Sunday 31 July 2011


Picture an elderly gentleman, living on his own, in his own flat, for 10 years.

He's been a recluse, family bringing him all his groceries, the dentist visiting him there, he's literally not been out of the property for a decade. He had lived in gloom (the curtains always had to be closed). Then his GP (who's not been able to see him for years) refers him to me, worried he might have dementia since he's not functioning and he's become paranoid and feels the man above him is wafting smoke at him, he's being watched by people, neighbours try and set him on fire, they're tampering with his water. He now feels afraid in his own home.

He agrees to stay with family, crossing his doorway for the first time in so many years. In their home he's no better. Pictures talk to him. The pets are telepathic. The family are variously helping him, or poisoning him, so he lashes out with a walking stick.

He was unwell. He needed an antipsychotic to make him better. This was done. He recovered. He's now relaxed, happy, sociable and active. He's no longer housebound, he goes to shops and the seaside with family. He was going to go back to his flat but he's such a great sense of humour and so fun and so good with the grandchildren the family have moved him permanently into their home, which he's delighted about.

He wasn't acutely paranoid. He's been unwell for at least a decade. He's been appropriately referred, treated and most of all supported by family, and now he's well. Cured. From housebound and antisocial and afraid, sitting in the gloom, he's now happy and well. He doesn't have dementia. He's had no acute illness at all. He's simply been mentally unwell for over a decade and now he's had the combination of care he needed to help him. He's cured. It's not often I get to say that.

Saturday 23 July 2011

Patient Safety

We have been told (by the General Medical Council) how doctors' revalidation will improve patient safety, back in October 2010.

The sagely Jobbing Doctor muses over whether nurses' revalidation/governance will tighten up, querying what the fallout will be, here.

It truly isn't a cynical comment, it's simply an observation, that I really can't see how revalidation will make any difference to patient safety. Post-Shipman we've had rigorous annual appraisals, taking literally days to do each time. And Consultant peers looking at our cases for Case Based Discussions. And Peer Groups (which should have happened anyway) actually happening, looking at our learning objectives and what we're doing/what we've done. I really can't say patient safety's any different.

Realistically, how would you spot someone like Shipman? We frequently have very different outcomes with different clinicians. A real example from my training : one surgeon wants low mortality rates and only operates on those who will have good outcomes, leaving most to no active treatment/palliative care, so those with moderately advanced cancer are denied surgery and go on to die. But those he operates on do very well and his perioperative death rate was incredibly low, since he only operated on those with early cancers and decent health. Another surgeon would try his hand at even the most desparate cases, figuring that death was inevitable and pretty immediate if he didn't. Many (indeed most) of his patients did very well, but some of course died soon after surgery. His perisurgical death rate was stratospherically higher. But understandaly so. He was still the better surgeon (and arguably the better clinician). Mortality rates alone are just numbers, we need context and understanding of the patient population, the interventions, others involved in care, comparative data with others, understanding of norms and bell curves and variability, it's not simple to speak with a doctor and dichotomously allocate them in to a "safe" box or "murdering" box.

What it boils down to is, usually, over a coffee, hoping to trip up the bad apples through slipping in a question such as, "Well Bob that about covers things. Oh, by the way, d'you have any urges or are you planning on murdering large cohorts of your patient population, within the next year?"

It's as good as governance systems would seem to be . . .

Thursday 21 July 2011


I've finally accepted the truth of it. Personalised Budgets were constructed with willfully malign glee and, clearly, are naught but the machinations of the devil, made real.

I can not begin to rant over the hideous, hideous consequences 'pon vulnerable folk with dementia that the change to Personalised Budgets has inflicted.

Access to care is now beyond grim.