Sunday, 30 May 2010

Toenails, advertising, media and disease.

A recent item on a BBC news program got us thinking. It said that brushing your teeth twice daily would prevent heart disease. Nothing new to your average grunt in General Practice here in Northernshire as the link between dental disease and heart disease which has been known for decades.

Many of the diseases we see in General Practice have been around as long as human beings have. Examples are such life threatening things as colds and sore throats.

Amazingly, despite their self limiting nature and relative lack of harm, the human population continues to expand. It has more than doubled since the 1960s with most of the world being completely untouched by the NHS.

Other diseases are of far more recent an origin for example HIV/AIDs and we have seen these diseases and watched them evolve from their infancy.

Another group of diseases we have noticed over the years are born of the media and advertising and for years people rarely did anything about them.

Take the humble toenail.

For many years in general practice we have been asked occasionally to look at what is known locally as “manky nails”.

These are usually the result of fungal infections. Until recently the drugs used to treat them would have had to have been used for 2 years in order to try and get a cure which was not guaranteed.

We would, because of the length of time needed to treat, usually have sent nail clippings of to the labs, and wait 6 weeks for confirmation that it was a fungal infection before starting treatment.

By which time most punters would have lost interest as there was no instant medical “fix”. A week in politics is a long time. A manky nail for 6 weeks without life saving treatment is far longer and as manky nails are not harmful they are quickly forgotten.

Word obviously got round and we only rarely saw people asking for treatment.

More recently there seem to be loads.

Now, unless we have missed something, there does not appear to have been a “Careless nails costs lives” campaign run by the Ministry of Information/Health that has raised public awareness. Certainly we as doctors are not doning our capes and ringing our bells shouting “bring out you manky nails, there’re killing yer”.

However, if one watches daytime TV or looks in magazine or newspapers there appears to be loads of advertisements for products for the life threatening scourge of the manky nails.

Most of the products being touted aren’t that good compared with more recent anti fungal drugs which can really cure these infections in months rather than years. This means that people are happier to treat for a few weeks or months rather than years.

Coupled with the continued search for the body perfect and the fact sandals are making an appearance as temperatures sore into the high teens Centigrade the demand for treatment for manky nails has grown year on year here in Northernshire particularly in the grossly obese for whom appearance is a huge issue. “I can’t wear sandels with manky nails that is so gross you have to do something for them”.

Another disease that has been with us for years was impotence.

We reviewed our referrals a while back and found that in the 5 years BV (before Viagra) there was one patient who had requested help and referral to a specialist for this problem when there was nothing available (apart from loads of dubious quack medicines).

In the year AV (after Viagra) there were 5 referrals for impotence. This was, we suggest, due to the appearance of many excellent and articulate practitioners in this sensitive field for example, and we are not making this up (North), Sister Nollie Biggins (albeit way down South from us) who has featured on the national media.

The advertising for Viagra we recall was clever in that it hit the television screens before we as GPs could get any prescribing information and so patients were demanding it before we knew anything much about it.

Another clever use of the media and advertising to create interest in a “new” disease and demand for that which had been lived with for centuries?

Now is there anything wrong with this you may ask? Well we don’t know is the answer. We have just noticed subtle changes in what people now consider to be a disease worth wasting a doctor’s time for which a few years ago they would have quietly lived with.

Is the treatment of manky nails a major public health issue? Probably not - unless undiagnosed diabetes is the cause.

The treatment of impotence?

More difficult as it is not a public health issue* but for men, and their partners, it is possibly a private happiness issue.

(*certain studies suggest it may be linked to heart and vascular disease before anyone starts).

Such was the concern of the Party that they issued dictates as to who can or cannot have it on a prescription. Look and see who qualifies. You are compelled to pay for your “sex” drugs but see a prostitute and pay for intercourse and that is a crime?

Compare the above two examples with statins for heart disease which were once touted by the media as the “new aspirin”, initially denied by the Party as “too expensive”, and are now being thrust down the throat of anyone whose cholesterol is considered too high after coming off patent so the cost plummeted.

Same basic problem, namely heart disease, same risk factors, different media hype lower cost and therefore political outcome. The illness and treatment stayed the same throughout apart from the drug cost. The advice however changed.

The crux of this for doctors is that we are meant to provide the best for the patient.

Fungal nail infection, no real treatment, ignore.
Fungal nail infection, real treatment, treat.
Local managers then object as treatment costs rise.

Impotence. No real treatment. Ignore.
Impotence. Real treatment so try to treat. Media hype regarding treatment leads the moral minority to jump on the bandwagon and that which helps is denied to most.

Statin good, statin media friendly, statin expensive = no statin.
Statin cheap, political imperative, statin for all.

The media and advertising affect us all whether we like to admit it or not. Whether this is good, or not, in medicine is debatable as if you go to the US the advertising of drugs and medicines is so much more in your face than it is here.

Despite this relatively low level of advertising of medical products here in the UK it does impact on general practice as diseases that were previously ignored are now thrust into our faces by the media inspired patient.

None of us here at ND Central have a problem with disease. What we do have is a problem with is non life threatening illnesses, present for many years, being presented abusively to receptionists as emergencies.

We return to our initial observation of lack of tooth brushing causing heart disease. How long before a commercial manufacture launches an anti heart disease toothpaste for your children that will prolong their lives?

Will that lead to lobbying and approval of a toothpaste that will be advertised and plugged on TV and so every parent will want it on prescription for their kids to help them as childrens’ prescriptions are free in the UK?

And then there will be the can I have 5 packs of toothpaste just in case my not seeing an NHS dentist and smoking 40 a day which I can afford will make me get heart disease but if I use my childrens’ medicine for free I won’t?

Praise be to the Party for “knowledge”. If only the grunts on the ground had some input into media output. We might just then see some proper illness for which treatment would make a life changing difference.

Unfortunately we don’t and we have to follow whatever tune the media plays to our patients.

Saturday, 22 May 2010

Health Policy: fundholding reborn per chance?

Yesterday the current UK coalition love in published their The Coalition: our programme for government.

Now normally we don’t have much interest in matters political but we thought we would have a read. To say we were disappointed would be an understatement but we are also waiting for next week’s financial review to see if certain white elephants in health care might be scrapped.

We thought there were lots of woolly ideas but little detail but one paragraph caught our eye.

It reads:

We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf.

You will notice the C word there. A return to fundholding anyone but of course commissioning is not fundholding?

Those of us old enough to remember fundholding realize that if this is devolved to practices, or possibly groups of practices, this will inevitably lead to the employment of more managers and administrators just as it did first time round.

However another paragraph reads:

We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line.

Sounds good doesn’t it?

We suspect that NHS administration might be cut but, just as with fundholding, and with rumours of GP practices getting individual “real budgets”, this “cut” will lead to GP costs rising as “resources are transfer to support doctors and nurses on the frontline”.

We love support on the frontline. It usually means more work dumped onto primary care for little, if any, gain or improvement.

These costs cuts will appear to disappear from the NHS budget.

Just as with the end of fundholding when all the fund managers and admin staff were redeployed it might be that all the “cuts” in NHS admin costs will be but smoke and mirrors and history will repeat itself but in reverse.

So will all the cuts in NHS administration by a third result in needless NHS managers and administrators being paid to do the same thing with a different name in General Practice?

Praise be to the Party for possibly reinventing the wheel. The future of the NHS is bright, the future is possibly coalition green?

Where is the patient in all of this?

Monday, 17 May 2010

Choose and Book some more. A patient’s experience.

At the end of last year we had a little rant about the how to use C&B properly book.

Well one of us here at ND Central has had to use C&B first hand for a family member and to say that it is a crock of brown stinking useless sh*te would to be give it more credit than it could ever merit based on how well it works.

Have a look at the scans above and we shall dissect one of the most expensive pieces of useless government software ever devised and its complete and utter failure to do anything.

Remember dear reader that this software was designed to be used by doctors, some of the most intelligent people in any society and very few (if any) of them use it because it is complete and absolute crap.

If someone suggested Brillo pads as an alternative to toilet paper would you use it? Ask any UK medical secretary Brillo versus Andrex? Choose and Book versus the old paper system that worked and was so much less labour intensive and quicker?

By way of background we wanted two appointments for the family member concerned one of which we were able to book in the surgery the other we could not.

So let us look at the letter. Easy to read as we copied the text to a grammar checker and it gave a Flesch grade level of 7.4 equivalent to a college graduate or very difficult to read.

So your average demented, elderly or illiterate patient will have no problems based on the words but the concepts contained within the easy to read text might be more difficult.

Go to section 2 and see where you can make your appointment.

A call centre? Well our experience of call center’s staff whose sick notes we sign is that they are usually drug addicts or alcoholics so you know at once you are in capable hands to navigate though the complexities of “choosing” your healthcare with these experts. This is an enhanced service where if your referral has been screened by a clerk in a referral management center you will have to argue the case in order to get your, or did we mean their, choice for your appointment?

This is just our experience from the local commercial call centers. We know from our experience of swine flu that those employed by NHS call centers are a completely different caliber of operative. Far better than anyone with a medical degree as they can diagnose and prescribe in 3 hours of training something that no UK GP could.

Now section 2 also hides a very publicly hidden “cost” to the NHS “free” at the point of need agenda so beloved by the Party.

For a pensioner on a budget a mobile is good way of saving money until you start to use Choose and Book and try to use a government sponsored call center “please wait while I put you on hold as the computer is not working”. Something is usually not working in call centers and it is called the staff. Trust us some of our better staff dished the dirt when they joined us looking for better jobs.

Look at the last paragraph regarding mobile phones. How many real GPs, not politicians, have had patients ask them to make their appointment as when they try to do it on a mobile they are put on hold and charged a fortune to the point of no credit and more importantly no appointment. They are repeatedly told to ring back as no appointment slots are available.

When you can neither Choose, or Book who you going to call? Your free at the point of delivery GP and their staff of course.

No wonder pensioners are called bigots for how can they not afford to use mobile phones as they have all been to the same public schools and universities that politicians have been to and they get massive pensions and expenses as well?

Section 3 says “Your choices”. In the letter it says you can book ONE of your choices. Curious that we had asked for 4 choices of hospital (can’t “choose” your consultant though comrade) but then we are only good communist serfs so therefore 4 now equals 1 in NHS “Choice” la la land. Go to the nhshealthspacewebsite and you choose all four to see what appointments are available.

Clearly good one size fits all here comrades and remember we have the benefit of a University education and one CSE in Maths between us at ND Central so we should find this all a walk in the park.

We have access to the Internet as do just 66% of the population which means Choose and Book is true egalitarian medicine and "choice" along the lines of if you can afford to pay you can have more "choice". If you have Internet your choice is greater than those with just phones (90% of population for landlines 79% mobile phones source).

On to the second page and there is your password. This is the thing that we as GPs have seen most of with Choose and Book a whole generation of people of all ages saying “I rang up and was asked for a password but I couldn’t find it”.

In the good old days, when most people could read, the only password you needed for a referral was “Good morning/afternoon doctor”.

Now we come on to the most interesting bit. Being techies here we have been using the internet for the last 4 weeks to access an appointment. And what do we get?

“Please choose one or more of the clinics below and click “Continue to Step 2” to view all available appointments.”

Select all 4 we did as clearly as internet babes we are given more “Choice” than those using telephones and this is what we got:

Hospital 1 Approximate wait time 80 days
Hospital 2 Approximate wait unknown
Hospital 3 Approximate wait unknown.
Hospital 4 Approximate wait time 39 days

And the most important bit after all of this was the message in red:

There are currently no appointments available please try again later. Please call the C&B Appointment Line on 0845 6066 8888 for further information.

This cycle for many people is repeated time and time again and mobile phone bills increase as calls to Choose and Book are charged at a higher rate than from landlines.

The old system consisted of patient using the password and this simple system:

“Good morning doctor. I think I have a hernia can I see a surgeon?”

“Certainly. I will examine you, confirm you have one and who would you like to see?”

“Who would you recommend as I would not like a call centre smack head to decide? I would rather to talk to a professional. I would like to see Mr X who did my friends and he thought highly of him, can I see him?”

“Of course, Mr X is very good, I will dictate a letter which our secretaries will type and send off to the hospital and you will receive an appointment through the post. Let us know if you hear nothing in 4 weeks”.
(Text in quotes 117 words vs 300 for C&B Call Guidelines core from the C&B text above).

If you examine just the text of the Choose and Book Appointment request letter there are 216 words. That does not include the appointment or the instruction of how to make a choose and book appointment

Now someone once said that The Ten Commandments required a mere 300 words and the American Declaration of Independence 1,300 words. However, the EU regulations regarding the export of duck eggs require 26,900 words.

So what used to be a simple system has evolved into a monstrous system that fails to deliver. Our family member is still waiting after 4 weeks to be given an appointment. Does that mean that when they get one it will only take 14 weeks until treatment? Or has the waiting not yet begun because they have been denied an appointment by the Party and its all wise commissars?

Look on Choose and Book websites and this scenario of no appointments does not exist.

Remember we know the system where would you suggest we go next?

We did manage to book one appointment in the GPs office for the patient concerned and chose a date that would mean no time off work to take our family member to their appointment. Our choice was respected as a few days later a letter arrived from the hospital concerned with another appointment date and time. We now have to lose half a days work as the appointment has been changed to another day with no explanation as to why.

More massaging of the 18 week wait target by giving a dummy appointment which does not exist? 18 week wait target met box ticked when actual wait longer? Cancel the non existent appointment and send a real one. No gamesmanship here comrade patients just genuine “world class Choice”.

Praise be to the Party for giving us something we never needed “Choice” = none and the ability to “Book” not an appointment.

Choose and Book is a lasting legacy to the centralized, institutionalized incompetence and inability in UK healthcare. If anyone wants to save money shut it down and efficiency saving would be instant as staff time wasted using C&B could be more usefully deployed by doing something useful for patients.

Tuesday, 11 May 2010

The Party is dead, long live the Party(s)?

This evening, here in Northernshire, as the sun came to set, news has arrived by carrier pigeon that our unelected Prime Minister, Gordon Brown, has finally resigned. For the best part of a week patients have all said the same thing “I voted to get rid of him why hasn’t he gone?”

We here at ND Central do, of course, live in the incredibly affluent parts of Northernshire where all NHS managers have Harvard or Yale MBAs, most of our patients drive Range Rover Sports, and all GPs and our staff drive Ferraris so we do have to admit to a slight cultural bias compared with the rest of the country in the patients we see and treat.

For a lot of people a change is said to be as good as rest. For those in healthcare both in hospitals, and in General Practice we have had so much change we should be unconscious. Unfortunately we are not. We, and our staff, daily live the nightmare of 13 years of change mostly for the worse.

Still we have now one healthcare certainty for we are now in the foothills of healthcare uncertainty. The climb will get steeper as change is coming as a new Government always equals change or “reform”. The pack will get ever heavier as more change will be piled on our backs and the rewards will get ever thinner as “efficiency savings” and initiatives will sprout like nettles.

We are in a recession while the population ages and illness enjoys a year on year growth without any check as we cannot yet turn the clocks back. Politicians will feed patient expectation to distract from their shortcomings as fiddling with healthcare is always an easy target for them. Healthcare costs will rise as treatment improves but until the economy is sorted there will be less resources.

Praise be to the old Party for never in the history of British healthcare has so much been spent and mismanaged by so few to deliver so little to so many but so much to a select few.

To the new Party(s) we would say: ask not what the healthcare budget can do for managers and political ideology, instead, ask what can the healthcare budget do for real patients’ healthcare?

We await your orders, Sirs.

Wednesday, 5 May 2010


For the first time in at least 5 years today patients, and those who work in healthcare, are being given a real “Choice”.

It is called a General Election.

We, the United Kingdom electorate, have a choice and what a choice it is.

All politicians use the health service as a football to kick around as they please until the football is punctured, deflates and does nothing useful and then like delinquent youths they find something else to trash or have a fight over.

So for those of us in healthcare we now have a real “choice” that we can exercise and hope to influence possible “change” as those in the US have recently done.

Change is a great word but only if it is for the better. Most grunts on the ground know that subtle change (if ever allowed by politicians) can sometimes make a huge difference in healthcare. Unfortunately politicians do not do subtle they do sound bites.

The patient and their care should always be our priority and not a political football.

It is a choice to vote, or not, and it is a choice that the Party cannot determine.

We will use it and we would urge those who have a vote to use it, please. If you have never spoken to those who do not have a vote who envy those that do, you do not realize how valuable a thing it is however much you may despise politicians or feel that your vote is worthless.

Whatever the British public decides today those in healthcare will still deliver a service to the patient as an individual to the best of our ability tomorrow.

In the same way that if you handcuff a boxer’s hands behind their back that might influence the outcome of the fight the only thing that by and large will influence your healthcare is your choice of politician.

Please choose wisely but, given the recession, regardless of the outcome things in healthcare can only get worse. It is not much of a choice but it is still a free choice that we can, if we choose, exercise.

Praise be to the Party for finally giving us real choice.

Tomorrow will tell us our choice but today we shall go to work as usual with a slight detour at some point to put an X in a box.

Monday, 3 May 2010

The Circle of Life.

For anyone who has worked in the NHS for longer than any reforming politician’s mayfly like lifetime involvement with the NHS you start to see what we at the ND Central term the “cycle of life” otherwise known as idiots effing up (sorry about the grunt word) the health service.

What is this?

It is where a politician decides that something that works does not work and therefore needs reform.

Therefore a politician reforms it (because they have power but not necessarily the ability or more importantly the knowledge) and creates subdivisions to manage the same problems more “efficiently”.

For example: we have an inefficient large local Health Authorities “unresponsive to local needs” and a “drain on resources” so we will create “more locally responsive” and “efficient and accountable” Primary Care Group(s) to “improve patient care”.

So in an area with one health authority you might get 2 (or more) Primary Care groups each of which needs its own and new Chief Executive, Secretary etc.

Result a growth in front line healthcare professionals called managers. Work is duplicated to achieve the same or less and no doubt “efficiency savings” result. Wages do not go down for individuals but the wage bill increases as you have 2 or more parallel organizations working side by side instead of one before. They do the same jobs albeit with new and often more important sounding titles.

This is not like opening a new hospital in an area where the extra beds and doctors and nurses employed could treat extra patients it is doing the same job as before but creating more managers to do so.

These don’t work so now the Politicians will now create more efficient “Primary Care Trusts”. In doing so we will re employ all the former Health Authority and Primary Care Group employees (as redundancy payments cost too much) and so save the Public millions by increasing management costs to do the same job as the original Health Authority but with more people than before.

This process seems to occur in 10-20 year, or 2-4 Parliament, cycles, costs millions, does not improve healthcare but does increase bureaucracy.

Another example is we shall abolish the district general hospitals (run by the former health authorities). We shall create NHS Trusts (lots of them) and after a few years merge them into the same hospital units that were the former district general hospitals but with new names e.g. NHS “Foundation” Trusts.

More managers, lots of work for printers, sign painters and web page designers all on the front line treating patients but bugger all improvement for patients as there is zero extra healthcare provided via reforms.

Praise be to the Party for supporting the Circle of Life or is it actually an ever widening spiral of increasing management with each change in Party? And so the cycle continues ever downwards, more inefficiency, less front line care and there is an election coming.

Joy unconfined.

Saturday, 1 May 2010

Emergency medicine at 36,000 feet. Who would you want?

For various reasons here at ND Central we have not posted recently. The biggest cause of this is the fall out from the Icelandic volcanic ash cloud in terms of reducing bodies on the ground which only now are finding their way home from foreign shores.

An article in an obscure bit of the medical press caught our attention. If you can find it, it is on the letters page of the freebie found with the British Medical Journal called BMA News which is normally about as thick as a piece of quality toilet paper.

On their letters page there was a short letter entitled “Trust me, I’m a physio”.

The crux of the letter was that a doctor, who is an anaesthetist, volunteered to help in response to a request for inflight medical help only to be told by a steward that someone else had volunteered “who is a physiotherapist”.

What does this tell us about dumbing down?

So now if there is an acute medical emergency like a heart attack, a pneumothorax, meningititis, a cardiac arrest on an aeroplane a physio is now to be preferred over an ansaethetist? We are sure that the prompt administration of some core stabilizing exercises with some gentle mobilization and stretching will be of huge benefit for any life threatening emergency at 36,000 feet.

We do wonder what the acute medical emergency was that a physiotherapist would have been able to manage better than an anaesthetist?

Praise be to the Party for telling us all that anyone can be a doctor. It would seem like someone, somewhere, might be starting to believe them.