, quick and cheap operations will make lots of money, while centres that carry out lots of tricky specialist work well but expensively are being driven out of business. Take fractures of the neck of femur for one example, if one treats this with a bad and arguably negligent operation which is also cheap then one can make a lot of money, however if one carries out a good total hip replacement in some patients one will start to make a lot less money. The same goes for many other fractures, where fixing fractures badly with cheap materials is much more profitable than fixing fractures well with expensive devices.

I'm sure you get the point, the system is barmy, it has been created by morons who were obsessed with the gimmick of the market who understood nothing of the clinical practice of medicine. It results in market forces pushing standards of care lower against the best interests of patients. As I have been rather frantic at work recently I haven't had much time to read, but I always try to find time to read Dr Grumble, he has a wonderful knack of being able to succinctly sum up the daftness of the NHS we live and work in.

PCTs sum up the daftness, they used to be small organisations, they are now huge bureaucratic monsters which are run by people who have no understanding for what they throw money at. It is simply amazing that people with no medical training are allowed to spend thousands of our money on evidence-light health initiatives without a public health doctor in sight, it is as barmy as a country being run by ministers who are shuffled around so frequently that they barely have time to learn the name of their new department. The more they talk of quality, the more you should feel very very afraid.