Sunday, 17 February 2008
It's been a while since I wrote anything on this blog and I owe an apology to the small circle of readers who visit regularly.
Some of you will have read about the huge public demonstrations against school closures in Herefordshire which were provoked by Nulabour attempting to do to local schools what it is currently doing to local hospitals. I'm proud to say that Dr Ray will be able to look his grandchildren in the eye and say that he played his part in the Great Herefordshire Revolt. Although I have now taken a back seat, the campaign was draining and I now need a rest from blogging and political rabble-rousing.
I do have other excuses.
I originally set up this blog to help publicise UK-radiology, our profit-sharing private scanning and radiology setup in Herefordshire. Along the way the blog exposed the poor value the taxpayers were getting from the Mercury Healthcare (now Care UK) 2nd wave diagnostic contract and soon after the contract was canceled. The blog also documented the experiences of what seems to be the only hospital consultant to attend one of the early Darzi rallies and revealed the scam that was passing for consultation. The Department of Health was forced to admit to offering "expenses" to only some groups of participants and, having attended a meeting myself since, I sense the blatant vote-rigging has been reined in.
The original aim of website promotion has achieved its purpose, with UK-radiology, or one of its many variants, on the first page of Google for all the relevant search terms. In fact this has led to its own problems because I now get a large number of emails which, either have to be deleted (penis enlargement and money making scams mostly-poor targeting I say, being well provided for in both departments!) or individually answered.
Many of the genuine enquirers fall into two groups. One group are unhappy with the medical care they received locally and are really after a second opinion. When I get the details, the advice they had received seems to me, in fact, usually quite reasonable. The problem is that expectations are often unrealistically high. The other group of enquiries are from people wanting total body scans just to check things out. I made a conscious decision not to offer this type of scan when we started out because I am not satisfied that these scans are ethical. The problem is that explaining all this is very time consuming and I still have my full-time NHS job to do.
As any consultants reading this will know this is also a busy time in hospitals. The annual mutual arse-sniffing exercise, more commonly referred to as "Appraisal" has come around again and everyone suddenly realises they don't have enough Continuous Medical Education points (because reading the textbooks and journals doesn't count, whereas attending a meeting to listen to a manufacturer's sales pitch does) and that they haven't done the requisite annual audit (because discussing a diagnosis with the surgeon and pathologist doesn't count whereas documenting the number of toilets in the department with jammed paper hand towels does).
The other thing that has come around again is the so-called Clinical Excellence Awards which link consultants' pay to ability to exaggerate and fill in forms. I don't think an anonymous blog counts towards such awards though I am so desperate for material I might try it this year.
Finally, one of our number is on maternity leave and we decided to do her work between us rather than employ a locum. Radiologists suffer a credibility problem in hospitals and a bad locum can undo, in a few weeks, what has taken years to build up. Fortunately it is working quite well but its another chunk out of my evenings.
What I am getting at is that the blog has to go, at least for the present. I will return when I have more time or if I need to get something off my chest but for now I will stick to reading other blogs and posting the occasional comment.
As a football manager might say: "At the end of the day, the sun will rise again"
Friday, 25 January 2008
There was a time when the expression "Trust me. I'm a doctor" would not have had everyone falling over in laughter. Unlike politicians, who have always had a reputation for being dishonest and never waste an opportunity to confirm this reputation, doctors place great emphasis on professionalism and trust. This is as it should be if patients are to divulge their most intimate details and expect an opinion not influenced by anything but clinical considerations.
The present UK government, currently under investigation by the Metropolitan police for breaching their own regulations on electoral fraud, have always judged the professions by their own standards and imposed increasingly onerous regulation. At the same time there has been a move to replace professionals by untrained or minimally trained personnel with the mistaken belief that clinical judgment and professionalism can be replaced by strict protocols and close regulation.
Telemedicine, and in particular teleradiology, distances the doctor from the patient and the radiologist from the clinician and would seemingly demand extremely high levels of professionalism and trust or alternatively cast-iron regulation for the system to work. In the USA, physicians and radiologists offering out-of State consultation are required to be licensed to practice in that State. The UK seems less concerned with protecting standards. Before Mercuryhealthcare had their MRI contract withdrawn, their business plan involved sending the scans to Hungary for reporting. The reports were supposedly to be done by GMC registered radiologists but almost none had qualified or trained in the UK or sat any UK examinations. It is questionable whether, a few years ago, many of these people would have been recognised as doctors let alone as radiologists. At the time the GMC was so desperate to maintain its position in charge of medical regulation that they acceded to Government demands that European qualifications be recognised as of equal value and offered GMC registration to these overseas doctors.
Last week I received an invitation from a company in India offering teleradiology which I reproduce in full (emphasis mine- name deleted):
"Hello Doctor !
We provide teleradiology pre reading & reporting services from India by the name of XXXX XXXX Ltd.
XXXX XXXX Ltd.offers complete, round-the-clock, fast & 98.9% accurate teleradiology services for hospitals, clinics and physicians.
We have a panel of 30 dedicated & experienced Indian radiologists interpreting MRI, CT Scans & ultrasounds. All radiologists are MD & FRCR
some of them having more than 7 years of experience in the field. We have a setup at the city of Delhi in India. We use the most
advanced technology /RIS /PACS/ Synapse/Emed that enables a rapid transmission and interpretation of diagnostic medical images.
Since in US, You need license for each state , so we can not operate directly by the name of our esteemed radiologists .So, we cater to few
US based radiologists and teleradiology who operates by their name but outsource the work to us.So less overheads and more
quality productivity for them with 98.9% accuracy level.
Our 30 MD radiologists each can read and report 16 cases a day at 12 hrs TAT (turn around time) and yet excel in terms of quality of reports. We
usually, start with a pilot service which comprises of few 4-5 test cases and then do some back log cases with 1-2 days TAT. As we get
comfortable working with each other we go live with 12 hrs TAT cases. We suggest a test sample/pilot Project to know our quality and competency level.
To ensure customer satisfaction and quality, our Quality Measurement processes document your radiologists evaluation of each PreReads accuracy. Our
Medical Quality Improvement Board reviews aggregate statistics and individual studies in an effort to help your radiologists guarantee the highest degree of clinical quality. The Board also conducts random evaluations of completed PreReads from our personnel.
We are currently looking forward to foray into the UK and EU markets for which we already have FRCR radiologists in our pannel.We shall be highly privileged to forge any alliance /collaboration with such an eminent company like you. We look forward to a long term mutually beneficial relationship with you .Hope to hear from you real soon with more of your kind suggestions.
Thanks & Regards"
So even the strict US regulations have been bypassed. It just goes to show; where money is involved the dishonest will always outwit the regulators. As Nu Labour and Societe General have found out and UK patients will soon find out.
Sunday, 20 January 2008
I am finding it increasingly difficult to blog about what I know well. Other medical bloggers seem to be having similar problems and dropping out or posting infrequently. I think I know why. The targets are becoming less obvious.
My broad-brush understanding of what Nu labour has always wanted to achieve is the wholesale destruction of the network of DGHs which provide the majority of secondary care (and NHS hospital doctor and nurse employment) in the UK. Once DGHs have gone, the vast army of NHS staff could be re-employed by the private sector at locally negotiated rates with disregard for the complex and expensive banding structure.
When Nu labour started their micromanagement of the NHS they chose a very direct, in your face, approach to dealing with the profession. This came to grief when Dr Richard Taylor successfully stood for Parliament and overturned a Labour majority in Kidderminster over the downgrading of the local DGH.
There followed a more subtle approach of "divide and rule" by which they hoped to drive a wedge between Hospital Doctors and General Practice. Separately negotiated contracts made both groups suspicious of each other and more easily manipulated by government. For example, in hospitals, the basic wage was set on a downward path relative to living costs with the additional remuneration through additional sessions and CEA awards being increasingly at the whim of managers. Similar mechanisms for political interference were set up in the GP contract. Plans were then put in place to "encourage" GPs to shaft their local NHS hospitals. An example is the provision of NHS MRI scanning by the private sector, which, had it succeeded, would have closed down DGH x-ray departments over the next few years and thus made DGHs non-viable.
It surprised me, and I think it surprised Nu Labour, that GPs put their patients' long term interests first and failed to support the 2nd wave diagnostics program and over the last few months many of these schemes have been quietly dropped.
I don't think Nu Labour have changed their ambitions but they have clearly changed their plan of attack. Alan Johnson (remember him?) has been remarkably quiet and non-confrontational, unlike his predecessors. In the meantime the focus has drifted to a direct attack on GPs. Wave after wave of bad-mouthing and spin have been used to soften them up and now the private sector (such as Boots and Virgin) are being encouraged to provide direct competition to them by providing a parallel system of primary care clinics run by the "iffy for the iffy".
These clinics will be providing some diagnostic services "in the community" and will presumably have a financial interest in referring to their own facilities rather than the consultant staffed local hospital. They are also unencumbered by notions of "professionalism" and "patients best interests" and will opt for using the service which provides the biggest profits. Thus our system of general practice, widely acknowleged to be a well performing part of the NHS, is to be sacrificed to get at the DGHs.
These are the classical tactics of a long term siege. First try an open direct attack on the walls of the castle. If that doesn't work bring in some high tech mobile equipment to undermine or scale the walls. If the high tech equipment only proves as good as the morons operating it, settle down for a long process of attrition and starve the besieged out. If supplies continue to be smuggled in, destroy the surrounding countryside too and bring in your own food supplies from a secure source elsewhere.
There are similar moves to destroy state education in rural areas. Under the guise of Building Schools for the Future local authorities in metropolitan areas are more generously funded than rural areas and in rural areas funds for new schools are only provided if widespread closures ("modernisation" in the Nu labour sense) of rural schools takes place. This is currently occurring in Herefordshire and is bringing the population close to mass civil disobedience. Public meetings are being attended by a full third of the population (almost the whole adult population once children and babysitters are accounted for) in some market towns and plans for street marches are being drawn up. Head teachers, local councillors, local MPs and even the Church have denounced the proposals.
I have been involved in my own little way which explains the drop off in postings on this blog. I haven't gone away. Nu Labour seems to have shifted its attention to destroying State Education and this is now the more important battle to be fought.
Friday, 11 January 2008
Many years ago I worked on a specialist medical unit where mortality was approximately 50% per admission. I managed to stick it out for longer than most but one day a patient complained to my consultant that he didn't like me because I didn't smile. A few weeks later my consultant suggested radiology might be a good career choice for me. It's like being told I had the looks for a career as a radio presenter.
I read somewhere once that you should want your pathologist to be a pessimist. The same applies to radiologists so I am well suited to my work. I know radiologists who are nice jolly people and they don't make very good radiologists. I, on the other hand, start off with the assumption that each scan I look at harbours a tumour which is going to cut short a life and destroy a family. All I have to do is keep looking until I find it. I think it makes me a good radiologist but a miserable person to know.
I awaited the results of our Local Authority Review on Education suitably pessimistic. In fact I was planning the next stage of the campaign to save the school and was looking into the cost of banners to drape across one of the main route from Mid and West Wales into England which passes through Staunton-on-Wye and wondering if I could cut templates out of X-ray film so that a crack squad of villagers could go out at night and spray paint our slogans on public buildings.
When the result was published today there was no mention of our school but an axe had been taken to primary and secondary education in Herefordshire. Some of our best schools were to close or be incorporated into unpopular ones. Some parents who had recently moved to the area and bought a house near a good school saw their plans ruined. The cuts were more savage than anyone had expected and most people in Herefordshire had no idea that such cuts were even being considered. Parents in Herefordshire are in a state of shock tonight as they begin to plan for transporting their children across the county to the surviving schools or figuring out if they can afford to educate their children privately. In one move, and without consultation, a small unelected group of officials have hatched a plan to deprive the population of a high quality local education for their children. Without warning, headmasters and mistresses at 37 schools were told they are to be made redundant and will have to apply for any remaining jobs.
I don't know a great deal about political interference in local education but there is the "Stalinist Central Control's" fingerprints all over this. The local education department claimed the closures were necessary to access central government funds for new buildings. This looks very much like the privatisation of education. The plan goes like this. Close the existing locally managed schools or else be starved of funds. In return for closures and staff redundancies Central Government will provide a shiny new school (preferably in a Labour voting inner city area) built with PFI money and owned and run by a NuLabour supporting private company. Employ staff under locally negotiated (imposed) T&C of service and make sure the person in charge of the school is a Believer and "on message". Far fetched? Well I always look on the dark side but isn't this what is happening in health care?
My children have not been completely spared. The state school we chose is to lose its 6th form requiring them to go to a ghastly "sink school" on the rough side of town which, instead of being closed down, has been increased in size and given a new name and fancy website. I don't know if they removed the razor wire and security cameras when they changed the name; its not a part of town I ever venture into.
Tuesday, 8 January 2008
With political interference and social engineering in state education and with my own children of primary school age, it was inevitable that I would be drawn into campaigning not only for the local district general hospital but also for the local village school.
The school at Staunton-on-Wye, a village close to the Welsh border in Herefordshire, was opened in 1860 and is in a Grade II listed building on three floors. It was originally built with money given to the region by George Jarvis, a local boy who made his fortune in London in the 18th century. The charity still owns the building although the school is now run by the local authority.
The historic buildings and generous surrounding land have served the local children well but are poorly suited to modern safety regulations and inclusion of adults and children with disabilities. Plans were made to move the school to a new building. Land was bought and funds for the new school were secured.
Late last year the local authority announced that it was reconsidering whether to allow the new school to be built because making this excellent school even more attractive to prospective pupils would threaten the viability of less popular schools. Furthermore the local authority argued that demand for school places was generally in decline and wanted to reduce school places by shutting schools.
The logic that a lower standard of state education was preferable to allowing the parents any choice struck me as typical Soviet-style government of the type which gave the lucky folk of East Germany the Trabant car (if they could bribe an official or were in the political ruling class, that is - otherwise they had to wait 15 years). The population trends were based on the 2001 census and have recently been shown to be highly inaccurate and underestimated immigration and the effect of increased birthrate in the indigenous population. We are currently seeing the chaos of this underestimate on midwifery services and we shall see the effect on schools in a few years just as school places are cut.
Deaf to our reasoned arguments the education department is due to announce school closures on the 10th January and we fear the worst.
On the radiology front things have been more positive.
On Monday Gordon Brown announced that the NHS was going to set up screening programs for stroke, heart disease, renal disease, diabetes and aortic aneurysm. Obviously the medical readers will recognise that this is basically meaningless waffle. Screening for stroke, diabetes, heart disease and renal disease presumably means having blood pressure and bloods taken, which I see from a flyer I got with my Clubcard statement this week, is being offered by Tesco for £10 (with a pedometer thrown in) and is already available for nothing from your friendly GP.
Aortic aneurysm screening is more interesting and Gordon was suitably vague. Very large studies published in the last few years have shown screening for AAA is both cost effective (by NHS criteria - less than £36000 per year of life saved) and offers benefit to men in the 65-75 age group. This is only true however if operative mortality is less than 5%. Ultrasound screening of the at risk group is relatively easy - even Mercury Health might be able to manage this with a few hundred imported Eastern European sonographers and it would go some way to compensating them for the loss of the MRI scanning contracts. The treatment of aneurysms however has to be done at a specialist centre with ITU facilities and the extra work would completely overwhelm the system. When I set up Aortascan, our private aortic aneurysm screening service in Hereford, I anticipated that NHS screening would be hyped up and publicised and then inevitably rationed, creating a demand for private scans. This is exactly what seems to be planned. The scans are going to be phased in for 65 year old men some time before 2011. What are the 66-75 year olds going to think about this; after all they are at even higher risk? What about women? The studies are in favour of screening for men but women die of aneurysms too. How is the government going to refuse screening for women without running foul of sex discrimination law and, more importantly for Nulabour, losing popularity?
The Conservative Party website called the announcement "chasing headlines" and allows reader comments on the issue. I am eternally grateful for someone who has posted the information that, instead of waiting for Gordon's largess, private scans are available for £50 at http://www.aortascan.co.uk/
I now have Gordon Brown pumping up demand for our aortic aneurysm screening service and David Cameron carrying an advert for our service on his website! You would have thought, with a team like this behind me, I would be inundated but the only call I had today was a Sun reporter who wanted to interview me. Our hospital corporate affairs director told me to steer clear and despite the lost publicity for our service I thought it was probably good advice. I really don't want any "Hospital Consultants Cash in on Patient Misery" headlines with my photo underneath.
Anyone know what Dr Grumble is up to? He has made his blog private and I don't have permission to view it. Was it something I said?
Sunday, 30 December 2007
As MRI scanners became more widely available and patients began to shop around, or even go abroad, for their scans MRI providers began to compete on price.
I think the first to break ranks was the Cobalt Appeal in Cheltenham, who suddenly found themselves with vast overcapacity for their mobile service as hospitals in the West Midlands installed their own fixed scanners. As a registered charity they have financial advantages over purely commercial organisations and could also rely on charitable donations to provide working capital, rather than have to borrow money at commercial rates.
With little competition and clever marketing to potential referrers and directly to the public they established themselves fairly firmly as a low cost quality provider and drew patients from throughout the UK.
Last year Vistadiagnostics in London entered the market with a variable charging structure depending on the time of day but as low as £250 for one area and actually cheaper than the Cobalt Appeal for multiple areas and for contrast enhanced scans. Their business is based on the EasyJet model and relies on using the scanner 7 days a week for 13 hours each day with aggressive promotion of their service. I think this was quite a risk because rents and radiographers still have to be paid if the scanner is idle and costs in London are high. With such narrow margins they could only survive if they ran the scanner at full capacity.
They had the lucrative London market to themselves for about a year but just before this Christmas, Med-Tel, another private scanning centre in the City, announced a "special deal" matching Vista's prices for MRI. Not to be outdone Vista has taken the classic poker player's route and upped its stake and cut its headline price to £200.
Both companies are haemorrhaging money with Google pay-per-click advertising campaigns and, unlike the Cobalt Appeal, can't rattle tins at village fetes and shopping centres to restore their cash flow. It looks like the town ain't big enough for both of them and I foresee the one who blinks first will be eating dust before the new year is out.
Meanwhile, our private scanning enterprise, UK Radiology, which still offers scans cheaper than all of them, sailed serenely on, gradually taking business off the commercial scanning centres and Cobalt Appeal while spending virtually nothing on advertising. Irritatingly though, after my self-contented last post on this blog, it has disappeared off the first page of Google again for the search term "private MRI scan". I think getting a high Google ranking is a bit like sailing a tanker. Where you are now depends on actions taken weeks or months before and I now realise I had become complacent over the year and took my foot off the throttle (sorry about the mixed metaphor - do tankers have a throttle?). Out of interest I looked into the cost of pay-per-click. To put a company's link in the first four places for the search term "private MRI scan" costs 0.43p every time someone clicks on the link. Google accounts for around 75% of my visitors and if I were in the first four places it would be many more. Based on the number of click-throughs I get from Google, Met-Tel, Vistadiagnostics and Cobalt Appeal must each be spending hundreds of pounds every month on Google. At the margins they are working to now and with unused capacity that must be hurting.
A happy and prosperous New Year to all my fellow bloggers and readers. (Especially Dr Crippen - I hope you decide to come back next year- even if its just the occasional blog).
Wednesday, 19 December 2007
When I wrote my article last week I meant to mention one other development which had cheered me up but I forgot at the time and, when I remembered, the moment had passed. What I was going to add was that the CT screening companies, the prostitutes of modern healthcare, were coming under critical examination.
Many people in the profession, and in particular Radiologists, have been alarmed by the lack of regulation of these companies and their direct marketing of CT scans to the worried well for purely profit motives.
The screening business had flourished for a time in the USA but, as the public became better educated and began to realise the lack of evidence for the claims the companies were making, there has been a tail off in demand. In the UK we are still on the upward slope of the curve with the worried well believing the claims that the scans can find your cancer and thereby allow you to be cured by timely surgery.
Considering the close regulation of industries which expose people to ionising radiation I have always been puzzled by the way these companies are allowed to irradiate the public with no proven evidence of benefit. The irradiation of someone without informed consent is technically assault. In hospitals we generally assume consent for irradiation but each investigation has to be justified such that we are satisfied that the benefits outweigh the risks. The benefits of screening CT are largely anecdotal so, by definition, the benefit/risk ratio is unknown and I cannot see how someone can give informed consent. I presume they ask the punters to sign a disclaimer rather than a consent form.
Anyway, last week there was a Jeremy Laurance article in The Independent that raised the issue of the dubious claims made for these "medical MOTs" and the risks to the unsuspecting public. This week calls for regulation have been made by COMARE, a government advisory panel on radiation. Even Liam Donaldson stuck the boot in.
Now, like many other bloggers - most notably DK, the news that an unelected, pressure group want to inflict more regulation and restrict the individuals choice does not generally cheer me up but in this case the public really does need to be protected. The very same public who worry about living close to a power line or having a mobile phone mast near their childrens' school are quite happy to part with anything up to £1300 to be subjected to radiation doses similar to those which caused excess cancers following the use of nuclear weapons in Japan.
Dr John Giles, a radiologist who runs Lifescan, one of the more aggressive and successful "radiation-for-reward" companies put a brave face on it today, claiming that he welcomes the report and, bizzarely, that Lifescan don't do screening scans but target individual organs. This might wash with the gullible public Lifescan usually deals with but as a radiologist he knows that CT scanning doesn't target individual organs; everything in the region scanned is irradiated. If he "targets" just the lungs and bowel that is a screening scan of the whole torso. Notwithstanding Dr Giles' welcoming of the report, COMARE states "...we have strongly recommended that services offering whole body CT scanning of asymptomatic individuals should discontinue to do so."
In fact its probably a distraction to focus too much on the radiation risk, which is unquantified for small doses. The main problem with the "scans-for-spondulis" companies is that they make unsupported claims of benefit, expose patients to the anxiety and physical risk of further investigations, and cost the taxpayer a large amount of money.
The scientific evidence in favour of screening is notoriously difficult to prove. There are still eminent scientists arguing whether breast screening is effective. CT screening for cancers is much less studied. Some cancers will not be reliably detected, others will be detected too late to alter outcome and others will be detected that would not have shortened the patient's life anyway. The best example of a cancer that is worth finding and is often picked up by chance is a renal tumour. You will find this mentioned in all the testimonials ( an indication of quackery) on the scanning company websites. The other abnormality worth finding is an aortic aneurysm. Both are easily picked up on a £50 ultrasound.
The anxiety, physical risk and cost to the taxpayer stem from the large number of false positive scans. These are scans that either show something which looks abnormal but isn't present or something that looks serious but is harmless. The scanning companies don't reveal how many "patients" have false positive scans but, in my experience, the majority of patients will have either a cyst or haemangioma in the liver, a cyst in the kidney or a solitary lung nodule. These patients would need a further investigation such as ultrasound, a repeat CT with contrast, a repeat CT after an interval or even a biopsy. Many of these would look to the NHS for these further investigations and some patients will suffer as a result of unnecessary biopsies.
Patients often contact me for screening scans and I find it difficult to explain why we don't offer them at UK-Radiology. The first time I was asked I wrote a long thesis on the scientific arguments; there just isn't a quick way to explain it. Now I say we don't consider it ethical and send a copy of my reasoning. I have been thanked a few times. If I were a quack I could use the comments on my testimonials page!
The other bit of good news this week is UK-radiology's return to first page of Google for the search term "private MRI scan". My colleagues simply don't appreciate how difficult and labour intensive it is to do this. Some have even criticised my methods (i.e. this blog - they haven't found out about my other methods yet). The easy way would have been to copy our competitors, charge the patients an extra £50 each and buy a pay-per-click campaign. That would have left me my last month's evenings and weekends free for me to enjoy away from my PC. Then again, we run an ethical company.