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.

Pay for Performance and Perversion of Data

JAMA Network | JAMA | Tension Between Quality Measurement, Public Quality Reporting, and Pay for PerformancePublic Reporting and Pay for Performance

Excellent demonstration how in the USA, public reporting of outcomes and pay for performance, 2 interventions now being used on this side of the Atlantic, have reduced the reliability of the data itself.

When Surgeons lead.

This article published recently in JAMA surgery describes how in the US, surgeons are often taking the lead when it comes to healthcare reform. It gives excellent examples of how they are achieving this.  It also interestingly explains the circumstances why surgeons end up taking the lead - and it is not just because we are all dynamic go getters by nature!!

The Royal Colleges of Surgeons could do worse than emulating many of the initiatives shown by our colleagues across the water. In his defence, the current President of the English college, Professor Norman Williams, seems to get it and understands the opportunity that healthcare reforms in the UK presents to the surgical community. 

What however is really needed to save the world of healthcare is for primary care doctors to seize the moment - and that I suppose is where in the UK the private sector sees its role over the next few years  - to transform primary care in fundamental &  innovative ways so as to cure problems further down (or is it up) stream. 

@PatientsAssoc True Patient Empowerment

This story published on November 22nd, received a lot of attention in the media. More accounts of elderly patients being treated badly by healthcare workers are horrible and frankly very depressing. Ironically in my opinion there is a good point behind the story - and this is the fact that the story is published by the Patients Association - a body representing patients, not hospitals, or nurses or doctors or hospital administrators or regulators.
I wish they could do this more often. Trusts nowadays only prioritise targets that are set by government, regulators or I imagine in the near future, the NHS Commissioning Board. More reports like this one from the Patients' Association may persuade hospital organisations to concentrate on issues that really matter to patients - such as for example operation/procedure cancellations. They still occur too frequently in the NHS and I know that if an operation for a close relative of mine was cancelled, I would be absolutely livid.

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Why Jeremy Hunt' s Work is Cut Out for Him.

I 've heard of the Nufffield Trust but until yesterday I could not really tell you what the trust did. I am currently in the very early stages of designing a study looking at frailty in elderly patients coming for cardiac surgery. As in many parts of health care and as a consequence of that oft repeated word, demographics  frailty is becoming an important resource gobbling issue in cardiac surgery. During discussions with various potential collaborators, I was given the name of Dr Martin Bardsley.  Dr. Bardsley is a recognised expert on ways of the extraction of useful information from established NHS informatics systems. He is Head of Research at the Nuffield Trust whose website contains an amazing wealth of information with accompanying presentations. It really is an amazing resource. Here is an interesting one published back in March of this year.

Snapshot survey of health leaders on NHS reforms from Nuffield Trust

Who will lead change in the new NHS?

If the Twitter feeds from the recent annual conference of the NHS confederation are to be believed, David Nicholson, the larger than life CEO of the NHS gave an inspiring final day speech - a kind of colonel Tim Collins effort and the troops were dispatched in fine spirits. A comment from the speech that was quoted by, amongst many Mark Newbold, medic, NHS Trust CEO and all round good egg was that change in the NHS will be driven by providers. This view struck me as curious. IMHO, from my vantage point on the increasingly lowly shop floor, changes over the past 5-10 years have occurred in response to dictats and targets set by commissioners - some of them sensible and an equal number nonsensical. Maybe the beast of Doncaster does not trust the medic dominated newbies, the CCGs, to be so demanding or discriminating or even so careful with the pennies. It is surely a sign of the developing tension between the 2 axes in the new NHS, the clinical commissioning groups and National Commissioning Board, a tension that will form a major part of the narrative for the NHS over the next few years.

 

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Wanting your CEA Cake and eating it.

Consultant frustration grows over CEA limbo » Hospital Dr

Currently, there are many reasons why doctors in the UK (& I mean the UK, not just England) are unhappy - pensions, pay freeze, CEAs freeze and of course in England, the Health and social Care Bill. With this last issue, doctors' Trade unions and professional bodies i.e. Royal Colleges (well most of them anyway - I personally am very pleased with the stance the English College of surgeons have taken) have pitted themselves against the government and have made the lives of Andrew Lansley, the Prime Minister and the whole government very difficult. What is lacking from many of these bodies, in particular the British medical association is pragmatism or real politik. Their intransigent position, in my humble opinion , completely undermines their positions on CEAs and pensions. Do they really think that the big beast of government will listen to them pleading for more money at the same time as they are kicking the s**t out of its shins?
As Harry Hill would say ' I quite like being a rebel but I also quite like brownies, there's only one way to find out - FIGHT.'

Polly Toynbee - Enjoyable, Rational and Wrong

I found this piece by Polly Toynbee in the Guardian's 'Comment is Free', surprisingly enjoyable to read, completely rational but unfortunately utterly wrong.
It is clear that Polly has little knowledge of what NICE (National Institute for health and Clinical Excellence) actually does. Just like big Pharma on her polar opposite she thinks that NICE is or should be  an instrument to ensure equity - according to the left the most important or only function of the National Health Service. Like many doctors in the land & all over the globe, I use NICE frequently. NICE gathers evidence of effectiveness of different treatments from studies carried out all over the world - in countries both rich and poor and most of which do not have a comprehensive state funded and state provided service such as the NHS. NICE then makes suggestions for use of these treatments according to this evidence. It does its job very well.  The decision whether to pay for treatments is made by those with the money - i.e. commissioners - soon to be groups of GPs. NICE is indeed a extremely valuable resource and a gift to health workers all over the globe. In my opinion, it ranks up there with PubMed and the National library of Medicine, gifts  of the federal government of the US to the world. The article however raises an important issue about the REAL function of NICE- I suspect that the Labour government did plan for NICE to be an instrument of social engineering. It however evolved into something else -something far more useful. One does get the impression sometimes of a split personality at NICE when it tries to show off its 'Toynbeean/Toynbeeite' clothes - it should resist the urge to do so. It has become a global institution and should therefore behave like one and not as a political instrument of the British left!

NHS Reforms and the American Right.

This Olifaunt is a Puritan?—not the less like to be a Papist‥for extremities meet.[1822 Scott Nigel III. iii.]


In recent days, social media and blogging contributions to discussions on the NHS and Social Care Bill have become extreme in their tone. 99% of these contributions come from those who oppose the bill because I suspect that those who do support the bill are reluctant to raise their heads above the parapet for fear of being vilified. Posts from this past week suggest to me that their fears are justified. 
The tone of the language contributors have used reminds me of that used in posts found in some medical blogs from the American right on the changes to health care that President Obama wants to introduce - the changes disparagingly referred to as Obamacare. 
The discussions in the UK have been one-sided with multiple scaremongering claims of doom and gloom coming from some. This is not very useful for democracy or the future of the NHS.  

Why Doctors will never go on Strike

The air is electric  - my twitter feed is going bonkers (though not on the scale of the London riots!)  - pensions, NHS bill, doctors on strike, Lansley  - all these words just flashing by and frankly distracting me. Twitter is truly atwitter - hence the name I suppose.
Let's get real - although I am sure the majority of doctors are not happy about their pension arrangements being interfered with, most (70%) have decided to remain stum about what they plan to do about it. The situation is even less clear when it comes to the NHS reform bill. Most docs, including myself are sensible souls and would subscribe to the the idiom - if it ain't broke, don't fix it, and the NHS is clearly not broke. Nonetheless nobody and I mean not even people who inhabit the higher echelons, where noses bleed,  at the department of health know what the NHS will look like if the bill goes through. Andrew Lansley and others think things will get better. So would YOU go on strike against something you don't understand?
Most of us have gone into medicine because we CARE about patients and I genuinely cannot think of anything that will anger me SO much as to change that - and the fact is everyone , Lansley and the BMA included  know that! 

Public Reporting of Outcomes - History, Ethics, Keogh and the NHS Reforms

I recently posted why I felt that reporting of the outcomes of an individual clinician was wrong. I believe very strongly however in the principle of outcomes reporting.

Individual Consultant Outcome Reporting is Poor Health Policy

The decision by the society of cardiothoracic surgeons of Great Britain and Ireland to publicly report individual surgeons' outcomes on a regular basis  was inevitable. No other avenue was open to them after the Bristol Paediatric heart surgery scandal and the efforts of Sarah Boseley who, in 2005, used the Freedom of Information act to obtain the death rates of every heart surgeon in the country. The Society president at the time of the Bristol imbroglio was none other than the current Medical Director of the NHS, Bruce Keogh.
Patient choice is an integral part of the NHS reforms. Patients will be able to choose their own consultant - hence the importance of publishing outcomes of individual consultants. I have always felt that the variation between outcomes after surgery is more likely to be due to deficiencies of process and pathways of institutions rather than differences in abilities of individual clinicians. It is more important and informative for patients to be able to choose the institution where they want to be treated based on published outcomes rather than individual consultant surgeon. This article from an American cardiothoracic surgeon expresses the same sentiment. KevinMD.comCardiac surgery is a team sport

Shared Care Decision Making in the NHS

Kevin Pho was kind enough to post a piece I wrote several months ago and which I originally posted here on my blog. It has provoked alot of interest and comment most of which has not quite been complimentary!
I was pleased that two experts on Shared Decision making were able to leave comments - one unflattering  from Angela Coulter and the other, considered from Glyn Elwyn.  Both  have written extensively on the subject and on the Salzburg statement.  I myself have written on SDM previously, specifically with respect to medical notes.

WHY SHARED DECISION MAKING IS IMPOSSIBLE IN THE NHS

The relationship between doctors and their patients has changed dramatically over the past few years. Medical Beneficence became paternalism and is now near obsolete. Shared decision making is the new lofty ideal we should all be striving for. It is guiding  new health policy both in the UK, with the new mantra 'nothing about me without me', and in the US. We are at the start of the Century of the Patient. New appropriate societies have been formed such as the Society of Paticipatory Medicine and the Foundation for Informed Medical Decision Making.

This is all excellent stuff. As a doctor, I'd like to think that I have practiced so called partcipatory medicine all my life.
There are caveats with all of this. In a universal health service such as the British NHS, funding is through general taxation and whose levels are determined by politicians, albeit elected. Because of this, the NHS will always, whatever the protestations of different health secretaries, be controlled from the top.  Shared decision making, which surely also means an input into how much I want spent on me as a patient,  is clearly not possible.
With shared decision making must come the counterbalance of responsibility and accountability on the part of the patient.  Without this,  patient involvement becomes a sham. This has been recognized in the Affordable Care Act, the Health Reform Act introduced by the current administration in the United States. This will allow 'rebates' for good behaviour - and good healthy behaviour can easily be measured e.g. weight, markers of smoking etc. In the UK, we have the Downing Street Nudgers who will nudge (nanny state lite) all of us into behaving in a way that will not break the NHS bank in a few years. It does not need a Committee in the House of Lords to tell us that Nudge alone will not work. Being nudged itself is anything but being involved in decision making.
All the good ideas in health care are now coming from across the pond.
You just cannot have your cake and eat it and you just cannot have meaningful true Shared Decision Making in the British NHS and the way it is currently funded  - the 2 are incompatible - PERIOD

SHAPE OF THINGS TO COME

I read this article in the newspaper of the Society of Thoracic Surgeons, one of the 2 cardiothoracic professional organisations in the USA. It highlights the direction of the travel of the employment status of American specialists in the dominant private sector.  

THE NEW NHS

                 

http://www.hospitaldr.co.uk/features/what-do-the-plans-to-reform-the-nhs-really-mean-an-alternative-view

This article first appeared in the journal Red Pepper which as the name suggests has left of centre leanings and was created by "a coalition that supported the miners' strike of 1984-1985" . Now I'm no leftie but this article somehow resonated with me. Like the authors, I've often wondered why the process of commissioning needs to be so damned complicated and expensive.

I would agree that once the planned changes have taken place, the National Health Service in England  or whatever is left of it would look very very different to today's institution. Many significant changes have taken place in the NHS (UK and latterly and seperately,  England, Wales, Scotland and North Ireland) over the past 10-20 years but for many employed in the service, and for patients, these changes did not quite affect their day to day lives. I just cannot help but feel that this time, it will be very different. Everyone who works for or is served by the NHS will find themselves in a completely unrecognizable landscape in 5 years time. Like many I sincerely hope that that these changes will benefit primarily patients served by the NHS and secondarily ( a close selfish second at that) those who work within it. But like after other high stake revolutionary changes, the results will be either spectacularly successful or painfully disastrous for all.