WHAT AN UTTERLY HORRIBLE MESS !

Today I am depressed and sad &  I write this with a very heavy heart
I have resisted the urge to write or do anything about the Junior doctors' dispute apart from showing my support for the juniors in our department.
But after today's developments, I just cannot hold back any further.
The poor Syrian people and junior doctors in England have alot in common  -  let down by everyone around them,
a health secretary who is obsessed with a single issue and who seems to have lost the plot completely,
a trade union that since the days of Tony Blair has tried to convince everyone that the NHS is about to be sold off to big bad American Corporations and that this dispute is about privatisation and saving the NHS,
a trade union that has continued to argue for huge increases in the number of doctors paid at a premium rate at a time when the the country is indebted to the hilt
by Health Education England and their predecessors for not  developing the role of Physicians/Surgeons Assistants  or whatever they're called nowadays,  as a separate profession for school leavers (rather than raiding depleted stock of nurses and other healthcare workers).
By educationalists and royal colleges who insisted on removal of the apprenticeship model and  developing and formalising training for junior doctors ( a good thing in itself) without insisting on a decrease in the huge amount of service they were still providing  -
by senior healthcare managers and public health doctors who continue to argue for fewer hospital beds and seem to missed the fact that the population is ageing fast and that these elderly people require both increased social and healthcare services resulting in a unbearable burden that seems to fallen on, amongst others the shoulders of junior doctors,

and I could go on and on.
Something had to give and I fear we are all about to pay a very high price.

PS I gave a talk to 6th formers last week and the ones who plan to do medicine are applying to Scottish and Welsh medical schools because of the doctors' dispute.

I was speaking with junior German doctors last night and their jaws dropped when I told them that the UK government wanted to classify Saturday as a normal working day for doctors in training in England. 

Identifying Opportunities for Quality Improvement thru Mortality and Morbidity Review.

The Problem with Incident reporting in HealthCare

Two reasons why Publication of Surgeon Specific Mortality Data is Anachronistic and just anti-NHS

Since writing the post on the latest edition of the Bulletin of the Royal College of Surgeons of England, I have thought, pondered and cogitated on the subject of  publication of surgeon specific mortality data (SSMD) - the theme of the above mentioned edition. (containing 2 articles which all surgeons must read, here and here). And the more I cogitate the more I realize that publication of SSMD is not 'modern' or essential as Professor Bridgewater suggests but flies contrary to the way the NHS and healthcare generally is developing. All healthcare is a team sport, and this includes Surgery . The days of conspicuous individualism, the Sir Lancelot Spratt era are thankfully long gone. Ironically, proponents of publication of SSMD will argue that one of the functions of such publication is to deter 'have a go' surgeons. It certainly is achieving that in spades in cardiac surgery where an increasingly large number of surgeons are 'not having a go' (even though they should be !) A phenomenon, increasingly occurring because of the need to adhere to waiting time targets is for patients to be seen and listed by one surgeon and to be operated on by another. So, which surgeon's SSMD should the patient look up before coming into hospital ?
This relatively recent change is emphasised in the consent form which patients are asked to sign and which contains the statement that 'The NHS Trust cannot guarantee the surgeon who will operate on you'.
In this age of Multi-Disciplinary Team Working where the decision to operate is taken by groups of individuals, publication of surgeon specific outcomes is just SO yesterday.
Patients want to and are entitled to know what the chances of a successful outcome after their surgery are. Publication of SSMDs is just NOT the way to do it. 

The Human Cost of Scrutiny?

This story appears in the health section of BBC news online today.
The BBC are wee bit late onto this story. There was an excellent article on the subject of the mental health of NHS staff published 2 weeks ago in the Lancet.
The ever excellent and compassionate Claire Gerada makes some very important points on the need to look after NHS staff.
Maybe noone should be surprised at the findings of these surveys.

Life used to be like this - you are a nurse/doctor. You therefore must be compassionate. You have been trained well. Because of who you are you must be going your best - end of story.

It certainly is not like that anymore.

Why Healthcare Insurance to pay for NHS services is probably closer than you think!

Recently, this story featured quite prominently in the UK newsmedia. The response from NHS devotees on social media and blogs was muted. Its significance, in my humble opinion may have escaped obsessees of the UK or English NHS. This is why I think so.
I sit on the cardiac surgery CRG or Clinical reference group.
Please let me explain before you surf away or fall into a deep slumber!!

The Challenge of Treatment of Patients with Aortic Stenosis in the NHS

This paper from the United States is extraordinary because it deals with mortality on waiting lights in patients with aortic stenosis.

UK Falls Behind in Genomic Medicine Race.

The great Norman Shumway, the true father of heart transplantation, had many witty sayings. One that particularly appealed to me was 'the future of transplantation is xenotransplantation and always will be' reflecting his belief that the interspecies immune hurdles would never be conquered in a clinically meaningful way. The reason this famous Shumwayism appealed to me was the fact that he often visited me in the lab when I was working in the lab at Stanford Universiity in the early 1990s on a xenotransplantation project!

The future of medicine IS genomic medicine - and will become the present long before xenotransplantation ever will. This paper published recently in the JAMA, describes the findings of 2 recent studies and speculates how genomic or more accurately exomic medicine may be used in every day practice in the near future.

Both of these studies come from the U.S. and this should surprise no-one. This contrasts with the protracted and top heavy way genomic medicine is still being organised within the NHS in England as described in this painfully long document published by NHS England - another example if ever we need one of how the UK is falling behind its competitors in the hi tech world of specialist services.

 

Posted with Blogsy

Patient Centredness, Ethics and Why You can' have them.

Two articles in a recent issue of the British Medical Journal illustrate different ways hospitals and healthcare institutions can introduce interventions to improve patient outcomes. The need for a response to poor cardiac surgery outcomes in one hospital in the Netherlands proved to be the impetus to radically change the way the institute and its employees deals with patients is described in the first.

Required - a National Framework for Heart Valve Disease.

The National Service Framework for Coronary Disease, published in March 2000, transformed the management of patients with coronary disease in the United Kingdom.

The Problem with a growing Complaints System

http://m.bbc.co.uk/news/health-28965026

The fact that the number of complaints in the English National Health Service has risen sharply should not surprise anyone. After years of terrible headline stories about Midstaffs, and other institutions followed by the Francis report and Keogh reviews, anything else but a massive increase in complaints would have been an abnormal response from users of the National Health Service. There are many, including victims and relatives of victims of poor practice, who feel that what the NHS needs to get it back on the straight and narrow is such an increase and more.
This rapid increase cannot however be sustained .
Increased complaints and an undoubted  increase in funding for the NHS by whoever is elected next year makes my heart sink.
The expected response from a service that is hooked on process will I fear produce a megamonster  that will eventually strangle its parent and make efficient working increasingly difficult.  This is clearly self defeating and will threaten to produce a service that is less and not more safe.
I am not advocating that complaints should be discouraged or ignored but that the response of the NHS should be smarter. There surely must be good examples out there in the world outside the NHS bubble from whom lessons could be learnt.

Posted with Blogsy

The Unstoppable Risk Creep

• 
  ACC: TAVI's Results Endure in Real World
  This registry report, at the recent annual meeting of the American College of Cardiology, on outcomes after TAVI (or TAVR) is a marker for the future.  TAVI (Transcutaneous Aortic valve Implantation) , a percutaneous treatment of aortic stenosis,  is making headway into 'surgical' territory. No-one should be surprised by this. 
  At the moment, within the English NHS, TAVI cannot be offered to a patient with aortic stenosis until that patient is turned down by surgeons - originally 2 and now locally in Yorkshire that seems to have dropped to one. Risk creep i.e. offering TAVI to lower and lower risk patients is real - especially so in the UK, where cardiac surgeons have become risk averse. As lower risk patients are operated on, results invariably get better turning a creep into a canter!
• What is slowing down the inevitable expansion of TAVI in the National health Service is cost - many institutions are still making a loss with the currently offered tariff.  That will change when the market does open up and unit costs will come down. Edwards, maker of the first TAVI device are clearly trying to delay that time with their silly (IMHO) legal action against Medtronic.
• As younger and fitter patients undergo TAVI, there will come a point when the patient will start to outlive the prosthesis, which is after all a limited life pericardial prosthesis which has been crushed and deformed!.
• When that happens will we go back to the extraordinarily safe, effective and long lasting surgical operation or shall we see more TAVI in TAVI procedures? I know what industry would like to see!!
  tags: TAVI aortic stenosis aortic TAVR

Posted from Diigo. The rest of my favorite links are here.

Doctors Delaying becoming Cogs in the Wheel

BMJ Careers - Planning an “F3” year: opportunities and considerations for aspiring surgeons
I was interested to read about the increasing popularity of taking a year out between the F2 year, the second 'compulsory year' of British (and Maltese) medical graduates and the beginning of specialty training.
One should not be surprised by this - to be 'forced' to make such an important life lasting career decision barely 36 months after leaving med school is just too early.
In the past (or when I were a lad  - said in the most Monty Pythonesque of Yorkshire accents), you could delay starting proper specialty training for as long (within reason) as you liked. It is strange, is it not, that doing extra things in your life like a Duke of Edinburgh award or taking a gap year before University, maybe working on a ward, is seen as an asset whilst after graduation there is an almighty mad rush to get you on the specialty register and working for the greater good of 'THE SERVICE' as soon as possible.
I don't think that is a good thing - medical graduates are not just NHS fodder - they need time to plan a fulfilling career for themselves and this may involve looking at different options. Young doctors are now increasingly saying so by voting with their feet.

Safety in the NHS - Should be more Local

Brilliant, NHS to create 'world's largest safety programme' | News | Health Service Journal: http://t.co/YKfkCYE2O1 #clinicalgovernance
— Clinical Governance (@ClinicalGovTool) November 30, 2013

If the Francis Report on the human disaster at Midstaffordshire NHS trust and the ensuing Berwick Report on NHS safety have done, it is to concentrate everyone's mind on patient safety and quality in the NHS, the universal healthcare system in the UK. Patient safety is the number one yardstick with which every intervention or plan in any hospital or healthcare organisation, however small or large should be measured against.

This tweet therefore should encourage patients and healthcare workers in the NHS who have banged on about this for a long time.

It pains me therefore to express a doubt about the effectiveness of having a gigantic uniform system being imposed from above on a whole range of diverse institutions that make up the NHS. Quality and patient safety awareness should be in the DNA/blood of every health service manager and healthcare worker and not yet another programme coming down from big brother above - humans just do not work like that.

If big brother want to do anything, they can publish a generic (and not stupidly long) set of quality outcomes around which local institutions can construct a meaningful quality programme. IMHO, a locally designed system is far more likely to be successful.

The Tipping Point

This post  on the BBC health webpage by the excellent @nicktriggle explains the concept of 'healthy life expectancy'.  I was very surprised that this is actually formally measured. I suppose one should not be surprised when GDP and pension projections depend on the number of healthy older people who can make a contribution to the economy. The converse is also true. Even though lifestyles may be getting worse in some quarters with obesity and alcohol intake on the increase, drugs and other health interventions are lengthening lifespans irrespective of lifestyle. As a cardiac surgeon, I have noticed in recent years the increase in the number of premenopausal women who have been admitted with myocardial infarcts or heart attacks and referred for urgent coronary bypass surgery.  Invariably they are very overweight and heavy smokers.
A sharp rise in the number of unhealthy elderly people represents a demographic nightmare for health services around the world - non productive and big scale consumers of welfare and healthcare services.
For years, much has been written and said about the dangers of obesity, smoking and heavy drinking. And yet it always seemed as if these changes represented clear dangers to society at some point in the future - well the future is here now and we have reached a tipping point.
Who is it who predicted that we do not need as many hospital beds in the future?  Dive back into your crystal ball mystic Meg! I suspect that the type of facility required to deal with the surge of unhealthy elderly has not yet been invented. 

Robert Francis Has a Point

Two points in this article resonate with me, and I am sure with many of my peers - the first is the one that makes it to the title of the piece - every patient needs ONE hospital doctor who is responsible for their care.
My instinctive response to this is 'absolutely. It's the way it used to be before the wretched European Union stuck their oar in'. The contrary argument is that doctors need to go home or go on leave sometimes, but patients still need looking after. although the system clearly failed at Mid staffs it did not in countless other hospitals in England. The broader point is that the current norm, i.e. the involvement of many junior doctors and consultants in the care of a patient, carries risks. It is also clear to me where the risks originate from - inadequate handover. Sort handovers out (and technology has an important part to play here), and the risks will diminish. The increased use of MDT working in the management of patients may also be associated with a dilution of accountability and responsibility - here Robert Francis has a point.
The other part of the article that really resonated with me was Robert Francis's observation that 'in the NHS, nothing gets done because nobody has been told to do it' - or words to that effect. This must surely be the greatest weakness of the current model that has been chosen for the NHS - the top down, central control model. The QC is absolutely right - nothing gets done, unless there is a carrot or a large stick dangled in front of managers. It seems to me sometimes that NHS organisations have lost the power of independent thought. They only look upwards for guidance, and yet it is patients and their own staff that probably hold the key to the future. This way of working also makes a mockery of all the efforts of the NHS to develop leaders. Progressive patient empowerment will mean the current model is doomed to fail, eventually.

Is this A Dangerous Precedent ?

I really cannot tell whether suspending paediatric cardiac operations at Leeds General Infirmary was the right or wrong thing to do - I just do not have the facts to make a judgement .
What I can tell for sure is that Sirs Bruce Keogh and Roger Boyle, both of whom I know and greatly respect, have set a precedent on how to deal with adverse surgical outcomes.
From April 1st,  Bruce Keogh promised that outcomes of a number of surgical procedures performed in England will be published. There will be surgeons and units with mortality rates that are double the national average.
Are we therefore going to see a whole host of closures and investigations started before the month of April is up?

Surgical Outcomes Reporting - why we are Missing the Point.

JAMA Network | JAMA Surgery | Failure to Rescue Patients After Reintervention in Gastroesophageal Cancer Surgery in EnglandFailure to Rescue in Gastroesophageal Cancer

Although cardiac surgery is very different from other surgical specialties (and cardiac surgeons seem alien to many!) there is a lot I, as a cardiac surgeon can learn from more conventional surgical specialties. I often browse through thoracic and general surgical journals. I even enjoy reading the Annals of my College - the Royal College of Surgeons of England. I stop short however of reading orthopaedic rags - I have never had ANY professional affinity with that lot - no offence boys/odd female!!
I digress. This paper in JAMA surgery (the journal formerly known as Archives of Surgery!) is fascinating. It confirms what has been previously publicized in yet another excellent piece by surgeon racconteur, Atul Gawande in this piece in the New Yorker. Gawande describes the findings of a research study from University of Michigan that demonstrated that a major reason for variation in mortality rates after surgical procedures between different hospitals was not the incidence of things going wrong or morbid events but the ability of the institution to rescue patients once things went pear shaped. This study from England looking at events occurring after (o)esophagectomy replicates these findings. If one thinks about the incidence of morbid events or death after surgery, these findings are perhaps not so surprising. We know from many studies in different surgical specialties that a major contributor to the spread of incidences of complications are the patients themselves - advanced age, co-morbid conditions etc.   But how much does the surgeon's ability contribute to variation in mortality between centres after surgery? In any one developed country, the vast majority of surgeons are trained to the same standards -standards which  do not vary greatly between schools of surgery. In addition graduates from each school end up working all over the country. Both these factors contribute to the uniformity and narrow standard deviations of surgical ability in any one country.  This  paper is therefore significant on a number of levels - it confirms the fact on both sides of the Atlantic that variation between surgical outcomes are due predominantly to systemic institutional factors. It is also important because Bruce Keogh, medical director of the National health service in England and ex cardiac surgeon has decided that many surgical specialties should follow the Cardiac Surgeons and publicly report individual surgeons' outcomes. There is a moral case for this - patients are entitled to know what the clinical outcomes of the surgeon who is about to operate on them, are. This paper above, other studies and common sense suggest however that Bruce Keogh and many of the colleges and professional societies who support this stance, are missing the point.

What the Francis Report should say part 2 - breaking out of the bubble #midstaffs

Another post on the inevitable.

What the Francis Report Should say about the NHS #midstaffs

This document about the culture Netflix are trying to develop in their company was dubbed as the most important document to come out of the Valley for years.