Wednesday, 30 May 2012

Should doctors strike about their pension and expect the public to support them?

I am saddened by the news that the majority of doctors have voted in favour of the British Medical Association (BMA) ballot calling for strike action. Today, the chairman of the BMA announced that half of its 104,000 members took part in the ballot and a high proportion of GP’s, Consultants and junior doctors will be taking direct action for 24 hours on June 21st.

Are they unhappy with the NHS Reforms? Are they worried about patient safety? Do they fear for closures of hospitals? Are they concerned about budget or staff cuts, care in the community, public health inadequacies? Probably all of the above. But what are they striking about?

Their pensions.

I spend a significant amount of my working time with doctors and consider myself fortunate to work with such professional, caring and committed individuals (usually). So I am really surprised to read that doctors will, in effect, down tools for the first time in 40 years.

There are quite a few ticking time bombs affecting the health sector at the moment. Obesity, Diabetes, lifestyle generated diseases, chronic conditions…. and pensions. Anyone with an iota of financial acumen and a sense of reality knows that the private sector recognised the pension black hole years ago and started reining in the employers’ exposure. Final salaries pensions are unsustainable without increased contribution form the employee. Average salary pensions are a realistic alternative. Of course no-one wants to see their nest egg depleted through no fault of their own but it’s a tough world out there right now. No-one would dispute that the medical profession is awash with worthy, hard working individuals who care deeply for their patients. But I believe that this call for industrial action is damaging and probably futile.

A BMA statement explains how the strike will be implemented as follows:

‘Non-urgent work will be postponed and, although this will be disruptive to the NHS, doctors will ensure patient safety is protected. All urgent and emergency care will be provided and we will work closely with managers so that anyone whose care is going to be affected can be given as much notice as possible. Patients do not need to do anything now.

“We will also run our own publicity campaign to make sure that members of the public understand what the action will involve and how they can find out what it might mean for them and their families’

What this will 'mean for them and their families' on June 21st is that although clinical staff will be on-site, most operating theatres will be idle. Outpatient clinics will fall silent, minor procedures suites empty and GP surgeries may be open, but not for their daily business. Patients will be inconvenienced and some may well suffer as a result of delayed consultations, tests or surgery. The resulting backlog will not just affect patients – just imagine the hassle for support staff in hospitals and surgeries dealing with this backlog.

The public purse is being squeezed till it bleeds tears of pain and desperation. Money needs to be allocated with wisdom, compassion and fairness. Taking a day out of the packed theatre lists, clinic sessions and GP appointments will result in a shameful waste of a precious resource.
The BMA assures us that patient safety won’t be compromised and I have no reason to doubt this. But one thing that will be compromised is the public perception of a profession that they have long held, with good reason, in very high esteem.

The elderly lady with a crumbling hip surviving on a state pension may not be as sympathetic to the BMA members as they might hope.

Friday, 25 May 2012

Surgery slippage - an unwelcome addition to the NHS vocabulary

Whenever I am wearing my project manager hat, one of the major risks I need to identify, avoid and/or fix is ‘project slippage’. The term sounds quite benign but is in fact a posh way of describing missed deadlines, unforeseen problems or even catastrophic events seriously derailing original plans.

I fear that ‘surgery slippage’ may be a phrase that creeps into the NHS psyche as cuts and reform implementation starts to bite. Rationing is a dirty word within healthcare although every sane commentator would have to admit that we don’t live in a perfect world of unlimited funds and treatments must be offered within that context. Health inequality is an even dirtier word as some PCTs (primary care trusts) or CGGs (clinical commissioning groups) take an inconsistent approach to eligibility and funding for certain conditions. I suspect that surgery slippage may become an insidious way of rationing and creating inequality across regions.

Andrew Lansley, UK Secretary of State for Health has said he doesn’t like targets but quotes outcomes instead. He doesn’t want to measure waiting lists but brandishes figures such as ‘reduced hospital admissions’ as though they were a band of honour. We need to look behind any statistics to emerge from the new regimes borne of the Health and Social Care Bill. Comparing apples with pears is never a good thing. Cancelled or delayed operations for those on a waiting list are distressing for the patient and bad PR for the NHS. This is where targets and statistical reporting can be useful in focussing the mind of Trusts to ensure that patients are not kept on waiting lists too long. But with limited funds and a shift of power to CGGs my concern is not just for the lengthening of waiting lists, but the moving of goalposts when it comes to eligibility for surgery.

In the same way that we delay paying the gas bill or get our car serviced a couple of months overdue to keep our cash flow under control at home, it would appear that some NHS Trusts, PCTs and CGGs are changing eligibility for surgery to delay the point at which a patient joins a waiting list.
The Royal National Institute of Blind People has recently reported on data showing that over half of the 152 NHS trusts in England had imposed their own criteria which were tougher than national standards for cataract operations. This means that patients are waiting longer for sight saving and life enhancing surgery, saving money for the trust but diminishing vision and quality of life for their patients along the way.

It’s not just hospitals making these tough decisions. I was speaking to an orthopaedic surgeon this week who told me that he was about to attend a commissioning meeting with is local CGG. That’s great – I thought – perhaps the NHS future forum really did work and GPs are involving other clinicians in key commissioning decisions. Yes, the orthopod agreed that it was good for him to be invited to this meeting. However one of his challenges is that, presumably to balance their books, the local CGG has changed the criteria for hip replacements, so patient’s joints have to demonstrate a more pronounced deterioration before they are deemed eligible for surgery (and therefore delaying their addition to a waiting list). This surgeon told me that he suspects that a year or so down the line – he will start to see patients with more severely damaged hips which will of course make the surgery more difficult and means that the patient has endured the pain of a crumbling joint for longer. Who is best to decide whether surgery is necessary? Surely that has to be the surgeon.

So there you have it – surgery slippage. An effective cost containment initiative, but hard to quantify or prove and with the potential to be significantly detrimental for the very people these reforms are supposed to help – patients.

Saturday, 19 May 2012

Statins – mass prescribing for the healthy may create a different kind of problem.

Healthcare is, like most things in life, all about balance. As each new ‘magic bullet’ - a new medication, procedure or technological miracle is discovered, the balance of one disease or condition may be slightly tipped in its favour, but this is often to the detriment of some other ailment.

I’m not talking about allocation of funds, I’m talking about how solving one problem can either create or expose another. It’s a bit like building a ring road round a major city. In theory, business and leisure travel either side of the conurbation will become easier. But what usually happens? You simply move the traffic jams to another point in the transport system. Just ask anyone who has travelled on the M25, hailed as the end to London’s potential gridlock but now known as the biggest car park in the UK as the motorway struggles to cope with the high volume of traffic it has created simply by existing.

The biggest killer for some age groups in the UK is heart disease closely followed by cancer. Add chronic conditions such as dementia, diabetes and all obesity related conditions and a turgid melting pot of health nightmares bubbles away fuelled by bad lifestyle choices and social inequalities. It is expected that there will be 1 million dementia sufferers within the next decade and there are currently 3.8 million people suffering from diabetes – expected to double in the next 20 years.

Sadly or happily – whichever way you look at it – state funded health care is a victim of its own success. The reason dementia has become such a problem is because we are actually pretty good at keeping people alive for longer. And now there is talk of prescribing statins to everyone in the UK over 50, whether they are obese, sedentary, super fit or just plain average. Following a study by Oxford University, it is estimated that mass prescribing of these ‘cholesterol busting’ drugs will avoid 11 heart attacks per 1000 individuals. Tempting as this may seem, giving drugs with a worrying range of potentially unpleasant or dangerous side effects to healthy individuals feels like a bridge too far, especially if this lets us off the hook for increasing exercise and adopting a healthy diet. In the ‘good old days’ – if your cholesterol was a bit high – you were advised to eat better and move more. Often this was sufficient to reduce the cardiovascular risk.

Yes, of course statins are life savers especially for those with familial hypercholesterolemia, genetically inherited and potential life threatening high level of ‘bad’ cholesterol. But should we be tempted to, as Janice Turner in The Times newspaper so beautifully put it – ‘pop a pill if you’re not ill’.? If the subliminal message is that it’s OK to get fat and don’t  exercise,  but take statins to counteract the damage that high cholesterol will cause, then there may be a new generation of obese patients, living longer but prey to other obesity-related conditions.

As cardiovascular disease falls, cancer incidence may rise.

Saturday, 12 May 2012

NHS – the movie. Romcom or horror story?

The NHS movie rolls on, an on-going  franchise to outshine Harry Potter and nearly as long running as arguably the greatest film of all time, Citizen Cane. But is the NHS genre a romcom, family adventure, farce or horror? A bit of all of course as just a few hours feedback confirmed yesterday.

The day stated well – an 8am meeting in the operating theatre suite of a North West London hospital with a dashing surgeon. (yes – romcom would have done very nicely thank you…) We were discussing a project that should benefit patients, staff and the Trust and the consultant kindly spared an hour of his time before starting a full operating list. Just for the record, over the past few years in my role as a project manager, 99.9% of consultants I have met have been courteous, charming and constructive. They have given their time and shared their knowledge freely, often in their own time at the end or beginning of a long day.

Several other meetings later, I could confirm that many of the doctors, nurses, medical secretaries, IT and finance teams were all upbeat, busy but positive in their efforts to balance budget and care. I then visited to the stroke unit to find a community coffee morning going on to celebrate the unit achieving a high level of accreditation (a set of standards required to earn a higher level of tariff for the hospital – note to Andrew Lansley – targets can work). Stroke physicians, specialist nurses and therapists were welcoming patients who had previously been treated at the unit. There was a jolly atmosphere as medical teams were reunited with those whom they had cared for.

I realise this all sounds a little too good to be true and I have no doubt that the staff at this hospital continue to face the challenge of staff shortages, budget cuts and lumbering bureaucracy that is the daily grind of the NHS. However you could also be forgiven for assuming that this particular hospital is still functioning effectively with a viable future.

But then I got home and took two phone calls. One was from a friend whose 86 year old grandmother had broken her hip a couple of days before.  Suffering from early stage Alzheimer’s and osteoporosis, this poor frail lady epitomises the financial nightmare facing socially funded care but nevertheless she should expect exemplary care. Just a few hours after admission and confused at her surroundings, the poor old soul fell out of bed and broke her arm. It is highly likely the reason this happened was that someone forgot, or didn’t bother, to put the side guards up on her bed leading to increased suffering and further mobility challenge for the lady when she finally gets home.

Another friend, a counsellor, called to tell me of a case of a very sad young man who had just lost his mother. The tale he had to tell about the shameful standard of his mother’s care was shocking. Deeply disturbed, this tragic woman had attempted suicide on numerous occasions and had been let down again and again by her local mental health services. After taking yet another overdose and after a couple of nights in hospital, she was discharged without her family being advised. Clutching a ‘bag full of pills’ (probably her ‘take home’ drugs), she was taken to a bus stop to help her catch the bus home. Bless her – of course she didn’t go home and of course she took the pills but again survived. For some reason, she wasn’t sectioned (compulsory or voluntary residential mental care order) and continued to live with inadequate community mental health support until she finally succeeded in her tragic quest and killed herself.

You cannot help but wonder if these two tales of woe would have been different if those unfortunate patients had been treated in the hospital I described at the start of this post.

And this is the dichotomy of the NHS movie, feel-good plot lines, uplifting stories and exhilarating adventure tempered with farce, horror stories and tragedy.

The scandal of the NHS isn’t just about inappropriate funding – it’s about inefficient use of resources, and worst of all – inconsistency and inequality in standards of care.

Wednesday, 2 May 2012

Prescriptions and patient safety – it’s all about teamwork

Another shock horror medical story has been widely covered in the UK press today. ‘GPs making too many errors when prescribing drugs in patients, the official regulator says’  Another headline is enough to make any patient choke on their tablets, ‘lethal errors in 2 million prescriptions’

A BBC presenter on a radio phone-in programme dubbed pharmacists as ‘heroic’ in picking up and correcting the majority of prescribing errors.

As they say in all the best courtroom dramas – ‘let us look at the facts m’lud’

Yes – the study, by the General medical Council, based on 1200 patients confirmed that there are a significant number of errors in prescriptions written by GPs. To be precise, the figure quoted was 1 in 20 prescription items showed an error. Many patients are prescribed multiple medications, so this translated to an error for 1 in 6 patients and naturally this is more likely to affect the elderly who tend to take a variety of regular medications.

Only 1 in 550 of these prescription errors had lethal potential. Yes, this is still a frightening statistic but if you consider that the majority of the 900 million (yes, 900 million in England alone) prescriptions are checked and dispensed by pharmacists, the number of dangerous errors slipping through the professional net will be relatively small.

And as for heroic? It’s a pharmacist’s job to spot mistakes on prescriptions. These errors can include over or under dosage, drug interactions, inadequate monitoring, unsuitable treatment and lack of clarity on usage. Regular readers will know that I qualified as a pharmacist in another lifetime and practiced in hospital, community and industry. It was an acceptable part of my role that I discussed prescription anomalies with the prescriber and was never really a big deal.  Pharmacy training is complex, comprehensive and lengthy. A year’s post graduate tutelage follows a four year degree with on-going registration and education. For GP’s (and hospital doctors) on the other hand, prescribing is a small, but key part of the consultation/treatment process

That is why pharmacists are such an essential link in the treatment pathway. Not to trip doctors up but to identify and rectify prescribing weaknesses, and to support fellow clinicians in ensuring that treatment for every patient is as appropriate and safe as possible.

I welcome the GMC’s initiative with this survey and agree with their statement that ‘it’s important that we do everything we can to avoid all errors’. In my opinion, reducing the number of ‘dispensing doctors’ and ensuring that the pharmacist continues to act as a permanent safety net has got to be the best way to do this.

Andrew Lansley (remember him? Secretary of State for Health) said that the government would be working with GPs to improve practices, continuing ‘the vast majority of prescriptions are checked by community pharmacists who spot and put right any errors..’

As the NHS reform implementation continues and GPs become embroiled in budgetary control and potentially become distracted with commissioning, I suggest that pharmacists stay on high alert as this error rate could increase.