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Archive - Month: September 2018

September 9, 2018

Medicine Balls, Private Eye Issue 1475, 27July 2018
Filed under: Private Eye — Dr. Phil @ 9:56 am


In this new era of candour and transparency in the NHS, how hard is it for the media to expose poor practice? Very, if you’re taking on a national treasure. On April 18, 2018 tucked away at 10.40 pm, ITV Exposure screened ‘Great Ormond Street: the Child First and Always?’, a documentary collaboration with the Bureau for Investigative Journalism.  It revealed that consultants in GOSH’s Department of Gastroenterology had been misdiagnosing and overtreating young patients with Eosinophilic Gastrointestinal Disease (EGID). Children had been prescribed powerful immunosuppressant drugs and/or put on highly restrictive diets too quickly and left on them for too long. This was well known within ‘gastro circles’ for years and was documented in a Royal College of Paediatrics and Child Health (RCPCH) review in 2015. So why did it take nearly three years to surface?

When hospitals realise they have a problem, they can invite a Royal College in for ‘independent expert opinion’ safe in the knowledge that the Trust senior management ‘owns’ the report and can ether refuse to disclose it or heavily redact it. Reputation management still trumps transparency in the NHS. When the RCPCH returned to GOSH in 2017 to check for improvements, it found it hadn’t even shared its 2015 report with key members of staff, never  mind parents or the public. However,  journalists working on the story managed to get a copy and when they started challenging GOSH, it spent £130,000 of public money on an aggressive defence from Schillings to try to muzzle the exposure. This resulted in interminable delays to the documentary and when it finally aired it contained compelling evidence from consultant whistle-blowers, patients and parents of the harm done but no interview from GOSH, no mention of the legal threats, no-one called to account by name and no mention of what the commissioners and regulators knew and when.

GOSH rightly shared the urgent concerns letter and critical report from the RCPCH with the Care Quality Commission (CQC), which had recently inspected GOSH yet staff had not apparently raised these concerns with inspectors, which makes a mockery of the inspection process. The CQC was fully aware that, according to independent experts, the gastro service‘was not being delivered to the standard we expected’ which ‘results in children undergoing invasive procedures and treatments which could unnecessarily compromise their physical or psychological well-being.’ In addition, staff were fearful of the consequences of putting a name to their concerns. When the CQC report appeared, it mentioned that the RCPCH review had taken place and that the GOSH had acted on it, but made no mention of the serious concerns. Unbelievably, it rated medical services (which includes gastroenterology) as ‘outstanding’ and praised the trust for its ‘open and transparent culture’.

The CQC’s inept report raised reputational eyebrows at NHS England which commissions specialist services from GOSH and had seen the RCPCH report. Dr Andy Mitchell, medical director for London at NHS England, wrote: “I believe there is a significant reputational issue here, not only for GOSH but for the CQC,” he said. “Seems to me this could attract a lot of attention, much more than the Leicester/epilepsy saga.” (a reference to the overdiagnosis and overtreatment of children with epilepsy– Eyes passim). GOSH also commissioned two reports into long-standing concerns about safeguarding across the Trust, an aspect of care which the CQC had somehow praised. One review found a tick-box culture in which safeguarding had been delegated to a committee by the hospital board and there was little evidence of learning from mistakes. “There was universal agreement that the level of record keeping, body maps and safeguarding medicals is far below the standard required. This has serious medico-legal implications. Some children with bruises and fractures were sent home in breach of procedures, and “a number of children presented with ritual burns and the response varied”. A child with a non-accidental injury after an alleged assault was “not examined adequately” and referred back to the local service.  A further review confirmed these findings.

GOSH, like many other trusts, is sinking under the weight of demand but it should have sorted out the problems in its gastro department long ago. Instead, it closed the department to most new referrals, a damage limitation exercise that has caused chaos in surrounding hospitals, and it fiercely defends its reputation.  If hardened hacks struggle to hold it to account, what chance anxious parents? Meanwhile in 2018, the CQC finally noted GOSH’s‘defensive approach when challenged on performance and safety’, and rated the leadership as ‘Requires Improvement’. So does the CQC.

Medicine Balls, Private Eye Issue 1474, 13 July 2018
Filed under: Private Eye — Dr. Phil @ 9:54 am

Happy Birthday NHS?

 The NHS was 70 on July 5, with just five years to wait before all the introspection, celebration and politicisation is repeated for what remains of it at 75. The UK will forever be remembered as the first country to introduce universal healthcare and the last to fund it adequately. The NHS is constantly playing funding catch-up with Europe but nothing can reverse the damage done by decades of parsimony. If we had committed the same percentage of our GDP as Germany to health since 2000, we would have put £260 billion more into the NHS. Germany too sometimes struggles with demand, but not in crumbling estates using outdated equipment and technology, with queues extending down the corridors, patchy access to GPs and millions on the waiting list for hospital treatment. This isn’t about how we pay for healthcare, simply that we don’t pay enough.

Jeremy Hunt hopes that an NHS App will revolutionise the service and end the ‘8am phone scramble for GP appointments’ but it won’t end the desperate shortage of GPs, and the tech-savvy patients will simply jump the queue. In its 70 years, the average annual funding increase over that time has been 3.7%, to absorb the costs of inflation, new treatments and the demands of patients living longer with diseases that previously killed them. After eight years at 1% funding growth, the strictest politically-enforced rationing program in its history, the Office for Budget Responsibility concluded the NHS would need 4.3% growth a year to stay on the road. The Government has pledged 3.4% for the NHS England budget only over the next 5 years, omitting increases for health education, training, public health and organisations such as NICE. This works out at 3% of the overall budget, which isn’t enough to halt the decline of universal care. Theresa May and chancellor Phillip Hammond insisted the money be ‘wisely spent’ and the Pavlovian poodles at NHS England promptly announced 17 ineffective treatments it would scrap to save money. It’s important to embed evidence in the NHS, but blanket bans are rarely sensible and tonsillectomy and varicose vein operations will greatly benefit some patients. Any money saved is dwarfed by the money wasted on continuous political ‘redisorgnisation’ and the fees for lawyers, accountants and management consultants that goes with it, never mind the pharmaceutical industry rip offs. The NHS needs evidence-based reform above all.

Labour is keen to claim all credit for the NHS but its origins go back to the Public Health Act of 1848, which realised the importance of clean air, clean water, nutritious food and humane living and working conditions to health. This realisation was not entirely altruistic, and in part triggered by a shortage of workers and soldiers. On discovering 30% of working class recruits were malnourished and unfit for military service in the Boer War,  a school health service, school meals and school milk were established in 1906.  After the first world war, Lloyd George promised ‘Health for the Heroes’, set up a ministry for health and introduced health insurance but for workers only. Churchill’s war-time coalition agreed the need for a National Health Service, and universal care was an essential cornerstone of William Beveridge’s visionary welfare reforms in 1942. True, the NHS would not have happened ‘overnight’ without the passion and commitment of Labour health and housing minister Nye Bevan, who had to overcome repeated objections from both the BMA and Conservative MPs.  Prior to the launch, Labour Prime Minister Clement Attlee gave a placatory speech thanking all parties for their role in establishing the NHS. This incensed Bevan, who was determined to brand the NHS as a Labour creation. He had also witnessed the harm to his family and community caused by prolonged Tory austerity. So instead of celebrating the eve of the NHS on July 4, 1948, he delivered his infamous ‘Conservatives are lower than vermin’ speech in Manchester, which attracted even more excrement through his letterbox and allowed Churchill to declare he was mentally unwell and should check himself into one of his new NHS asylums.

Some Conservatives joined ‘Vermin Clubs’, including a young Margaret Thatcher, who thirty years later tried to strangle Bevan’s baby and switch to a private insurance system. Her ministers dissuaded her, but instead she started off the internal market that has slowly suffocated the service over 40 years. Thatcher believed that the NHS is for poor people and emergencies, and anyone who can afford to go private should do so.Yet despite the underfunding and over-meddling, the NHS fares well on international comparisons for cost-effectiveness and fairness but lags behind on outcomes. This is largely because the UK has poor public health and alarming inequalities that determine disease incidence and premature death far more than NHS funding levels. The NHS is mainly a National Illness Service, designed to repair and rehabilitate but not to prevent. We dive deeper and deeper into the river of illness, treating the untreatable, without wandering upstream to stop people falling in. Unless more funding goes to into preventing illness, the NHS will not improve. The government is merely turning the funding taps on a little more without putting the plug in. Happy Birthday.

Medicine Balls, Private Eye Issue 1473, 29June 2018
Filed under: Private Eye — Dr. Phil @ 9:52 am

The Gosport Scandal – another cover-up, another failure of consultant-led care 

At Gosport hospital from 1989-2000, Dr Jane Barton was deviating so widely from the accepted clinical guidelines for prescribing opiate drugs via syringe drivers, that it could be spotted from space. The situation may not have been helped by the use of easily confused syringe drivers, one of which discharged its contents over an hour, the other over 24 hours. Many countries replaced such drivers long before the NHS, which still operates on the CATNAP principle (Cheapest Available Technology Narrowly Avoiding Prosecution). The Gosport inquiry found that hundreds of patients admitted for respite care and rehabilitation, who should never have come anywhere near a diamorphine driver, died shortly after this ‘treatment’ was commenced (often combined with the sedative midazolam). Some of the nurses charged with starting the drivers tried to speak up and were silenced, others accepted that was just how things were done in Gosport. As at Bristol, the institutional blindness to poor practice was known by many people over many years at many levels of the NHS, from the consultants who supervised Dr Barton and reviewed her drug charts, to the managers who failed to act on the concerns of the whistle-blowers and eventually the coroner, police and a full-house of incompetent regulators.

The NHS had plenty other dirty secrets at that time, largely attributable to the stress of trying to provide universal care with insufficient resources. When MD qualified in 1987, junior surgeons would do major operations for the first time unsupervised, with their consultant not even in the hospital. Patients would have no idea about the competence and experience of their surgeon. Doctors of all grades and specialties would work ridiculous hours and make catastrophic errors under pressure, but notes would be lost or altered and they were rarely exposed. Patients were often not told their diagnosis for fear it might upset them, and were usually designated ‘not for resuscitation’ (NFR) by the medical team without any prior discussion with patients or relatives. Staff who questioned such resuscitation policies, such as nursing student Kenneth MacDonald at two Aintree hospitals in 1992 (Eyes passim), found themselves removed or suspended from working on the wards in question.

In such a ‘hard to challenge’ culture, it’s easy to see how Dr Barton’s prescribing prevailed, and nurses could mistakenly believe that patients who weren’t terminally ill but died shortly after commencement of a diamorphine infusion must have been close to death anyway. As the late Dr William Pickering asked ‘Who picks up doctors mistakes?’ (Eyes passim) MD has long agreed with Pickering that the NHS needs a truly independent medical inspectorate – free from loyalty to any NHS institution, professional or political brotherhood – that is properly resourced and  staffed by experienced doctors and nurses who are mandated to swiftly investigate all serious staff, patient and relative concerns, as well as any ‘red flag’ mortality data and unexpected deaths. By having full and swift access to all medical records, inspectors could spot the rudimentary diagnostic and treatment errors that constitute the great bulk of NHS harm, and publish their reports contemporaneously and in full so they can be acted on and learned from,  rather than wait for an inquiry to report 30 years after concerns were raised. This would require significant funding, to be repaid by better outcomes. The Government’s current solution is a lame Healthcare Safety Investigation Branch which only investigates ‘up to’ 30 incidents a year and will keep some of its evidence secret in a ‘safe space’, which hardly inspires confidence.

Opioid drugs such as morphine and diamorphine have revolutionised end of life care, relieving pain and distress, and, when used appropriately, often prolonging a good quality of life rather than shortening it. Individuals can have very variable responses to such drugs, with some requiring much higher doses than others for control of symptoms. Patients need to be carefully monitored and have their spiritual, social and emotional needs tended too as well to give them relief from what Dame Cicely Saunders, founder of the hospice movement, called ‘total pain.’ Towards the end of life,  doses of opioids often need to be increased to relieve pain, but if this shortens life, it is not illegal if the prime motive was to relive suffering (the so-called double effect). A very over-worked Dr Barton was prescribing this palliative care treatment for patients who weren’t terminally ill, often without any discussion or consent from patients or relatives. She may have been doing it ‘just in case’ they developed pain or distress when she wasn’t there, but there were many more appropriate and less risky drugs that should have been used.  It was left to the nurses to decide on the precise dose. ‘Just in case’ became the institutional norm, unthinkingly accepted and often fatal. The fear is that the Gosport scandal may discourage the proper use of opioids in palliative care and any meaningful debate on assisted dying. As with all of medicine, consent, explanation and understanding are key.



September 7, 2018

Life and Death… but Mainly Death
Filed under: #VoteDrPhil — Dr. Phil @ 5:42 pm

Here’s my favourite and most personal show, recorded at the Komedia in Bath in 2017. It was first performed as ‘Life and Death… but Mainly Death’ at the Edinburgh Fringe in 2016. There are some home truths, some half truths and some lies for laughs – but I’m most proud of the positive health messages. Think of it as a Fit and Proper Person Test…

September 4, 2018

Turning healthcare on its head: the bidet revolution (feat. CLANGERS)
Filed under: #health4all — Dr. Phil @ 8:54 am

‘Why treat people and send them back to the conditions that make them sick?’
Michael Marmot

Universal healthcare in a society that is poor at prevention and in denial about death is like attempting to rescue a never ending stream of people from a river of illness. As science advances, we dive deeper and deeper into the river to pull out people who are sicker and sicker. The right to healthcare for all means that all too often, we treat the untreatable. Just because we can do something doesn’t mean it’s kind or wise to do so. A high-tech death can be very unkind. We spend so much time, effort and money pulling bodies to the riverbank, that we have no energy left to wander upstream and stop them falling in.

We live in a very unequal society, with huge disparities in both life expectancy and years lived in good health. Unless we can improve living and working conditions as well as lifestyle, with a strong emphasis on helping people to build resilience and stay mentally healthy, then no system of universal healthcare can cope, no matter how it is designed or funded. Those of us who are lucky enough to be healthy at present have a responsibility to try to remain so for as long as we can. The best hope for the NHS lies outside its structures. We must reduce poverty, promote healthy minds as well as bodies, lessen the burden of avoidable illness and permit choice in dying. There’s more than enough unavoidable illness to keep the NHS in business.

This burden of avoidable illness could be further reduced by being honest about medical harm and the limits of medicine, and restricting over-medicalisation. Too many serious errors have been covered up and repeated in healthcare systems primed to protect professional, institutional, corporate and political reputations. Too many tests and treatments of marginal benefit turn healthy people into anxious patients. Enough people fall into the river of illness without being sucked in by the health industry.

There simply isn’t a sound evidence base for the mass medication of the elderly, many of whom are either unable or unwilling to take so many drugs as prescribed. Waste due to ineffective treatments, non- attendance and non-adherence is significant. When patients are given the time and opportunity to fully understand and participate in decisions about their care, taking in the likely long-term risks and benefits in absolute as well as relative terms, they often choose less medicine, not more. Universal healthcare must also be prudent healthcare, using the minimal effective intervention wherever possible. Sound evidence based on real life data, as well as compassion, must inform health policy and provision.

Above all we must see healthcare in the context of all care. The boundaries between self, health and social care are entirely superficial, and we must extend our circles of collaboration and compassion as widely as possible and consider the environmental impact of what we do. Indigenous populations have a better understanding of how to live on this planet without taking so much as to threaten the health of future generations, and how to die. We only die once, and a gentle death for as many people as possible is the kindest service society can offer. As the Australian Aboriginal elder Dr Noel Nannup explains: ‘Human beings are the carers of everything.’ But to care for everything, we must first care for ourselves and build our own resilience. The NHS has had enough top down ‘re-disorganisations’. It’s time for a bidet revolution. From the bottom up.

Healthcare begins with self-care

‘Tell me, what is it you plan to do with your one wild and precious life?’
Mary Oliver

Self-care requires time to reflect and to do some ‘self- work’. What are our goals, values, passions and purpose? Can we get near them without burning out? How can we be kind to our minds? How will we cope with pressure, failure, and adversity? Is our current lifestyle making avoidable disease more likely or even inevitable? Physical health stems from mental health, and learning how to be happy, how to self-care and how to cope under pressure should be taught and revisited at every stage of our lives. And we need to build happy and resilient cities, communities and organizations that promote mental health and allow individuals to flourish.

And yet as a society, we aren’t great at talking about what matters most (mental health, sexual health, how we want to die). Self-care needs the self-knowledge that comes from these difficult conversations, and also self- love. Can you disappear inside your mind and like what you find there? Enjoying our own company is key to happiness and resilience. Accepting responsibility for self-care is also fundamental to the sustainability of universal healthcare. Every day we don’t need to use the NHS, someone who does benefits.

The CLANGERS self-care model

Universal healthcare must embrace the continuum of self-care to intensive care, and I would restructure it around the CLANGERS model. The Clangers of the children’s television series were, and probably still are, a community of mauve mice who spoke in whistles and ate sensible portions of soup, made by a dragon, and blue-string pudding, none of which was processed. They lived a simple yet serene life built around friendship, collaboration and enjoying the little things. Very seldom, if ever, did they need to go to hospital or indeed die, because they were so good at self-care and pleasuring themselves in a safe and sustainable way.

The Clangers’ habit for a satisfying and meaningful life can be learned by anyone, at any age:

Connect with the world around you. Reach out to people, pets, plants and places. We like to feel as if we belong, as part of something bigger. These connections are the cornerstones of your life. Take time and care to nurture them. And don’t forget to connect with yourself.

Learn. A purpose in life often stems from learning what matters most to you, developing a passion for learning and keeping your curiosity alive. Why do you get out of bed in the morning?

• be Active, in mind and body. Rediscover activities and passions you left behind, and have the courage to try new ones. Aim for five portions of fun a day, each different, at least one outdoors and one that involves getting pleasantly breathless.

Notice, and be present in, the world around you. Fill up your senses. Catch sight of the beautiful. Remark on the unusual. Enjoy the everyday. Savour the moment, and your place in it.

Give back. Helping and caring for friends, strangers and those less fortunate than ourselves is fundamental to good emotional health. It cements us as part of a community and develops more meaningful connections and insights. The joy of being human is to be humane.

Eat well. Learn what’s good and enjoyable to eat, and in what quantities. Learn how to grow it, where to buy it and how to prepare it. Set time aside to sit and eat with friends and family. Eating well on a budget isn’t easy. For excellent help try Cooking on a Bootstrap by Jack Munroe

Relax. Take time to rest and reflect on the day you’ve had, reliving and re-savouring the happy memories and having gratitude for friends and family. Learn to meditate. Be kind to your mind and let it wind down and de-clutter.

Sleep. Don’t cheat on your sleep. It’s vital recovery time for mind and body, and boosts your energy, creativity and productivity. You eat better and exercise more when you’re well rested. Relaxing and winding down beforehand is key. Learning to housekeep your mind and deal with stress is vital. If you doubt the power of sleep, read Why We Sleep by Mathew Walker

Some lucky people will do all eight steps intuitively, partly out of habit. Others will struggle through sickness and circumstance but with support and time, can continuously improve and slowly raise their own bar – hopefully without the stress of comparing themselves to others. If you need more detailed help with your CLANGERS, I recommend the book The 4 Pillar Plan – Eat, Sleep, Relax, Move – by Dr Rangan Chatterjee. He is one of the few lifestyle medicine gurus who isn’t trying to sell you a fad diet or his own brand of nutritional supplements, and his enthusiasm is infectious. You can also check out his podcasts here.

Your Clangers may be very different to my Clangers, the only rule is that we should try not to harm ourselves or others. The ‘clang’ in CLANGERS comes from the government-funded Foresight report, ‘Mental capital and wellbeing: making the most of ourselves in the 21st century’. It gathered the evidence on simple ways to a fulfilling life that just about anyone can do, irrespective of wealth or health. I added the ‘ers’ because they’re also fundamental to living well and slowing down the rust.

CLANGERS works not just as a model for living well, but also as a way of coping in adversity. When I interviewed patients and carers for a book about how to get the best from the NHS, it was striking how it fitted in with a successful model of patient engagement.

• Connect with the team treating you, and get to know them if you can. Know their names and something about them. It’s easier to ask questions when you know someone.

• Learn as much as you can about your illness, the treatment options, what you are entitled to, the standards of care you should be getting, what you can do to improve your odds and who to speak to if you have concerns.

• Be Active, both in the management of your illness and preventing further illness, be your own advocate when you can, have others to act for you when you can’t. The five portions of fun a day may be different to the ones you might enjoy when you’re well, but still try to have the energy for joy, warmth and purpose each day.

• Notice the good and bad in your care, and speak up if you have any questions or concerns. Notice the little acts of kindness that make illness bearable, and be thankful for them.

• Give back to the NHS and your carers by providing thanks and constructive feedback. Share vital information with other patients and carers. Get involved in research, service improvement and design and volunteering for your local NHS and charities.

• Eat well, Relax, Sleep – even more important when you’re ill.

The CLANGERS model equally applies to staff engagement and wellbeing. Health systems will always be high pressure places to work and so need to comprise of resilient organisations that support the mental health of the staff, encourage learning, are free from fear, bullying and blame and encourage everyone – patients, carers and staff alike – to speak up, feedback and continuously improve.

Ultimately, patients and carers must be handed as much control and responsibility as they want, and supported to live lives governed by their own goals and values, not the mass-produced end points of clinical trials. The best population evidence has to be combined with empathy for the individual. There is no single structure for healthcare provision that works in any context, and to continually seek the perfect structure in the NHS has proven to be hugely disruptive and disastrous for morale. Different models and structures will work in different parts of the country, but they must be built around common values and understanding of the needs of the individual. If each person can go about their daily CLANGERS, united by compassion, candour, competence and collaboration, then we can rediscover a values based service that is also effective and affordable.

Conclusion: competent, compassionate, cost-effective collaboration

In the 34 years since I first set foot on an NHS ward, I’ve lived through a dozen major structural reforms, more ideological than evidence-based, seldom embedded long enough to prove their worth before being uprooted by the next political vanity project. So I’m loathe to suggest any structural miracle pill for universal healthcare. Continuous evidence-based improvement is far more likely to work, raising the quality bar a little at a time, as resources allow. Consultations – or rather meetings between experts – must be long enough to be safe, effective, enjoyable and meaningful. Transparency and accountability must embrace innovation and learning from failure. The spirit of competent and compassionate collaboration must triumph over competition.

Patients and carers must have as much choice and control over their illnesses as they – and a fair system – can manage. Anyone must feel free to speak up and challenge, knowing their concerns will be acted on. Pure knowledge, like pure water, must be available to all who need it. Communities must promote health and meaningful work for all, and we should all be taught the skills of resilience from a young age. The healthy must accept responsibility for trying to remain so, and society must support them. Artificial divisions must melt away (self-care, healthcare and social care are all care). And all of this care must be prudent, and mindful of the cost for the planet and the payer. The minimum necessary intervention is usually the kindest and the least obstructive. We have but one wild and precious life, and we want healthcare to improve us, not imprison us. Release the joy of your inner CLANGERS.

Above all, we need Collaboration to solve the complex problems facing us. It was defined brilliantly by Margaret Heffernan in her book ‘A Bigger Prize

‘Innovative organizations thrive not because they breed superstars but because they cherish, nurture and support the vast range of talents, personalities and skills that true creativity requires. Collaboration is a habit of mind, solidified by routine and prepared on openness, generosity, rigour and patience. It requires precise and fearless communication, without status, awe or intimidation. Everyone must bring their best. And failure is part of the deal, an inevitable part of the process to be greeted with support, encouragement and faith. The safest hospitals are those where it’s easiest to acknowledge an error. The biggest prizes grow as they are shared.’

I believe politics would lead to much more progress if we adopted this constructive, collaborative scientific approach to all the great challenges of our time – Brexit, improving public health, reducing poverty, funding public services and pensions, caring for an older population, Global warming etc. I also believe we need experts rather than politicians overseeing their fields of expertise (education, pensions, health etc). The issues facing us are far too complex for politicians with little or no experience and damaging tribal loyalties to flit in and out of every few months. Time to put some grown-ups in charge.

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