Saturday 26 June 2010


'It's now very common to hear people say, "I'm rather offended by that", as if that gives them certain rights. It's no more than a whine. It has no meaning, it has no purpose, it has no reason to be respected as a phrase. "I'm offended by that." Well, so fucking what?'
- Stephen Fry


Thursday 24 June 2010

Nursing levels

There has been a lot of discussion about inadequate staffing levels. It's abundantly clear that having too few qualified nursing staff on wards compromises patient care and results in more deaths. The evidence consistently shows this. Accounts within clinical practice consistently illustrates this. Patients admitted (and their course, with some unnecessary deaths) consistently experience this.

It's therefore not surprising to me that when the Healthcare Commission investigated shabby care in hospitals, they found ward staff to be good, but management systems not supporting them (through cutting costs and not staffing wards with adequate numbers/adequate qualified staff). Subsequently the Care Quality Commission (CQC) have done the same. The CQC regulates hospitals, challenging them on quality and services. How deeply have their investigations and reports rocked managers worlds?

Has it changed anything in practice?

We learnt of the woeful outcomes at Mid Staffordshire NHS Foundation Trust with the report stating :
"It appears that some staff from whom we heard were often demotivated, undervalued and working in an understaffed and stressful environment"
"The staff who worked on these wards all agreed that there was a shortage of nursing staff."
"We heard these wards were significantly short of nurses, especially at nights and weekends."
"Some staff expressed the view that there were insufficient nurses before the reorganisation and that there were fewer after."
"Many witnesses noted that there were too few nurses and that those that were there were doing their best in difficult circumstances."

The Mid Staffs report described good nurses doing the best they could. To my knowledge, nobody was reported to the NMC for poor professional practice. Nor should they be. They worked as well as they could within the environment that managers generated for them. Indeed, the independent and detailed investigation found and documented that the nurses worked inordinately hard and beyond their duties, putting in huge effort to care for their patients.

The issue wasn't poor nursing, the hospital was fortunate and had great nurses. The issue was the the hospital, to save cash, didn't staff the wards with enough nurses (i.e. qualified staff) to keep patients safe. How huge is that. Not that there weren't enough nurses for gold standard care. Not that there weren't enough nurses for reasonable quality care. There weren't enough staff for safe care. Patients needlessly died.

But time's moved on.

Things surely have improved. Lessons learned. Erm, sadly it seems not. Scarborough looks to be operating in a scarily similar manner to Mid Staffs.

So it goes.

This week I read a new report by the CQC. This is dear to me, since it's about older adult mental health services, within a Trust providing mental health services. Not mine, I may add. The CQC are positive about the Trust. "The Trust has cooperated fully with us during the course of our enquiry . . . the Trust has not waited for the publication of our report. It has proactively started a process to improve its mental health service for older people."

One unit was terrible (and closed), the other units were fine.

So it's a decent Trust, with decent units, providing decent care. The management structure quickly made management changes and 'fessed up to shoddy care, investigating things themselves and reporting themselves to the CQC and making changes themselves. All genuinely poisitve stuff, the way the Trust behaved really does seem sound.

Most of the problem seems to have been one unit which was doing quirky things which nobody knew about. Things like using strong opiate analgesics inappropriately and hooking folk with dementia up to syringe drivers to control agitation. This was a huge error in governance which the Trust raised it's hand up and sorted out. Grand.

So the Trust, a decent Trust, find an area of rubbish care, sort it out and 'fess up to the CQC they've been rubbish, they're investigated and all's seen to now be okay.

Apart from one area.

Page 30 : "We looked at the relative costs of nursing staff against the trust’s spend on senior managers and managers for the years 2005/06 to 2008/09. Our analysis showed that while the spending costs for qualified nurses had dropped over that period from £26.1 million to £25.4 million and for unqualified nurses from £14 million to £12.5 million, the costs for senior managers and managers had risen from £4.5 million to £6.8 million"

"Our impression as we visited the older people’s mental health inpatient units was of highly dedicated ward managers, nurses and nursing assistants working under constant pressure. On more than one occasion, we came across ward managers who were trying to do their best for their patients with too little resource and fearful that they had not covered every aspect of patient care and the management of their ward."

Page 52 : "We found that members of staff working in these clinical effectiveness and risk roles in the trust appeared to have a good grasp of what needed to be done but were frustrated by the lack of effective systems to enable them to feel as confident as they should around overall clinical governance and compliance."

The CQC evidence that the wards were understaffed and staff knew what needed doing. And the Trust board spent a lot on management and moved from generating loss to generating surpluss. What have the Trust done to support nursing colleagues on the ward?

They closed the ward. They appointed a lot of Modern Matrons. They appointed a Director of Nursing.

Okay, I'm sold that they need the Director of Nursing but the Board minutes reporting ". . . outstanding concerns against overspending on in-patient wards and [the Director of Finance] pointed out the need to ensure optimum ward rotas," leaves me cold. More nurse management, less ward nurses.

The pages on community staff levels, case loads of 27.2 cases/staff is a whole post in itself, with community resources and practice meritting discussion. But to stay vaguely on topic, suffice to say that governance of ward process and staffing on the in-patient ward lead to grim patient care.

How many Trusts are staffing in-patient units well? How many Trusts are staffing in-patient units, if not well, at least adequately? Gah. So it goes.

Read the report from the CQC and see what you make of it.

Wednesday 23 June 2010

NHS Costs

There's been much discussion on the blue/gold government's health policies. Rightly so. It's serious, it really really matters and it's possible to cock it up, spectacularly, if they get it wrong.

Some areas, such as qualified nursing staffing levels, have been poorly resourced in most in-patient and many community teams, for years. What will the new "austerity measures" mean? For our Trust we're already uneasy, with no uplift from any of our PCT commissioners this year, so we're having to do more with the same amount of cash (but inflation means we of course have less). And, of course, we're still obliged to make cost reduction efficiency savings each and every year, trimming off literally millions from what invariably are our staff costs.

Local and regional "stretch targets" mean we lose millions if we don't meet the quality targets (and evidence that we meet them). We won't. We can't meet some of them. Others, if we did meet them, it'd cost more to do that than we'd get paid. So we're destined to lose cash that historically has been part of our base income. Even less cash to pay our staff with. Not good.

Although it looks ugly in Secondary Care, in fairness it looks uglier elsewhere. My poor colleagues in Primary Care are being pushed into a corner. Instead of seeing patients and providing clinical care, they're going to be expected to commission services from providers. With the best will in the world, how could 30 consortia get different services from our Trust? Would providers tender for activity from a single practice if that GP practice wanted services that couldn't be easily provided? Will a Trust provide "loss leading" services? Our Trust has declined work from a PCT that's invited us to undertake activity, but won't pay us enough to consistently break even, so even with large amounts of cash from a PCT we're saying no; what influence will a group practice have? I do not know. But the GPs I know are not enthusiastic about having to sort out all this commissioning nonsense for all their patients for all clinical community and hospital and acute and mental health activities. At the moment, GPs are independent. Unlike a PCT, or SHA, they're not directly accountable to the Department of Health. If they commission quirky services, is there any accountablity? Not at the moment. Will GPs be brought into an accountability framework?

It doesn't look fun to be be sitting in GP land, right now.

The government quite rightly is looking at management costs within the NHS and thinks too much cash is spent on management. They're right. It is.

Slimming down Whitehall to do less and tell us to do less, such as disbanding oodles of targets, has to be a good thing.

Slimming down the regional Strategic Health Authorities (SHAs) seems a fair plan. Less intrusion and more cash saved.

Slimming down (or almost getting rid of) local Primary Care Trusts (PCTs) has left my PCT colleagues in a state of anxiety. Sadly, in all honesty, I'd not miss much of the PCT if they went. I'd miss the PCT pharmacists who are dynamic, sensible, pro-active, helpful and clinically focussed. But much of the managers and their committees and generated paperwork doesn't make quite as much impact on the district's health provision as some might imagine. Certainly the cash thrown at the buildings and staff and operation of the PCT doesn't seem to deliver wondrous value for money. But I concede I don't see all they do.

So the central DoH, the regional SHAs and local PCTs are all in the firing line. None of this seems bad, to me.

GPs are to have more duties, responsibilities (and accountability).
This does concern me, since most GPs I know aren't keen on this and aren't equipped to do this.

Secondary Care providers continue to provide secondary care.

Could have been a whole heap worse, dismantling front line services. But to be hitting the tiers of management actually is a positive intervention that can save money, reduce intrusion and improve how GPs and hospitals deliver care.

I remain optimistic.

Tuesday 15 June 2010


I saw a lady who'd tried to kill herself, pretty seriously, with paracetamol and strong opiates and alcohol.

After being ventilated and coming out of intensive care, it was clear she wasn't clinically depressed. She'd had low mood through relationship changes, chronic pain, changes in health, her GP'd started an antidepressant last year but it hadn't helped. A sensible thought to try one, but not surprising it did nothing, given she was low in mood through reacting to grim life situations, not through endogenous clinical depression.

We talked for an hour and a half. She wasn't mentally ill. She was psychiatrically fit for discharge. She went home to her husband with numbers of our crisis team (which she'll never call) and an appointment with our psychologist, which hopefully will afford her changes in perspective, acceptance and alternative ways of coping that're useful, enabling her to feel she is equipped to manage.

I stopped her antidepressant. Sometimes suicide isn't about clinical depression. Sometimes it's not a mental illness, sometimes it's a choice. But I hope she'll choose a different way.

Monday 14 June 2010


I've a wife and children so am not a workaholic, I arrive at 8.20am or a bit earlier and leave when I can, which usually is before 6.00pm. At home I do end up doing a fair bit of work on nights, usually generating presentations or reviewing/ammending policy documentation or teaching materials or interview questions and model answers or Continuing Professional Development, so there're many extra hours of work there, too. I guess that's almost 10 hours a day at work, plus an hour or two most nights at home, making for a reasonable investment in time whilst trying to keep a decent work/life balance.

On top of this there is on call work, out of hours. As a doctor approved under section 12 (2) of the MHA 1983, that means all Mental Health Act work comes to me, out of hours. Since junior doctors can't do liaison psychiatry now, all hospital queries come to me, too. A&E and police seem to like to have my point of view, too. Our in-patient wards have junior doctor support, but these doctors have to discuss pretty much everything with me (eg they're not allowed to prescribe anything off licence . . . which pretty much makes up all out of hours prescribing decisions).

Whilst on call I'm just waiting to be hassled by anyone and everyone. It is not restful. There are many calls. Unlike many Consultant colleagues in the acute Trust, I frequently have to go out to see a patient in the middle of the night. Not uncommonly, several patients.

In one recent week on call I had 21 hours sleep over 5 days, averaging a touch over 4 hours a night.

Against the background of working something like 11 or 12 hours a day anyway, the nights on call are a real kicker. Still, I'm paid £3.17 an hour for this (less 40% tax then other deductions), so for £1-something an hour I'm certainly not doing it for the cash.

Investing blood, sweat and tears into a vocation you're passionate about is commonplace amongst my medical colleagues. I could hug Nurse Anne for, in an inadvertent comment lost at the bottom of a thread of much more important themes, reminding folk that doctors invariably work very very hard. Bless her cotton socks. *hugs*

Friday 11 June 2010


I had a message left with my secretary from an orthopaedic ward. It was about a post op elderly patient who'd fractured her hip and was profoundly confused, apparently throwing hot tea and drinks at people, pulling out lines and battering the staff.

I 'phoned up the ward, who know me well, and spoke with a staff nurse, saying I'd received some info about a patient causing havoc and could I make arrangements to review her that afternoon. I gave the nurse the patient's name (which was quite common) and asked for identification details (date of birth, NHS number) so I could see if we'd any past details from CMHT, GP, memory therapy or memory clinic contacts.

The nurse said she couldn't give me that information.

"So you're referring a patient to me, but you won't tell me who they are?!"

"Sorry, it's the policy . . . seems a bit silly, doesn't it?"

You couldn't make it up.

Wednesday 9 June 2010

Charities and groups

Do you have much to do with charities and groups?

Odds are you do. Is seems there's been thought about hospitals and charities on blogs for a few years now with some 1530 hospital Trusts having charities. Whether charities should be paying for MRI scanners and the like is a valid question, with different views having been aired.

As well as hospital charities, there're other charitable groups. In my corner that boils down to the Alzheimer's Society, MIND and Age Concern. They tend to contribute an incredibly useful and independent role in offering supporting information, shared perspective and emotional support from peers, which NHS services can't (and shouldn't) compete with.

Local hospital charities. National special interest charities. What of patient groups? I'm enthusiastic about most of them; one of the best conferences I've ever been to was an annual Hearing Voices Network international conference. The patient perspective was so clearly and powerfully and helpfully presented I didn't even blinch at the emphatic liberal use of "survivor" instead if "patient" since it was so congruent with the account. Perspectives shared in presentations and workshops and over pints on an evening changed my views on mental health care more than any training or placements or CPD ever did. I even gleaned more on the consideration and use of therapeutic interventions there than I did in any other conference. I'm uncomfortable with minority patient groups misrepresenting majority patient groups e.g. patient focus groups who insist on being called 'clients' or 'service users' have ingrained this into national dialogue, because a vocal few have demanded this. Yet local consultation with 4 patient groups and 2 carer forums and Alzheimer's Society groups in 3 areas found the prefered term was 'patient' from all parties, which fits with a paper published in the psychiatric bulletin that proactively asked people what they wanted to be called and got 'patient' back too. So a small very vocal minority group have changed things in a way that's at variance with local and national evidence.

That's undue and unfair and unhelpful influence.

But apart from this tiny, tiny issue of vociferous minority groups misrepresenting majority views, I'm all for patient groups and advocacy for change for the better. So if there's independent thinking, helpfully generating constructive challenge or interjecting alternative viewpoints, why am I uneasy about the Kings Fund?

Although founded in 1897 as an independent charity essentially to look at better hospital care in London, it's now a behemoth that asserts that they ensure, ". . . independence and expertise remain at the heart of we do."

What is the heart of what they do, you may ask. They tell us. It's about how they, ". . . play a special role in shaping policy, developing effective practice, and supporting individuals and organisations."


Policy with implemented effective practice, independently generated by experts, what's not to like? I met with and spoke with folk from the Kings Fund, their passion and motivation was self evident. Their message and the change they're effecting was crystal clear. Inspired independent change being joyfully and enthusiastically progressed, what's not to like?

Well, it's just that more than a small part of me feels intense disquiet that it's not really that independent. In fact, isn't it all well represented either directly by Department of Health workforce (directly or indirectly through Select Committee or quango appointment), or private health company presidents, or Monitor, or other interest groups. So not independent at all. Indeed, they're placed to advance either government policy or the interests of private healthcare companies, yet overtly state they're independent. Grrrr.

I note that cleverer folk spotted this before me in December last year.

Much badness.

Thursday 3 June 2010


Times are changing. Allegedly. Although maybe not changing an awful lot, since our PCT 'fessed up today that the money the SHA has given them for the implementation of the National Dementia Strategy, not being ring fenced, has been swallowed up by other stuff and spent on other things. So it goes.

Cash that could have been used to improve dementia care therefore's evaporated and the acute Trust down the road grumbles along, despite the national picture reported by the Alzheimer's Society showing that, well, it's all a bit shabby.

Is there any hope, then? Locally, the acute Trust is working with us and is keen to improve. There's a lot of work to be done, though. For example, the DoH have accepted Prof Banerjee's report and recommendations around antipsychotic prescribing in dementia care. 180 000 patients with dementia on such drugs with only 36 000 getting benefit rightly raises concern that prescribing practice needs to be more robust. How're things to improve? Exceptionally and very hearteningly, there's no requirement for more committees and no desire for more management. The report requires that Medical Directors and existing governance structures deliver on this. Deliver on what? Just one bit of one recommendation is that the Trust has to ensure good practice in initiating medication. And ensure good practice if it's maintained (e.g. a patient comes in on it and the hospital ward continues to administer it to them). And ensure good practice in discontinuing medication. All sensible stuff.

What's intrigues me more is that in addition to the clinical quality improving, there Trust has to ensure this is done. So just bashing out some protocols or care pathways or policies or naming a couple Dementia Champions or Medicines Management Champions or Lead Practitioners or having a standard operating procedure or drafting guidance ain't enough. They need to ensure that the system works. First the clinical care has to improve, then evidence of this meaningful implementation needs to be generated. Without more managers or committees or nonsense.

Having met with PCT and LA and colleagues today, I am hopeful. But the acute Trust having to do this, with no new cash 'cause the PCT snaffled it . . . somehow this seems less than ideal.