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!

The Elephant in the Room is a Drunk!

The current mantra of our healthcare policy makers is "moving care closer to the patient". The reason (excuse) for this catchy little phrase is money. It is now assumed that moving care out of hospitals and into community settings is cheaper and on paper this is entirely reasonable. That's the "what" and the "why". It's the "how" that always terrifies me.

As a taxpayer, I wan't the NHS to be looking to ensure it doesn't spend money unnecessarily. There is one area where it could save itself a fortune if there was anyone brave enough to grasp the mettle. It's drunks!

Before shaving threepence off the community chripody budget, all politicians should be required to spend a Saturday night in the casualty department of the general hospital that serves their constituency. What they will see is an NHS emergency service overwhelmed with young, drunk, vomitting, often-aggressive pillocks who think that ending up having the contents of their stomachs vacuumed is a sign of a good night out.

Our risk-averse managers ensure that we care for these tossers with skills that are in short supply and very expensive to provide overnight and at weekends - how much would extra you want to be paid to be puked over on your Saturday night?

I think the answer is to adopt one of the United State's more sensible policies - the "drunk tank". If you're drunk and incapable, then get shoved in a large cell with all the other serial idiots until you sober up. In the morning you can pay the spot fine and find your own way home. Make sure the cell is tiled so it can be hosed down easily in preparation for the next batch. I don't wish to be uncivilised about it. Female drunks should have their own cell next door.

To start with, some cities will need something the size of an aircraft hangar (and there are plenty of those lying around) but once the message gets through to what's left of their brains, demand will surely lessen?

Your trusted GP?

Back in January this year a young baby, one of our patients, died whilst waiting in A&E. It was unexpected but actually no great surprise. The poor mite had been born with a number of severe heart defects which skilled surgeons were doing wonderful things to fix but only a few at a time.

I have just received "Form B" from them upstairs.

On the front page it says:

"Each agency representative is to complete this form by summarising information available within their agency. Each representative should complete only those sections for which they have information. The CDOP manager will collate the information from the different agency reports to provide an overall case record. This collation will be agreed at the local case review or by the individual agency representatives in consultation with the CDOP manager.

You can see where this is going.

Let's fast forward to page 4:

"Factors in the family and environment:

Include comments on family structure and functioning; wider family relationships; housing; employment and income; social integration and support; community resources.Include strengths and difficulties."

Had enough yet? No?? Page 8 then ...

Is either parent a smoker? Was the baby an asylum seeker? Are the mother and father related to each other (excluding marriage)??

It stops at page 10.

After the death of Victoria Climbie, the NHS spent millions and millions on a massive change on child protection procedures in GP surgeries, most of which would not have stopped Victoria's "aunt".

After Shipman, the NHS spent millions and taking Class A drugs out of GP surgeries because they made the paperwork so awful that it was easier not to bother. Another huge system upheaval not because the system didn't work, but because individuals in the system failed in their duty of care. I can only surmise that this form is a result of the baby P case.

Officialdom's response to a failure is to change the system but it's the people that don't do their jobs that's usually the problem.

Everybody knew.
Anybody could.
Somebody should.
Nobody did.

Here's a suggestion: save the money spent on completing this form (which is arse covering in triplicate) and spend on on front-line social care that might just reduce the incidence of further Baby Ps.

Sacred Medical Records

You are currently spending lorryloads of money creating the ability for clinicians everywhere in the NHS to view your summary care record ("SCR"). Whenever this investment is challenged and for whatever reason, the shroud wavers emerge to say that it will save lives. They give examples of people who would suffer a severe anaphylactic shock if given drugs to which they will react badly. They are correct but that must not be the end of the argument.

Medical records as we maintain them are mostly utterly irrelevant to present or future health care.

Elderly patients have letters in their records telling me that in 1955 they had a baby with a normal delivery at a hospital that long ago became a luxury apartment complex. That baby is now collecting their old age pension.

I know that's an extreme example but very little of what has gone before has any relevance to urgent care or current management.

You are spending billions moving paper and electronic versions of all this medical ephemera between GP practices and from practices to hospitals and back again.

Instead of upgrading the NHS wide area network, let's buy some shredders.

Targets Are Not Management

The Government has made much of its decision to scrap a couple of NHS targets: the "48 hour target" within which time a patients is guaranteed to see a GP; and the "18 week rule" within which time a patient should have been treated in hospital following a referral from a GP. I really disliked these targets but perversely, I am sorry to see them go.

Firstly, what didn't I like?

Well, let's start with the 48-hour target. The way in which GPs fiddled their appointment systems didn't really sort out the structural confilct between seeing the GP when it suits (a future appointment) and seeing the GP "now - it's an emergency" (even though it almost never is!).

Some of the outcomes of the 18-week rule were frankly, bizzare. If a patient tried to change a hospital appointment, they were "discharged back to their GP" (NHSspeak for taken off the system) and invited to join the queue from the start when a further 18 weeks could be counted. This is clearly poor care and there is no excuse or justification for it.

So, why am I sorry to see them go?

I should explain that I am not opposed to quantitative measurements of performance to inform management. Looked at in isolation, these targets are reasonable; if you in some distress it is reasonable to be able to obtain medical help within two working days. Four months ought to be enough time for a patient to pass through the hospital system and be treated (providing there have been no unforeseeable delays).

The problem is not the targets but the way in which The Health Kremlin uses them.

Targets are not management or a substitute for management yet this is precisely how they are used. The orthodoxy is that we set these targets and leave the front-line to reorganise themselves to meet them. What doesn't happen is sensible pragmatic supervision and management of the behaviour of GPs and hospitals that are aspiring to these targets. Providing the PCT or Hospital can let their local Politburo tick the correct box, then the target has worked, even when a short stroll around the patch would reveal some of the nonsenses that have been carried on since the targets first appeared.

Another classic: the "no more than 4 hours in A&E target".

Introduced after countless lurid headlines of patients left lying on trollies in corridors for hours, days, weeks, etc. The target has resulted in a huge surge of patients admitted as in-patients because the precautionary test results (x-ray, whatever) wasn't available within 4 hours; all of this at considerable additional cost and inconvenience to everyone.

Before we had targets and no management.

Now we don't even have the targets!

It Only Works because It Doesn't

In the left corner:

Our PCT, insisting that we provide ever more appointments that have to be bookable two weeks in advance; also insisting that we see patients immediately when they say it's "urgent" even when it's clear it isn't; and also providing minimum number of appointments each GP must provide each week. Their targets are ambitious but we do our best.

In the right corner:

The BMA Guidance on child Protection which says amongst all the other excellent advice: "Doctors have a key role to play in child protection (case) conferences and the BMA considers it important that , as far as possible, doctors attend in person, in addition to sending in a written report containing relevant information such as ..."

In the middle:

The GP. We usually receive less than 48 hours notice of a case conference (that's because best practice is to convene it a.s.a.p). So the GP has usually already got fifteen or so patients each with a ten-minute appointment booked up to two weeks in advance, exercising their right to see the doctor of their choice.

The Outcome.

We rarely attend case conferences and until someone works out the realities of the conflicting demands made of GPs, that situation won't change.

The Moan

It's one of the things that really gets my goat. Managers have produced glossy (and expensive) books containing impressive procedures that are faultless in ambition, aiming for very best practice and overflowing with care. They simply don't work and nothing will change until they look at the realities of general practice. Try asking us - that would be a start.

Uncle Noel RIP

Yesterday I went to the funeral of the last of my mother's seven siblings. Uncle Noel died peacefully at the splendid age of 93. He started as a miner at the age of 14 but continued his education and after the war became the Deputy Master of Worcester Workhouse. What a splendid title! Pure Dickens, porridge and all. For the rest of his working life, together with my aunt, they cared for old people and they did it really well. My Aunty Mair's cooking was legendary!

When Mair sank into the swamp of dementia, it was all the more frustrating (polite version) to see the lack of care that she received despite the determined afforts of a feisty eighty-odd year old husband. Hospitals trying to discharge her because she "wasn't ill as such" and local authorities acting with a complete lack of urgency. After all, Uncle Noel could help (no, they hadn't noticed he was crippled by two very arthritic hips).

After Mair's death, Noel moved into a care home run by MHA (a methodist charity). At last, he received the sort of care that he and Mair had given to others. So thank you to MHA, the staff at Norwood, Ipswich and to Noel and Mair for lives spent providing real care for people not clients.