Life after Retirement

This my first post since retiring after fifty years employment, self-employment and then employment again. It has been "interesting" as in the Chinese curse version of that word. On our first day of retirement, and driving out of London to our country retirement idyll, we got only as far as Hammersmith Flyover before the results of my recent PSA blood test resulted in a phone call urging me to see my GP as matter of urgency. For all my whinging about the NHS, what happened thereafter, my patient journey, was a example of text-book excellence.

I registered with a local GP and saw him the following day. My "two-week wait" referral resulted in a urology appointment at my local district hospital (DGH) in seven working days.

What I Thought Would Happen

After watching patients endure the local DGH where I had worked, I warned my wife that I would probably see an SHO or, if I was lucky, a registrar who would decide to ask for a repeat of the PSA, order an ultrasound and make a follow-up appointment a couple of weeks later to review the results.

What Did Happen

My 10am appointment was with the consultant. First, the ultrasound machine which was next to his desk. Completed by five past ten. Good news: didn't appear enlarged.

Next, the dreaded gloved finger did the necessary. Ten past ten. Mmmm... there's some sort of nodule there so we'd better get a biopsy. Can you come back at three o'clock?

Biopsy completed by half past three.

Now for The Bad News

Seven days later, back for the results. Adenocarcinoma of the prostate. Advanced. Aggressive. Oh bugger. Left hospital with first batch of drugs. Radiotherapy started on the first possible day after allowing the drugs to do their stuff.

And finally The Good News

All clear.

So dear reader, it can be done well. I asked the specialist nurse why it was so good. She told me that the whole team had sat down together and worked out how to do it all better. What an amazing thing .. asking the people who know how it works (and doesn't)  and who need to make it work better.

A&E Treatment Targets

It's been an "interesting" summer (as in the Chinese curse "interesting"). One of my more forgettable moments was taking myself down to St Thomas's one Wednesday evening with what I suspected was an unwelcome return of the double pneumonia episode a couple of months earlier.

I arrived into a pretty quiet waiting area at 20:45 and was booked in almost immediately. A few minutes later, I was taken into the treatment area and into a cubicle. Routine obs were taken and after a while the new JHO - Junior House Oficer (it was week one of the great August musical chairs) learned of my previous bout. She said she'd arrange an x-ray and this was done within the hour. Pretty good ... so far!

About 23:15 JHO returns and says chest is clear so they're going to take some more blood for some tests. Blood duly extracted. I wait in cubicle.

23:45   Still sitting in cubicle
00:15   Still sitting in cubicle.
00:30   I say to my wife: "You watch; in the next fifteen minutes all sorts of stuff will happen".
00:40  JHO returns and says they're going to admit me.

Me:   Why?
JHO:  Pardon?

Me:   I've been sitting here for the past 1½ hours. Why have you suddenly decided to admit me?
JHO:  We're still waiting for results of your blood test.

Me:   Can't I wait here?
JHO: No.

Me:   Why not?
JHO:  My care pathway coordinator won't allow it.

Me:   Well how long will the results be?
JHO: About an hour or so.

Me:  Well I'll wait here then rather than take up a bed.
JHO: You can't.

Me:  Why are the results taking so long?
JHO:  Um, um, actually there was a problem with path system.

Me:   What problem?
JHO. Er, we forgot to send them to the lab.

Me:   You are not admitting me to adhere to some arbitrary four-hour target which you will exceed because you made a cock-up.
JHO:   You can't stay here.

 Me:  Then I'll go home. I live over the road less than five minutes walk and you can phone me when you have the result.
JHO:  Oh, you'll need to fill in the self-discharge papers.

Me:   OK.

Two hours later the phone next to my warm comfy bed rings.

JHO:  The results are back. You need a CT scan. You need to come back straight away.
Me:    Does that mean I have the CT scan when I get there?

JHO:  No. They don't open until nine o'clock.
Me:  Then I'll come back then. Good night.

If I'd agreed to be admitted, St Thomas's would have charged my GP's commissioning budget because they'd cocked up their management of my treatment by forgetting to send my bloods to the lab. The likely cost to the GP's budget would have been hundreds of pounds because of the way it would be coded with my advanced years and a non-related chronic disease.

As long as this goes undetected. There is no incentive on hospitals to be more efficient when treating A&E patients long as they can be admitted, even without a diagnosis, after 3h:55min. In theory the tariff allows a set number of days for particular episodes but this was an episode that could have been completely unnecessary (e.g. my first ever attack of gastric reflux - which it wasn't).

Dr Lansley's Brave New World?

We are now well into the convulsions caused by Andrew Lansley's radical reorganisation of the NHS in England. Already, the NHS senior management establishment is undermining much of what he set out to achieve. We were told that it was expected that there would be about 550 consortia formed. Clearly this is far too anarchic for the bureaucrats and they have fought back with dogged determination to ensure that the "new" NHS structures retains as much as is possible of the "old" NHS structures (that got us where we are today).

Now, the NHS hierarchy seem determined to create much bigger consortia than was originally envisaged. They are suggesting that in East London, the minimum size they see as sufficient to create the necessary economies of scale is about half a million patients. That is roughly the combined populations of the London Boroughs of Newham, Tower Hamlets, Hackney and The city of London. Amazingly enough (or not), that is precisely the description of the existing "cluster" formed by the amalgamation of the three PCTs last year. If you divide the poulation of England by half-a-million, that would mean about one hundred consortia for the instead of the 550 suggested by Dr A and his merry men. This is all a far cry from the original plans as they were explained to us.

Meanwhile, the PCT/Cluster seems determined to fashion things as it thinks they ought to be rather than what the commissioning groups think or want. Since it is these same PCT managers that got primary care where it is today, they’re mostly the people I would rather were NOT designing their replacement. However,  turkeys rarely vote for Christmas and here in East London, the turkeys still reign.

I now longer have either the energy or the enthusiasm to try and change things.

At a personal level, I am saddened by how little of the energy that is being expended is making any difference to patient care. Things are being rearranged, usually at some considerable cost, but rarely to make things better. We have been tricked into doing the government’s dirty work for them presiding over significant cuts in funding despite all the rubbish that ministers spout about “spending in real terms”. Primary care is 90% of the care and 10% of the funding. Giving us amateurs the budget for the other 90% whilst slashing it can only be poor value for taxpayers and poor value for patients. The answer to the problem of NHS managers that clearly can’t manage is to find managers that can, not give it to GPs who have no training or experience.

I am glad I will have retired by the time that our local general hospital announces firstly that it will have to close its A&E service (probably done in stages by first reducing opening hours), and then that it is closing most of the rest of the hospital too. For consortia, they should realise that the politicians will be quick to point out that this will be a commissioning decision so it will be their fault.

Dr Lansley or Dr Pangloss?

In a little under five months, GP commissioning groups are supposed to take over the reins of most of the prodigious NHS budget £106 billion for 2011/12. If you have read previous entries, you know I like the real numbers:

So that's one and and six, thousand, thousand thousand pounds. £106,000,000,000. Even the Greek economy doesn't need that much (this time round).

Well, MrTaxpayer, how do you feel about handing over control of this much money to a complete load of amateurs?

NPunFIT

Probably because it got off to such a poor start, the National Programme for IT ("NPfIT") got a rebranding and became "Connecting for Health". Several billions later, we are still light years away from any system that delivers good quality decision support so I prefer to call them NPunfIT since that is exactly what we've got: a system that is definitely not fit for purpose.
I suspect that people operating in the commercial arena assume that we have functioning management systems to control such a collosal organisation consuming over £100,000,000,000 each year.  We don't!
I think "the management" gets away with it because they operate the most byzantine of systems, usually at least three months behaind the event, and often with little resemblance to financial reality.
We are supposed to taking over commissioning budgets (the financial responsibility for funding a patient's hospital or specialist care).

• There is no financial system in place that provides any accurate information that is less than ten weeks old.
• There is no system in place that can accurately price the actual costs being charged to us by hospitals (since they are so often subject to local variations).
• The same patient can have the same procedure twice in the same hospital but we could be charged different amounts depending on which order they hospital codes the record of treatment (i.e. if they put "old" before " depressed" it might be a different charge to being "depressed" and them "old".)
• There is no system that accurately identifies whose budget should be deducted for which patient.so we are supposed to spend time working out whether we should have been charged for the treatment for that patient on that date.
• There is absolutely no forecasting system that monitors actuals against forecast against budget.
• Budgets are frequently set well into the year to which they apply. The record for us was November for a year starting the previous April.

 No we're taking the responsibility away from the so called "professionals" and handing it over to the "amateurs". GPs.


Be scared. Be very, very scared.

Obesity - Illness or Just Plain Stupid?

If you click on the title of this entry, it will take you to a BBC news article about Professor Tony Leeds - an obesity guru at Central Middlesex Hospital. His underlying concern is that "The impact of Britain's obesity epidemic continues to increase, and so does the cost, both human and financial. Obesity now costs the NHS around £4.2bn annually, and the wider economy a frightening £16bn."

Though it's not why I feel compelled to put pen to paper, I do wish people would say "it costs YOU and ME £4.2bn (assuming YOU like ME are a taxpayer). He argues for an "fully-funded army" of obesity specialists in every GP practice. He talks about "obesity management", "surgery" and a "fully-integrated national scheme" and much more.

Apart from the fact that Professor Leeds obviously lives on another planet as he has no idea what's going on with NHS funding here on Earth, I am growing ever-more exasperated by the NHS's preoccupation with helping people to lose weight. Whatever we do and however much we spend, I reckon over 90% of it is a complete waste of time and YOUR money.

How many overweight people do you know who don't also know:

• about healthy eating?
• about the risks of excess weight?
• about the benefits of exercise?
• somebody with diabetes?
• somebody with heart disease?
• other people who are overweight?

Exactly. We all know what to do and how to do it. Most of us simply don't! It's a choice we make and I don't see why spending even more taxpayer's (yours and my money) will make the slightest difference.Don't get me wrong - I am worried about obesity. I am 14st 10lbs (92kgs) and underneath my well-built exterior is a skinny bloke. I reckon my healthy weight should be 26 lbs (12kgs) lower than that. Clearly I am not that worried!

Both of my offspring are overweight and they know it too. Where I work, half of the staff are overweight and some of them meet the (BMI>30) definition of obese. We cannot claim ignorance - we watch patients arriving everyday seeking help for the damage caused by years of over-indulgence.- and most of our team talk about their concern but clearly they are not that concerned.

Looking around us, London seems to me to be the crap food capital of the world. We seem to have more places to eat fatty, greasy, and decidedly dodgy fast food than anywhere but the United States (and look at what's happening there!). These outlets wouldn't be there if they didn't make money but they do, especially immediately after school finishes when they are filled with the next generation of podgies stuffing chicken 'n chips, coated in salt, dipped in sugary ketchup and washed down with a sugar-filled carbonated drink.

Our PCT spends over £2 million a year on "weight management and obesity" which includes prescribing orlistat and then bariatric surgery (gastric banding). Only the latter works; the rest is a complete waste of time and money. Our patients tell us they want to lose weight, and next time they come they might have lost (or gained) a kilo or two. We rarely succeed in helping anyone do anything significant about their weight.

What do I think we (i.e. the NHS) should do?

Nothing!

I think our job should be to treat the symptoms and leave dealing with the causes to somebody else. Somebody else that is who has a billion or three that their government is prepared to cough up.

We could also:

• apply a supplementary levy on all fast-food outlets;
• discriminate against fat people in the workplace (they cost employers a lot more than skinnies);
• price transport tickets by passenger weight;
• ban unhealthy foods in places in schools, hospitals, government offices;
• insist that all radio and TV broadcasts a set amount of anti-obesity propaganda;
• fine parents that don't feed their children properly.

Too radical for you? Well, I guess so.

But the problem is not medical,; it's social and that's where we need to supply the solutions. The best thing that GPs can do is scare the pants off fat people but too many GPs are way too squeamish for that.

Don't believe me. Those of you who remember Harry Secombe will recall him as the jolly, rotund "Goon". Suddenly he lost a lot of weight. A LOT!

Why? Because a doctor (not in UK) told him if he didn't, he'd be "dead in six months"! He freely admitted that up until then, despite being told about the consequences, nothing had worked.

The current government has increase the financial pressure on the NHS that was first exerted by their predecessors. Don't you love creative English? For "financial pressure" read REDUCED FUNDING. So we have less money to care for more people, living longer and getting ever fatter. If it was your money and your relative that needed a hip replacement, spinal surgery or renal dialysis, or it was your local A&E that was closing, I'm sure you wouldn't mind that part of the reason was that while you and I just kept on eating chips, health bureaucrats kept spending money on you and me, even with the knowledge that £90 million in every £100 million was a complete waste of money.

Let's think the unthinkable - smoking

In the 1970s, I spent a great couple of weeks in Bristol learning about "Operational Research". This was the original name of what is now called "Applied Statistics" - using statistics to solve a specific "here and now" problem. The course lecturer had formerly worked on the great technological white elephant that was Concorde.He explained that he watched the Concorde project abandon financial commonsense as delays, overruns, modifications all added to the bill. That's the trouble with big numbers. They start to reach a size where we loose our grip on reality. Once you start talking "billions", then £0.05 billion seems like petty cash.

But it isn't. It's fifty million quid!

Our lecturer explained that he kept his sanity by converting all these overspends into Mars Bars. He knew the volume of a Mars Bar and how much it cost. It was fairly simple arithmetic to represent the "latest cost overrun on the Concorde undercarriage system" into enough Mars Bars to fill three aircraft hangars - floor to ceiling .. wall to wall! You may think he was potty but it kept his cost accounting feet firmly rooted on the ground instead of in project-financial fairyland. I have taken advantage of his wisdom ever since. It helps me to ensure that cost projections, financial forecasts, etc. can all stand up to real world scrutiny.

Which leads me to the NHS expenditure on helping people to stop smoking. Why are we forking out MILLIONS of pounds for smoking cessation treatments? People smoking a packet of fags a day are spending £42 a week on the habit. They could afford to buy any of the various OTC patches and potions for a fraction of that. I've checked on Amazon and patches vary in price from £1.05 each up to £1.75 or in cigarette terms that's between six and eight ciggies a day. If they do give up, then they will reap the financial benefit for the rest of their lives.

By this point, any "health professional" reading this will have marshalled the forces of righteous indignation to attach me as an inhumane and illogical idiot (which may be true but that's not the point). Helping people to stop smoking saves the taxpayer money. You've all see the headlines. Smoking costs the NHS £1.5bn, £3bn, £5bn a year (what's a few billion matter here?). Don't believe me? Just click on this link to Google and see what numbers pop up for "smoking costs NHS". Read the headlines for yourself.

Increased likelihood of coronary heart disease, lung, throat and mouth cancers, respiratory disease, etc.etc. are all consquences of smoking. However, there are also savings to the NHS and the taxpayer.

• The excise duty on cigarettes is vast: excise duty in 2010 is estimated at £8.8bn and VAT is a further £1,7bn. (Tobacco Manufacturers' Association). That's ten percent of the total NHS budget of £103.8bn
• The biggest cost to the NHS is in treating the effects of getting old. If smokers (on average) die sooner, then whilst they still incur the costs of their chronic conditions but save on the costs of elderly care.

If the NHS wants to have a financial debate about smoking, then perhaps it should consider encouraging us to smoke. It looks as though there's a net gain in terms of revenue and expenditure here! Even if I'm wrong, about the big picture, I still don't see why we should be subsidising people who want to stop smoking any more than we should subsidise people who want to stop biting their nails or sucking their teeth.

The NHS is running out of cash. We have more important things to do than this.

(for the record: I use to smoke - sixty-a-day in fact. So did my son. He now runs marathons and I get my exercise watching him occasionally).

Lions Led by Donkeys?

The title of this posting was first applied to the allied soldiers rotting in the trenches in the first world war. It is a phrase that often haunts me when I collide with NHS management. I am weary of sitting with groups of managers and those GPs that get involved in management and hearing them defend the NHS as something that is far too good and noble to be tainted by the whiff of commercialism or those with a "profit motive". From where I sit, the NHS isn't very good at all. It is grossly inefficient; appallingly profligate with taxpayers money; and it delivers a large amount of mediocre care in buildings that would be the subject of criminal prosecutions if they were not the responsibility of the government.

The average NHS manager has no real grasp of financial management and no grasp whatsover on the real meaning of cost. Few managers have any formal training for whatever role they assume. My son is a project manager for an international telecomms giant. His team are experienced in project management and work effectively in every corner of the globe. I dare not recount to him how my PCT is (not) managing our NHS broadband connection whilst he's eating as he could easily choke whilst laughing. Few if any of our local managers have the faintest idea how much the services they manage actually cost and there is no accurate means of measuring forecast vs actual costs. Our prescribing budget is usually set six months into the year. Mind you, there is no point having a real management information system. The management couldn't work it nor usefully interpet it anyway.

Before you all start shouting at me, let me acknowledge the tens of thousands of workers in the NHS trying their best to deliver good care to sick people. There are many small islands of excellence. I am grateful to live in a country where I will get treated if I am ill even if I can't remember the PIN on my credit card. However, these facts have nothing to do with the way the NHS is run. In fact, shouldn't it be these people shouting the loudest?

Blair and Brown inherited an NHS that was leaking vast amounts of money (billions!) through waste and inefficiency. It was grinding to a standstill with waiting times, poor access and declining hygiene. This dismal catalogue was the evidence of NHS management outcomes. Blair's prescription was to throw money at the problem. Even our village idiot could tell you that whilst you might eventually fill a leaky bucket if you poured enough water in, the moment you stopped pouring it, you will be back at square one.

And so we are!

Even as I speak, the same management is now working out how to cut spending in real, historic and any other term you wish to use. The bucket still leaks as much. The level will drop. Waiting times will creep back up. Hospitals will close and management will blame it all on the government and most of you will believe them.

The Buck Stops Here

The TV programme was all about the experiences of an undercover reporter in hospital and the subject was the awful food. I have no idea why this reporter felt the need to hide under the covers; hospital food is almost invariably awful and everybody knows it to be so. Anyway, having puffed up his feathers into a fit of righteous indignation, he confronts some poor hapless politician to demand what is to be done? After floundering around talking about anything but money, this drowing MP reaches for the usual "get out of jail free" card:

"Your local GP" says he, " is the chap to sort this out! We are giving them the budget and they are in the best position to drive up standards and make sure you are a happy bunny."

Oh really?

Here's a question for the reporter: how will you feel if the next time you need to see your GP, you can't get an appointment because his morning surgery is full of people angry about hospital car park charges, the lack of a direct bus to the surgery, the district nurse arriving late, the curtain pattern in Nan's sheltered accommodation, young Henry's lack of choice for designer prescription spectacles and all the other things with which the "I want it all and I want it now" brigade can fill their spare time?

Lots of managers but not much management

The meeting had lasted 1½ hours and was drawing to a close. We had been discussing the improvements in performance of a screening service that our PCT had taken over and then completely buggered up. Right at the end, they produced their performance report and in it were two graphs (which I have combined into one shown on the right).

You will see that routine referrals by the service to hospital consulants (the top line) oscillated between 38 and 225 a month. Urgent referrals also varied between 1 and 39 a month.

Everybody was really impressed with the report but then I spoilt it. I asked why there were such large variations from month to month.

Not a bloody clue!