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?