Merry Go Round

So todays story to get my goat-In the University teaching hospital (Trust A) in which I work I am treating someone with pancreatic cancer with chemotherapy. They live near hospital B at which I run a peripheral clinic although I do not normally treat pancreatic cancer there for historical reasons. My patient asks if instead of travelling on a 70 mile round trip every week they could possibly see me at Hospital B and have their treatment there. So the same patient sees the same doctor and receives the same treatment in a more convenient setting. Simple? A no brainer, I thought.

Oh no. So far I have had emails from the following: Lead clinician of Trust A, Head of commissioning at Trust A (several), Clinical service manager at trust A, Head of Drug and Therapeutics at PCT, secretary to D and T commitee at Trust B, lead cancer nurse at Trust B and cancer services manager at trust B. The problem? I have no idea, but this fairly simple decision is not only taken out of my hands and sent-who knows where? but has involved a significant amount of time for me, as well as at least 7 colleagues Yes 7. seven! seven! seven!

Manwhile the patient continues to wend his way up and down the motorway. Am I alone in thinking this is unsustainable?

What should be provided on the NHS?

Again today I had to tell a patient that an effective treatment was not available for them because NICE had deemed it to be "not cost-effective", which makes me wonder what we should be providing on the NHS. Here's 5 yes and 5 No:

Yes:

1) Cancer drugs-nearly all of them (OK I'm an oncologist, so I'm biased, but I seriously object to the way NICE works against non-curative treatments. more later)
2) Interferon for MS
3) Alzheimers drugs
4) Community rehabilitation services (eg community physiotherapy)
5) IVF (Actually I think this is rather controversial, but I'm in the lucky position of having children-I am sure I would want IVF to be available if we didn't)

No:
1) Any cosmetic procedure-including tattoo removal, breast reduction, breast augmentation, botox etc. Not including reconstruction for victims of burns/accidents, and exceptions for disfiguring congenital abnormalities obviously
2) Transport to and from hospital unless for real medical incapacity. I'm sorry but my hospital spends nearly (maybe more than) £500,000 per anum on transport, and I reckon at least half of this is for people who could come under their own steam (if they could find anywhere to park...). If needed for financial reasons, this should be funded, but by social services, not the NHS.
3) GP out of hours services. What I mean by this is that I do think that patients really can suffer through the fact that their GPs no longer cover out of hours work, and god knows what it costs to pay for all the out of hours services
4) European working time directive what are we playing at? the whole system of looking after patients in hospital has completely collapsed due to this directive. and again, what is it costing in junior doctors' pay? Unbelievable
5) Patricia Hewitt's salary £135,337-for what?

OK so I was struggling to find things we shouldn't pay for, but I bet there are plenty I haven't thought of-would be grateful for any views

Health fascism

Thanks to Iain Dale for this-why we should oppose ID cards and health fascists everywhere! Dont forget to turn up the sound.

Abortion and Euthanasia

John Crippen poses difficult ethical dilemmas on NHS Blog Doctor today which have set me thinking about these issues. Essentially they have a morbid connection as both involve doctors taking life. Interestingly I suspect many people would say that in an ideal world there would be no abortion but they would like to be able to choose when to die (and therefore by implication euthanasia). It is a bizarre manifestation of how much is not right with this world that I find myself arguing for exactly the opposite position.

I am absolutely and steadfastly against euthanasia. As a practising oncologist I have only once in my career had a patient ask me for an assisted death. I firmly believe that my whole reason for being a doctor is to ease suffering and to preserve life. If I took the step of deliberately ending another life, I feel that would diminish me. It would change the way I look at my patients - perhaps I would always be looking at them and wondering when was the time.

It is only a short step and a minor psychological derangement from there to Harold Shipman and I want no part of it.

I am moved by the stories of people who rationally and maybe appropriately decide that their life is not worth living, and therefore they call for euthanasia to be allowed in specific and defined circumstances. I sympathise with their individual cases and if they wish to commit suicide I would understand why- indeed although I cannot imagine it, maybe I would take the same way out myself. But I would never ask a doctor to kill me.

Aside from the moral position, with which many will disagree, what about the practicalities. This is what the Joffe Bill says, and like Dr Crippen I advise you to read it:

"Before the assisting physician can assist a patient to die the conditions specified in subsections (2) and (3) must be satisfied...

(2) The first condition is that the attending physician shall have—

(a) been informed by the patient in a written request signed by the patient that the patient wishes to be assisted to die

(b) examined the patient and the patient’s medical records and satisfied himself that the patient does not lack capacity;

(c) determined that the patient has a terminal illness;

(d) concluded that the patient is suffering unbearably as a result of that terminal illness;

(e) informed the patient of—

(i) his medical diagnosis;

(ii) his prognosis;

(iii) the process of being assisted to die; and

(iv) the alternatives to assisted dying, including, but not limited to, palliative care, care in a hospice and the control of pain;

(f) ensured that a specialist in palliative care, who shall be a physician or nurse, has attended the patient to inform the patient of the benefits of the various forms of palliative care,

(g) recommended to the patient that the patient notifies his next of kin of his request for assistance to die,

(h) if the patient persists with his request to be assisted to die, satisfied himself that the request is made voluntarily and that the patient has made an informed decision; and

(i) referred the patient to a consulting physician

(3) The second condition is that the consulting physician shall have—

(a) been informed by the patient that the patient wishes to be assisted to die;

(b) examined the patient and the patient’s medical records and satisfied himself that the patient does not lack capacity;

(c) confirmed the diagnosis and prognosis made by the attending physician;

(d) concluded that the patient is suffering unbearably as a result of the terminal illness;

(e) informed the patient of the alternatives to assisted dying including, but not limited to, palliative care, care in a hospice and the control of pain;

(f) if the patient still persists with his request to be assisted to die, satisfied himself that the request is made voluntarily and that the patient has made an informed decision; and

(g) advised the patient that prior to being assisted to die the patient will be required to complete a declaration which the patient can revoke."

Some of what I believe to be the most contentious passages are in bold, but in the end it comes down to this: what is unbearable suffering? I make the following predictions:

If this bill becomes law then the incidence of assisted dying in an area will be in inverse proportion to the quality of palliative care in that region.

Patients somewhere will be put under pressure to sign these declarations by unscrupulous doctors, nurses or relatives

Doctors and other healthcare professionals will end up in the dock for not fulfilling some of the criteria above.

Many more people will be put at risk by this act than the relatively few with genuinely intolerable symptoms who will benefit.

As with abortion, in 40 years this will become commonplace and doctors will be asking, as with abortion, why they have to go through the legalistic charade of signing all these documents and do so many healthcare professionals really have to be involved?

So, I urge all doctors to refuse to engage with this act. And for all of you who are wondering why you have to go through a legal process and why two doctors are needed to authorise a termination I would say this: for better or for worse you are authorising the ending of a life, all be it one which has not and may not ever have been born. It is right that there should be a legal as well as a medical authorisation for this, and it is right that as a society we should not regard the taking of life as a trivial medical process.

Don't get me wrong: Although my instincts are pro-life, in the current way of the world I absolutely support a woman's right to choose. But in allowing that right we must not forget what we are doing or ever stop asking if it is right that we are doing it.

Every unborn child deserves at least that

Save us from the Media

Poor Jane Herbert, chief executive of Hinchingbrooke hospital in Huntingdon. This is probably the most threatened of our regions Hospitals with a £30m deficit and a catchment population of only 160,000. She was appointed after the resignation of the previous chief exec. Since appointment she has been under almost constant fire from the Cambridge Evening News-vide HERE, HERE AND HERE. Oh and HERE.

What has she done to upset editor Murray Morse? I have great sympathy for hospital managers who manipulate waiting list figures-I am sure that all do it to some degree. Setting of ridiculous targets will lead to this sort of activity. It is wrong, she made a mistake, admitted to it and was very open about the issue when interviewed for her current post, so what’s the issue?

I agree she may not have been a wise appointment, but the board had the facts available when they appointed her and so far she has done nothing in her current post which should give cause for such opprobrium. Surely hospitals are under enough pressure from “Pat the rat” Hewitt and it is our duty as local health professionals to get behind the management, at least as long as they seem to be doing the right thing. A concerted campaign to get someone to quit before they have had a chance to show what they are made of is not going to help to save Hinchingbrooke.

And a lot of pius moaning from local councillors which seems more aimed at increasing their media profile than helping improve local healthcare provision doesn't help either. what does a health scrutiny committee do anyway? Sounds like another group of underqualified idiots being paid to stop anyone making any progress

Let the poor woman get on with her job

Blair backs NHS Reform

Ha! Ha! Ha! Tony Blair has made a speech urging the public to embrace NHS reform, claiming that a massive reconfiguration of the service is required to improve services to all. If very keen you can watch his speech HERE. If lucky you may hear of Sir George Alberti,(former RCP president and presider over the introduction of the shambles that is acute medical care of the emergency patient in NHS hospitals today) and Professor Roger Boyle, cardiac tsar, recommending this new reconfiguration, which would mean moving much acute and specialist care to specialist hospitals

2 points:

1: NHS reconfiguration is being driven by acute financial constraints, especially in SE England, and not by demands to improve the service. We will be found out in the end as A + E and maternity departments in DGHs are forced to close and capacity to replace the sevice will be inadequately funded. I am all for reconfiguration of some services into larger specialist centres, but the quid pro quo for that should be the presence of several small hospitals (I would envisage mixed private and NHS facilities) which will be able to repatriate most of the routine work that is performed in supercentres and will be able to provide genuine patient choice, the ability to be treated locally and competition on cost that will save the NHS money overall and increase capacity in the Superhospitals.

2: The drivers for this change are ivory tower dwellers who have an interest in part 1 (get all the work to the specialist centres) but not in part 2: (get routine & potentially lucrative work out into a competitive local health economy)

So I can see a classic House of Lords reform maneouvre coming up here: First take money and services away from small district hospitals-don't close them (politically unacceptable in most areas-except in safe conservative or Lib Dem constituencies) but let them wither on the vine, along with patients' trust and confidence in local community services and facilities. Then second...was there a second? No I don't think so-lets leave it as it is it will be too difficult to change things any further, and we might lose control. Oh dear we already have...

Save Bedford Hospital-Lib Dems up to no good?

Hey ho what a surprise-the Lib Dems are using a local NHS problem for their own ends. Dr Rant and Dr Informed both have blogs on this topic. The facts are as follows: On a background of catastrophic budget deficits across the South East there is a strong suggestion that at least one of the region's hospitals may be forced to close or downgrade services, Barry Monk, a consultant dermatologist at Bedford Hospital, inspired by "the kidderminster experience" has decided to run for parliament, as reported HERE. Note the date of report: 18th September. Dr Monk has gone so far as to register "save Bedford Hospital" as a political party. Now have some fun: type "save bedford hospital" into Google.. 7 Links to lib dem sights organised by local lib dems. Hmmmmm could it be just an astute bit of local campaigning and political nous?

Yes but...now lets look at some domain names on whois:

1) savebedfordhospital.com = Conrad Longmore registered at 16.29 on 18.9.06;
2) savebedfordhospital.org registered by Conrad Longmore on 18.9.06
3) savebedfordhospital.co.uk Tim Prater Registered 18.9.06...are we beginning to see a theme here?...
4) savebedfordhospital.net Conrad Longmore 18.9.06;
5) savebedfordhospital.org.uk? Tim Prater registered 18.9.06. Need I go on.

I can tell Dr Monk that they seem to have missed "savebedfordhospital.biz" if he is looking for a website for his party.

In case you haven't guessed, Conrad Longmore is a Bedford Lib Dem who specialises in website parodies. Tim Prater comes from Folkestone in Kent and is..yes you guessed it a Liberal Democrat. Maybe they know each other. Or perhaps just a coincidence.

Now type any of these links and surprise surprise back we are at Lib Dem campaign HQ

So Sherlock Holmes is not required to realise that Conrad buys the local paper on 18th September and reads about Dr Monk and Save Bedford Hospital. A charitable explanation is that he thought"cor! is there a problem with Bedford Hospital? I hadn't realised. I'd better register a website (or 2 , or 3) and start a campaign to save the hospital."

I am not charitable. I believe he thinks "This is a live political issue and will a) get a lot of publicity in the next couple of days and b) be a votewinner if we can get rid of this doctor or maybe get him to turn out for us. Oh and look the silly boy hasn't registered a domain name for his funny new political party. Come to think of it, save bedford hospital has a sort of catchy ring to it" So he registers every savebedfordhospital domain he can find. Later in the evening he rings his friend Tim who points out a couple of sites he has failed to register and out of charity does it himself, even though he appears to have no connection whatsoever with Bedford

Now this seems to me to be ungentlemanly to say the least. One thing to take advantage of political naivety on behalf of a Labour or even Conservative Candidate, but to rough up an independent in this way is not likely to be popular locally and could well backfire. Lets hope so

I must say that I would argue that Dr Monk would be ill advised to stand. I admire his integrity and commitment, but this seat would very likely be a Conservative gain in the next election and the best way to save Bedford Hospital would be to get rid of Patricia "the woman who put the pat back into patronising" Hewitt and get some common sense back into NHS finances. Judging by the kidderminster experience, he might win but if he didn't he could turn a 2 way marginal into a free for all which the Lib Dems might gain from-especially if people thought he was one of them because his political party's site redirects to the Lib Dem one....

A new approach to the NHS

Doctors for reform report HERE on their recipe for NHS reform. I agree with their basic tenets, but I have some issues with some of the proposals: for instance Karol Sikora's ideas for new cancer treatment centres sounds more like an advertisement for his private venture than a helpful idea for health service reform.

Liberty or Doctor knows best?

Alex Singleton in The Liberty Log writes that he believes we should all be able to buy our own drugs over the counter. I am an instinctive libertarian, but I'm not so sure about this. Maybe its just that I have been brought up in the NHS of prescription-only medicines, but I am concerned about the safety issues. Many people will have the necessary common sense or responsibility to be able to take responsibility for their decisions, but many will not. I agree with Alex, though that this is an issue we need to look at-has the health and safety bar been set too low as with so many aspects of life in Britain today?

Trust or Control?

It has finally occurred to me that society needs to make a choice. This is true in healthcare as in education, police services and many other fields. The fundamental issue is this: Do we trust profesionals to do their jobs? If so then we do not need routinely to monitor performance, targets etc unless there is a question that people or institutions are failing. The vast resource devoted to NHS monitoring and targets can be devoted to healthcare. Policemen can walk the streets. Teachers can teach.

However this may come at a cost: For the best to thrive do the worst have a chance of getting away with it: Does this allow Harold Shipmans, or more possibly racist policing or failing schools to go undetected and unimproved? I don't know, but I am sure that the solution in health lies in much more targeted monitoring with most priorities and assessment of performance being carried out at a local level by local health boards.

David Cameron and the NHS

So David Cameron's main priorities are n.h.s. I agree that he needs to take this line to reassure the public but I dont think he really understands what the nhs means. The entire system is struggling under a series of contradictory government edicts (eg no postcode prescribing vs Local commissioning and budget control).

The finances are in a complete mess with the relatively healthy south being penalised for being healthy (because they use their healthcare services) at the expense of the less healthy north (who dont). Therefore the PCTs in the south have less money per capita, the hospitals in the south have higher demand and the GPs in the south cost more because they achieve their targets better (though not necessarily improving the health of their patients). No wonder the entire healthcare system in south east england is bankrupt. Meanwhile hospitals and PCTs in poorer areas are happy because they have more money and need to spend less. In theory they should be spending it all on prevention and improving the health of the local population-but are they? Even if they are its much easier to cut a smoking cessation or obesity awareness programme than to halve your mental health budget. Theis is not a criticism of these organisations, it is just that the govenment has stacked the odds in their favour.

So what is the solution? I don't believe the government can or should retain control over the whole nhs. Myself I would favour local health boards made up of capable people with representation from primary and secondary care as well as lay members and members with sound financial expertise who would commission local health services. But this would inevitably lead to postcode prescribing and different quality and scope of services in different regions-I dont know that this is necessarily a bad thing provided patients are able to travel.

One thing is for sure if we continue as we are the whe system will collapse in 3-5 years