Friday, 25 January 2008

Trust me. I'm a doctor.

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 Before Mercuryhealthcare had their MRI contract withdrawn, their business plan involved sending the scans to Hungary for reporting.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 radiologist’s evaluation of each PreRead’s 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

Nu Labour, Nu Tactics

Nu Labour's Nu battleplan

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

Staunton-on-Wye Part II

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

Staunton-on-Wye School

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
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?