NHS Blog Doctor

The case against co-payments in the NHS

noreply@blogger.com (Dr John Crippen) — Mon, 07 Jul 2008 13:45:00 +0000

There is a particularly unpleasant piece of mischief in today’s Times from the normally reliable Stephen Pollard. It’s the usual doctor bashing stuff which is now sadly de rigueur from journalists who have swallowed all the government propaganda. I expect this sort of stuff from Polly, but not from Pollard.

Hamish Meldrum, the BMA chairman, has just expressed his concerns at the idea of allowing co-payment within the NHS.

“My gut instinct is that this goes against the sort of NHS I believe in, which is free at the point of use, fair and equitable to all.” (Hamish Meldrum)

Stephen Pollard does not like this at all and finishes Meldrum’s statement thus:

And which, [Meldrum] didn't add, would let patients die rather than use a drug their health authority will not supply. Equity it may be; but it can be the equity of death. But no one should be surprised at the sheer callousness of Dr Meldrum's position. The notion that an organisation which represents doctors ought somehow to have the patient's interest in mind is attractive. But it is also naive. When it comes to the public, the BMA sees us as little more than a cash cow. (Stephen Pollard)

Does the general public really think that doctors see patients only as a cash cow? God, I hope not. I find that truly upsetting. But, whether or not Pollard is right in making that statement, the article as a whole is both credulous and naïve. The recent cases of patients being banned from the NHS for buying drugs only normally available to private patients caused a furore, and understandably so. The decisions were outrageous. But hard cases make bad law.

Let me try to explain what Hamish Meldrum and many other doctors, including Dr Crippen, are worried about. If the right of NHS patients to make co-payments, in other words their right to “top up” their NHS treatment with some form of treatment deemed to be superior, becomes a routinely acceptable option, how long will it be before it becomes compulsory?

For a co-payment of £1000 you may have your hernia repaired now rather than in nine months
For a co-payment of £500 you may have your MRI scan now rather than in six months
For a co-payment of £500 you can be guaranteed an appointment with the consultant rather than with the nurse-practitioner
For a co-payment of £100 you can have the branded drug rather than the generic version imported from the third world

Co-payment structuring in the USA

The potential is endless and would be a real cash-cow for an over-borrowed government. It would be a short cut to a two-tier or even a three-tier system. To some extent it goes on already. As any GP in the country will tell you, many patients already pay for a quick private consultation with a specialist, or for a private MRI scan. In my area, the waiting list for a “routine” MRI scan is currently sixteen weeks. A long distance lorry driver off work with lumbago may well choose to pay for a private scan.

It goes on all the time on the quiet. It should not have to, but it does. Best not talked about in company for, let it become formalised, it will become the rule rather than the exception. That is what doctors are worried about. I am surprised that Stephen Pollard cannot see that.

Liver transplants and Cadbury's Dairy Milk

noreply@blogger.com (Dr John Crippen) — Sun, 06 Jul 2008 21:50:00 +0000

Scott's liver

Scott Hull has a rare disease called PSC (very long name that won’t mean much unless you are a doctor). Basically, over time the bile ducts leaving his liver are squeezed closed which causes fluids to back up into the liver and evenutally, cirrhosis (liver damage). This is not caused by drugs, alcohol, or anything else he did. Although the symptoms are treatable eventually it will get worse, and the only long term cure is a liver transplant. To make matters worse, there is a 15% increase in the chance of liver cancer - which also goes back to normal with the transplant. (If he does get the cancer, the chances of getting the transplant before it spreads are unlikely). - Martha (Scott’s wife)

++++++++++++

There is a waiting list for liver transplants.

I have a patient who is waiting for one. I have three patients who have had liver transplants and so far, touch wood, and who knows what tomorrow brings, they are all doing well.

I have this vague, wishy-washy, feeling (the DK is now reaching for his revolver) that the EC is a “good thing” – you know, nation talking to nation and all that. And yet, every time that I have a specific example of what the EC does, I don’t like it. For example, I know what chocolate is. We invented it. Chocolate is Cadbury’s Dairy Milk Chocolate. It’s not that nasty, bitter, black slabby stuff that European’s like. This is chocolate:

Note that because of Eurocracy, the word chocolate no longer appears on the wrapper. That makes me cross. They have stolen British chocolate. It gets worse. Now they are stealing British livers. Literally:

A London hospital has been referred to health watchdogs after concerns that too many liver transplants are being given to foreign patients. The Healthcare Commission was alerted after 72 non-British EU nationals were given new livers in four years at King's College Hospital. In a statement, King's College Hospital, Europe's leading liver transplant centre, said it carried out 210 liver transplants in the year to this April, including 24 on patients from other EU countries. Eighteen of them were from Greece and Cyprus.

It said: "King's carries out liver transplant surgery on non-UK EU patients, as it is required to do so in accordance with NHS guidance and European Law.

"In accordance with current NHS guidelines for transplantation and European law, all EU patients awaiting liver transplant surgery at King's are assessed and prioritised according to clinical need only.
A Department of Health spokesperson said: "The transplantation of donated livers into non UK EU residents who qualify for NHS treatment is lawful. This is guided by European law which effectively regards such patients as having equal access to the NHS. (BBC)

I know, I know, I am going to be criticised for xenophobia, for being a little Englander, for being anti-European, for discriminating against poor old Johnny-Foreigner. I don't care. This is wrong. It is more than wrong, it is a scandal. It is a betrayal of the British taxpayer who funds the NHS.

I want my chocolate back. I want our livers back. If I am killed in an road traffic accident, I want to keep my liver in the UK. Can I put that on my donor card? Of course I can. But would anyone take any notice? I doubt it.

Time to leave the EC.

Happy 60th birthday, NHS : your very good health!

noreply@blogger.com (Dr John Crippen) — Sat, 05 Jul 2008 21:35:00 +0000

The NHS was set up to provide comprehensive, high quality health care for all, without regard to means or status. In one of his finest posts, Dr Rant looks at what is left after sixty years

Comprehensive coverage

The NHS provides great comprehensive coverage unless:-
It’s a dental problem.
It’s dementia: your needs are social and not medical you see, and be a good taxpayer and sell your house to fund your nursing home bill.
Fertility- we’ll pay for contraception and abortion…but we don’t to create new babies.
It’s a new cancer drug.
You need rehab rather than curative treatments.
You need adaptations to your house.
You don’t want to wait.
You have a mental health problem.
You want a permanent and recognisable psychiatrist.

High quality service

The NHS provides high quality service except that:-
It ignores foreign comparisons.
It actively manages against its staff achieving this.
It sets targets for quantity not quality, and refuses to admit that there is a trade off to be made here.
The criteria for high quality are poorly defined.
It pretends that “excellence comes as standard” which, as any fule (except Alan Johnson, Ed Balls, Darzi, Bradshaw and Donaldson) kno, is an oxymoron.
It pretends that guideline implementation and measurement and compliance is an assurance of quality.
It dreams that a computer (or nurse drone) could replace a thinking human being.
It believes that rationing is merely a technical issue rather than a moral issue.
NHS direct still exists (see below).

Full details from Dr Rant in “The NHS at sixty: it’s great, but…”

It's those "naughty nurses" again!

noreply@blogger.com (Dr John Crippen) — Fri, 04 Jul 2008 13:30:00 +0000

Time to move away from the horrors of diphtheria, and the mendacity of Ben Bradshaw. Time for a little Friday afternoon light relief. And there is no better place to visit for light relief than those dear, dear ladies at the Centre for Nursing Advocacy. I had not visited for a while and so there was a bumper crop of hilarious paranoia awaiting me. First the new ABC documentary on Johns Hopkins:

Based on the first episode, "Hopkins" will deliver the same basic messages viewers have heard a thousand times: Physicians are brilliant life-saving demigods and they are increasingly diverse, but their work requires great personal sacrifice. Note we said demigods, because as on other Hollywood dramas, the physicians will display flaws that make the overall portrayals all the more persuasive. TV Guide's preview piece on "Hopkins" went so far as to call the show the "real Grey's Anatomy," and to actually line three of the profiled physicians up against their supposed "Grey's" counterparts. The only mention of nurses in that story was in the profile of an attractive cardiothoracic surgery fellow. (Cinema Faux)

They don’t like Desparate Housewives either. (Does anyone? – yes, Dr Crippen’s daughters do)

Tonight, ABC's "Desperate Housewives" gave us a hospital nurse as mousy, pathetic physician lackey who can be bribed into revealing sensitive patient information with free lunch at a French bistro, and who has time to leave the hospital mid-shift to eat that lunch. Yeah, we know--it's just Wisteria Lane. We're sure that the episode's 16 million U.S. viewers can all separate the serious (even pretentious) voiceover-related themes and ostensibly realistic drama from this contemptuous portrayal of a nurse. (Desperate Nursemaids)

ABC's "Private Practice," the only new health drama of the 2007-08 TV season, is another prime time soap about smart, pretty physicians from "Grey's Anatomy" creator Shonda Rhimes. But in addition to the seven physician characters who dominate here, the show's LA "wellness clinic" also has cute surfing receptionist Dell Parker. The earnest Dell just got his "nursing degree" and is studying to be a midwife. He seems to be a young, network version of "Strong Medicine"'s Peter Riggs--except Dell uses his nursing skills to be a receptionist. Despite good intentions and an intense interest in the clinic's patients, Dell seems to be the least knowledgeable major nurse character in the last decade of prime time US television. The show's early episodes suggest that his clinical studies consist of whatever ad hoc assistance he can give to clinic physicians. "Is that even a word--midwifery?"

They don’t approve of what is going on in the UK either

Recent U.K. press articles have highlighted the "naughty nurse" video for pop singer Kavana's comeback single "Automatic." The video stars actress Suranne Jones (from the U.K. soap "Coronation Street") as a sexy half-dressed "nurse" who flirts with Kavana while tying him to a chair with tape. Kavana told one writer that the video was inspired by the film "One Flew Over the Cuckoo's Nest." The video isn't likely to match the cultural impression that film made, but it still reinforces a damaging stereotype of nurses--as do January press pieces gleefully promoting it in The Daily Star and The Manchester Evening News. Let’s pretend we are nurses

Whilst not totally critical of the film Atonement, they are still not happy:

The movie adds visuals to the book's nurse-centered account of hospital care, showing the courage required of nurses in mass casualty events and the formidable authority of senior nurses. Wright's movie does not match the force of McEwan's vision of the trauma the nurses face, the full rigor of their training, or Briony's growing skill. The film, like the book, also conveys little of the technical expertise nursing requires, and may suggest that nursing is more a vehicle for atonement than a modern scientific profession. (Atonement)

And they certainly do not like the soar-away sizzling Sun:

The Sun (U.K.) published an article and online multimedia presentation of the 2008 Babes and Boys calendar that features real nurses dressed in lingerie.

The Sun article is most distasteful. I can barely look. You don't see front pages of semi-clad "naughty solicitors" - well, not in the magazines I read, anyway. But then, they pay solicitors properly. It's a shame that the Center for Nursing Advocacy does not concentrate on something more productive - like the fight to get decent pay for nurses. But then, they would not be funny, would they?

Does the Center for Nursing Advocacy like anything? Well, yes. They like this:

A first step to repair some of this damage is to make more images like the "Male Nurse" from Archie McPhee. The accompanying x-ray doesn't symbolize much of a staff nursing role, so we'll assume he's a nurse practitioner. Our "male nurse" (as if we can't tell he's male from his appearance) is described by the creators as such:

"Armed with a stethoscope and a clipboard holding an X-ray, this 5-1/4" tall, hard plastic Male Nurse Action Figure is ready to treat your symptoms and fix what ails you. Male nurses make up six percent of the nurses in the United States and only slightly more in Australia and the UK, but this number is growing. These men are blazing the trail as role models and mentors for generations to come. Thank a male nurse today!" (Increasing the public understanding of nurses)

Love it. "Armed with a stethoscope and a clipboard this tall, hard plastic male nurse is ready to treat your symptoms and fix what ails you." Could be the epitaph for the NHS.

Daily Persaud covers the diphtheria vaccine shortage

noreply@blogger.com (Dr John Crippen) — Thu, 03 Jul 2008 19:46:00 +0000

NHS BLOG DOCTOR first reported the shortage of vaccine for routine childhood immunisations on 11th June in "More good news from the Department of Health" and followed up with "How long before a British baby dies of diphtheria" on 1st July. The most recent post was "Death from Diphtheria" earlier today, pointing out that, contrary to my original suggestion, there has in fact already been a death from diphtheria.

Over the last day or so, Dr Crippen has been talking to a reputable journalist from a reputable paper who was about the give the story some wide publicity, with acknowledgement of sources. It was not to be. The Daily Persaud has already published without, of course, mentioning the original source of the story.

One of the frustrations of blogging.

Death from diphtheria

noreply@blogger.com (Dr John Crippen) — Thu, 03 Jul 2008 15:11:00 +0000

Princess Alice of Hesse

In November of 1878, tragedy struck Alice's home. Her eldest daughter Victoria came down with diphtheria, and the girl's fever was extremely high. Four days later, Alice sent her mother a telegram stating another daughter, Alix, had also contacted the disease, and it appeared the child would die. Not soon after, May also became ill. Eventually all the children with the exception of Ella were infected with diphtheria. As it turned out, all but little May pulled through. The disease had resulted in a painful choking death for the little girl. Alice kept the news of May's death a secret from the others for as long as she could. Eventually the children started to question their mother about May's absence, and she finally confessed that their sister was dead. Ernie, still recovering from the illness, was extremely grieved. In an attempt to comfort him, Alice kissed the boy, and she contacted diphtheria as a result of this action. Weak from sleepless nights of nursing her family through the ordeal, Alice had no strength left to fight her illness. On December 14th, the 17th anniversary of her father's death, she passed away. She was only 35. (source)

___________________________

Like Dr Crippen, you probably thought this sad story was of historical interest only. I hope that is correct. But the shortage of vaccine is worrying. I must apologise to readers for implying that there has not yet been a death from diphtheria in contemporary England. A reader points out that I was wrong:

Death of a child infected with diphtheria in London
8 May 2008

The Health Protection Agency has been responding to the death of a child in London. The most likely explanation for the child’s death is an infection with diphtheria. The Agency is recommending that people ensure that they are up to date with their routine immunisations. Diphtheria is extremely rare in the UK due to the success of vaccinations children receive as part of the childhood immunisation programme. The few isolated cases that are seen are usually in unvaccinated people who have travelled to countries where the disease is still common. These cases do not usually spread the infection to others in the UK because the population is well protected through immunisation. Professor Peter Borriello, from the Health Protection Agency said, “It is rare for people to die from diphtheria as severe infection is prevented by immunisation and the majority of children are routinely immunised against diphtheria in the UK. This child had not been immunised. (Health Protection Agency)

Meanwhile the government dishonesty and doublespeak about the shortage of vaccine continues. My practice is currently cancelling baby immunisation clinics because we cannot get enough of the appropriate vaccines.

Ben Bradshaw gets it wrong

noreply@blogger.com (Dr John Crippen) — Thu, 03 Jul 2008 13:44:00 +0000

Ben Bradshaw might be forgiven for hating GPs. He fought his first general election in Exeter against the appalling, self-promoting, god-bothering, pole-dancer hating, homophobic GP Dr Adrian Rogers.

Dr Adrian Rogers

Prior to the 1997 general election Ben Bradshaw, the openly-gay Labour candidate in Exeter, faced a sustained campaign to ‘Stop the Pink Flag flying over Exeter’. Opposing candidate Dr Adrian Rogers distributed leaflets at schoolgates and Exeter FC deriding homosexuality as: “sterile, disease-ridden and God-forsaken”. Bradshaw secured a higher than average 11.91 per cent swing to Labour on polling day. (Stonewall)

The victory in Exeter was welcome but there is little else to recommend about Ben Bradshaw. He has now risen to his level of incompetence and survives only because he is an oleaginously compliant prime ministerial acolyte.

GPs have been attacked by a minister for operating "gentlemen's agreements" whereby they promise not to accept other doctors' patients. In a BBC News website interview, Ben Bradshaw accused family doctors in some areas of blocking patient choice. Mr Bradshaw said the lump sum "dampened the incentive" to attract new patients and meant some doctors were able to survive with very few patients. He said government research had found one practice in the south of England with just two patients, but he refused to say exactly where that was. Nor could he say how widespread the issues were. He added the introduction of choice in GP care could drive up standards in the same way it had for hospital care. (BBC)

Patients have always had the right to register with the GP of their choice. Nothing new there, Ben. The MPIG is designed to support doctors with small lists. If you abolish it, Ben, the GPs working in rural areas with large practice areas and small lists will go out of business. So what will happen in the Orkneys, in the Shetlands, the Lake District, Bodmin and the North Yorkshire moors? The patients will be left without a local doctor and will have to commute fifty miles to the nearest “competitive” nurse-run polyclinic. That will save the government a lot of money, but is that what we really want?

Mr Bradshaw made the comments ahead of publication of the government's primary and community care strategy on Thursday. The strategy, which builds on the Darzi review published on Monday, is expected to set out a vision for a more personalised GP service. It will call for more use of e-mail and telephone GP consultations - these only happen in rare cases currently. (BBC)

Oh dear God! Telephone consultations? Email consultations? We all do a few of these and it is not unreasonable for the “I have run out of hayfever medication” sort of problem. But doctors are not clever enough to make diagnoses over the telephone. Only nurse-specialists can do that, and it is the nurse-speciaist you are going to be seeing at the new “competitive” polyclinics.

And what of the allegation that GPs do not compete for each others’ patients? That we have a gentleman’s agreement not to “poach” each others’ patients?

Laurence Buckman, chairman of the BMA's GPs committee, said he was not opposed to phasing out the lump sum and putting more weight on the size of GP lists. But he added: "It is absolute nonsense to suggest there are gentlemen's agreements - it just doesn't happen.

"Nor are we going to compete for patients, that is not the way general practice works." (BBC)

Laurence is only half right. We are certainly not going to start “competing” for each others’ patients. We are doctors, not soap powder salesman. Doctors who tout for patients risk being struck off. It is right and reasonable and proper to make clear what services one’s practice offers. A practice booklet and a website is acceptable. But offering inducements – for example free gym membership – is unethical. It is part of the “pile ‘em high and treat ‘em cheap” big business ethic. It is not what reputable doctors do.

But – and I speak for my practice area now, I cannot generalise on the whole county – we certainly do have a “gentleman’s agreement” not to take on patients from other local practices. We are a big group practice. There are three single handed GPs within the area as well. We don’t routinely take their patients and they don’t routinely take ours. This is not to try to strangle competition. Far from it. It is because the patients who try to change practices are usually heart-sink, difficult people who are trying to move because their doctor will not do as they want.

"I want to change because Dr Smith never gives me antibiotics and my neighbour who is with you says you always do.”

So, when we are approached by such patients, one of us always sees them personally to ask why they want to change. If it is because there has been one of those occasional breakdowns in the doctor-patient relationship (it happens to all of us) then we probably take them. It is a difficult area, and difficult to predict what we will do in any individual case. We may not get it right on every occasion.

But let us put the problem in proportion. We get one or two such request a month. Never more. Usually less. Ben Bradshaw gives the impression that nationwide this is a huge problem. It is not. There is and always has been complete freedom of choice of doctors and, once they have signed on with a practice, very few patients wish to change.

Sir Richard Branson, Virgin Healthcare and BRANSON Pickle

noreply@blogger.com (Dr John Crippen) — Wed, 02 Jul 2008 10:02:00 +0000

Help is about to arrive

The man in the street is not going to lose sleep about the impending abolition of the MPIG. He has never heard of it. Few have. Even some GPs – the ones who don’t get involved in practice finance - do not know what it is. The MPIG is the “minimum practice income guarantee.” You are probably not much wiser. You probably think that GPs are paid a sum of money proportional to their list size. A “capitation” fee. That would be logical, and simple and indeed has considerable merit. However, if GP pay were based solely on capitation, it would encourage a “stack ‘em high and treat them cheap” mentality. It would discriminate against rurual GPs with large practice areas but small lists and it would reward GPs who took on large numbers of undemanding patients and refused to take on older patients with chronic illness.

It seems the MPIG is to go. My Lord Darzi thinks this will enourage “patients’ choice”. Postman Pat has bought into that belief:

But MPIG ‘mitigates against people exercising that choice, and is a barrier to tackling health inequalities’, health secretary Alan Johnson said. ‘That needs to be tackled.’  (source)

I will let The Jobbing Doctor sort out Johnson’s execrable use of English. Dr Crippen is in favour of choice and also in favour of tackling health inequalities. So is the Jobbing Doctor. Who is not? Unfortunately, the abolition of MPIG will have precisely the opposite effect. It will open the door to Fradd the Destroyer, to Dr Peter Smith OBE and to all the “GP entrepreneurs” (if you will pardon the oxymoron) who see the opportunity of making a fast buck out of the NHS. Why employ one doctor when, for the same money, you can have five nurses? Enter the polyclinic where patients will indeed be “piled high and treated cheap”. No MPIG to encourage rational medicine, only the capitation fee to encourage large numbers. List sizes of 10,000 managed by a group of HCPs with Fradd the Destroyer and his clones somewhere in the background, notionally overseeing the nurses, but in reality carrying the money (the taxpayers’ money) to the bank.

These “GP entrepreneurs” (pardon the oxymoron) are but midges in the economic firmament. Somewhere, in a balloon near you, Sir Richard Branson is casting his eyes toward the NHS honeypot. Sir Richard is the country’s most successful branded venture capitalist. He eats people like Fradd the Destroyer and Dr Peter Smith OBE for lunch. Virgin Healthcare is tooling up for battle. Sir Richard and Virgin Healthcare are in business to make a profit. There is no other motive. There is nothing wrong with that motive, either. What you have to ask, however, is whether the profit motive alone is sufficient to run healthcare efficiently. Most doctors think not, but few will listen to us.

Successive governments have waged a PR war against the medical profession successfully portraying doctors as lazy, overpaid and avaricious. Nye Bevin started it with some obiter dicta about GPs, Ken Clarke did the same, and the current Labour administration has continued the propaganda war. Although on the front line GPs remain the most respected professionals of all, the BBC in particular and the media in general have swallowed the government propaganda. Any doctor now suggesting that he/she has the welfare of the patients at heart is met with howls of laughter from the likes of multi-millionaire, champagne-socialist journalist Polly Toynbee.

Let's get that nice Sir Richard Branson to take over. He has the best interests of the patients at heart. You think so? You think that a Virgin Healthcare polyclinic with its 50,000 patients and its hordes of HCPs is going to provide the same level of care as your GP? Is going to be governed by the same ethical code as your GP? Is going to have your interests at heart as your current GP does?

Come with me now to BRANSON Pickle. It’s a whistleblower’s website. It is written by John Spencer, who was a Virgin employee:

John Spencer

I worked for Virgin Healthcare from 7th January to 21st February 2008. In my time there I made my concerns known regarding the ethics of some of the discussions that were being had by Senior Management. I did this in a professional and courteous manner but I felt my input was not really considered helpful by senior management. Nevertheless I continued to make my concerns known in a discreet and polite manner. In fact I was a much-appreciated employee who worked very hard for you and had nothing but excellent feedback. Out of the blue, on 20th February, seven weeks after I raised my initial concerns, Sarah Clarke, the commercial director (in relation to a perfectly decent report that I produced), called me ‘unprofessional’. Inevitably, I offered my resignation, which was accepted with some haste by senior management. Later, when I asked for the claim of ‘acting unprofessionally’ to be substantiated it was completely and readily withdrawn - but my resignation stood.

It is difficult to be a whistleblower, particularly when you are taking on the might of Sir Richard Branson’s empire. And it may be that John Spencer is nothing but a dissatisfied ex-employee who could not hack it in a successful business. All whistleblowers have to deal with that accusation. It may be that there is not a shred of truth in anything that John Spencer says. You will have to make your own mind up about that.

My Concerns - John Spencer

During my time at Virgin Healthcare I brought several ethical issues to the attention of Senior Management at Virgin Healthcare. I know you are already aware of all these issues as I bought them to your attention in a letter sent by recorded delivery to Necker Island on 22nd April. As you have made no response to these concerns I have no choice but to raise them here. Details of each concern and evidence for them can be read below.
Attempting to circumvent regulations on patient confidentiality
Planning to reward 'independent' NHS GPs for sending private patients to your clinics
Financially coercing GPs to offer 'little emotional resistance' to your plans
Virgin's relationship with the PCT
Seeking out lucrative patients who are healthy at the cost of treating patients who are ill and therefore ‘put a great strain on resources’.

If you dismiss everything that John Spencer says, then you will be signing on at the first Virgin Healthcare polyclinic to open in your area. It is a free world, and it is your choice.

+++++++++++

A reader draws my attention to this:

Medical businesses profit from young patients
If you're in business, the ideal patient is not someone with a rare and interesting condition, it's the young male professionals.

Is the ideal patient someone with a rare and interesting condition? Not if you're in business. Then it's the young male professionals who are of “particular interest”, says a report by Goodstuff, a market research firm. The document was commissioned by Virgin Healthcare, reports Pulse (June 25).

“From a business point of view, this audience [is] the most lucrative to recruit,” says the report. “They help [to] fulfill a quota without putting a great strain on resources.”

Virgin Healthcare says in a statement that “the advice has not been used or considered by any of the current management team”. Mark Adams, CEO of Virgin Healthcare, tells Pulse: “The Goodstuff report was commissioned in 2006, and I can hand on heart say [that] I haven't even seen it.”

Other documents from February 2008 show the breakdown of patients at the first practice Virgin Healthcare plans to open in January - Taw Hill Medical Practice in Swindon. The practice has a “growing population of affluent professionals with young families” and about 75 per cent of the list is under 40, with just 4 per cent aged 60 and over. (The Times)

Covert rationing in the USA : Grand Rounds

noreply@blogger.com (Dr John Crippen) — Tue, 01 Jul 2008 14:42:00 +0000

Dr Rich is one of my American colleagues, a cardiologist by training and a writer of repute. He writes, inter alia, "The Covert Rationing blog". Yep, you got it. It's happening over there too. Dr Rich has just selected his pick of the best of medical writing from the USA and around the world.

How long before a British baby dies of diphtheria?

noreply@blogger.com (Dr John Crippen) — Tue, 01 Jul 2008 13:55:00 +0000

Greetings comrades and good news as we join together to celebrate the 60th anniversary of our glorious health service. Our esteemed leader is continuing the work of the late Comrade Bevan. Meanwhile Comrade My Lord Darzi has produced a health care plan for the next sixty years. Every local soviet will commission comprehensive wellbeing and prevention services personalised to meet the specific needs of all our comrade patients.We continue to focus on the immunisation of our children. There is no shortage of vaccine. All children will be immunised on time. Appropriate supplies of vaccine have been despatched. Any comrade doctors who have received too many vaccines are free to ask for a reduction in their allocation.

Meanwhile, back at the coal face, Dr Crippen is trying to advise the two practice nurses who run our baby immunisation clinics. We have run out of vaccine. We have ordered and re-ordered. We have emailed, faxed and written to the suppliers and to the Department of Health, all to no avail. I have just cancelled the next two immunisation clinics. There is no point in bringing babies down to the health centre on a wild goose chase. Today we had this letter from the vaccine supplier:

click to enlarge

Ok, you may say, Movianto UK is a private sector company. The government will do something about this. Yes they will, but you will not like it. They are refusing to admit that there is a crisis. They are telling lies. Flagrant, brazen lies.

“we are currently distributing more (vaccine) than is needed to vaccinate all infants…”

“…in order to maintain stability in matching deliveries to supplies, we will introduce ‘allocation’ of the above vaccines…” (DoH Vaccine Newsletter June 2008)

How will the allocation be decided?

It will be "based on your previous use of these vaccines and cannot be increased". (ibid)

But our list has grown. We have more young, fecund families, and thus more babies who need their immunisations. For the first time in my practice life, I am having to turn away small children who need routine immunisations. I cannot offer them protection against diphtheria This is the reality of eleven years of Gordon Brown's health service. We no longer have enough vaccines to provide routine immunisations for our children.

Sacrilege by juxtaposition : how dare they?

noreply@blogger.com (Dr John Crippen) — Tue, 01 Jul 2008 13:10:00 +0000

Pictured in today's Times

sac·ri·lege ((skr-lj)
n.
Desecration, profanation, misuse, or theft of something sacred.

[Middle English, from Old French, from Latin sacrilegium, from sacrilegus, one who steals sacred things : sacer, sacred; see sacred + legere, to gather; see leg- in Indo-European roots.]
sacri·legist (skr-ljst) n.

Lord Darzi : offensively inoffensive

noreply@blogger.com (Dr John Crippen) — Tue, 01 Jul 2008 10:22:00 +0000

Alan, Ara & Gordon

Lord Darzi is a clever guy. Of that there is no possible doubt. He is a highly accomplished, pioneering laparoscopic surgeon. That does not make it intuitively obvious why he should be able to provide what is being trailed by the government as the single most important NHS master plan since 1997. I suspect he has been picked for his voice. There is something enormously relaxing about his mellifluous tone and his gentle Irish cadences. Such a shame, then, that his report is a load of meaningless drivel.

It was always going to be so. This report is, more than anything, about front line NHS services; about what you will get when you walk into your local general practice, or your local accident and emergency department. Lord Darzi knows nothing of general practice. He knows nothing about front line nursing care, or physiotherapy, or of the Community Mental Health Care Team (God help us all). Next the government will be asking Dr Crippen and the Jobbing Doctor to write a report about “Future developments in laporoscopic surgery”.

The best way to cover up lack of knowledge is to brazen it out, to lie. And so Darzi starts with a whopper:

In previous reviews of the NHS, frontline staff have been on the fringes or bystanders. This Review has been different. We and our colleagues in the NHS have been at its core.

Utter bollocks. Frontline staff? Look at the list of the eleven names attached to the report. There is only one GP. The rest are academic or administrative hospital doctors and managers. Not a single representative of the Royal College of Nursing. No psychiatrist. No physiotherapist. No one who can advise Darzi about what is really going on. This is not a consensus report. This is unadulterated Darzi. Count the number of times you see the word "I" in the document.

Darzi is going to tell NICE to make its decisions about new drugs more quickly. The Jobbing Doctor is impressed. We shall see. Dr Crippen is more cynical. I suspect this is sleight of hand. If NICE decides that most “new” drugs are too expensive to be cost effective, we have not progressed.

The report taken as a whole is offensively inoffensive. Colour photos of Ara, Gordon and Allan. Soundbite after soundbite

high quality care for patients and the public

Think about that. What does it mean? Patients and the public? Extraordinary. And so it goes on. There is lots more where that came from:

Change : locally led, patient centred and clinically driven
Quality at the heart of everything we do
Freedom to focus on quality

You begin to lose the will to live as you wade through this morass of focus-group soundbites. Is there any meat on the bone?

Every primary care trust will commission comprehensive wellbeing and prevention services, in partnership with local authorities, with the services offered personalised to meet the specific needs of their local populations.

Our efforts must be focused on six key goals:
tackling obesity,
reducing alcohol harm,
treating drug addiction
reducing smoking rates
improving sexual health
improving mental health.

Don’t eat, don’t drink, don’t smoke, don’t take drugs, don’t have sex and don’t go mad. All good stuff. You can’t fault it, can you? You can’t criticise motherhood and apple pie. Trouble is, you cannot build a health service on soundbites.

The biased BBC just produced a report saying:

The government has been accused of acting like a nanny state in the past over some of its public health initiatives. But the survey of 1,040 people in the UK revealed most wanted ministers to take more responsibility for getting people to make healthier choices. (BBC)

What questions were asked? "Do you mind the government trying to persuade the people to drink less alcohol?" Most might well say "no" to that. But try this question. "Given that we have limited resources, would you spend more money on eradicating MRSA from hospitals even it that meant there was less money to spend on health education?"

In Dr Crippen's experience what most patients want to know is that, when they are ill, they can have quick access to a doctor they trust and to a hospital service that is clean, efficient and free from MRSA. They may not mind being nannied about preventative health care but it is not their main priority. In any case, the drive to improve public health, commendable though it may be, is not best done by doctors. We are not very good at it. We find it boring. Let the epidemiologists, the sociologists, the advertising industry and the nurses concentrate on preventative medical education. Let us concentrate on what we do best. Seeing patients who are ill, diagnosing them and treating them.

Jesus and Mo : a work of genius

noreply@blogger.com (Dr John Crippen) — Sun, 29 Jun 2008 22:31:00 +0000

click to enlarge

I have just discovered something very special. Jesus and Mo. Can't believe I have missed it before. Earlier today I was bemoaning the fact that while Christianity was always fair game for humour, no one dared do the same for Islam. But then I had not seen Jesus and Mo. Humour does not get better than this

click to enlarge

Both these cartoons are used with the specific permission of the author. "Jesus and Mo" is available daily here.

Fish and Chips : the attack begins

noreply@blogger.com (Dr John Crippen) — Sun, 29 Jun 2008 13:35:00 +0000

A few days ago we looked at the government’s attempts to police our children’s lunch boxes:

It may seem like a small point and yet somehow it epitomises everything for which this government stands. The government funded School Food Trust is now telling me what to give my children for lunch and, if I do not conform, they are going to discipline me. (The lunch-box police)

I mentioned that my daughter was taking a bar of chocolate to school that day. I was amazed by the number of critical comments that revelation attracted. Maybe most people approve of centralised control of our eating habits.

Now the authorities are to attack that greatest of British Insitutions, the Fish & Chip Shop. No really. They think we are putting too much salt on our chips. So they are going to spent taxpayers’ money on giving away salt pots with fewer holes. You don’t believe it? Nor did I.

...elements of the elite Special Projects H&S Gestapo have turned their attention to the British chippy. Sodium enforcement officers from several local councils have toured chippies up North replacing traditional 17-hole salt shakers with a new 5 hole lo-salt version. All at taxpayers' expense. (Full story here.)

Why are they attacking the few remaining indigenous English Fish & Chip shops? Why instead don't they do something about the fat content of Indian meals?

A single Indian takeaway can contain more saturated fat than a person should eat in a day, according to consumer watchdog Which? An average portion of an Indian takeaway contained 23.2g of saturated fat, 3.2g more than a woman should eat each day, the study found. (source)

The answer is they would not dare. Forcing Indian restaurants to change their cooking methods would not be politically correct. It would be seen as racist. You can criticise the good old English chippie, and you can slag of Christianity as much as you like. That's OK. But the Indian restaurant and Islam are beyond criticism, beyond mockery. That is where we are now. Tell me honest, tell me true, don't you want to take the piss from this? But you would not dare, would you? The main stream media does not dare either.

Mobile phones cause HIV-Aids

noreply@blogger.com (Dr John Crippen) — Sun, 29 Jun 2008 10:18:00 +0000

Has Dr Crippen taken leave of his senses? Certainly not. It’s the newsagent's fault. This morning he accidentally delivered the “world’s greatest newspaper” rather than the normal “Independent on Sunday” and therein is an article by a much respected government advisor:

THE spate of deaths among young people in Britain’s suicide capital could be linked to radio waves from dozens of mobile phone transmitter masts near the victims’ homes. Dr Roger Coghill, who sits on a Government advisory committee on mobile radiation, has discovered that all 22 youngsters who have killed themselves in Bridgend, South Wales, over the past 18 months lived far closer than average to a mast. He has examined worldwide studies linking proximity of masts to depression. Dr Coghill’s work is likely to trigger alarm and lead to closer scrutiny of the safety of masts, which are frequently sited on public buildings such as schools and hospitals. (The world’s greatest newspaper)

This sounds like inflammatory wibble to Dr Crippen but we must not rush to hasty conclusions. So, off to Dr Coghilll’s website to find out more. You can tell that Wendy Denning is a doctor of medicine because in all the pictures of her on her website she has a stethoscope round her neck. Dr Coghill does not wear a stethoscope so perhaps he is not a medical doctor.

Roger Coghill

He has a beard, though, which lends a certain gravitas. And like Dr Wendy, he "advises" the government. He is obviously very clever and knows a lot about electromagnetic radiation. He knows how to magnetise water too. How does that help, you may ask? Why not ask the dog:

The Coghill dog water magnetiser

Given the choice your pet will always choose to drink magnetic water, they can tell the difference. Magnetic water is more natural. Using a pet coaster ensures that your pet receives maximum benefit from their drinking water. They will love the taste. Helps with- Painful and stiff joints, muscular complaints, skin problems etc. (Coghill sales)

Dr Coghill’s expertise extends to humans as well:

Coghill's Moodmaker

Can help with impotency without the use of powerful drugs. The Mood Maker will gently and gradually increase circulation in the pelvic area. The small unit discreetly attaches to your underwear. Viagra, eat your heart out!! (Coghill sales)

A man capable of producing such wonderful products deserves to be taken seriously. He writes at length about HIV_Aids

AIDS and the Man: Electromagnetism and the Immune System

"It ain't just me, it ain't just you; this is all around the world".
Paul Simon, Graceland, 1986.

The idea that AIDS is caused by a virus is a well-protected fiction. The possibility that immune deficits, both mild and serious, can be acquired through over-exposure to non-ionising electromagnetic fields is, however, real, and proven in the laboratory. If these two statements themselves were not paradigm-shifting enough, there is a distinct possibility also that all viral structures are simply a physical manifestation of coherent electromagnetic fields, and are not really organic creatures at all, lying on the borderland between the organic and the inorganic, the material and the field, the ghost and the machine. This possibility has been known in the highest echelons of the U.S. Government since 1943, as a result of wartime experimental work on high EM fields. (Roger Coghill)

The things that Uncle Sam didn’t tell us! That explains everthing.

This is all, of course, the most despicable wibble and one wonders how a man who purports to be a scientist can trade on the credulity of the general population not only to promulgate his cod science, but also to sell his ludicrous products.

Ben Goldacre at Bad Science is already on the case. In one of his funniest and most wonderfully understated posts, he takes a look at Roger Coghill, his "qualifications" and his “science”. (sic)

Dr Wendy Denning : the GP chelator

noreply@blogger.com (Dr John Crippen) — Sat, 28 Jun 2008 17:56:00 +0000

Dr Wendy Denning

Those nice people at Holford Watch recently introduced me to Dr Wendy Denning. She is an experienced family doctor now in private practice in Central London. She is widely travelled.

Prior to returning to the UK in 1998 she took specialised training with Nutritional Doctors in the USA and also attended the Institute of Optimum Nutrition in London to further her longstanding interest in Nutritional Medicine. (Dr Wendy Denning)

ION is based in Richmond, south west London, and was founded in 1984 by Patrick Holford. Patrick was awarded a Dip ION Honorary Diploma in Nutritional Therapy by his own institute. Don’t you love it?

But back to Wendy. As an experienced GP, her practice provides most of the routine services you would expect from a GP but, in addition, she also offers:

Nutritional Education
Body Composition Analysis
Food Intolerance Testing
Blood Tests for Vitamin and Mineral Deficiencies
Chelation
Heavy Metal Detoxification
Intravenous Vitamin Therapy

Dr Crippen’s practice does not offer any of those treatments. Particularly not chelation and heavy metal detoxification. I was wondering for what conditions Wendy might offer “chelation” treatment, and how much it might cost. Please God, she doesn’t offer this for children with autism. Her website says,

To make an appointment, feel free to contact Michele

Tel: +44 207 224 2423
Fax: +44 207 935 4763
e-mail: michele.ahlin@drwendydenning.com

The Health Doctors
4 Duke Street
London
W1U 3EL

So I did feel free, and duly sent the following email to Michelle:

From: Dr John Crippen
Date: Wed, 25 Jun 2008 22:22:27 +0100
To:
Conversation: Chelation treatment
Subject: Chelation treatment

Dear Michelle

You have been recommended to me. My 18 year old son is autistic, and has never been easy to care for. We have been advised that i.v. chelation treatment might help. Could you kindly advise if you can provide this service for an 18 year old, and also advise on the costs that would be involved?

Yours sincerely

John

And this is the reply I received:

Dear John,

Thank you for your email.

Dr Denning has said that she can provide this service for your son.

He would initially need a consultation with Dr Denning which is £195, he may also need some tests and possibly a challenge test, these may amount to approximately £400. Each chelation is then £130 and the amount and frequency your son requires will be decided by Dr Denning in the consultation. If you should like to make an appointment please call in to reception on the number below, or if more convenient I can organize via email.

Kind regards

Michele Ahlin
Administration and Research Assistant
The Health Doctors
4 Duke St
W1U 3EL
020 7224 2423

-----Original Message-----
From: Dr John Crippen [mailto:nhsblogdoc@googlemail.com]
Sent: 25 June 2008 22:22
To: michele.ahlin@drwendydenning.com
Subject: Chelation treatment

Oh dear! Oh dear, oh dear, oh dear.

Clement Attlee was right about the NHS

noreply@blogger.com (Dr John Crippen) — Sat, 28 Jun 2008 09:18:00 +0000

Professor Lord McColl

The past is a foreign country; they do things differently there.

A long time ago, in a land far away, Dr Crippen was houseman to Professor Lord McColl as he then wasn’t. Those were the days. Each medical and surgical "firm" had two housemen, two SHOs, a registrar and two or even three surgeons. The housemen worked over a hundred hours a week thus providing continuity of care for the patients. You did not go on Prof McColl’s ward round without having the details of all the patients at your finger-tips. A senior nurse always came on the ward rounds to present the nursing side of story. Nurses were nurses then. Those really were the days.

I remember assisting Prof McColl at an operation. Tired and concentrating hard I leaned forward slightly too much and my forehead touched the back of his hand, desterilising it. He held his hand up for a nurse to change his glove. He did not shout. He never shouted. He was a quiet, meticulous surgeon, renowned for minimising blood loss during an operation. An anaesthetic registrar once put down the estimated blood loss after a long operation as “two RBCs and a macrophage” (you know who you are if perchance you are reading this!)

Enough of this reminiscence. I was thinking of emeritus Professor Lord McColl as he now is, because I was listening to him talk in the shower this morning. I was in the shower. He was on the Radio 4 Today programme. He talked of the introduction of the NHS and of the great Clement Attlee. He revealed something of which I was hitherto unaware. When that famous Labour government introduced prescription charges it did not do so solely to increase revenue.

Differences of opinion arose in the Government. The immediate cause was a proposal in the Budget to make charges for certain of the Health Services in order to prevent abuse. (Clement Attlee “As it happened”)

There you have it, from Clement Attlee himself. Within three years of the introduction of the NHS he was already talking of abuse and of front end charges. If only he had introduced a real front end charge for all medical care, the NHS would not have been brought to its knees by unrealistic expectations and selfish abuse.

++++++++++

Thank you for the emails about the first line. I know. I know. It was deliberate. Just my little tribute to Dr Persaud.

The rise of the Health Care Professionals : don't say I didn't warn you

noreply@blogger.com (Dr John Crippen) — Fri, 27 Jun 2008 12:46:00 +0000

Health professional

From day one of NHS BLOG DOCTOR I have been determined to warn of the gradual destruction of the NHS. Like government taxation policy, it is being done by stealth; by gradually dumbing down front line NHS services.

The destruction of psychiatry.

Three days after I started I wrote about the Community Mental Health Team in Shocking Psychiatry. In days gone by, when I had diagnosed someone as suffering from a serious mental illness that required more specialist treatment than I could reasonably provide, I referred then to a psychiatrist. Not with much enthusiasm it must be said as the psychiatric services in my area are, for the most part, dreadful. GPs no longer have direct access to psychiatrists. In my area the psychiatrists are so lazy that they refuse even to read GP referral letters. Instead, the letters go to the collection of unqualified amateurs who think psychiatry is a game; a game that can be played by anyone who has learnt a little plausible jargon. Some are well-meaning; some are arrogant fuck-wits, so intoxicated by their own perceived “power” over the patients that they think they know more than doctors. Their mickey-mouse tick-sheet medicine causes incalculable damage and demeans the patients. Those who read the Times may have seen this today:

Mentally ill are 'jollied along' rather than treated by psychiatrists

People suffering from mental illness are frequently being misdiagnosed or receiving inadequate treatment, according to a group of leading psychiatrists. The doctors say that patients with serious problems are often referred to psychologists and social workers rather than clinicians and do not receive the medical therapies they need.

“If a GP suspected a patient had cancer, he wouldn't dream of referring him to anybody other than a cancer specialist. A cancer patient might need jollying along, but what he really needs is the correct diagnosis and treatment. That's what he gets from a specialist. But patients with mental illness are not automatically referred to psychiatrists. If they only see a social worker, there's every chance that mental illness, or underlying physical illness, will be missed. Patients are getting a bum deal.” (Professor Nick Craddock)

Describing their letter as a “wake-up call” to British psychiatry, the psychiatrists say that the desire not to stigmatise people has also done damage by implying that there is no such thing as mental illness. Patients are now known as “service users” rather than patients — even though, when asked, 67 per cent preferred the word patient and only 9 per cent service user. Treatments are provided at “mental health” centres, not mental illness clinics.

Psychiatry, the group says, is the only medical speciality to adopt an approach that so distorts its original purpose. “For those with severe mental illness, to avoid medicalisation is at best confusing and at worst damaging or even life-threatening ... these individuals are being let down by the current state of affairs.”

Full article here

Don’t say I didn’t warn you. Of course, the government loves it. It saves money. To make it sound good they call it “New Ways of Working” as though there is some intrinsic merit in the something new.

A spokeswoman for the Department of Health said: “The introduction of New Ways of Working has been widely welcomed by service users, carers and psychiatrists. Working with multidisciplinary teams has allowed the needs of people who use mental health services to be better met and frees up psychiatrists' time to work with more complex clinical cases.”

You can fool some of the people some of the time… It is extraordinary how the government can get away with this breathtaking dishonesty. But make no mistake, they are getting away with it and they are extending it to the whole of the health service.

The destruction of general practice

NHS review to push for more nurse-led care.
The long awaited review into the future of the NHS by Lord Darzi will next week propose a big boost in the size of independent nurse-led provision of primary care, similar in ambition to the rise of independent foundation hospitals. The government has proposed an expansion of nurse-led services in the primary care sector in the past, but progress has been slow. In an effort to speed up the process, Darzi will suggest that nurse-led partnerships should be given a statutory right to request a local primary care trust to allow them to set up as a not-for-profit trust. (source)

Here we go again. Remember, nurses are much cheaper than doctors. Five GCSEs and three years as a student nurse and out pops nursey. Ten GCSEs, four “A” levels, five or six years at medical school and another four or five years post-graduate training and out pops a family doctor. Who do you want diagnosing you?

Darzi quotes the Central Surrey Health Partnership as example of independent nurses working in primary care. Dr Crippen has never heard of Central Surrey Health Partnerhip and had to call in Dr Google. It’s all here.

Central Surrey Health is a not-for-profit, limited liability company under contract to provide community nursing and therapy services on behalf of the East Elmbridge and Mid Surrey Primary Care Trust. The contract is similar to those held by GP surgeries (a specialist medical services contract). Central Surrey Health employs around 650 staff who formerly delivered community nursing and therapy services from within the PCT. They are:

district nurses
community hospital nurses
school nurses
specialist nurses
health visitors
nursery nurses
physiotherapists
podiatrists
dieticians
speech and language therapists
occupational therapists
support and administrative assistants

On transferring to Central Surrey Health all staff were presented with a single share in the company. As co-owners, they are responsible for delivering patient services and shaping the company's future. (Source)

Surry PCT has flogged off some of its nursing and other community services to an independent body of entrepreneurial nurses. I have no problem with that. New Labour would never admit it but this is stealth privatisation of the NHS. Is it working? I have not got a clue. Can anyone in Surrrey let me know?

Whether or not it is working does not matter. To take the usual airline analogy, this is just a load of trolley-dollies joining together and taking over the on board cappuccino and sandwich franchise. You would not want them flying the aeroplane. Which is where my Lord Darzi is being fraudulently dishonest. He is suggesting that because the sandwiches are good, the trolley dollies can fly the aeroplane.

Ministers believe nurse-run services have enormous potential to cut bureaucracy in primary care and focus care more directly on the needs of patients. (source)

Ministers also believe that you can employ four nurses for the price of one doctor but they are not going to say anything as vulgar as that. As always, you get what you pay for and, in this case, pay peanuts, get monkeys. The government knows that untrained monkeys are no substitue for doctors but thinks they may be able to fudge it by issuing the monkeys with Disease Management protocols. With a protocol, anyone can play doctor. As Professor Sir Michael Rawlins the Chairman of NICE, the National Institute for Clinical Expedience, said today they are going to produce “guidelines for health professionals”.

Say hello to the “health professional” run polyclinics and say good bye to the family doctor. This will save you, the taxpayer, a lot of money. Maybe you will be happy to have your health problems managed by people who are not medically trained.

If that is what you want, so be it. It’s a free world. If that is not what you want, take out private health insurance as soon as possible.