Monday, 30 July 2007

Of mice and Milburn

2nd wave diagnostics was a scheme originally promoted by former Health Secretary Alan Milburn as a way of transferring diagnostics from the NHS to the private sector where it could be done more "efficiently" by lower skilled and lower paid folk from Eastern Europe. He was a paid advisor to Alliance Medical, a company that expected to benefit from such work.
Alan Milburn was one of the more disliked of our recent Health Secretaries, especially by Gordon Brown who feared him as a prospective "Stop Gordon" candidate, so it is with great pleasure that I report that the whole 2nd wave diagnostics scheme is beginning to look sickly.
There have been a number of signs that things were not going to plan. BUPA pulled out of the contract on the South Coast and were replaced by a building company called Carillion, causing the start date to be delayed. The Group who won the London contract initially wanted to recruit UK radiologists at Eastern European rates of pay but they have found few takers. Now Atos Origin, a French company who had won the contract to provide diagnostics in two regions, has been sacked. They were due to start the service last April. Atos also has the contract to provide Choose and Book - the other useless and unwanted scheme burdening the NHS.
It all looks like its quietly going to go the way of Milburn and disappear into the dustbin of failed Nulabour hopes. Good riddance.

Friday, 27 July 2007


Its all gone to plan and I am registered with The Motley Fool again (see previous post).

Yesterday I went to post something on the back pain forum but, instead, I found a really good link to a site devoted to exposing health fraud and quackery written by American doctors. As I mentioned before, this was the original role of the GMC but they are now too busy using our money persecuting doctors and sticking their heads up politicians backsides to do this and it seems the whole country is now wasting its money on faith healers, fad diets and food supplements with no-one interested in protecting the gullible, vulnerable or stupid from being fleeced.

There is a touch of Emperors New Clothes about it too and anyone who is prepared to say what most scientifically literate people know is the truth about food supplements or homeopathy is denounced as narrow minded or protecting their own status and interests.

This sort of quackery does blend into the sort of quackery that we see in the NHS where opinion and bullshit count for more than hard work, intelligence and experience. If you have time to read some of the articles on Quackwatch you will see that the snake-oil salesmen use much the same terminology and selective quoting of dodgy research to justify their existance. Embarrassingly, the author quotes the use of the word "holistic" as one of the giveaway signs of quackery. I used this on my uk-radiology website and have been known to describe myself as a "holistic radiologist". Obviously this is a meaningless term and I originally used it as a joke but it seems to tick all the right boxes and no-one has queried it. Somehow it conjures up a softer, gentler image of radiology than the use of Hiroshima levels of radiation justifies.

Tuesday, 24 July 2007

Black-balled by The Motley Fool

People have different reasons for writing blogs and I was surprised to hear on Radio 4, this evening, that blog writing popularity had actually decreased from 15% to 12% of internet users. Personally I find it difficult to believe it is anywhere as high as 12%.

Anyway, some write a blog because it helps them set out their thoughts, others lead a sad and lonely life and want to leave their mark and others do it for financial gain. I am happy to admit that I started this blog as a way of driving traffic to UK-radiology and maintaining its first page Google listing. Once I started writing it I found myself making political statements on it, which, from the business point of view, might seem a mistake, but no-one is going to read a blog which has nothing of interest on it (I assume someone does read this but as I don't get stats I might be wrong).

One of the other ways I seek to drive relevant traffic to UK-radiology is by contributing medical information to health discussion boards. I don't spam them of course but I look out for discussions where my radiology knowledge is helpful. It should be obvious that a doctor can't do this under their real name or give specific medical advice so I use one of a number of nicknames. If permitted I give my website URL in my signature or on my profile but if not permitted I usually tell readers to look on the internet and not pay more than £200 which just about narrows it down to our group without actually naming it.

Last week, the moderator on The Motley Fool, a financial website with a very small health discussion board, deleted my posting because I had, in truth, gone over the mark and put my URL on it. As a site which depends on advertising income they certainly don't want to offend BUPA or one of their other sponsors. Fair enough, so I posted again and this time just indicated that readers don't need to pay more than £200 for an MRI scan. Instead of deleting this post the moderator posted a public reply accusing me of posting under a nickname to mislead the readers and listing other examples on other websites where I had also posted under the same nickname. Now that looked bad though, in fact, it was quite proper; the moderator was posting under a nickname too. Funny thing was that the idiot went further than I dared and provided a valuable hyperlink to my website from the Motley Fool. I was thinking that "any publicity is good publicity" and was going to leave it there but it didn't fit with our image of a sincere and ethical company so yesterday I emailed The Motley Fool and asked to be voluntarily struck off their register and have my postings deleted, which they have now done. Obviously they had to delete their allegations too.

I'll give it a couple of days and register again under a different name;)

Wednesday, 18 July 2007

The Great Escape

Many people, who do not work in the NHS, must think doctors are an ungrateful lot. Largely educated at public expense, paid huge amounts of money and doing a job most admit they enjoy doing, and yet they complain; usually about politicians or hospital managers.
Just to give an idea of what we put up with and what is p!ss!ng us off I have reproduced an email sent out this week to all the consultants at a Trust somewhere in the UK (I have taken out the initials which identify the Trust and replaced them with ....):


1. Introduction

This paper sets out for discussion a (high level) outline approach to the development of a medium term strategy in line with the logic of ‘The Great Escape’.

2. Some context

‘Strategy’ is defined as follows

• Strategy is about role and direction
• A strategy should be based on an analysis of the external forces and drivers for change impacting on the health care system and/or individual services
• This environmental analysis should in turn drive a definition of organisational purpose (mission) and the development of a set of organisational values or decision making criteria; mission and values in turn should shape stakeholders thinking about service development, service design and service delivery together with the nature of the relationship between partner agencies.
• A strategic plan needs to cover a minimum of five years and specify key milestones.
• A strategic plan must be explicit about both income assumptions and the balance between costs, volumes and quality.
• A strategy should be sufficiently succinct for service staff to carry it ‘in their heads’

The key force or driver for change in an NHS which is moving towards a competitive market-driven regime is the aspirations of ....’s customers: PCTs/ LHBs, GPs and individual patients.

It also needs to be recognised that strategy formulation and execution is as much a micro – political process as a technical one.

3. A suggested approach

A three stage approach based on a modified version of the ‘top down, bottom up, top down’ model is suggested. It also suggested that the process is overseen by a reference panel made up of representatives of the PCT/PBC groups and .... LHB, local politicians, members of the public and senior clinical staff (possibly based around the existing FT Project Board?). The development of the strategy will need to be supported by a managed communications plan.

STAGE 1: Production of an .... strategic framework

The objective of this stage is to agree a Trust level strategic framework to provide the parameters for more detailed directorate and care group level clinical strategies

The strategic framework will be based primarily on the IBP and outputs to date from ‘The Great Escape’.

STAGE 2: Production of directorate level clinical strategies

The objective of this stage is to develop draft directorate and care group level clinical strategies.

This more detailed work would involve workshops focused on answering the following questions:

1. What are the forces and drivers for change impacting on and shaping the future of .... and the services provided by the directorate?
2. What gaps or weaknesses are there in the services provided by the .... and the directorate?
3. What are the outputs of any benchmarking exercise?
4. What issues (relating to capacity and efficiency in particular) do ... and the directorate face in delivering access targets and other S4BH core standards?
5. What ‘fixed points’ are there in ...’s strategic ‘trajectory’ over the next 5 – 10 years?
6. What values or deign principles should underpin the development and delivery of ...’s services (including expectations of partners within the local health and social care community)?
7. What are the options for service delivery and what is ...’s and the directorate’s preferred direction of travel?
8. What are the corollaries of this direction of travel in terms of location, site usage and accommodation?
9. What are the critical success factors in realising the preferred direction of travel?
10. Of these critical success factors, what is the top priority?

Debate at the workshops will be supported by where possible by ‘hard’ analysis of demand/workloads, changes in clinical practice, policy and comparative performance. Critically, the resulting draft strategies will be need to be ‘owned’ by the relevant clinical teams and ‘signed off’ by commissioners and patient groups. The Medical Director will have a particular role in challenging and supporting the work of the clinical teams.

It is suggested that a consensus development conference is run to secure the ownership and sign off required. The conference consensus (which would need to run for between one and three days) would be divided into two parts:

• Part one: An internal ... event in the course of which the Medical Director and Care Group Clinical Directors take the lead in ‘cross referencing’ the draft clinical strategies to ensure consistency with the strategic framework and with each other and in ensuring that their contents represent a robust and ambitious set of proposals.

• Part two: An ‘external’ event to which .... customers (commissioners, GPs and patient/ public representatives) are invited to review and comment on the emerging clinical strategies.
Each strategy will need to be tested for affordability in advance of its submission to the Board for approval in principle.

STAGE 3: Production of the Trust strategy

The objective of this stage is to review/refine the clinical strategies and incorporate them into an overall Trust strategy for approval for the Board.

This will involve the Board and Executive Team ‘reading across’ the clinical strategies to ensure that they complement each other and testing them against the strategic framework for consistency. The resulting Trust service strategy can then be amplified to incorporate a capital and financial strategy. The role of the reference panel will be to ‘referee’ the development of the overall Trust strategy. The Trust strategy will be tested in a second consensus development conference for stakeholder groups before formal adoption by the Board.

4. Timelines

The key determinant of the timetable for delivery of a formally adopted/ Board approved strategy is the FT application process.

5. Communications

Although the primary focus is on the engagement of clinical staff, workshops for non – clinical staff and support organisations employing the format set out in section 3 will also be organised.

A week long interactive exhibition to attract patients/ visitors sited at a suitably prominent part of the hospital will be organised.

Invitations to the Consensus Development Conferences could be extended to members of existing patient groups. Certainly the opportunity to participate in dedicated workshops would be provided.

Finally (in support of increasing FT membership) a suitably amended version of the attached would be widely distributed.

6. Recommendation

The management team is asked to discuss the above."

I don't blame anyone for giving up after the first couple of lines and if you did read it all I don't blame you for not understanding it. No-one does understand it but the "logic of The Great Escape" is intriguing. Several senior managers at the Trust where this email was circulated have already made their Great Escape and some now work for the private sector so perhaps they are suggesting the managers plan their exit before the DGH is closed down. Here is an email reply sent by one of the Consultants which I thought was funny:

"I've worked it out I think!! In the classic film a huge effort was put into the planning and execution of the escape involving extensive team working and coordination. Unfortunately, although the escape went ahead, the end result was unsuccessful; all the escapees except one (Charles Bronson) were recaptured and if I remember correctly rounded up and summarily executed. Thus the take home message was that despite all the careful planning and teamwork and effort, the plan was ultimately comprehensively thwarted. So what's new about "The Great Escape" thinking in NHS strategy??"

This report was written by a highly paid director while the Trust is making front line staff redundant. And you all wonder why we complain.

Monday, 16 July 2007

Scanning charlatans to be brought to order.

While the GMC has taken its eye off the ball in order to apologise on behalf of all doctors for the actions of a mass murderer it has forgotten its original role in protecting the public from quacks and charletans. This has allowed patient-for-profit companies such as Prescan to offer private screening scans with unfounded claims of the benefits and no regard to the risks.
It now looks like the Government may be stepping in to make up for the GMC and the Royal College of Radiologists inaction and are set to introduce legislation to curb the excesses of private screening. Here is an article I found on Medicexchange

Private medical screening faces regulation in UK
by Tim Castle

Companies selling private medical screening face government controls over concerns the tests make patients anxious and put pressure on the National Health Service, a senior medical advisor said on Thursday.

Muir Gray of the government's National Screening Committee (NSC) told medical magazine Pulse that the private health sector needed regulating over the tests.

Medical screening on offer from private firms ranges from cheap cholesterol checks to whole body scans costing thousands of pounds.

"We are thinking of how we control private testing because it's an example of low value activity which generates work for the health service, may cause harm and does not benefit the individual," said Gray, the NSC's programme director.

"Lots of GPs I know are very concerned about people who go to a private clinic for a blood test and then the people who run the private clinic say 'Oh your kidney results look a bit funny -- just go and see your GP'," he added.

Since 1996 the health service has had to submit all new screening programmes to the NSC to ensure they are effective and beneficial to patients.

Gray said private sector screening also needed to be controlled.

"We'll look at different forms of regulation -- some from the Healthcare Commission, some through the Advertising Standards Authority, some through the Office of Fair Trading. It will be an evidence-based regime," Gray said.

"I don't think we've got a proper system of regulation at all for the independent sector," he said.

The Royal College of GPs backed the concerns. "Screening is becoming increasingly popular and is not without hazard if done in an unprepared way," said RCGP chair Mayur Lakhani.

"Working to national standards would bring added peace of mind," he added.

But leading providers of private testing vigorously defended their services.

Private medical group BUPA said more than 80 per cent of its customers had health insurance and so any follow-up tests or treatments were usually covered with little or no impact on the NHS.

"BUPA health assessments provide early detection of many serious and life-threatening diseases from high blood pressure and diabetes to cancers and stroke," said BUPA Wellness Assistant Medical Director Peter Mace.

"They also save NHS resources by dealing with minor problems during the assessment or at subsequent follow-up appointments," he added.

Simply Health, which includes medical insurance company HSA and testing firm Your Health Screening, said it did not offer tests of "dubious value".

"Our screens are based around mainly heart and lung disease, which are widely recognised to have a significant impact on the health of the nation," said Simply Health Chief Medical Officer Malcolm Stone.

The Department of Health said it had yet to receive the NSC's advice on private medical screening, but would consider its recommendations carefully.

Source: Reuters

Dr Ray has dipped his toe into the screening business with private aortic aneurysm scanning. Increased regulation will be unwelcome but the case for screening for aortic aneurysm has already been accepted in the UK and USA and it's just a matter of the government deciding who should be doing it and how they can cope with the entire cohort of 65-75 year old men all arriving for a scan on day one. For £50 quid I would not hang around while they decide how to "manage demand".

Friday, 13 July 2007

Private vs State Healthcare

Readers of medical blogs will know that the most heated debates revolve around the best way to provide health care. Unfortunately, for all the heat there is little light and the protagonists remain entrenched in their positions.

The right wing, free market supporters argue that health care would be better, and even possibly cheaper, if patients could take their custom where they choose while the supporters of socialized health care argue that a comprehensive, fair and truly national provision can only be provided by the state run N.H.S.

I think that the problem is that we are not arguing about the same thing. It has long been a Nulabour ambition to abolish private medicine in the UK and it is also a Nulabour ambition to destroy ("modernize") the network of District General Hospitals which form the backbone of the N.H.S. Abolishing private practice at a time when the government were pledging to cut waiting lists would have been suicide and this was put on the back burner. Dr Richard Taylor gave Nulabour a drubbing over the "modernization" of the D.G.H. at Kidderminster and continues to be a thorn in their side as an MP, so more subtle means had to be employed.

The Nulabour plan, and it seems it will be continued under the I-had-nothing-to-do-with-Nulabour Brown Party, is to pay private companies to take over the role of the N.H.S. This is not the same as private medicine and it is this involvement of the private sector that I, and many doctors object to. This untried experiment in health care will combine the worst aspects of profit hungry, short term interest, Venture Capitalists with the take-it-or-leave-it attitude of a monopoly provider and employer. It will do nothing to improve patient care, safeguard employee conditions or provide for training and future development of services. The potential for chaos and disaster is huge and unknown.

We have seen Mercury Diagnostics win a contract to provide scanning in the W.Midlands on such generous terms (all set up costs and 80% of income guaranteed for 5 years) that it immediately sold the contract on for £77 million, without ever providing one scan. This was taxpayers money essentially given away. Contrast this to when telecom operators bid for 3G licenses about 10 years ago which brought in £billions to the state at the expense of private companies. We see the same process with PFI, where private companies are paid so handsomely that some building companies (eg Laing) now find that there is more money to be made from winning contracts from the Government and selling them on than in actually doing any building. The government is essentially subsidizing private companies to compete against the N.H.S. and then arguing that the private sector can do it better and cheaper. There is some evidence that this policy is beginning to collapse and even Nulabour are unable to continue to claim it has been a success.

Readers may know that I work in the NHS and I have also worked in a private, not-for-profit hospital in the U.S.A. I also work in a private, not-for-profit hospital in the UK and I am also trying to provide a private service within an NHS hospital via UK-radiology.

My experiment with UK-radiology continues to succeed and, to me, represents the way forward. Whereas before, the managers got a bonus if the consultants worked harder, I have been able to align the consultants interests with that of the Trust by providing reward for private work consultants do in the Trust. This means that the consultants can use their ability, ingenuity and capacity for hard work to attract income to the trust. The income is used to fund improvements to the NHS service and protect NHS jobs so that capacity is not lost. This, in turn, will allow us to compete with the private sector NHS providers and maintain a real choice for both NHS and private patients.

Control needs to pass back to the doctors as we have a long term interest in health care provision, as employees, entrepreneurs and potential patients. Venture Capitalists, Chief Executives and politicians move on when they see there is money or votes to be had elsewhere and can afford private health care for themselves when required. When all the political interference is over we will still be there sorting out the mess.

Wednesday, 11 July 2007

No change in the NHS-the destruction to continue.

It is becoming clear now what Gordon Brown meant when he said that there would be changes in the way politicians deal with the NHS.

The more gullible of us thought he was going to end the micromanagement, doctor bashing and confrontational stance taken by Patricia Hewitt and the previous Government, but those of us who saw how Gordon worked while he was in opposition knew that what he says is seldom what he means. It now seems that the only change is to be an acceleration of the disastrous policies started by Milburn and taken up so incompetently by Patsy Halfwit
The Grauniad has an interview with Ara Darzi who, it seems, has been chosen so as to suggest that the medical profession actually agrees with the transfer of healthcare to the patients-for-profit sector and loss of local NHS facilities.

This looks like it might be quite bloody and I think Gordo's honeymoon might be short lived unless Ara is told to shut up and go back to his White Elephant of an underutilized* ambulatory care and diagnostic centre at the Central Middlesex Hospital.

When Ara recommended that the good folk of South Teeside might like to manage without a local hospital it caused a storm of protest. Now he is suggesting selling off the land that the London local hospitals stand on and (presumably) giving the money to the private sector to run shiny walk-in clinics for people with "nice" diseases. He doesn't say what will happen to those too old or sick to walk in.

* What is the current unfunded spare capacity in NHS treatment centres, including NHS Elect? (Dr Taylor, Q74)

In the financial year 2003-04, for the four treatment centres which are members of the NHS Elect network (Central Middlesex ACAD; Ravenscourt Park; Kidderminster; Weston-super-Mare) management information shows that they were working at 81% of their planned activity. So far in this financial year (to August), management information shows that they have working at 78% of their planned activity.

Sunday, 8 July 2007

Modernisation out; change in.

One of the most irritating things about Nulabour and the NHS was the way it commandeered the word "modernise" to hide its intention to dismantle the NHS and hand over health care to the private sector. Nulabour has made an art out of euphemisms and modernise (used in the sense that the Luftwaffe modernised Coventry) is a particularly clever one because anyone who objects to "modernisation" is, by definition, a backward looking dinosaur who is stuck in the past and not to be taken seriously. Unsurprisingly, not many people want to be thought of like this so find it best to say nothing, which gives the modernisers a free hand to do whatever they want. In fact the use of the word "modern" was so successful that they named the department tasked with destroying the NHS the "modernisation agency".
It never really worked for me. I suppose the strategy was devised and aimed at people a little younger than me, but for baby-boomers "modern" conjures up images of streaked concrete council flats (a product of the Modern movement and modern materials) and exquisite antique furniture being painted white so that it looked like something from Habitat - the iconic modern furniture shop of the late 60's
Gordon Brown doesn't seem to do "modern" but he does seem to want "change". I am not quite sure what he means. Is he admitting his Party has been wrong for the last 10 years and is going to try something else or does he mean he wants to continue the change where modernisation left off. Appointing Ari Darzi as health minister and asking him to review the NHS was clever. In one move he has silenced the doctors that want clinicians to decide health priorities and, at the same time, appointed the very same person whose ideas have driven the changes in the NHS that they dislike (ISTC, closing DGHs) to a position where he will essentially be reviewing his own ideas. I suspect that, at the end of his review, he will not be handing back his knighthood in disgust over the "modernisation" of the NHS.


While on the subject of "modern" I was treated to an amazing aerial display yesterday evening. There was an airshow featuring a Spitfire locally but, I think the pilot must have found it a bit tame so, in the early evening, flew out to the rural area where I live and for about 45 minutes put the Spitfire through its paces with a series of stunts I am sure would not be allowed at an airshow. He flew at tree height and did loops and spirals. He flew low and fast and climbed almost vertically. All the time the engine kept its same throaty rumble without any evidence of stalling or strain. I could not believe a piece of machinery approaching 70 years of age could work so sweetly.
Today I decided to cut the grass and got my modern ride-on mower out. I have had it since November but I have only used it 4 or 5 times because the front axle broke the second time I used it and it was out of action for a few weeks. Half way through doing the lawn it just putt-putted and stopped. No obvious reason. I will be lucky if this mower outlives its first oil change.

Monday, 2 July 2007

Sir Liam vindicated

The revealation, in the papers today (Doctors of Death-The Sun), that one of the people linked to the terrorist attack on the departure lounge at Glasgow Airport is a doctor entirely vindicates Sir Liam's belief that doctors need much closer and more onerous monitoring. Had recertification been in place for all UK doctors, it seems very unlikely that this terrorist would have taken the trouble to complete all the paperwork required and would have carried out his terrorist act somewhere else.
I would go further than Sir Liam over this. Our medical schools have now trained one mass murderer (Shipman) and one failed mass murderer. It doesn't need a brain surgeon to reach the obvious conclusion here. The more doctors we have, the more potential mass murderers. Therefore introduce systems to ensure that the lazy, greedy, murdering barstewards f**k off to Australia and we will have less mass murderers to deal with. Replace these murdering scum with nice cuddly nurses and mass murder will be a thing of the past.
Furthermore, I firmly believe that the standards of proof in legal cases involving doctors should be lowered on the assumption that they are all terrorists or capable of terrorist actions or, indeed, capable of terrorist thoughts (be afraid Dr Rant, be very afraid). This would allow the authorities to detain them without trial rather than just vilify them without trial as at present. In cases where any proof might be difficult to obtain it would allow for summary execution or, at least, a jolly good shooting.