I wouldn't get too excited, but...

"Crikey, two posts in under a month-- what's he playing at? You wait months and months and nothing at all, then this..."

"Shh I think he's trying to say something!"

"Well I for one am not holding my breath so there!"

(And you're right not too. It's been a bit quiet round here of late I know, but here goes...)

As you can probably gather 2011 has hardly been a vintage year at Jest Acres. In fact we’ll none of us be too unhappy to see it go. There have been times this year when it’s been hard to string a coherent thought together, let alone get anything down on the page—virtual or literal. I miss writing hugely, but for large chunks of this year the words just wouldn’t come. There have been moments and punters worthy of anecdote, but it’s just not been possible, and for that I apologize to those of you who might have stopped by from time to time.

I’m hoping for better things in 2012, though if we’re to start looking after 25% of the inpatient population in addition to doing the day job (as one boffin seems to think we ought, to the rapturous reception of Mr Lansley among others) that might be a trifle ambitious. Whatever the case I’m determined to try harder to put virtual pen to paper as it were.

I hope ’11 was good to you all, and whether or not, I hope ’12 will be fantastic for us all. There’s a lot of doom and gloom about pretty much everywhere at the moment, but despite it all there is much to be grateful for (among many other blessings I’m especially looking forward to sampling some home made Mars Bar Vodka over the New Year holiday—if I survive I’ll report back).

So a slightly early Happy New Year one and all, and I’ll be back, soon I hope, to see you all next year.

East of Eden

Whether you take it as revealed truth or allegorical myth there’s something compelling about the argument that we live in a flawed and imperfect world. Perfection is there to be striven for, but it’s unrealistic to expect that we shall get there alone. We allow in our oral histories that transcendence *is* possible, but only to a very few very special individuals, and then generally with the help or agency of some higher power. For the rest of us East of Eden is where we are expected and expecting to remain—in this life at least.

Indeed, if anything just now it feels we’re heading further and further east, away from calm, plenty and fulfilment as each day passes. Perhaps it doesn’t help that it’s winter now for real in Ambridge, after an Autumn so mild half the bulbs at Jest Acres seem to think it’s Spring again, but the old Crystal Ball resembles more a Snow Globe than anything else looking to the next year or two.

In the midst of all this gloom and angst we get a bizarre assertion in the news today. 24,000 deaths a year could be avoided if diabetes were treated better. With a token apology for pedantry, avoided? Really? Now I know modern medicine is pretty hot stuff, but I’m not aware of any innovation potent enough to permit us to avoid death. It’s not clear from the reporting whether this is a verbatim quote of a grandiose claim or just sloppy journalese, but I fear I have to disappoint you all. The best we can attain for now is a deferral, which in the colloquial idiom “ ain’t nothin’" but I fear falls far short of the alleged outcome.

I’m also a little uncomfortable at the assertion that there’s some kind of blame to be attached in each of these 24,000 “un-avoided deaths”. It’s almost certainly true that a great many could be helped to look after their diabetes better and in so doing delay or avert death from this condition, but it is equally the case that a number of them would prefer to be let alone, not seeing a prolonged existence as desirable for any of a number of reasons, some well thought through and some, to external scrutiny apparently frivolous.

I worry that in seeking to target this group of patients for “better” care we risk trampling on their autonomy. This is an increasing trend in all areas of modern patient care, where we are pressed to treat to a target—evidence based for sure, but paying little or no regard to the individual on the receiving end.

This is in no way to suggest that trying to offer better holistic care would be a bad thing, and if by so doing patients can be engaged and encouraged to try a bit harder to reach the targets then this can only be a good thing, but where like Mme. Voizin in Chocolat there are patients who know their choices are unhealthy, but opt to continue to indulge, accepting a shortened rather than an impoverished span, who are we to deny them.

Where there's a Will...

Peggy was in today. She’s well into her eighth decade and in pretty good shape. She survived a cancer diagnosis – going through surgery then chemo and radiotherapy and follow-on operative procedures all over ten years past, and has never looked back. The surgeons have told her she’s cured and she hasn’t needed follow up in more than three years.

Today she’s in to talk about a minor injury, sustained a week or so ago, and healing nicely, so no need to worry. And yet... worried she is.

How do I know? She tells me so—though she did look far more apprehensive that the minor injury warranted so I had already guessed as much.

And why? Not through the injury, and not from her past health scares. No today she is worried because last week she and Jack visited their solicitor and made their Wills. As she put it “We’d never made a Will before, and now I have I’ve got to face up to the fact that I’m going to die.” It’s as though the simple act of making a testamentary disposition has opened wide the door to the Grim Reaper, The Fourth Horseman, The Pale Rider (no not Clint—the real one*). In short she has had to formally acknowledge her mortality.

What impresses me most is that after everything she went through ten years past it hadn’t even entered her consciousness that cancer was something she might not survive. Her faith in the undeniably excellent care and support she was given then, and for the years after, had allowed her not to have to do so. She’s a little surprised that she feels this way now, but I can reassure her it’s something I’ve seen many times before and so, far from cracking up, she’s displaying a normal if utterly irrational response to the feelings generated by this simple act of forethought.

I’ve tried to calm her fears by telling her that to the best of my knowledge there is no hotline from Hades to the offices of the legions of probate solicitors worldwide, and especially none here in Borsetshire. At least I hope not.

*That said, these days Clint is looking his venerable age, and might pass in a dim light for the Bony Fingered Wielder of the Scythe.

Re-Assura-nce ?

O.k. I know I’ve not been around much lately—or indeed at all, for months. I know there’s a lot to say right now, and not having a voice with which to say it has been a huge frustration, but sometimes words just elude me. So I’m grateful for an email from a friend that gave me a prod to try again.

I fear it’s polemic time, but since I imagine so many of you have drifted quietly away in the long silence perhaps I won’t end up boring too many people. I should also point out that the email came over two weeks ago, so I fear this is not the best place to come for an answer to any queries you may have. Certainly it’s unlikely to be the speediest :-(

So on to the email. My friend was talking with a consultant who revealed the following;

“Apparently the PCT are refusing to fund all 3 monthly hospital reviews, and have been for some time (ie before Coalition took over) The hospital are still arguing about this, to get the PCT to accept those patients they put on pathways exempted from the GP's…”

I have to say the same is true, in some form, in our own PCT and likely in almost every PCT in the country. The reasons for this are many and complicated and though driven by finance are not purely dictated by the bottom line. What we have to bear in mind is our fractured, battered, beloved but struggling NHS has been through six decades of continual change. This change has been technical and clinical every bit as much as financial.

So, how dare a PCT dictate to a consultant when and how a patient should be reviewed? Well the first motivation right now will undoubtedly be financial. Each encounter of a patient with any hospital or “hospital-supplied” service since at least the early 1990s has carried a price tag. So the initial encounter at outpatients generates a bill. There is then a tension between hospital and PCT, both of whom have a primary statutory duty to deliver a balanced budget which overrides any other duty they may have. So more hospital outpatient reviews means more money for the hospital, and a bigger drain on PCT resources.

In the time I’ve been in family practice the level of care and expertise available in the community has gone through a quiet revolution. Pretty much everyone, including our consultant colleagues still see general practice as a sleepy medical backwater of two surgeries a day and a round of golf in between. Anyone who has had any regular dealings with their GP surgery over the past decade or more will know that things aren’t like that anymore. At least they will if they take a quick look around. First, it’s likely that their surgery has a number of doctors rather than just the one or two that was the norm in the first few decades of the NHS. Next, as well as the normal surgery appointments there are likely to be dedicated clinics for a number of conditions including diabetes, heart disease, asthma and COPD as well as “lists” for minor operations ( a rarity in 1990 and near universal by 2000) wart treatment, travel clinics, counseling, physio, and in some of the more adventurous, even “alternative” therapies like acupuncture, chiropractic and a host of others. (True in remoter and more deprived areas not all of this will be so, but even there the GP is still likely to be offering a range of services that thirty years or more ago would have been the preserve of the hospital).

All of this activity is also funded by the PCT. So if the PCT can agree diabetes reviews as an exemplar, in practices, for a fixed price well below that of the hospital, and if the practice is geared up to provide a service at least as good as that of the hospital for the vast majority of punters, why would they opt to have these patients reviewed in hospital or hospital led outpatients? Particularly when the service commissioned from General Practice is a “block contract” paid per capita and not per encounter. But there’s great deal more to this than mere finance. Any regular user of hospital services will tell you that they seldom get to see the same doctor two clinics running, because of the way hospital careers and training are organized, and because the minimum realistic interval between appointments is many months. In practice a GP will generally take a lead role in a given clinical area and will be rather more available. When patients are stabilized and well managed yearly or six monthly reviews will generally be the norm and these could be delivered in either setting, but in Practices the team doing the reviewing will de facto be smaller and longer in post, and so likely more consistent, delivering better continuity and with a greater hollistic knowledge of the patient. And when things are more complex practices can generally respond if needed in a day or two and review in a week or two, where the only option available to the consultant would be admission or “urgent” outpatients which—in this locality at any rate, could be anywhere upwards of 4 to 6 weeks.

This is not to deny that there are some, rather iller and more complex patients who genuinely need more frequent hospital care, and for them the existing system is undoubtedly flawed, to the unending frustration of Consultants and GPs alike.

There was another point raised in the email, “(h)is other interesting information was that here the GP's refer to a private company called Assura as well as the NHS. He pointed out that many of the local GP's have significant shares in Assura and therefore a clear conflict of interest…”

Here’s where things start to get complicated and not a little murky. Before I start I must declare an interest in that our locality has services provided by Assura in which every practice in our consortium are partners.

Assura was started some years ago as a commercial supplier of outpatient style services to GPs run by GPs. They have grown down the years and to the best of my knowledge now continue this model and also help practices with premises development in a model similar to PFI. They tend to develop local services as stand alone ventures—franchises if you like, in joint ownership with GPs, and often engage some of those same GPs who have developed particular expertise, alongside Consultants and other practitioners as appropriate, to provide the service. Their services can range form Physio to Dermatology to Orthopaedics to name but a few. I believe they have also been involved in tendering to offer out of hours GP services as well but cannot be sure if they presently run any.

True they are a “private provider”. So are many others currently offering care and services under the NHS umbrella. And true they provide services in partnership with local GPs, and invite referrals from those same GPs. However, to be able to provide such services they are obliged to tender in an open market to the PCT who commission the service, in competition with other providers, NHS and Private Sector, and stringent attention is paid in that tendering process to cost benefits and to potential “conflicts of interest”. So much so that it can take anything upwards of 18 months to 3 years for tender to gain official sanction.

This is the shape of our modern NHS and current reforms look set to oblige commissioners to look not just to NHS-allied organizations like Assura, but also to the wider marketplace, opening the door for strictly commercial private sector providers who will not have either the tradition of engagement with the NHS nor the public service ethos that alliance with GPs who are grounded in the existing systems carry in their “DNA”. One of the consequences of these new arrangements in our locality has been an increase speed of access to specialist opinions for patients who would otherwise have had to pay personally to see a consultant privately. Under these arrangements the PCT is paying the franchise and the patient is seen as an NHS patient. I wonder if this has some bearing on my friends’ consultant’s concerns over conflict of interest?

That sinking feeling...*

I suppose it had to happen sometime. The word is out. There are times when consultations don’t go so well. Like any other human interaction a slight misread of body language, an ill chosen word or a momentary friction between personality types derails things and the express train of therapeutic discourse and discovery goes hurtling off down the wrong track, or smashes headlong into the buffers.

(Yes yes I know derailed trains don’t do either of the above in reality, but it’s my train set and it follows my rules ‘k? ‘K.)

I’ll be the first to admit to my share of disasters, but I hope that I recover most of them before any lasting harm is done to the therapeutic relationship. And though you might not believe it of us as a group, we all try our best not to put our size nines in our mouths too often, or to deliberately rub our patients up the wrong way.

After recent discussions with friends, both face to face and “virtual” (you know who you are) I’m a little worried that sometimes the poor souls of the receiving end of such consults then feel they’ve been labelled, and somehow singled out from the rest for “special” attention. So allow me to set the record straight.

There are times when the doctor-patient relationship dysfunctions, and continues to dysfunction repeatedly and serially over a sustained period. To be non-PC about it terms like “Heartsink” and “Quack” get bandied about and a rift opens between patient and the profession as a whole.

Let me be quite clear about this—though the term and the concept of the “heartsink” patient exist and I’m perfectly certain that the equal and opposite concept of the “heartsink” or “quack” doctor also exist, from where I sit the terms loose currency through overuse. In a career of over 25 years responsible for the care of upwards of 14,000 patients on a day to day basis, and with a dedicated personal list of over 2,000 patients theoretically entirely my own in that they have named me their personal physician by registering on my list, I can’t think of even a handful of patients whose name would instil in me that feeling of apprehension implied by the term. Yes I have many patients who at times test my patience, just as I’m sure there are even more patients whose patience I test from time to time. That doesn’t amount to the same.

One bad consultation, even a run of awkward encounters doesn’t amount to the same thing. Indeed often you have to negotiate a period of awkwardness until you achieve an understanding as with any other interpersonal relationship. Patients know how they feel, even if they don’t intuitively know why. Problems arise when the way they express their symptoms, feelings, fears and apprehensions isn’t heard or isn’t interpreted correctly, or appears to have been ignored and disregarded.

If we can be grown up enough to acknowledge this and back track a bit and try over mostly we can make progress and though we may not be destined to be firm friends we can work together—after all it’s the patients who do all the heavy lifting in any therapeutic process barring the most trivial. We might prescribe the meds, the lifestyle changes or perform the operations, treatments, manoeuvres needed to fix things, but the punters have to take the pills / advice and adapt to the aftermath of the procedures. If we get it wrong first go we have to have the trust of the recipient that our next effort will be better. It’s when this breaks down, and stays broken that we risk loosing an effective therapeutic relationship. At that point the majority of patients, quite sensibly decide that it’s time for them to find another doctor—who will hopefully understand them and their needs better. Sometimes it behoves the doc to suggest this perhaps by means of a personal recommendation.

Where we risk sliding into a longer term “institutional” dysfunction that ends in mutual “heartsink” is where a patient runs through a series of such dysfunctional relationships, or feels trapped within one, ongoing and without possible exit. It’s easy then for patients to feel abandoned, doc’s to feel their well intentioned advice is ignored and for both sides to give the impression either that they’ve stopped trying or are completely disinterested and merely going through the motions.

* anybody else know where I nicked the title from? EVCHN on offer as per usual.

Addendum: For the counterpoint see this from Anna. (Thanks Anna).

You can't get better...

O.K. so it's not quite the speedy revival I was hoping for. Still perhaps if I aim for a post a month for now that will do? Well it might have to. And to be honest I'm not sure you're going to like this one. Still here it is...

This week saw the publication of the Health and Social Care Bill, the road map for the much heralded changes to our health services in Blighty under the present administration. You'll notice I've omitted the word National and the capitalization. The thing is, it's hard, sitting here, to see the coming changes as anything other than the final nail in the coffin, ending the pretence that we have such a thing as a unitary "National Health Service" at all.

Ever since devolution, health in Scotland, Wales, and Northern Ireland have been devolved too (in fact the Scots had their own service even before that), but these four separate services still cannot really be regarded as truly national even within the definition of the "home nations" that make up our fractious little "United Kingdom".

Even before this the rot had started with the experiment that was "Fundholding" where GPs held a tiny proportion of the NHS budget to buy operations for their patients from hospitals. The vast majority of these operations were still performed in the NHS (soi disant) but already the "internal market" had hospitals (later "Trusts") vieing with one another for the cash. And even then a small proportion of procedures were shuffled sideways to the private sector on the basis that they could be done quicker and at no more cost to the taxpayer.

This hypocrisy was swallowed hook line and sinker by the monster that was the incoming faux "Nu" Labour administration. Competition and choice became holy writ, and so they remain. True, levels of investment in health went up, and at last we reached a level comparable to other developed economies. Sadly that increase was built on the foundations of decades long underinvestment, so although current spend might be comparable, past investment has been anything but and our infrastructure remains woefully inadequate as a result. Worse yet, dear Gordon found a splendid way of burying the cost of new infrastructure in the PFI scheme where we, the humble taxpayers, sign up to a 30 year mortgage every we time we want a new hospital / surgery / clinic, and said facility is built, operated, and owned (for gods sake) by private enterprise. So not so much mortgage as "rent" then. And at the end of the 30 year term what happens to the infrastructure? (No that's not rhetorical-- I'm pretty sure the builders will own it and our successors will be renegotiating the lease, but I'm not 100% sure).

Oh but then there was even worse to come. ISTCs anybody? Well some of you might have been treated in one. Most PCTs have one. Remember our old friends choice and competition? Well to enshrine them in our hearts PCTs were compelled to establish Independent Sector Treatment Centres. Yes Independent Sector-- "Private" to you and me. Set up by the NHS and awarded fat contracts for surgical procedures and outpatients. They bussed in Consultants from far and wide. Mostly from the expanded EU and Scandinavia, all thoroughly decent chaps and impeccably qualified, but with no grounding in the workings of the NHS. They were guaranteed income for operations and creamed off all the "easy" cases. They did good work, but on fitter, younger, less complicated patients. Anyone who crossed their threshold with a sniff of a raised blood pressure, wheezy chest or high blood sugar was politely declined and sent back to wait for the NHS "proper" to sort them out. And remember the "guaranteed contracts"? Well they meant that in a year when they didn't perform the required number of procedures contracted, they got to keep the money anyway. And all paid for by the PCT and therefore the NHS. And if, and when one of their patients did become more complicated, they were shipped out of the ISTC and back to the local hospital to be sorted by the NHS consultants who had been denied the opportunity to treat their initial problem by the establishment of the ISTC.

Add to that the lunacy of ever more micro-management of contracts and setting of targets as Nu Lab imploded and our poor PCT colleagues have spent much of the last five years running around in ever decreasing circles. And now we get the Health and Social Care bill. Where once we had fundholding, now we get GP Commissioning, and instead of 10% of the NHS budget we get something approaching 60-70%. We're still mortgaged to the hilt with hospitals we don't own, and now every "provider" of NHS services is going to be compelled to become, or to join, a "Foundadtion Trust". Where prices for specific treatments were set nationally now these trusts will be at each others throats striving to win contracts, and now we get the added imperative to consider, when contracting, "Any Willing Provider". Until now the assumption in contracting has been that the NHS family is the "Preferred Provider" and so when bidding for contracts for NHS services, Trusts could presume their bids would be considered ahead of any other. Now that protection is gone and not only will thrusts be at one anothers throats, they will do so with wolves circling the fold ready and waiting to pick off the choicest prey.

And the best bit, the absolute best bit... PCTs (the health service managers we've all derided for all these years, but who have done the best they could to shield us from the twin madnesses of the Department of Health and the Foundation Trusts) have been told that they must continue to run the show for the next year or so whilst GPs gear up to becoming managers themselves, knowing that at the end of their term, they will vanish. Some will doubtless be reabsorbed into the new commissioning bodies or the overseer NHS Commissioning Board which will be there to insure the Commissioning consortia are working properly. But with massive cuts in funding for NHS management demanded throughout the restructuring, many more will be looking for jobs elsewhere, just at the time the Private Sector "wolves" are seeking a foot in the door.

The NHS I joined in the early 1980s gave me freedom to refer patients anywhere in the system, based on their need as that system was bought and paid for in its entirety as a monolithic state run enterprise. Since the foundation of the PCT my freedom to refer has been constrained, in large part, to the county I work in, and to the two or three Trusts my PCT contracts with and preferably to the hospitals we are shackled to by PFI contracts. With commissioning, all the early evidence suggests my freedom to refer will be constrained still further. "National" no longer applies. Even "Local" is beginning to look dicey. True for most of my patients, most of the time, this won't mean a lot. Right up to the point it means their hip replacement will be done by Kwik-fit as the cheapest willing provider!

16.ii.11 Addendum.
In a similar vein just seen this which you might like to read. Not sure I agree 100% but there's some honest to goodness venting going on and much truth. (Thanks to BG for tweeting the link).