The best laid plans....

As Robbie Burns said over a century ago, ‘the best laid schemes o’ mice and men gang aft agley’. For the non-Celtic among my readers – the best paid plans often go awry. And so it is with the Health and Social Care Bill.

Andrew Lansley, UK Secretary of State for Health has created his NHS reform plans on the basis that the lion share of the annual state funded health budget should be handed to GPs. They would create Commissioning consortia, responsible for treatment pathways, resource allocation and direction of care. I won’t bore you all again with the extensive list of organisations, professional bodies and medical commentators who warned that this was an untenable and badly thought out premise. Despite the NHS Future Forum exercise and some re-working of the Bill, anxieties are still manifold and practical difficulties continue to emerge.

An article in today’s UK Daily Telegraph regarding GP numbers provides a stark reminder that plans for change, any change, should be formulated with reference to their specific context. It is generally accepted that the ideal size of patient list per GP is between 2000 and 3000, but the article estimates that over 1 million patients are registered with a GP who is responsible for over 3000 patients. And this burden is before additional commissioning duties are accepted.

The article goes on to report that GP numbers are falling, with 7% less trainees this year and quotes the British Medical Journal survey which estimates that 1 in 8 GPs are expected to retire within the next 2 years. There are various reasons given for this loss of resource, including the influx of Asian doctors in the 1960’s and 70’s now due for retirement and the growing number of female GPs working part time due to family commitments. But I suspect there is also a significant number of doctors taking early retirement because they ‘simply can’t be doing with’  the reforms and the additional burden the Bill places on them. I personally know three such GPs, all excellent practitioners who will be hanging up their stethoscopes at least five years early for this very reason.

Lansley should have taken all the above factors into consideration before trying to reshape the NHS. However good his plans are in theory – if there aren’t enough GPs then we will face extreme difficulties with access to care in the not too distant future. Lansley is right that primary care is a crucial starting point (after public health of course) in the health and wellbeing of the nation. Many of you who were unfortunate enough to be unwell over the Christmas period will have experienced the delight of trying to access primary care out of hours. It is the basics, the resources available, the quality of personal and clinical care provided, and most of all access to care which should be addressed.

In the meantime anxieties about reform and the much beloved NHS continue to build – again beautifully summarised by the Scottish bard…

‘Our sulky, sullen dame, gathering her brows like gathering storm, nursing her wrath to keep it warm’

The NHS – with a little help from Charles Dickens

‘I am the ghost of the NHS present’ said the Spirit ‘Look at me’

And Scrooge looked at the NHS and he saw:

• Hospitals struggling to achieve foundation status
• Disenfranchised staff, bickering between disciplines and striking about their pensions
• General practitioners split between those embracing the challenge of commissioning and their new powers and those who don’t want the extra hassle and responsibility as the Royal College of Practitioners consider balloting their members on another motion to scrap the reforms
• Divisions between primary and secondary care, with community care coming a very poor third.
• Scandals such as the elderly left literally starving on hospital wards, waiting list manipulation, crumbling facilities, unsustainable patient pathways and care staff not fit for purpose.
• A Secretary of State rightly intent on reform  but wrongly focussing on top down restructure instead of the basics of strong clinical practice, service improvement, measurable targets (yep – the T word) and recognition that every qualified individual along the care pathway has value.
• A population taking little responsibility for their wellbeing, with  poor diet, poor lifestyle choices and an expectation of freely available care and choice of treatment.
• Incredible achievements in medical innovation, ground-breaking treatment capabilities and examples of exemplary care and dedication among many staff.
• A core of committed, concerned and talented clinical and support staff and a general population who value the NHS but do little to support it.

‘I am the ghost of the NHS past’

‘Long past?’

‘Your past’

And Scrooge saw an interesting vision:

• A new healthcare system available to all, created in 1948 based on the following principles:
• That it meets the needs of everyone
• That it be free at the point of delivery
• That it be based on clinical need, not ability to pay
• Two decades later in 1968 he saw Christmas Day in a ‘Nightingale ward’ in hospital (these are the wards familiar to all of us over 40 – twenty or more beds in one long room with the nurse ‘station’ in the  middle.) The patients had all been washed, with clean gowns or pyjamas, their bedding changed, the ward was spotless, truly spotless and the nurses bustle around the ward in crisp starched white aprons and black stockings.. The nurses bustled trough their busy day, responsible for every aspect of care, the cleanliness of the ward, patient, and themselves.  Antibiotics were still very effective in reasonably low doses and infection control was simpler. Matron was a force to be reckoned with. On Christmas day – the senior consultant would come in to carve the turkey on the ward and help hand out dinner to his patients– ‘Health and Safety’ didn’t get in the way of tradition.
• But Scrooge also saw that the survival rates for major diseases were poor in those days- cancer was synonymous with ‘death sentence’ – average lifespan of the UK population significantly lower. Deceased donor transplantation of kidneys had only been possible for four years and the first heart transplant had only taken place the previous year. Leukaemia survival rates were poor – nowhere near the 80% success rate in children achieved now.
• Diet was healthier and alcohol consumption lower than it is now
• Then the Ghost of NHS past  fast forwarded to the 80’s and 90’s – a melee of targets of variable validity, over-management and waste balanced with incredible medical advancement and innovation
• Then he glimpsed the noughties – huge advancements in cardiac, stroke and cancer treatment and survival rates , but slips in general quality of care and resource management.

And then Scrooge saw Ghost of the NHS Future. He exclaimed, "I fear you more than any spectre I have seen. But as I know your purpose is to do me good, and as I hope to live to be another man from what I was, I am prepared to bear you company, and do it with a thankful heart. Will you not speak to me?"

And the ghost of NHS present did speak to scrooge, through the NHS future forum. But the vision of the future was unclear – clouded with uncertainty, financial complexity, confusion, disillusionment and disappointment. So Scrooge asked the Ghost of the NHS future to create a prefect vision and it was like this:

• NHS staff working as a team, while taking individual ownership and responsibility for the very best care of their patients
• All staff demonstrating a strong command of the English language and appropriate communication skills.
• The elderly and vulnerable treated with special consideration.
• Mutual respect among professionals at every stage of the patient pathway (how many time have I pleaded for that this year?)
• Realistic expectation among the public and understanding that although the NHS is still a ‘national treasure’ and a ‘sacred cow’ – this amazing resource is provided at great cost, more of which should be borne by those who can afford it (through taxes or personal contribution)
• Close and constructive working relationship between the public and private sector.
• Individuals taking personal responsibility for keeping fit and healthy – resulting in tumbling incidence of diseases related to unhealthy lifestyle
• Government, clinical teams, administration staff and the voluntary sector working in harmony….

Oh dear – I seem to have slipped from a Christmas Carol to another classic novel. Paradise lost…

Happy Christmas everyone!

OTC medicine – when convenience can be deadly.

There was a very sad item in the UK news yesterday, telling of a 20 year old mother who died of liver failure after taking too many tablets of paracetamol, a widely used over the counter (OTC) medicine.

This was not an intentional overdose - indeed, the victim didn’t at any stage take one large dose of the drug. Instead she suffered a ‘staggered overdose’ by taking as her father stated ‘a few extra tablets’ over the course of a few days to alleviate some post-operative pain.

This is a stark reminder of the danger of ignoring the warnings on easily available medicines. Just a few extra tablets were the difference between life and death for this young woman. Although a cheap and intrinsically safe analgesic when taken within the recommended daily dose, paracetamol can be highly hepatotoxic after overdose causing liver damage, failure and ultimately death. Aspirin can also be highly toxic when taken inappropriately, leading to potentially fatal stomach bleeds.

When I first started practising pharmacy, more years ago than I care to admit, very few OTC drugs could be purchased outside pharmacies. I actually think this was a good thing. In the same way that cheap booze available round the clock from supermarkets has potentially increased alcohol abuse, over-use of painkillers and cold remedies can lead to problems.
 
In 1998 legislation was introduced to reduce the pack size of analgesics such as Paracetamol and Aspirin sold over the counter in the UK. You can now only buy packs of up to 32 tablets in pharmacies and 16 in retail outlets. Within the first year this had a dramatic effect in reducing mortality of Paractemamol overdoses by 20%. Liver unit admissions and transplants were reduced by 30% and non-fatal overdoses by 29% in the four years following the legislation. The effect on reducing large overdoses with aspirin was also significant with a reduction of 34%.

This proves that restricting availability of potentially lethal substances has a positive effect but presents the health legislators with a dilemma. We all like to convenience of nipping to the local shop/garage/supermarket to pick up cold remedies and painkillers and an estimated 30 million paracetamol tablets are consumed annually in the UK. But does that familiarity cause contempt? If a medication is only available either from a pharmacy or under the supervision of the pharmacist, then even if the purchaser doesn’t read the label properly they understand that there is a potential hazard lurking within the blister pack or bottle.

The general public need to be aware of these dangers, but we have to be careful not to give the vulnerable a recipe for suicide by clarifying the toxic effects of some readily available substances. However the majority of OTC related non-fatal overdoses are unintentional and the long term effects can be life-limiting and devastating.

Education may play a key role in improving patient compliance with all types of medication and maybe school is a good place to start to teach the importance of respecting the directions on packs of OTC medicine. Emphasising the safety message to all potential consumers should be the shared responsibility of the pharmaceutical industry, retailers and public health organisations.

Volunteers – please handle with care and proceed with caution.

There is an article in the Times Health News today, focussing on London Hospitals’  ‘fight for survival’. The piece starts with an endearing description of an elderly couple who work as volunteers at their local hospital. Apparently the 83 year old drives the buggy that carries patients around the facility while his 75 year old wife spends hours providing companionship to cancer patients.

The point (I think) of this piece is to stress that hospitals rely heavily on such volunteers. While this example of Cameron’s ‘Big Society’ is heart warming, I suspect that a slightly less Utopian scenario is nearer the truth.

Volunteers in hospitals can be an absolute nightmare. There – I’ve said it. Call me heartless but I suspect that at least half of these well-meaning souls are more trouble than they are worth. A health and safety hazard, often a law unto themselves and a potential hotbed of germs and inappropriate behaviour, they can wreak havock on an already stretched ward staff.

When I was an inpatient this summer, the kindly gentleman volunteer who brought round the water jugs looked so unhealthy and frankly, unclean, that I couldn’t bring myself to drink the water he left by my bed. On the other hand, the ladies, also volunteers, who swept into the ward and quickly made the beds were fantastic. They whizzed in with a bright smile and a no-nonsense approach and saved the permanent staff considerable time through their unpaid efficiency. These ladies were late middle age, fit and healthy and knew what they were doing.

And this should be the rule for all hospital based volunteers – properly trained and fit for purpose.

Bless the Womens Royal Volunteer Service tea ladies who man the canteens, but don’t try to get a cup of tea and a scone from their counter unless you have considerable time to spare. I swear that one of the ladies on duty in an Oxford Hospital recently must have been at least 90, was very frail and looked positively dangerous with a cup of boiling liquid.

While I accept that volunteers can provide real confort and companionship to lonely patients, (who should be identified by the ward staff), they can also be downright intrusive and annoying. Visiting a close relative in a palliative care unit one Christmas, the volunteers insisted on giving me and my daughter Christmas lunch despite our firm protestations that this was not required. The situation became even more ludicrous as lunch was delivered to us at the bedside, along with crackers! Did they really think that at a time of excruciating personal agony we would be wearing silly hats and reading jokes? It was like a scene from the darkest of comedies.

I am happy to see volunteers of all ages, working in our hospitals, as long as they are appropriately trained and carefully managed. But they cannot be a substitute for qualified and regulated staff.

Alas, I have many irritating volunteer tales and will finish with one that luckily caused my late husband great amusement at the time. As he was recovering in hospital following major surgery, a volunteer plonked herself by his bed and said ‘Are you awake deary – like a chat?’  Having been rudely disturbed from what had been (in his words) a lovely snooze – Bob wasn’t really in the mood for conversation but always good mannered, he humoured her. ‘What are you in for then?’ (like he was in prison?) she asked. ‘I’ve had a cancerous kidney removed’. The woman physically stepped back, shocked that this patient was clearly seriously ill. But fair play, she recovered quickly and smiled.. ‘Oh well – it’s amazing what you can live without these days..’

Lansley’s 60 step plan – the route to measurement overload

I fear that Andrew Lansley is, yet again, complicating things.

Like a plumber resorting to stuffing his own overalls into the leak to stop the increasingly violent flow of water, the Secretary of State for Health has come up with yet another strategy for improving the NHS. To endorse this new initiative, Lansley has made an extravagant claim in the Daily Telegraph yesterday, when he stated that he believed this could save 24,000 lives. He went on to say that his time as minister would be a ‘failure’ if 60 new outcome targets do not improve standards.

Interesting – so the T word (targets) has crept back into the agenda. This may not be a U turn but it is yet another path to be explored, accompanied by increasingly desperate narrative.

Lansley, quite rightly, has suggested that the bickering over the reforms has to stop and people should be concentrating on improving patient care. Yep – can’t argue with that! He continued with ‘We’ve really got to get into the big picture, which is delivering improvements in the results we achieve for patients right across the board – we know we can do it’. Alas, that statement had the scarcity of substance so common with answers we have grown used to from politicians these days, especially when it comes to health.

I fear for the practicality of these 60 benchmarks, which will include clinical data, mortality rates and patient surveys. You can almost hear the collective sigh from every poor soul in NHS hospitals who will be responsible for collecting this information. Surgeon’s success rates will also be under scrutiny. I hope, but very much doubt, that all this information will be taken in context. One patient’s favourite surgeon could be another’s nightmare. Survival rates are not just dependent on care as there are so many other pertinent factors.

With each new element of reform, comes the reassurance that this is the initiative which will deliver. We are now told that the 60 step plan of target standards is the magic bullet. I wonder what will come next?

The 60 goals are laudable, covering premature death, quality of life, recovery after ill health, the patient experience and treating people safely, but measurement and analysis will be complex, time-consuming and expensive. Even bereaved relatives will be surveyed – an emotional minefield to be crossed only by the most highly trained and empathetic.

Oh how I wish for those good old days when targets were based on proactive objectives not reactive surveys. As the ancient proverb states – ‘no one grows just because they are measured often’. I remember with fondness as we whinged about performance targets, based on best practice, measured with relative simplicity and rewarded by tariff.

Happy days – even if we didn’t realise it at the time.

NHS medical data – a ‘wealth’ of information in every sense.

This summer I was urgently admitted to hospital for high dose intravenous antibiotics to stop an ear infection that was fast tracking through my inner ear towards my brain. A close friend of mine is soon due to start chemotherapy to treat colon cancer. We all have similar tales to tell of loved ones saved by drugs.

These drugs have been produced by pharmaceutical manufacturers. They have been tested, manufactured, gone through quality assurance, packaging, monitoring, marketing and everything else associated with a new product for human consumption. An expensive business. The research needed to initiate or validate any healthcare innovation is as costly as it is vital. Equally vital are retrospective studies of data covering demographic, lifestyle, hereditary and aetiological factors associated with disease and treatment.  

The NHS is absolutely unique in holding generations of patient data - a potential academic and financial goldmine.

Extracting data from within the NHS is a political, logistical and, at times, emotional nightmare. I can vouch for this first hand. Working on stroke improvement projects for NHS London last year, patient flow information, survival rates and treatment records were crucial in establishing whether the new treatment pathway was benefitting patients. My project team (all employed by or contracted to the NHS) did everything humanly possible to facilitate the collection of anonymised, accurate and relevant patient data. The protection of patient identity was an absolute doddle compared to the delicate task of persuading busy clinicians and technicians to input treatment details and admission statistics. There was, at least in this case, a compelling incentive to complete this data collection as the only way a hospital trust could receive the elevated tariff associated with high standards of  care was to record the attainment of these standards. Even with the net gain of additional income for a unit, data collection represents a constant burden on staff.

I applaud David Cameron’s suggestion that medical data should be sold to research, life science and pharmaceutical organisations. I don’t have concerns about patient confidentiality as any private (or public for that matter) research organisation has protection of patient identity ingrained in every single data analysis policy and clinical trial protocol.

I don’t agree with the spokesperson from Patient Concern who says the ‘methods stink’ suggesting that patient records should ‘not be passed around by the Department of Health or sold to private companies without our permission’. This statement suggests that the fundamental aim of using medical data is misunderstood.

I am heartened by the good sense of Neil Patel from the Royal Pharmaceutical Society who stated ‘we need people to understand that the benefits for all of us – our children and people who have illnesses – are absolutely essential when it comes to using health records for research’ (sensible people – pharmacists)

Apart from the medical benefits of research, the pharmaceutical and life science industries are significant wealth contributors to the UK, employing an estimated 250,00 people and exporting in excess of £20 billion annually.

I hope that the NHS can find a way to enable the use of anonymous clinical data to earn additional income and drive forward medical research. But in order for this to work, may I suggest that whoever ‘does the deal’ includes the sponsorship, payment, or facilitation of additional manpower, funded privately, to collect and encrypt the data. Then patient care will not be compromised, staff will not be additionally stretched and the right data can reach the right people in the right format at the right price.

This time Jeremy Clarkson has gone too far.

So it’s the morning after the strike before. UK newspapers are full of reports about the public sector strike, plenty of opinion and some interesting facts too. Such as – 2 million workers joined the strike; 60,000 NHS operations were cancelled; security at Heathrow ran smoothly. Over 70% of schools were shut as shopping centres saw a welcomed hike in sales for the day.  There was clearly much sympathy for the strikers although surveys produced wildly varying degrees of the level of support estimated.

But one story has grabbed the headlines today. Jeremy Clarkson went to extremes in registering his views on the industrial action on the BBC yesterday evening. For my overseas readers, Clarkson is the front man for an ‘amusing’ TV show focussing on motoring. He is famous for his outspoken and irreverent approach to life and has been described as a ’50-something petrol head’. I used to find his programme fresh and funny, but like so many successful franchises, he and his team have become a caricature of an overplayed genre. He is bombastic and insensitive and I could describe him as slightly to the right of Attila the Hun. I suspect he’s actually quite a pleasant person with little mal-intent but he certainly hid those virtues successfully last night.

During a prime time interview on the BBC ‘The One Show’, Clarkson shared his opinion on the strike saying ‘I would have them all shot’. Sadly, like a little boy who causes amusement when he does something naughty, Clarkson was encouraged to extend his tirade by the studio audience’s nervous laughter to continue ‘I would take them outside and execute them in front of their families’.

Jeremy – that was the point when you went too far.

The interviewers went pale and shifted uncomfortably on their sofa and the BBC hastily issued an apology, but the damage was done.

I believe that Clarkson should be sacked from the BBC, especially as during the same programme he confirmed his own special brand of bigotry by complaining about train delays ‘….because somebody has jumped in front of it and somebody has burst….why have we stopped? What’s the point in stopping? It won’t make them better’. No-one should get away with such offensive and upsetting remarks.

Unison, one of the unions leading the strike, is considering legal action following Clarkson’s outburst. As the post mortem on the effectiveness of yesterday’s walk-out continues, this row is taking centre stage and it’s ironic that Clarkson’s extreme comments have probably galvanised even more support for public sector workers.

 If you are lucky enough to have a pension, Jeremy, I think it’s time you started drawing it.

Post script: (added 2^nd December) I’ve had some interesting response to this blog, including a tweet telling me that I’m past my best too! Nice. As the discussions continue I note that many people think that Unison is over-reacting to Clarkson’s comments and that the British public is suffering from a sense of humour failure and should ‘get over it’. Interesting that the BBC has re-run the entire section of the Clarkson interview relating to the strike including his comment that he thought the strike was ‘great – especially as London is quiet and the restaurants weren’t busy’. Strange how they omitted to show the section where he was particularly offensive about suicide victims.

I loved a tweet suggesting that as Jeremy Clarkson and his co-presenter James May headed for China yesterday at the same time that two giant pandas are being transferred in the opposite direction – this was a good swap! But the most poignant and relevant view came from a close friend of mine who was advised that the appointment for his wife’s first chemotherapy treatment would not come through on Wednesday as originally planned due to the striking NHS booking clerks. He emailed me ‘On my way to work I drove past the hospital with pickets outside and for a brief moment was very tempted to plough into them. But Clarkson was still wrong to say what he did – he went too far and even though he obviously didn’t mean what he said, you couldn’t help but feel there was an element of his true feelings coming through’

Enough already – we need to get back to the real issue in hand. How do we build an affordable and efficient NHS with the public and private sector working in harmony?

Guide dogs for the blind and my shameful past

I have struggled to find a topic for discussion today. I didn’t want to write about the public sector strike – it’s just too depressing. Insults are being traded, distorted facts and biased opinions spouted by both sides, and even Prime Ministers question time in parliament today was described as ‘silly comments flying about, lots of noise, just childish’  by Tory MP Andrew Percy on Twitter.

So instead I shall write about one of my favourite charities, Guide Dogs for the Blind. A story featured in the Sunday Times recently warned that this 80 year old Charity may be forced to stop offering dogs to the newly blind because of a £15.6m deficit. This would be a tragedy and I truly hope that fundraising campaigns will reap sufficient rewards to save this amazing organisation, which enables thousands of blind and partially sighted individuals to lead independent lives.

The reason I list this charity among my beneficiaries is because of a very embarrassing incident that occurred a few years ago. I was waiting at a traffic light controlled crossing, and noticed a lady with a guide dog standing next to me, also waiting to cross. Being one who is quick to interfere, often when not needed, but always with good intentions, I decided to ‘help’. When the little man turned green, alerting us to the fact that it was safe to cross, I took it upon myself to grab the harness of the dog and lead him and his owner safely to the other side. Except I didn’t. I ended up half way across the road, with a confused looking dog - without his owner who was left stranded, looking bemused, at the side of the road. I panicked and really didn’t know what to do next especially as the little man started flashing warning me that it would no longer be safe to cross very soon. I somehow ended up on the pavement, plus dog, minus owner, on the other side of the road. Acutely embarrassed, especially as several of my work colleagues witnessed the whole incident, I had to wait, red-faced until it was safe for me and my four legged companion to return to the original side of the road and back to his owner.

The woman was now clearly angry and as I blurted out my apologies I realised she was looking straight at me. ‘You stupid woman’ she shrieked ‘I’m not blind, I’m a trainer and your actions have probably set the progress of this dog back by weeks!’

At this point, my colleagues were in paroxysms of laughter and mirth at my total humiliation and the ludicracy of the situation! Needless to say, I went straight back to my office and made a donation to this worthy cause.

Moral of this story? Not all dumb animals have four legs..

Please give generously. www.guidedogs.org

Please don’t strike….

I had hoped to dodge this particular bullet, but alas it just won’t go away. I’m talking about the upcoming public sector strike on Wednesday. As a commentator about all things health and especially the NHS – I can bury my head in the sand  no longer and have to face my fears and put in print how I really feel.

I am really, really sad that health workers and other public sector employees plan to strike. While I absolutely support the right of anyone in this country to withdraw their labour if they feel strongly about an issue, I am at a loss to see how this action is going to help anyone – least of all the public sector community.

I am not going to go into the rights and wrongs of the government’s recent pensions offer and neither will I pontificate at length about what it’s like to work in the private sector compared with state funded employment as both arenas are fraught with challenges. Instead I shall just make a few points for consideration by anyone involved with healthcare who is contemplating strike action.

·        Please consider the devastating effect on individual patients if an estimated 28,000 non urgent operations, 38,000 non-emergency ambulance journeys and 200,000 outpatient appointments are cancelled.

·        Please understand that working in the public sector no longer means a job for life, and neither should it.

·        Please note that private sector pay is, on average, lower and pensions in the private sector are, apart from the most senior of managers, nowhere near as generous as in the public sector.

·        Please understand that the country currently faces a significant deficit, which, however it was created, must be addressed.

·        Please remember that the general public really do appreciate all the work you do although they may not have a clear understanding of the pressures you face in your day to day roles.

·        Please consider that every time you take extreme action, the support from the public could be eroded. There are 2.5 million people in this country living without jobs, on the breadline and without the benefits of employment open to you who would welcome the opportunity to have the relative security of your positions.

·        Please consider the fact that there seems to be a growing emotional divide between public and private sector workers, which is a real shame as we are all in the same boat. Apart from the very wealthy we all have mortgages or rent to pay, food to buy and futures to plan in the context of the real threat of double dip recession.

·        Please remember that is the most vulnerable who will suffer from your actions.

I think it’s highly regrettable that strong arm tactics appear to be in play. Danny Alexander, Chief Secretary to the Treasury is insisting that the offer made to unions earlier this month cannot be improved and Schools Minister Nick Gibb has repeated warnings to unions that the current offer on public sector pensions may be withdrawn if no deal is reached.

I have great sympathy with my friends and colleagues facing an erosion of their pension rights. I also have great sympathy for several of my friends from the private sector who have been made redundant or face reduction in hours with no opportunity for redress. But it’s a tough world out there, and the relatively soft bosom of the public sector can continue to be a good place to nestle.

The general public is in no doubt about how strongly you feel and your point has been made well by your representatives. So keep talking but be realistic, and please, please maintain the vital services that you normally provide with such dedication.

Caesareans on demand. ‘Nice’ to have but not need to have?

The National Institute of Health and Clinical excellence (NICE) has issued some new guidelines advising that pregnant women should be allowed  to choose caesarean delivery, paid for the NHS, even if there ‘is no medical need’

As always, I am writing this post with all hats on – mother, clinically trained, healthcare manager and commentator. Let’s start with the mother bit first. Childbirth, like so many other experiences, can be dramatically influenced by perception. My mother, bless her, told me that giving birth was ‘easy as falling off a log’. A strange saying as I don’t know anyone who has actually fallen off a log, but I guess that if you chose to do such a foolish thing – it would be easy. I was very fortunate to produce a tiny baby who was in a hurry to be born so it was just as dear Mama said – a doddle. But I won’t deny that it was a painful doddle.

I would not for one moment belittle anyone who has fears or concerns about natural labour. Neither would I dispute that C sections can be life saving and vital in some cases. But to choose to have surgery simply because you can, really isn’t good enough. Pregnancy is usually an active choice. Even unplanned reproduction is often a result of a choice not to be more careful! With choice comes responsibility. We are already very fortunate in the UK to have access to free maternity services. Those free services, up till now, included the reassurance that either a planned, medically necessary or unplanned emergency Caesarean would be offered. So prior to these new guidelines, mothers being cared for within the NHS would expect to have to go through natural labour unless sound medical reasons existed.

NICE recommends that mother’s considering to opt for a C section should receive counselling from a midwife. That seems sensible until you look at resources currently available. Just two months ago, the Royal College of Midwives warned that some areas of the country face ‘dangerous shortages’ as the number of trained professionals has not kept pace with the rising birth rate.

This is where all my other hats kick in. Yes – in a perfect world patient choice would be absolute, although the wisdom of choosing major abdominal surgery when not essential could be questioned.  But we don’t live in a perfect world. Especially in the land of healthcare. Midwifery resources are already stretched, so how can this counselling realistically be offered? NHS Hospitals are severely stretched so how can it be sensible to offer a potentially huge number of extra surgical interventions with the resulting increase in bed occupancy and procedural   costs?

Every treatment option must be considered in the context of medical inflation and the dire financial straits of the NHS. It isn’t helpful to those trying to balance the books when an official body eases open a potential floodgate of cost and resource pressure.

As the NHS faces it’s most drastic reform and cost cutting measures, all agencies must try to work within the context of this reality.

We don’t just need joined up care – we need joined up thinking.

A pharmacist is not just for handing out pills – the need to understand each other’s roles

I’ve just been ‘eavesdropping’ a conversation on Twitter regarding a recent, but not original, news event about a pharmacist refusing a patient the ‘morning after pill’  (also known as PCC - post coital contraception) due to religious reasons.

The gist of some of the comments were that the patient had been unnecessarily inconvenienced and embarrassed and pharmacists simply need to take the packet of pills off the shelf – no big deal.  I quote one doctor ‘It’s in a packet. Instructions are inside. Px (prescription) has been given. It’s easy- just give the meds surely’. The same, highly respected (by many in healthcare, including me) and influential doctor goes on to tweet ‘maybe the third way is to have a vending machine dispensing ‘off limits’ medicines such as PCC ‘
 
Ouch!

To try to give a balanced view (I aim not to subscribe to the Daily Mail method of health reporting) I should point out that the same doctor went on to say, wisely, that she wasn’t singling out pharmacists – ‘we all need to reflect’ and another tweeter (or is it tweep?) commented ‘…we all need to understand each other’s roles better’

I trained and practiced as a pharmacist for a decade before moving into healthcare administration. I must confess that I am old enough to remember mixing potions (I’m a great cook thanks to the rigorous discipline required in following formulae) - even making ointments and suppositories from scratch and when I first qualified very few medications were in premeasured packs. But then, like now, a pharmacy degree and post graduate training was in-depth, comprehensive and vital in producing highly knowledgeable and skilled specialists.

One of the aspects of my profession that often saddened me was not only the lack of understanding between doctors, nurses and pharmacists, but also the thinly veiled contempt that was held between different branches of the profession. I have worked as a pharmacist in hospital, retail and pharmaceutical research establishments and can personally vouch for the validity and complexity of each role.

I think, and hope, that things have come a long way since the 70s when pharmacists first started to play an active role in dispensing on patient wards and actively counselling patients in a retail setting. I also think there is more mutual respect across all branches of healthcare. But not enough.

I’m not brave (or even foolish) enough to get embroiled in the pros and cons of conscience of dispensing certain types of contraception, but one point that will always engage me is the value of each professional branch of delivery of healthcare services and the integration of that delivery.

Yes – that old chestnut. As a facilitator of clinical pathway mapping exercises, I often have to remind the organisers to include representatives from the entire patient pathway. Pharmacists included. Understanding and appreciation of the vital role that all of those associated with professional patient care should start in the classroom or lecture theatre and continue through induction and on-going development.

That is the only way we can provide truly integrated patient care – and enjoy multidisciplinary harmony along the way.

How to win a healthcare argument – The British Medical Association vs. the pro-smoking lobby

The British press was awash yesterday with commentary about the British Medical Association (BMA) suggestion that smoking should be banned in cars.

The main thrust of the BMA argument is a recent study which suggests that the levels of toxins from smoking cigarettes are 23 times higher in a car than in a smoky bar. The ‘smoking in vehicles’ briefing paper says children are particularly vulnerable to second-hand smoke, as they absorb more pollutants because of their size and have underdeveloped immune systems. BMA director of professional activities Vivienne Nathanson, BMA Director of professional activities said: ‘…We are calling on UK governments to take the bold and courageous step of banning smoking in private vehicles. The evidence for extending the smoke free legislation is compelling’

Up steps Forest (Freedom organisation for the right to enjoy smoking) - with their counter-argument coming head to head with the BMA spokespersons both on TV and radio. The discussions that ensued provide me with an excellent framework on how to win and argument (or not as the case may be)

Make sure that your factual case is strong:

The BMA have over half a century of proven studies that smoking causes life -threatening and life-limiting disease. A variety of scientific studies have also confirmed the effects of passive or secondary smoking for at least three decades. The study quoting the toxicity of smoke filled cars was undertaken by the British Lung Foundation. The Director of Forest, Simon Clarke’s ‘factual case’ is ‘The evidence is flimsy…. There is not a serious health risk to children’
BMA:1 Forest: 0

Pick your argument and make sure it’s winnable:

This is where I believe the BMA got it wrong yesterday. Children and pets – always a winner. Legislation to protect the vulnerable – can’t lose. Remove ‘civil liberties’ – much tougher game altogether. Forest were able to extrapolate the BMA’s suggestion about banning all smoking in cars, whether children are present or not and question how far the legislation would reach – suggesting that the government could then ban smoking in homes as well.
BMA:1 Forest:1

Stay calm and courteous:
The two BMA spokespeople remained professional and calm throughout. Simon Clarke from Forest often bordered on a rant.
BMA:2 Forest: 1

Never, ever say ‘with the greatest of respect’
A personal dislike of mine. Whenever that phrase is used, it means the exact opposite. If one of the opponents doesn’t agree with the other’s argument – say so. Alas, Mr Clarke – you committed this faux pas
BMA: 3 Forest: 1

Be careful not to counteract your own argument:
The BMA has a ream of strong factual evidence on the dangers of secondary smoking and the enhanced effect of smoke in an enclosed space such as a car. It is estimated that in the UK 4000 adults and 23 children a year die from the effects of secondary smoking. Forest used the statistic that there are 21% of the population and 8% of those smoked in cars with children present. In other words there are at least 1 million children currently at the enhanced risk of passive smoking in cars. Shocking figure – worthy of legislation surely. Own goal
BMA: 4 Forest: 1

Prepare for possible counter attack:
As Simon Clarke made the valid counter argument that the UK police have more than enough to do without trying to arrest smokers in their cars, the BMA countered with the fact that seat belt legislation was unpopular at the time of introduction but now is pretty much universally accepted in the UK with a resultant significant saving of lives. A draw on that point – one all.
BMA: 5 Forest: 2

Try not to let it get personal:
Forest are taking any attack on the right to smoke personally on behalf of the 12 million smokers in the UK, but in this argument – they managed to avoid attacking the doctors personally.
The BMA spokespeople were positively saintly in not criticising smokers directly.
BMA: 6 Forest: 3

Put your argument in context – always looking at the bigger picture:

Particularly important for healthcare issues. This is easy for the BMA – the good of the nation etc etc. Not so easy for Forest – sorry – no beneficial big picture argument available.
BMA: 7 Forest: 3

And finally…

Try to get the last word in:
I suspect that both Dr Vivienne Nathanson and Dr Dean Marshall have had excellent media training. In both the TV interview and radio debate – their final words were… ‘we are just trying to save lives’

Slam dunk, home run, century, win on penalties, serve an ace, whatever sporting metaphor you choose – that has to be the most powerful healthcare argument winner there is.

We are just trying to save lives

Is sentimentality getting in the way of progress for the NHS?

As predicted – there has been much ruffling of feathers and beating of breasts following the coalition’s announcement that a private health partnership Circle, will take over the running of the failing NHS Hinchingbrooke Hospital, near Cambridge.

‘No-one should make profit from health’ said Terry Christian, TV presenter on a daytime chat show. Liz Kendall, shadow health minister is ‘deeply worried’. ‘An accident waiting to happen’ warns Christina McAnea, from the union Unison.

In a £1bn deal, Circle has 10 years to run the hospital, which is currently £40m in debt. This debt has been accepted by Circle as part of the deal.

Perhaps the nay-sayers to this franchise agreement should hold their horses for one cott’n pickin’ moment. Let’s look at the facts…

Hinchingbrooke Hospital serves a community of over 150,000 people. A community who vehemently want their hospital to remain open, delivering care ‘free at the point of delivery’ as per the NHS founding values. Hinchingbrooke Hospital has been ‘failing’ for years. Failing to reach minimum standards in quality, safety and financial control. The hospital has floundered under a succession of NHS management teams who failed to take control of the escalating debt, poor morale and falling standards.

My grandmother had a saying ‘never throw good money after bad’. There was a growing pit of debt at this hospital. Something had to give and there were three options. Try yet another NHS management team, close the hospital, or put the management of this wounded beast up for tender. The third option had to be the best choice, although in true NHS fashion – the tender process took over 18 months, as money and quality dripped away in Cambridgeshire.

The appointment of Circle health partnership is, I think, courageous and worthy. Their track record in running hospitals is good so far. Their approach of partnerships – so effective in organisations such as the retail giant John Lewis, sits comfortably with NHS principles. And I think they have a very good chance of turning the hospital into an efficient, high quality care provider. Yes services may need to be rationalised – but show me an NHS hospital that isn’t going through rationalisation.

What are the real dangers of this decision? Not many in my opinion. There is an opt-out clause so the government can pull the contract if sufficient progress isn’t made. There must be regular and effective lines of communication between the NHS and its franchisee.

‘No front line jobs will be lost’ according to Simon Burns, health minister. I see that as a potential negative rather than a positive. One of the biggest problems with the NHS is the lack of performance management in some areas. I would like to think that Circle will ensure that staff perform to the standards required and poor attitude or performance is not rewarded with continued tenure.

The main ‘danger’ I perceive? Sentimentality. Speaking as one who is dreadfully sentimental (bereavement, age, parenthood are my excuses) – I feel we really must put sentimentality aside in this case. ‘Save our NHS’ is a popular Twitter hashtag, and I don’t think anyone would argue with that particular sentiment. But trusting the management of a failing hospital to an existing failing system for sentimental reasons just isn’t good enough.

Yes – I do get very sentimental about the NHS, especially when I comment on the Health and Social Care Bill, which I believe will do harm to the state funded care system in general. But when bits are broken and need fixing – sometimes you need to look further afield for the best organisation to do the job. And if Circle make some profit AND save a hospital, turn around £40m debt while providing cost effective high quality care and keep good staff in their NHS jobs - good luck to them.

How do you treat a bully like Sepp Blatter?

Sepp Blatter really doesn’t like the FA (English football Association) does he?

The President of FIFA, the international ruling body, has insisted that English football players cannot wear the poppy, a sign of remembrance, on their shirts for the friendly match at Wembley on Saturday.

Hiding behind the ‘rules’, I absolutely believe that Blatter is delighted to have yet another opportunity to have a dig at the Brits.

My daughter – who is my voice of reason, censor and editor, tells me that I really can’t voice my true feelings for Mr Blatter in this blog. ‘Incitement to violence’ was the warning phrase she shot across my bows when I blogged about the world cup bid fiasco.

Suffice to say – Mr Blatter is one of my least favourite people on this planet. In terms of my absolute contempt, he ranks only slightly below healthcare assistants, nurses and doctors who are mean to patients and anyone who hurts a helpless animal.

FIFA is a shambles. The world cup last year was a shambles. (South Africa put on a great show but FIFA failed its worldwide audience badly) The bidding process for the world cup 2018 and 2022 was a shambles.

So Mr Blatter – rather than bother about the English team paying their respects to generations of young men and women who gave their lives for their country – I would like you to address the following:

Corruption in FIFA: now proven

Bad refereeing: The brilliant Brazilian player Kaka was sent off after an Ivory Coast player, Keita, feigned an attack to his face, and even though this injustice was clearly viewed in TV replays, the one match ban remained.

Bad sportsmanship: As above – plus the pathetic diving, writhing in agony and clutching various parts of the body in mock anguish that cheating footballers use to illicit unwarranted red and yellow cards for their opponents.

Corruption: Yes – it is worthy of two mentions. 2018 World Cup – Russia, 2022 World Cup – Qatar. I rest my case.

Prince William, Duke of Cambridge has had the courage to write to FIFA telling them that he is ‘dismayed’ at their decision.  A quote from his representatives goes on ‘The Duke’s strong view is the poppy is a universal symbol of remembrance, which has no political, religious or commercial connotations’. His Highness is currently top of my list of favourite people…

Well done Prince William!

But back to Sepp Blatter. He is a bully. (At this point you will understand why I haven’t shown this blog to my daughter before posting).

So how do you deal with bullies? There are several options for the FA:

1)     Do nothing and suffer in silence - Please let it not be this option

2)     Take your concerns to a higher authority in the hope that they can sort it out - Prince William and David Cameron have tried but FIFA have shown previously their contempt for such worthy advocates.

3)     Reach  a compromise to co-exist - This is the FA’s current stand. They are suggesting measures that are almost laughable – filming the training sessions on 11/11 to show the players wearing poppies/black armbands on the day/wreath in the middle of the pitch before play/bla bla

4)     Walk away - we really don’t want to see the end of an English football team do we?

5)     Confront the bully – they are usually cowards and often back down. My preferred option, wear the poppies – what can FIFA do?

So I’m off the fence on this one. Come on England and the FA – take a stand and let the team wear their poppies with pride.

This blog is dedicated to all servicemen and women, all over the world, who lost their lives fighting for their countries with a special mention for submariner Daniel Craig Reid, NBC, who survived his war, but who carried his memories of the conflict for a lifetime.