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Archive - Year: 2010

July 23, 2010

Dr Phil’s Private Eye Column Issue 1268, July 21, 2010
Filed under: Private Eye — Tags: , , — Dr. Phil @ 2:20 pm


Just had a phone call from a very reliable source about the Oxford heart inquiry, due to report on Thursday, I believe. Apparently big failures in clinical governance and oversight at trust level, lessons not learned from Bristol etc but despite that, the Oxford unit has asked to be allowed to continue paediatric cardiac surgery. I strongly believe it should remain suspended pending the findings of the latest paediatric cardiac services review. Decision rests with the SHA. Who will take these decisions when there’s no SHA?

 Medicine Balls: The White Paper

How does Andrew Lansley’s Equity and Excellence: Liberating the NHS compare to White papers past? Frank Dobson’s  1998 bestseller, ‘A First Class Service – Quality in the new NHS’  gave us 191 mentions of ‘quality’ and promised to ‘publish outcomes to end unacceptable variations in health care.’ A decade later, Lord Darzi gave us ‘High Quality Care For All’ with 359 exhortations of ‘quality’ and a warning that the ‘unacceptable variations that have grown up in recent years must end.’ Lansley is also a firm believer that the way to achieve ‘quality’ (110) and to end ‘unacceptable services’ is to publish ‘outcomes’ (85). But after 13 years of Labour, we have precious little access to robust and valid comparisons of different clinical services. And without outcomes, offering patients ‘choice’ (Darzi 62, Lansley 84) is pointless, and you can’t ‘commission’ (Lansley 184) excellent services.

 There will always be variation in healthcare, and collecting and analyzing outcomes to try to understand which variations are due to chance and which to unacceptable practice is both complex and expensive. Labour made little headway and most commissioning was done on the basis of cost. So various PCTs gave Out of Hours Services to a company called Take Care Now because the price was right and they sounded as if they cared. Alas, they employed overseas doctors who didn’t know the patients, didn’t know how the NHS worked and didn’t understand how to use drugs like diamorphine. Dr Daniel Urbani killed David Gray by injecting him with ten times the safe dose because he was exhausted, had poor English and the drug was not routinely used in Germany. Prior to his death, two other German doctors had made similar errors (without causing death) but despite warnings from one of its own doctors that ‘it was only a matter of time before a patient is killed’, Take Care did not take note.

 One way to stop doctors giving ten times the dose of diamorphine is to not allow them to walk around with it in their bags. I’ve only ever carried one 5mg ampoule, so why Dr Urbani had 50mg or more on him is a mystery to most GPs. Lansley said before the election that he was going to put GPs back in charge of commissioning out of hours care, and it makes sense that clinicians should help commission and manage the services they know most about. Indeed Lansley is very big on services being ‘clinically commissioned, credible, approved, led and justified.’

 But just who are these clinicians? Midwives get 1 citation in Liberating the NHS, nurses 2, pharmacists 2, consultants 5 and GPs….. 75.  ‘Manage’ gets 43 citations but ‘manager’ only 3. GPs, apparently, can do it all by organizing themselves into ‘consortia’ (new entry, 64). Lansley has picked up the Tory baton from where it was discarded 13 years ago, just as fund-holding GPs were pooling themselves into multifunds, only to be scrapped by Labour and replaced by PCTs. In seven years as shadow health secretary, Lansley has had his ear bent incessantly by GPs complaining about the control-freakery and lack of clinical understanding of PCTs. So he’s calling their bluff, taking out the Strategic Health Authorities and the PCTs, and giving GPs the responsibility for commissioning nearly everything, while saving £20 billion and making sure the mighty Foundation Trusts don’t hoover up what’s left.

 GPs have always seen themselves as NHS gatekeepers, managing as much illness as possible in the community to present precious NHS resources being squandered in expensive hospitals. But emergency admissions to hospital are up by 12% and unless GPs can put a brake on this, they’ll be taking on an impossible job. It’s a bit like being handed the steering wheel just as the runaway coach approaches the cliff edge. And amidst all the financial pressure, it’s hard to see who will find the money to collect and analyze comparative outcomes in a meaningful way to guide commissioning and choice. Lansley’s catch phrase of ‘no decision about you without you’ sounds great for patients (217). But when they ask me which of my local hospitals is best for, say, hip replacements and which is ‘unacceptably poor’, I haven’t got a clue. And I’m supposed to be in charge. Now I must find out which consortium I belong to.


July 21, 2010

Pathology Audit Methodology
Filed under: Bristol Pathology Inquiry — Dr. Phil @ 9:59 pm

Pathology Methodology

This is the methodology, acquired under the Freedom of Information Act, that University Hospitals Bristol NHS Foundation Trust (UHB) used to select 3,500 cases/specimens (it’s never been made clear which), for one year only, 2007,  in response to an “allegation that there was a high error rate in the Bristol Royal Infirmary Histopathology Department”. Except nobody made that allegation. It was alleged that some serious errors have been made in the areas of respiratory, breast, gynaecological and skin histopathology, affecting patients of North Bristol NHS Trust (NBT) some of them going back to 2000.

The rule of selecting every fourth case was used until the methodology was found to have selected more specimens for one pathologist than the others. UHB then changed the rules so that each pathologist contributed approximately 550 things (cases or specimens?) to the audit. Whether these numbers reflect the relative caseloads of the pathologists is not known.

This methodology is likely to have delivered UHB’s desired audit result of an error rate of less than 2% for the 3,500, but it won’t answer the question of whether there have been serious, avoidable errors in the reporting of breast, respiratory, gynaecological and skin histopathology for both UHB and NBT patients from 2000 to the present.

Over a year after the 3,500 audit was announced we still don’t know whether it is 3,500 cases (an occurrence of disease or a disorder in a patient) or specimens (samples of tissue used for analysis and diagnosis).

As many cases will each have more than one specimen that has been considered in making a diagnosis, it would seem rather important to understand what exactly has been audited. Odd that Jane Mishcon’s Inquiry Panel hasn’t sought clarification for the public on this matter.

Taunton Specialist Centre for Gynaecological Cancer Surgery
Filed under: FOI Balls — Dr. Phil @ 8:30 pm

Patient and Public Campaigners who objected to NHS Bath & North East Somerset’s refusal, on the grounds that the RUH did not serve a large enough population, to consider keeping a joint Multidisciplinary Team for Bristol/Bath and surgery in both cities, were bemused to read this Freedom of Information Response from NHS South West in respect of Taunton:

“I refer to your Freedom of Information request of 22 June 2010.  In compliance with the Freedom of Information Act 2000, the South West Strategic Health Authority is able to respond to your request as follows.

1. Who made the decision that Taunton should become a Gynaecological Cancer Surgery Centre, despite not meeting Improving Outcomes Guidance recommendations in terms of population numbers?

The decision to designate Taunton as a gynaecological cancer surgery centre was made by the National Cancer Action Team in 2004, in response to an action plan signed by the Dorset and Somerset Strategic Health Authority and the Taunton Deane Primary Care Trust in June 2004. The proposal took into account the population size of 0.5 million and proposed that Taunton would be part of an Avon, Somerset and Wiltshire multi-disciplinary team with subspecialist support and continuing professional development provided by the Bristol specialist team.

The National Cancer Action Team provisionally agreed to Taunton as a centre subject to it performing well under external peer review in early 2006. The Peer Review Report for the Avon, Somerset and Wiltshire Cancer Network published in September 2006 indicated that the Taunton specialist gynaecology team scored 97% on 1* measures and 80% on level 1 and 2 measures. Against all measures the Taunton centre scored better than either UHBT or RUH Bath.

Therefore the decision to designate Taunton as a gynaecological cancer centre was made by the appropriate bodies and it does meet Improve Outcomes Guidance standards, as the Guidance allows for a centre serving a population of 0.5 million provided it is part of a multi-disciplinary team with a larger centre.

2. What were the reasons for making Taunton an exception?

It is not an exception.

3. Please describe what, if any, consultation took place with Somerset patients, the public and Health Scrutiny Committees to obtain their views about whether they supported the establishment of a non IOG compliant centre for their community.

No consultation took place with Somerset patients and the public and Health Scrutiny Committees about establishing a non IOG compliant centre as the centre was compliant with the IOG.

4. If patients, the public and Health Overview and Scrutiny Committees were not consulted under Section 11 Health and Social Care Act 2001/Section 242 Health & Social Care Act 2006, why was that?

Consultation with Somerset patients, public and health Scrutiny Committees was not necessary as this was the designation of a service as opposed to a substantial variation.

5. Please send me copies of all the documentation to show the audit trail for the decision to make Taunton an IOG exception for Gynae. Cancer Surgery.

Documentation on the 2004 designation process and the 2006 peer review is not held by the South West Strategic Health Authority. It is not an IOG exception for gynaecological cancer surgery”.

Note to NHS South West. The RUH serves a population of approximately 500,000. Taunton and Somerset NHS  Foundation Trust serves a population of approximately 340,000 (source NHS Education South West – Severn School of Medicine).

Despite what the SHA says, serving a population of only 340,000 certainly makes Taunton look very much like an IOG exception to patient & public campaigners – an exception that seems to be performing better than Bristol, the PCTs’ preferred site for a centralised Bristol/Bath Service.

July 9, 2010

Dr Phil’s Private Eye Column Issue 1267, July 7, 2010
Filed under: Private Eye — Tags: , — Dr. Phil @ 2:39 pm

Tory Health Policy

 ‘Health secretary Andrew Lansley has just spoken to more NHS managers than he will ever do again’. So observed the Health Service Journal after he told the NHS Confederation conference that management costs (i.e. jobs) would be ‘shaved’ by a minimum of £220 million this year. Redundancy packages and Brazillians all round.

 According to Lansley, we’ll need fewer managers because targets will be abolished, GPs will be in charge of the money and an independent NHS board will ensure fair play. If only it was that simple. Targets per se are not a bad thing. If you can prove they improve outcomes for patients and the staff are given a degree of flexibility in implementing them intelligently, they work. If you enforce them with a rod of iron, irrespective of the clinical context – as Labour did too often – then they lead to bullying and disillusionment,  and harm as many patients as they help.

 Too many targets are inevitably counter-productive, like squeezing a tube of toothpaste in ten places at once. Labour’s failing was to believe that the NHS was a linear system, easily controlled by central levers. Doctors have never have been easy to control but any central dogma that clearly isn’t helpful to patients breeds resentment. Lansley is right to focus on outcomes but to improve these, he will need some targets, whatever he chooses to call them. They just need to be relevant and evidence-based.

 As for GP commissioning, Lansley wants a ‘full system roll-out’ rather than the patchy adoption of budgets under the previous Tory administration,  where GP fund-holders negotiated much better care for their patients at the expense of patients who’s GPs weren’t interested or able to hold their own budget. This year’s model will require 500-600 ‘consortia’ who will be held accountable for £60 billion of spending money by ‘fiscal control and proprietary mechanisms’ of the yet to be established NHS board. And most of this should be up and running by 2012.

 Theoretically, it might work. The NHS is a clinical service and clinicians (not just doctors) should be in charge of it, rather than bleating about the management from the sidelines. GPs are generally good with budgets and can hire the cream of the redundant crop of NHS managers to help them spend it wisely, but they’ll also need to involve their hospital colleagues. Some GPs aren’t remotely interested in commissioning, so will need to be herded into consortia with some ‘can do’ enthusiasts, otherwise we’ll end up with the winners and losers of fund-holding.

 The Treasury is understandably twitchy about handing so much money over to one clinical specialty, and Lansley’s vision isn’t helped by  ‘no-can do’ NHS chief executive David Nicholson, who closed the Confederation conference by saying he doubted the Tory reforms would be ‘anywhere near ready for full implementation by  2012.’  Hardly the rousing call to arms Lansley was hoping for, but perhaps realistic given Nicholson’s failure to introduce GP commissioning under Labour. This was launched in 2005 with a target of ‘100% voluntary coverage’ by 2007, but there has only been sporadic interest.  Overall, Nicholson’s commissioning regime was rated ‘poor to mediocre’ by the common’s health select committee. Clearly something needs to be done and Nicholson possibly isn’t the man to do it.

 What the NHS needs more than ever was nailed in the Bristol Heart Inquiry 10 years ago: a change of culture. Lansley already has a public inquiry at Mid Staffs in his in-tray and private inquiries into the sacking of Cornish chief executive John Watkinson and Bristol’s dysfunctional pathology service. And there are strong calls for inquiries in East Midlands from allegations by Professor David Hands and Gary Walker, a former boss of United Lincolnshire Hospitals NHS trust. What appears to link all these allegations is a defensive, power-obsessed management culture that bullies whistleblowers into submission. Health care is complex and mistakes inevitably happen. But if we keep hiding them, we keep making them. Perhaps Lansley is right. Time to transfer the power to GPs. We may not have all the answers, but at least we won’t beat them out of you.


June 26, 2010

South West cancer service reconfigurations “on the fly”
Filed under: FOI Balls — Dr. Phil @ 6:13 am

Cornish people who campaigned against imposition of Cancer Improving Outcomes Guidance (IOG) without public consultation may well wonder why they appear to have been treated differently to Somerset people. Cornwall lost its Upper GI Cancer Surgery to Devon, despite John Watkinson, former Chief Executive of the Royal Cornwall Hospitals Trust (RCHT), obtaining legal advice indicating that to transfer the surgery without public consultation could be unlawful. Health Secretary Andrew Lansley recently ordered an inquiry into the circumstances leading to Mr Watkinson’s dismissal by the RCHT, including whether it was motivated by his position on the Upper GI transfer.

However in Somerset, despite Taunton not serving a sufficiently large population to be IOG compliant, a Freedom of Information response confirmed that “the establishment of Taunton as a specialist cancer centre for gynaecology was approved by the National Cancer Action Team, the Strategic Health Authority and the Avon, Somerset and Wiltshire Cancer Services (ASWCS)Network. The rural nature of Somerset as a county and its distance from Bristol was a strong influence on this decision”

Campaigners involved in an NHS Bath & North East Somerset (BaNES) led controversial review on reconfiguration of Bristol/Bath Gynaecological Cancer Surgery questioned why Taunton was allowed to be an IOG exception. One was told by a management consultant employed by the NHS to “forget Taunton”.

When quizzed at a July Steering Group 2009 meeting, NHS BaNES’ official transcript of the meeting records its former review Chair, Dr Kieran Morgan saying “Yes, well we took the view…….. NHS BANES took the view that that was Taunton and this is here. Whatever the reason for taking that decision is in the past and isn’t really anything to do with us”

The Steering Group was unable to agree whether the service should be centralised at Bath or Bristol. Later in the transcript, the former Medical Director of the Royal United Hospital, Bath, is recorded saying to Dr Morgan “you set up a process, you have reached the end of that process and beyond that we are now making up a series of things on the fly”

According to NHS BaNES, the Bristol/Bath Gynae. Review is now on hold following “a new policy direction from the Secretary of State for Health requesting PCTs to review health service reconfigurations”. Presumably to see whether local people have been properly consulted or had change foisted on them “on the fly”.

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