Well, My Black Cat, I’m back!

While The Witch Doctor was away it seems you have been rambling on giving your less than erudite thoughts on various things that you know nothing about.

I’m going to test you to see whether you’ve been concentrating properly.

Take these two recent publications for example.

INDEPENDENT REVIEW OF THE LIVERPOOL CARE PATHWAY

REVIEW INTO THE QUALITY OF CARE AND TREATMENT PROVIDED BY 14 HOSPITAL TRUSTS IN ENGLAND ; OVERVIEW REPORT

Professor Sir Bruce Keogh KBE.

Did you notice something unusual about them?

No?

Didn’t think you would…

If you listen carefully to this story then it will give you a clue.

Once upon a time in a hospital that The Witch Doctor knows very well, there were lots and lots of committee meetings. Indeed some doctors seemed to spend more time sitting round these talking tables than they spent in consultation with their patients.

The chairman of one of these committees became aware of this and he decided to do something that had never been done before. He looked at his watch at the start of each meeting and he made a note, not only of all those who attended, but he also privately graded them according to their likely salaries. He then worked out the approximate hourly rate that each attending member of the committee was paid.

When the secretary of the committee had completed the minutes the chairman insisted they were then handed over to him. He then calculated the number of man / woman hours that had been spent at the committee and indicated the approximate cost in sterling. This was an indication of the contribution made by the taxpayer to the meeting. The minutes contained this information when they were circulated to members of the committee and to senior hospital managers.

He could have gone further and added the time taken to read all the documentation distributed by the committee and the preparation time for any action taken. He didn’t though because he was just trying to make the point that committees have a responsibility not to waste taxpayers’ money.

This poor doctor didn’t last long as a chairman since it was deemed inappropriate to cost in this way the many meetings that were going on in that hospital.

But times might be changing.

For the better……

That’s the only clue I’m going to give you, My Black Cat. Now go back and read these two documents thoroughly and pay attention!

Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report

Professor Sir Bruce Keogh KBE.

14 HOSPITALS REVIEWED

Deficiencies in :

BED MANAGEMENT – FLOW (1)

BED MANAGEMENT – OUTLIERS (5)

MEDICAL STAFFING LEVELS (5)

NURSING STAFFING LEVELS (6)

STAFFING LEVELS (Unspecified) (6)

OUT OF HOURS / OVERNIGHT STAFFING (6)

EQUIPMENT SAFETY CHECKS (4)

INFECTION CONTROL (4)

RECOGNITION OF ILL AND DETERIORATING PATIENTS (3)

DELAY DISCHARGE LETTERS (1)

DELAY REPORTING SCANS AND XRAYS (1)

Huh! There is not much point in measuring mortality, morbidity, complaints, legal compensation costs etc as indicators of poor quality care when staffing levels are inadequate to examine, diagnose, treat, observe and provide even the most basic care for patients, if these patients are difficult for doctors to find because they are continually being moved around or are “outliers” (i.e. boarded out in inappropriate wards) or the equipment is unsafe.

Maybe correct all of this first, then count things if funds allow?

Eh?

But then, these are just the views of a simple witch’s cat with a preference for hands on activities like hunting rats rather than measuring them.

It is no secret that The Witch Doctor is no fan of the “Liverpool Care Pathway”, or indeed any of the “pathways” or “journeys” that patients are expected to stagger along nowadays.

She’s not keen on “tools” or “toolboxes” either.

And she loathes protocols because they make the people who tick the boxes witless.

She is totally and utterly against euthanasia or assisted suicide.

She also hates social engineering, especially when driven by governments.

It seems to The Witch doctor that the charity “Death Matters” started off as a social engineering outfit fuelled initially by the last labour government. It is an outfit fronted by the specialists in palliative medicine.

Maybe The Liverpool Care Pathway, the Mid-Staffordshires of the NHS, euthanasia and Death Matters are all intertwingled to a greater or lesser extent.

The NHS is unravelling and This Black Cat needs to get her head round it all.

For the life of her she can’t remember what The Witch Doctor has posted in the past about her scepticism about “a good death.”

So, there is some homework to be done before The Witch Doctor returns:

DEATH QUESTIONS

A COLLISION COURSE

THE EXIT BUSINESS AND DIRTY DYING

DYING – DOING IT THE GOVERNMENT’S WAY

THE SPIRIT OF CHARITY

HALLOWEEN AND THE DAY OF THE DEAD

POO AND TRIPLE SEVEN

THE MECHANICS OF DEATHLY CREEP

WE HAVE BEEN VERY PATIENT

THE EUTHANASIA OF A MEMBER OF MY FAMILY

THE ATHEIST HUMANIST PREDICAMENT OR NOT

THE SLIPPERY SLOPE

With a bit of luck, studying these posts will help This Black Cat make sense of these important Intertwinglements.

INDEPENDENT REVIEW OF THE LIVERPOOL CARE PATHWAY

MORE

“THE LIVERPOOL CARE PATHWAY SHOULD BE REPLACED

“The Liverpool Care Pathway should be phased out and replaced by an individual end of life care plan, an independent review led by Baroness Julia Neuberger recommended today.

The review was commissioned by Care and Support Minister Norman Lamb in January 2013, because of serious concerns arising from reports that patients were wrongly being denied nutrition and hydration whilst being placed on the Pathway.

Senior Rabbi at the West London Synagogue and crossbench peer, Baroness Neuberger and her panel now recommend that use of the Liverpool Care Pathway should be phased out over the next six to 12 months, and be replaced by a personalised end of life care plan, backed up by good practice guidance specific to disease groups.

The Review panel recognised that, when applied correctly, the Liverpool Care Pathway does help patients have a dignified and pain-free death. And they support the principles underpinning it. However, they heard of too many cases where the LCP was simply being used as a ‘tick box’ exercise, its users failing to take account of a patient’s individual needs.

Today the report makes 44 recommendations. In addition to replacing the Liverpool Care Pathway, others include:
• A general principle that a patient should only be placed on the Liverpool Care Pathway or a similar approach by a senior responsible clinician in consultation with the healthcare team.
• Unless there is a very good reason, a decision to withdraw or not to start a life-prolonging treatment should not be taken during any ‘out of hours’ period.
• An urgent call for the Nursing and Midwifery Council to issue guidance on end of life care.
• An end to incentive payments for use of the Liverpool Care Pathway and similar approaches
• A new system-wide approach to improving the quality of care for the dying.

Speaking today, Baroness Neuberger said:
“There is no doubt that, in the right hands, the Liverpool Care Pathway supports people to experience high quality and compassionate care in the last hours and days of their life.
“But evidence given to the review has revealed too many serious cases of unacceptable care where the LCP has been incorrectly implemented. Examples include leaving patients without adequate nutrition, hydration and inappropriately sedated. This is not only awful for the patients, but it is deeply distressing to their relatives and carers.

“Caring for the dying must never again be practised as a tick box exercise, and each patient must be cared for according to their individual needs and preferences, with those of their relatives or carers being considered too. Ultimately it is the way the LCP has been misused and misunderstood that has led to such great problems, along with it being simply too generic in its approach for the needs of some people. Sadly it is just too late to reverse this and turn the clock back to get it used properly by everybody. That is why we have recommended phasing out the LCP and replacing it with a more personalised and clinically sensitive approach.”

“What we have also exposed in this Review is a range of far wider, fundamental problems with care for the dying – a lack of care and compassion, unavailability of suitably trained staff, no access to proper palliative care advice outside of 9-5 Monday to Friday.

“All the major players in the health and care system, including the Government, need to do their part in reforming care for the dying, so that people everywhere can be sure they will be treated with respect and compassion, supported to die a peaceful, dignified death.”

The LCP was recommended as a model of good care by the Department of Health’s End of Life Care Strategy in 2008, by the General Medical Council in 2010, and the National Institute for Health and Care Excellence in 2011.

It was designed to be used as a means to manage a patient’s pain and distress when clinicians considered that they were in their last hours or days of life, and there was no appropriate reversible treatment for their condition.

The Review panel held four sessions around the country and heard evidence from relatives and carers and clinicians with experience of the LCP, along with a number of organisations.

More than 650 submissions were received and carefully reviewed by the Panel members, who undertook this work without payment because of their deep concerns.

The Panel has decided to meet again during the winter to monitor progress made on the recommendations.”

No doubt The Witch Doctor will be pleased that Her Ever Faithful Black Cat remembers her blog post of January 2010. Nobody paid any attention to it then and they probably won’t now!

However, governments, teachers, and naval gazers should beware of poking noses into lunch boxes.

After all, any one of them might belong to a Witch Child.

13 January 2010

As an act of rebellion, tonight The Witch Doctor had a big dinner plate of chips cooked in dripping and sprinkled with a huge bar of grated Cadbury’s melting milk chocolate.

And a big mug of tea with milk and 4 spoonfuls of sugar. Ugh – The Witch Doctor hates tea with sugar!

All because of THIS

Let’s talk about fruit and vegetables.

Over the years, The Witch Doctor has come across patients at her clinic who have never tasted a cherry, not a single one. Others wouldn’t know a gooseberry if they saw one. Many have never eaten peas shelled straight from the garden. Children nowadays think strawberries are a crunchy and tasteless fruit to be avoided at all costs and that pears and turnips come from the same family.

Almost no young person who has ever attended my clinic has tasted a Black Hamburg grape with stones. It is just as well, because they wouldn’t know what to do with the stones – because all the grapes they have ever tasted are cloned seedless. Yet they have never tasted the wonderful old sweet seedless sultana grapes.

And plums. Where are the dark skinned sweet juicy Santa Rosa plums? They have been replaced with horrible hard atrocities that are only fit for stewing. And what about the sweet, juicy seasonal Victoria plums that grow so well in the UK? Most youngsters have never tasted them.

Apples? How many youngsters know the UK is an excellent apple growing country and could have thousands of varieties to choose from (although probably many are now extinct.)

Ayrshire potatoes? You can barely find them even in Ayrshire. They are called “Ayrshires” of course. They are not. A true Ayrshire potato has to be grown in sandy soil that is fertilised with two different types of seaweed at particular times of the year. Pembroke’s and Jersey Royals are the nearest but are not a patch on the real Ayrshire potato properly grown.

No young people today have ever had the pleasure of eating a plate of Ayrshire potatoes smothered in butter. Yes, butter – the nasty stuff!

It makes me weep!

Ladies and Gentlemen who are trying to change the eating habits of our children, please listen to this witch.

You are getting it wrong!

Wrong!

Instead of poking your nose into school children’s packed lunches and giving them hang-ups that their parents are not feeding them properly, why don’t you tackle the supermarkets and tell them to sell local produce when in season. Then there might be some kind of incentive for local farmers to grow decent fruit and vegetables.

There are many reasons why parents may not feed their children properly. Some of them are very complex.

Why don’t you ensure that every school has a garden and the children are taught about fruit and vegetable growing every year. Let them take their fresh produce home for a good meal at night. It would be a superb investment. Gardening is an experience that will last a lifetime. It also makes many people happy and can help them through difficult times in their lives. It’ll probably keep the young tearaways out of trouble too!

And the exercise will keep them fit and slim.

In fact, why don’t all you busy-bodies get out your wellies and spades and volunteer as gardening supervisors at your local school!

If The Witch Doctor is an expert in anything it is in fruit and vegetables. She might even be a world authority! She is not a vegetarian but she eats more raw fruit than anyone she has ever met. She always has and she always will. In fact she has many stories she could tell you about fruit and vegetables. Perhaps some day she will.

What she would never do, however, is comment on the contents of a child’s lunch box unless she was specifically asked by a parent to do so. She would regard it as an intrusion into the life of a family.

Just as she regards this sort of thing as an intrusion also.

We witches are very contrary beings!

If you poke your nose into any lunch box belonging to A Witch Child, something with many legs and teeth will jump out and bite it off and then then crawl all over you!

a red apple ……………………

The Witch Doctor – Link to a random page

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LINK TO UK MISSING KIDS WEBSITE

LINK TO MISSING PERSONS WEBSITE

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In The Witch Doctor’s absence, it only seems right that Her Black Cat commemorates the day the National Health Service becomes a pensioner.

5 July 1948

THE NEW NATIONAL HEALTH SERVICE

“Your new National Health Service begins on 5th July.

What is it?

How do you get it?

It will provide you with all medical, dental and nursing care. Everyone – rich or poor, man woman or child – can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness.”

The NHS has metamorphosed.

NOTE: “In times of illness”

They say money for healthcare is short. If that is indeed the case, perhaps we should revert to the principles of the original NHS. With the exception of immunisation, the detection of contagious diseases, and ensuring children received nutritional supplements, it was largely a National Illness Service. It was not overly concerned with warning, screening or medicating healthy people.

“National Illness Service” sounds negative and depressing. “National Health Service” sounds positive and invigorating. It is no wonder they chose the latter name.

But maybe, with hindsight, that was a mistake.

It gave society permission to dabble in preventive medicine. Nothing wrong with that – except that everything The Humankind touches upon has the habit of creeping into absurdity.

Perhaps warning, screening or treating healthy patients (clients?) should be regarded as “special items” that you pay for as you choose, but not through taxation. Perhaps charities might have a more important role here – a role that is less dubious than some have at present.

Regarding preventive medicine – perhaps the NHS should send a brief annual leaflet to every household advising how to live healthily, updated yearly as medical opinion changes as it not infrequently does. Patient choice.

And leave it at that.

The Black Cats of the world are not fans of Facebook.

There is a right old hue and cry going on about something known as “Prism.”

The Black Cats of the witching community are not very surprised about the revelations coming out whether or not they turn out to be correct. There have been mutterings for some time about links between Facebook and the CIA.

It seems as if The Guardian has been following the trail of the security involvement with social media for some time.

This article appeared in The Guardian in 2008.

The Witch Doctor, being slow off the mark, didn’t mention it much until 2011 when there was a bit of a fracas among the medical profession in Facebook. At that time she took an opportunity to have a bit of a rant about what might be considered to be REALLY shocking in this world.

Here is the rant of 2011:

BLACK HUMOUR AND OTHER SHOCKING THINGS

No matter what your thoughts are regarding the last post where Cynthia, the employer, scouted around the internet looking for Candy’s (the prospective employee) “extended CV,” it has to be accepted that an individual’s internet presence will be tapped into by employers, prospective employers and disciplinary bodies. It is one of life’s realities – a by-product of the World Wide Web.

Candy, the Tantalising Tweeter, the Face Book Fanatic, The Bebo Baby, has learned much from the older woman. She will have been told many times by others to be careful what she said on Internet forums but this advice fell on deaf ears because it came from over cautious “old fogies” like her sister Carmen.

It was not until it became very personal that Candy realised that she had left important cyber-fingerprints that could influence important aspects of her life. And that influence could be detrimental.

She had never thought about what she said on Facebook, Bebo, Twitter, Blogging or comments on other’s blogs could become an appendage to her CV.

Last week some doctors said some pretty “shocking” things on Twitter.

Apparently.

It seems the conversation was continued into Facebook but this witch is not a Facebook Fanatic so she has no idea what was going on there. It was probably very rude as people became embroiled in the argument.

Apparently the news spread across the pond. Some were “aghast” over there rather than “shocked.” Some extracts are here:

STORM BREWS ACROSS THE POND

So far, nothing was said in what she read that shocked this witch in the slightest.

Well, that’s not entirely true. Perhaps The Witch doctor was shocked that other doctors were so easily “shocked!”

Irritated? Maybe. Maybe not.

Disappointed? Maybe. Maybe not.

Shocked.?

Angry?

Surely not.

These “shocked” and “angry” people are doctors, for pities sake! Since a doctor has to face many shocking situations during a medical career, she wondered how on earth, these sensitive “shocked” doctors would cope if faced with situations that were indeed shocking.

It even reached The Telegraph. Medical banter is clearly much more “shocking” news than the Health and Social Care Bill about to tip toe quietly through the House of Lords. A Bill that will be so subject to “Creep” that it will eventually destroy the NHS.

Perhaps everyone should waken up and be shocked and angry by that!

The derogatory terms mentioned by the tweeting doctors were Labia Wards, Madwives, Cabbage Patches and Birthing Sheds.

It is Black Humour.

Most Black Humour is derogatory if you want to look on it that way.

Doctors since the beginning of time have used Black Humour. There are probably many reasons for this. Maybe somebody somewhere has published research papers on the phenomenon. The Witch Doctor has never thought it important enough to study at all, but off the top of her head thinks it might be the result of:

A type of coping strategy

An attempt to “harden-up” emotionally

An attempt to hide an over-sensitive personality from colleagues

There may be all sorts of deep-rooted psychological reason for Black Humour, but in The Witch Doctor’s view much of it is simply clever banter by sharp brains.

The Witch Doctor is not a feminist although some who know her in real life suspect she might be.

She believes men and women are very different.

Women when huddled together tend to look into each others souls whereas men tend to cover up their souls with banter.

IS THIS BLACK HUMOUR OR JUST A CLEVER (AND OBSERVANT) CARTOON?

A couple of years ago The Witch Doctor was in a situation where a group of electricians, builders, painters and plumbers were all working together in a small space. They were all employed separately and none of them knew each other well. They were all thrown together. There was no delving into each other’s lives, or feelings, or souls. That was taboo. It was just bravado and banter. Banter at its best. Sharp and witty banter scattered with plenty of black humour. The Witch Doctor was in a small room next door almost rolling about on the floor laughing. These tradesmen forgot she was there. It was just as well because if they had remembered there was a witch, and a “lady” witch at that next door, then probably they would just have whistled!

Male doctors are just the same as these tradesmen. A few females are too. And like them, some can be very witty.

Are these doctors who use Black Humour offensive?

Are they less caring?

Do they need to be educated in the art and science of empathy?

Do they need to be provided with a “Tool Box” to teach them Compassion?

Do they need their regulators to spy on them?

Have a look at what the GMC are up to now.

Is this the beginning of something that will creep?

My Black Cat is of the opinion that such Creep is inevitable. She has also been muttering something about links between Facebook and the CIA after Dr Phil’s comment on the last post.

Now, if true, such a link might be considered by some to be much more “shocking” than the Black Humour of the medical profession.

Yes, The Health and Social Care Bill and the Creep that will follow, the GMC spying on the private lives of all doctors, and now the possibility that the CIA are involved in social media.

These are the kind of things that shock witches.

Not Black Humour.

Great. Just great!

Doctors are being nudged today!!!!

The Witch Doctor has asked me to open her mail while she is pussyfooting around The Parallel Universe.

This week’s British Medical Journal arrived this morning.

An enclosure fell out!

It is inconceivable that the editor of the BMJ has no knowledge of what leaflets accompany the BMJ each week. Especially when the enclosure touches on something as controversial as euthanasia and assisted dying.

Make no mistake about it. This leaflet accompanying the BMJ is designed to nudge the medical profession.

On the front page of the leaflet there is a photograph of a woman called Geraldine McClelland.

She says:

“By the time you read this I will have been assisted to die in Switzerland”

Inside are photographs of Sir Terry Pratchett OBE, Sir Patrcick Stewart OBE, Debbie Purdie, Prue Leith CBE, Sir Terence English. Their photographs are accompanied by words endorsing the work of the pressure group “Dignity in Dying.”

It is very easy to nudge The Humankind. Almost all of them find Creep easier than thinking things through for themselves. Governments, for example, know this.

If each individual thought through all to pros and cons of the euthanasia arguments for themselves without being brainwashed nudged by groups of high profile, vocal, articulate and sometimes terminally ill individuals who gather themselves together, it is likely most would see the downsides of allowing doctors or patients’ relatives to become executioners.

Life is not simple and tidy.

Death is not simple and tidy either. It should not be sanitised. Euthanasia, assisted suicide or not, there is no such thing as “A Good Death.”

Get real.

However, in death there can be a degree of dignity. But it requires the continuity of good medical and nursing care tailored to each individual patient and to those close to them. There is no reason either why a death should not take place naturally but accompanied with effective symptomatic relief in the patient’s own home and in his/her own bed if that is appropriate. That is what pressure groups should be seeking.

The Humankind often lacks empathy and and sometimes lacks an ethic too and that, along with not being bothered to think things through for themselves, leads to Creep. A Creep that easily can become evil.

No doubt The Witch Doctor will have much to say when she returns from her trip to Neverland.

In the meantime, by allowing this enclosure with the BMJ, it suggests to a simple Black Cat that the editor, Fiona Godlee, is in favour of promoting euthanasia / assisted suicide and is willing to play her part in winning round the medical profession to her way of thinking.

If so, she would do well to remember that both euthanasia and assisted suicide are illegal in the UK.

If not, she should say so, and stop allowing this pressure group access to the medical profession through the BMJ.

Here is a regurgitation of one of the Witch Doctor’s posts in 2009. It is becoming more relevant as time goes by since the The Skills Escalator is now seldom mentioned, polyclinics have died, Remedy UK has ceased to exist and politicians are in the process of going full circle as they are becoming attracted to the continuity of care that GPs once provided.

THE TROJAN HORSE – PART 1

One of the problems with the Female Variety of The Humankind is that they are unpredictable.

Especially when they have a partner who may have to move around the country to follow a career.

Especially when they have a partner who is financially secure.

Even more so when they have a partner and children to consider.

Even more so when they have a partner and children and aging relatives to consider.

Even more so when they have a partner and children and aging relatives and exams and all sorts of other hoops to go through to further their own careers.

There are just not enough hours in the day.

And they don’t want more hassle.

Nowadays, 60%, 70%, sometimes 80% entrants into medical school are female?

The Witch Doctor would really like to know why this is so.

One of the comments on a previous post remarks that where he is, 80% females are admitted to medicine because that is the proportion of females applying to get into medicine.

If this is so, it is very worrying.

We need to know if males are choosing other careers. In The Witch Doctor’s opinion this would be a disaster for patient care as well as the profession.

Regarding most female doctors with family commitments, The Witch Doctor can tell you what used to happen.

1. A few female doctors would have a clear plan of their career path shortly after they graduated and they would stick to this with tenacity whatever hurdles came their way. If they wanted to be a consultant brain surgeon, then they became a consultant brain surgeon and that was that!

2. The majority of women, however, decided for a broad base to their training – one that would allow them mobility in the future and the potential for part-time work if necessary. This usually consisted of going through GP training or obtaining an MRCP as soon as possible. An anaesthetic qualification was also popular from time to time.

3. Most women continued to work full time until they had children, they then took a break, perhaps joined the retainer scheme and kept ticking over on a part-time basis until they were ready to increase their sessions. Women went into general practice in droves because the route to being an independent practitioner there was shorter than in the hospital specialties, and GP qualifications meant they could pick up work in any part of the country. Many never took up full time work again and the majority of hospital doctors with children picked up sessions as Clinical Assistants, Staff Grades, Hospital Practitioners within various specialties. Some resumed work as full time registrars and continued to a consultant post. Once appointed some decreased their consultant sessions to become part-time.

4. A few gave up medical work completely and never returned.

5. Of the women who built up some kind of “work portfolio” for themselves, many would have been put off by the hassle of administration. Sessional work with minimal administrative responsibility, and minimum requirement for any more examinations suited them just fine.

It has to be remembered that full time in medicine used to mean just that – there was no respite. Even you were off duty there was reading, teaching preparation, exam marking, writing research papers, keeping up to date, thinking about an elusive diagnosis. A consultant or GP had 24 hour responsibility for his/her patients and family and personal life had to be worked round that.

That was the way it was.

How is it now?

The European Working Time Directive may enable more women doctors to work full time without all the crippling extra hours that were necessary before.

However, a longer time to train as a GP might not appeal to women doctors so much. Conventional practices are reticent about taking on new medical staff while the effect of polyclinics is being determined. Polyclinics will welcome a few female GPs on a sessional basis particularly if they are cheap to employ eg “competency qualified” rather that fully fledged GPs.

Litigation is becoming commoner. Defence fees are going up.

Silly sites like Iwantgreatcare may prove to be demoralising.

Control freaks reign in some trusts.

Will suspensions and GMC referrals increase as a result of revalidation?

Are there, at this very moment, precedents being set that will result in a formal complaint on any matter that is unrelated to medical practice being taken up by the GMC?

Is the door now wide open for vexatious complaints?

Childcare is expensive and women worry about the safety of their children when they are working.

Is it all worth it?

Women are unpredictable.

Women who can afford to, may get fed up going through all the bureaucratic hoops of ticking boxes for CPD, appraisal and revalidation and may leave medicine for ever.

The problem is that no one knows the effect of having nearly 80% intake of women into medicine in the current climate.

The current medical climate is oppressive.

Women do not like to be oppressed.

So how can a medical workforce be planned?

In The Witch Doctor’s opinion, at the present time, it can’t.

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The Witch Doctor who is still swishing and sweeping around on her broomstick in The Parallel Universe at the moment, has asked me to find out what they are saying about women doctors right now.

It seems there has been a potential spat between some female members of the government and some female doctors.

THE TIMES (Paywall)

TELEGRAPH

“Anna Soubry said that there were “unintended consequences” of the rise in the number of women studying medicine
.
Around 55 per cent of medical students are now female and experts have said that the majority of all doctors will be women by 2017.

During a debate in Parliament abut the new 111 NHS advice line Anne McIntosh, the Tory MP for Thirsk and Malton, warned that female doctors are putting a strain on the NHS.”

Other papers gave a figure of 70% females.

A high profile woman doctor responded:

“And Dr Clare Gerada, chair of the Royal College of General Practitioners, hit out at the comments.

“Well – then I have the triple whammy – female and GP and mother,” she said. “I must go and bow my head in shame. I cannot believe that women doctors are being blamed for problems in the NHS.”

Now, a simple Black Cat thinks that some of the doctors of the female variety were far too touchy on this statistical observation regarding women doctors. Fortunately the spat was temporary and seemed to end on friendly terms.

No doubt The Witch Doctor will have a view on all of this since she has had many questions on women in medicine since the start of this blog in 2007. Here are some of them.

IS MEDICINE STILL DISCRIMINATING AGAINST FEMALES?

THE LAW OF SUPPLY AND DEMAND

WALKING AWAY

However, in the meantime My Black Cat has decided it might be interesting to read the comments relating to the above article.

Her is one that for some reason or another is making this Black Cat give a smile that makes her look rather like a cat of the Cheshire variety.

“Personally I think this is a distraction. Women doctors contribute greatly to the NHS and are generally of high quality. Both men and women are now going part-time and most full-timers are now over 50 probably planning to retire at 55 or shortly afterwards. The future for most doctors is part-time work as the modern workload is just so high. Talk of taking back OOH for instance will just promote an exodus of the medical workforce and the collapse of primary care.

I would actually be more concerned about what doctors are doing all day. Seeing patients is now the minority of their workload. Paperwork has exploded, CCG and other meetings have gone mad, Revalidation has spawned an industry with an insatiable appetite for medical time. Then add CQC and a few other Quangos Drs have to deal with and produce reports for, to gather dust on the shelves at great cost to the practice. There are now 31 methods of complaining about Drs shortly to be increased to 32 that consume Drs time greatly by vexatious complainants.

Just think what could be done without all this extra rubbish which our Leaders are distracting you from. Never mind it is fun to bash GPs and women in particular and complain about their imaginary pay which has fallen 20% since 2004, but what to do when they are gone?”

These days everything is much more formal, disciplined and litigious than it used to be. Apart from post-graduate examinations, continuing professional development is a lifetime activity and now requires rigorous documentation and approval. Appraisal, the ridiculous 360 degree merry-go-rounds, revalidation, guidelines, statistics, meetings and much more are all activities that are expected of all doctors and many have become compulsory.

A part-time doctor, male or female, will need to spend at least as much time on all of these activities as a full time one.

How does a part time doctor, male or female, working say two days a week fit in any time at all to see patients? Once upon a time many activities that did not involve direct patient contact were largely done in doctors’ own time, but nowadays most of it is formally built into contracted time. Granted, doctors generally work well over their contracted hours, but after the new GP and consultant contracts were introduced earlier last decade, they no longer have to.

What if medical women, and the dwindling number of male doctors too, say enough is enough? What if they work to contract or leave the profession altogether? What if male doctors are already voting with their feet and not entering the profession? What if that is the reason why we now have 70% female doctors?

Presumably the law of supply and demand will kick in and doctors will be able to dictate exactly how and when they work.

As we Black Cats watch these interesting medical antics of our time we can’t help thinking that most of The Humankind are mentally deranged.

It was always blatantly clear that altering the child /staff ratios in childcare was a really, really stupid idea. It was obvious to Witches, Black Cats and even to the Rats that we avidly hunt, that this really, really stupid idea would put children at risk. Parents do not knowingly place their young offspring in risky places. Cost does not come into it. The most important consideration for a parent is the safely of their children.

How much time has been spent and consequently how much tax-payers’ money has been wasted in debating this really, really stupid idea?

How many other really, really, stupid ideas have this coalition and previous governments wasted our money on?

How many really, really stupid ideas will future governments waste taxpayers’ money debating?

How many really, really stupid ideas have present and past governments pushed through parliament without due consideration of the negative consequences?

It is the ideas that are stupid. It is not that governments are stupid. It is rather a matter of blinkered bad judgement that wastes our money.

We Black Cats believe that a way must be found to hold individuals in government to account when they succumb to blinkered bad judgement that is wasting tax-payers’ money.

Jail them, lock them in the Tower of London for a decade or make them pay back the money wasted!

Just do something to stop it for pities sake!

The Witch Doctor is supposed to be in repose at the moment but in her absence she keeps asking me, her ever obedient Black Cat, to re-blog posts that she put up a long time ago.

This re-blog was precipitated by the fact that Clare Gerada (Royal College of General Practitioners) and Chris Skidmore (conservative MP) were sparring in Monday’s Daily Politics show over privatisation of the NHS.

The Witch Doctor is of the view that regarding healthcare, it is often best to stop thinking of private or public services and instead to consider the various marketplaces, old and new, within the UK healthcare sector.

This is what she said a long time ago:

SEVEN HEALTHCARE MARKETS

Mr Cameron, Mr Lansley, Mr Clegg, many other individuals, governments and politicians of all shades, please listen to this witch!

The reforms are not just a Tory thing. They have been going on for years. All political parties have two problems.

1. How to keep UK healthcare safe, fair, and finacially viable.

2. How to stimulate the economy in a threatening global market.

You have intertwingled them, you stupid, stupid Humankind! And because of that you are becoming confused and making everyone else confused too!

Firstly this witch believes the majority of politicians want to do what is best for patients in this country. There will be a few scoundrels among you who will not possess even a vestige of altruism, I’m sure, but for the most part The Witch Doctor believes that most of you, most of the time, in all government parties are all pretty genuine in the matter of seeing patients properly cared for.

So for the moment, just concentrate on healthcare.

Forget about the economy and the worry of global markets and the balance of power spreading from west to east.

At least just now.

Forget in the meantime too about GP’s being private businessmen and the fact that some consultants do private practice (Paul Corrigan is getting his underpants in a twist about this at the moment). These things are red herrings that can be considered later.

MARKETPLACE NUMBER 1
VALID TENDERING FOR CONSUMABLES ETC.
There has always been a competetive market in healthcare. Of course there has. We all know that. We are not stupid. The companies that supply paper towels, toilet rolls, needles, syringes, bedpans, drugs, surgical insturments, beds, scanners, specs, hearing aids, ……. you know what I mean – tens of thousands of things. Commodities too – gas, electricity, telephones, internet connections. It goes on for ever.

This market uses taxpayer’s money.

Some of it is of great value to the patient but some will be a waste of taxpayer’s money.

Generally, we accept this market place. Just ignore it meantime. This is not the issue.

MARKETPLACE NUMBER 2
FUTURE VALID TENDERING
There will be a new competetive market place emerging relating for example to advanced surgery and investigations, telemedicine and other advances – devices for home measurment of BP, diabetic control, arrhythmias and a huge number of other things not yet even thought of. There will also be a market that involves data collection and distribution.

There will even be a market in training, management, continuing professional development of doctors and their revalidation.

This market will use taxpayers money.

Ignore this new marketplace of the future.  Some of it may be wholesome, some dubious, some will be a waste of taxpayer’s money.

MARKETPLACE NUMBER 3
THE FLUFFY MARKET
This is where things start to get seriously muddy. It is the Marketplace of intangible touchy-feely soft practices. It is also the marketplace that is not evidence based. You may find many opportunistic entrepreneurs in this marketplace. Some of the things they produce will be flouncy contributions to healthcare of little or no practical value. Some of their “products” and “activities” will be a complete waste of taxpayers money and a complete waste of time for those employed within the NHS.

This market uses both taxpayers money and personal money.

This fluffy market is already drip, drip, dripping money out of the NHS and into private companies but most of The Humankind have not given much consideration to the fact that this is happening. This market generates business and employment but decreases productivity and increases waste within the NHS.

MARKETPLACE NUMBER 4
PRIVATE COMPANIES USING THE NHS KITEMARK FOR CLINICAL CARE
This is the marketplace that The Witch Doctor, My Black Cat, most doctors and nurses, and most patients too are opposed to in various degrees. However, now that the new Health and Social Care Act has completed its journey through parliament, this is the market that will creep and will slowly become integrated into the “norm.”

This is The Market Place inhabited by Clients, Customers, Consumers, Businesses, Bonuses, Incentives, Multinationals, the Stockmarket, and the healthcare entrpreneurs. Patients too, if they can get a foot in the door.

It is the Marketplace where private companies are involved in the hands-on diagnosis, investigation and care of patients, and to this end are employing medical, nursing and other personnel.  The companies fund their staff and activities from NHS funds i.e. from the taxpayer. They will clamour after cheap labour and require to use a service driven by competencies and protocols rather than judgement and expertise. Some of the profits may be distributed to directors and shareholders although different arrangements are appearing by using Charities and a new breed of businesses called Social Enterprises.

Forget Charities and Social Enterprises for now – they just add confusion to the picture.

The Witch Doctor is not against the Stock Market, shareholders or Capitalism. She is however against Capitalism when it loses its sense of responsibility and proportionality and generates greed and recklessnes. She is not against entrepreneurs either. Indeed she has always known she is basically an entrepreneur herself (all witches are) and she considers she has the innate skills plus the knowledge acquired through training that could easily have been used within the private healthcare sector to make her seriously rich and ensure the family she leaves behind her will have no financial worries. She could have been trained in the universities and NHS hospitals and then in due course, when the time was right, walked away and cleverly generated her very own market. She thinks she would have been good at it. With the new NHS in England she could have positioned herself carefully so that her entrepreneurial services could have been purchased using NHS money. However, she did not go into medicine to make loads of  money, she will always resist becoming a healthcare entrepreneur, and consequently her family will have to make their own way in life.

That’s all you’re going to find out about The Witch Doctor!

The Witch Doctor acknowledges the NHS has many faults – over the years she has experienced most of them, but she still believes it could become the envy of the world once more. Otherwise she would not bother blogging. In essence she believes the NHS needs to simplify itself as knowledge and procedures become more complex.

This Fourth Market is the marketplace of sharks who swim silently and dangerously ready to grab and dismember; and monkeys too who are for ever trying to reach the highest branches on the tree. And yes, a few of these sharks and monkeys are medical practitioners, nurses, and others who currently work in the NHS but will happily default into more profitable activities when they feel the time is right, and they can justify what they are doing while retaining a degree of respectability.

The Fourth Market is where clients are given priority over patients because they are cheaper and easier to treat. If the NHS continues to be wholly funded through taxation and free at the point of use then an expanding Fourth Market, being part of the NHS family, will lead to the suffering of patients. It is simple arithmetic. The kind taught at primary school.

The Fourth Marketplace will be cleverly advertised and marketed by individual companies even if there is a fixed tarrif for each procedure for those private companies clever enough to ensure they are able to use the NHS Kitemark. Indeed, Dr No is currently in his bath thinking over ways the Fourth Marketplace will get round a fixed tarrif in order to gain more sales and so boost profits. (Later on he came across further interesting observations on gaming the fixed tariff).

In The Witch Doctor’s opinion it is The Fourth Marketplace that will lead to the downfall of the NHS and so if you believe in the principles of the NHS, it is the one that should be given most attention right now and should be resisted at all costs.

The Third Market is very suspect also and much of it should be abandonded in times of need. It is the dubious sugary icing on the NHS cake. But if the cake itself is made of cardboard it has to be spat out, sugar and all. But the NHS cake IS baked, the recipe just needs improving.

MARKETPLACE NUMBER 5
TRULY PRIVATE INDEPENDENT HEALTHCARE
These are the private providers that are more or less detached from the NHS. They will NOT normally carry the NHS Kitemark although they may do from time to time. Clients, patients and customers may choose to use these markets but they will normally pay for them out of their own pockets or separate insurance. However, it is likely that the activities of the fifth market will be selective and will in various ways introduce an extra burden of patient care into the NHS.

So, five healthcare markets!

All purchases and activites need to be designated into one of these markets. Some will straddle more than one market.

There will be two more health care markets of course. This is because The Witching Number is always seven. At the moment The Witch Doctor with her ageing brain has misplaced the last two.

No doubt they will turn up again somewhere…..

You think they are the charities and social enterprises which will need to be given due consideration later, My Black Cat?

I suppose they are.

Seven Markets. The Witching number.

In The Witch Doctor’s absence, this Black Cat feels obliged to draw your attention to an article in today’s Sunday Times. It was also mentioned in the Andrew Marr Show this morning.

“Pregnant women WILL be tested for smoking.”

“ALL pregnant women WILL BE ASKED to take breath tests for carbon monoxide to check if they are telling the truth about smoking.”

“The National Institute for Health and Care Excellence (NICE) says midwives should test ALL women with carbon monoxide kits at antenatal appointments.”

(The Green Capitals, the colour of cats eyes, are mine)

Don’t be fooled. This test is not about smoking.

The test is being used as a lie detector founded on the belief that the smoking, lying, women are too witless to find out for themselves when to take their last cigarette prior to visiting an antenatal clinic so that the lie detector will not pick up on it.

The Witch Doctor had something to say on Boxing Day 2010 about this matter.

No doubt her views are much the same today.

CREEPING DISCRIMINATION, FUMING PATIENTS

On the run up to Christmas there was an interesting skirmish going on in the medical blogosphere regarding surgical discrimination against the lifestyles of certain patients.

Have a good read at these posts as well as their interesting comments.

SMOKERS TO BE DENIED ROUTINE SURGERY TO CUT COSTS

NAILNG PATIENTS

A ROCK AND A HARD PLACE

A NON SMOKER WRITES….

So, it seems at the moment smokers and overweight patients are the most likely targets in stage 1 of this latest discriminatory scourge.

THE TELEGRAPH – SMOKERS AND FAT PATIENTS THROWN OFF NHS WAITING LISTS

“Under the plans drawn up by NHS bureaucrats in Kent, any smoker referred for “non-urgent” operations – such as hip replacements or cataract surgery – will not be allowed to join the queue until they have either given up smoking, or completed a 12-week course to help them ditch the habit.

Those who are seriously overweight will also be denied a range of operations until they have completed a three-month NHS diet programme.”

It is difficult to hide an overweight patient so lets forget about them at present.

It would, however, take a witch clutching the 2020 Edition of The Book of Spells to tell whether a patient was a heavy smoker, a light smoker, a non-smoker, or a “I just stopped last week and will never smoke again kind of smoker”

Doctor’s cannot distinguish the daily smoker from the non –smoker or the “I just stopped last week kind of smoker” just by doing a physical examination. They will routinely ask them about their smoking habits, of course, but what if the patient lies?

The smoking patient, desperate for hip replacement surgery, might have read The Telegraph, The Guardian, The BBC or the medical blogosphere on this matter. Therefore it might be reasonable conclude that such a patient might consider it a good idea to lie about his/her smoking habits in order not to be kicked off the waiting list for surgery because of their sinful lifestyle. After all, lying will come easy to those who are already the sinners of society.

Why would they not lie?

But hey, doctors have a tool in their toolbox.

(If you are a patient wondering about this handyman’s terminology, then you should know it is rife within the NHS just now. There is A Tool for everything, even if the reality is that most of them are just stupid protocols).

This Tool, however, is not a protocol. It is a kind of Lie Detector. Some would call it “A Carbon Monoxide Breath Test”

NICE was in favour of “offering” a similar breath test to pregnant women as an “encouragement” to stop smoking.

“Currently pregnant women are asked if they smoke by midwives and GPs but the National Institute for health and Clinical Excellence (Nice) wants this to go further.

The organisation has recommended that all pregnant women should have their breath measured for carbon monoxide levels when they book in with a midwife.”

That being the case, why should it not become a prerequisite for all patients needing elective surgery to undergo a carbon monoxide breath test?”

If it is deemed necessary for smokers to have given up smoking before elective surgery such as hip replacements or cataracts, then this is the obvious path to follow. The test will need to be compulsory for all non -smokers because there is no other way to tell whether they are lying or not.

Except………

If those clever, lying, sinful smokers, have any sense they will read the literature on this test and deduce for themselves when to take their last puff of a cigarette before the test, in order to render a negative result.

They’ll just do a Google search!

They think sinful, lying, smoking patients are witless semi-literates!

They are not!

Doctors are not witless either. They may be prepared it lie on behalf of their patient if after due consideration, the best medical practice is to go ahead with surgery.

Yes. Doctors may lie if it is in their patient’s interest.

Catch these lying doctors if you can, Great Uncle GMC!

And then decide what you are going to do with them! Will “Good Medical Practice” trump a lying doctor or will it be vice versa?

What stupid, creeping fools are The Humankind, My Black Cat!

They creep into a surveillance society and in so doing make stupid plans that are not even workable.

CONFLICT OF INTEREST

The Witch Doctor is a lifelong non-smoker who follows the following mantra.

Inhaling-smoke-into-your-lungs-cannot-be-a good-thing-and-we-witches-did-not-need-you-or-Richard-Doll-to-tell-us-so-we-worked-it-out-for-ourselves-probably-before-you-were-born!!!!

…………….

CHECK OUT WHAT MY BLACK CAT IS READING

a red apple ……………………

The Witch Doctor – Link to a random page

_________________________________________________

LINK TO UK MISSING KIDS WEBSITE

LINK TO MISSING PERSONS WEBSITE

_________________________________________________

© Dlundin | Dreamstime.com

While The Witch Doctor is resting, we Black Cats of the witching world were rather tickled by this conversation that is going viral at the moment.

We feel that The Witch Doctor will be tickled too when she hears about it because, although she keeps her own beliefs or lack of them to herself, the pro-euthanasia, pro-assisted suicide, missionary atheists who are spawning everywhere get under her skin.

An atheist was seated next to a little girl on an airplane and he turned to her and said:

“Do you want to talk? Flights go quicker if you strike up a conversation with your fellow passenger.”

The little girl, who had just started to read her book, replied to the total stranger:

“What would you want to talk about?”

“Oh, I don’t know,” said the atheist. “How about why there is no God, or no Heaven or Hell, or no life after death?” as he smiled smugly.

“Okay” she said. “Those could be interesting topics but let me ask you a question first. A horse, a cow, and a deer all eat the same stuff – grass. Yet a deer excretes little pellets, while a cow turns out a flat patty, but a horse produces clumps. Why do you suppose that is?”

The atheist, visibly surprised by the little girl’s intelligence, thinks about it and says, “Hmmm, I have no idea.”

To which the little girl replies, “Do you really feel qualified to discuss God, Heaven and Hell, or life after death, when you don’t know about shit?”

Then she went back to reading her book.

The Witch Doctor is having a little rest just now.

So am I. The two of us have temporarily faded away.

But, unlike The Jobbing Doctor, we will be back!

However, as an obedient witch’s cat, in view of the fact that NHS 111 is hitting the headlines once more, I have been asked by The Witching Community to un-vaporize for a moment or two and re-spew a post that featured here at the end of March about that afore-mentioned outfit and other related phenomenon.

Here it is :

WAITING FOR APRIL FOOL’S DAY:

My Black Cat is reminding me that they brought in people like window-cleaners to man the ‘flu helpline a few years ago.

The Witch Doctor thought this was ridiculous at the time but supposed there was a bit of a panic and they had either run out of qualified people to do the job or they were not prepared to pay a professional wage.

The new NHS111 service is due to be rolled out on April Fool’s Day. Who on Earth would be witless enough to roll out a new service like this over the Easter Holiday weekend? That speaks volumes.

According to Jobbing Doctor, those triaging patients are likely to be “trained” teenagers employed on low wages.

“Lets have a single number that can be used and services can be channelled through this. We don’t need expensive nurses to run it any more, we can now have barely trained teenagers to do it on the minimum wage. National standards, uniform quality, cost effective: what’s not to like?

The answer is just about everything. At least the nurses had a modicum of training in medicine to fall back on: the teenagers won’t. There will be a culture of covering your a*** in this system where any departure from the easiest algorithm will be met by “Call an Ambulance” or “Visit your doctor within 6 hours”

The Witch Doctor totally and utterly disapproves of doctors participating in telephone consultations apart from in circumstances that are well-defined and exceptional. It should never be considered best practice. In the past she herself has initiated a telephone consultation service in such well-defined and exceptional circumstances and so she knows a little about the advantages and limitations of such a venture. She can, however, think of no circumstances when it would be safe to use a routine telephone consultation in an emergency or out of hours setting. That means she does not approve of NHS Direct, NHS 24 nor any similar service manned by medical staff, nurses, or lay persons. These services up till now have been telephone consultations that generally do not in the first instance involve a doctor although the conversation with a nurse may well direct the patient towards seeing a doctor in a face-to-face consultation.

But doctors creep.

The General Medical Council creeps.

The government creeps.

It has gradually become OK with doctors, the GMC and government to employ “others,” untrained in medicine, to follow algorithms in order to make a diagnosis without seeing the patient. However, algorithms, although useful in certain circumstances as a type of personal “Aide Memoire” are really only a way of propelling a patient down a “pathway” which takes them on a “journey” which may or may not lead them to a proper face to face consultation with a medical practitioner. It may or may not lead them to an accurate diagnosis. In this witch’s view, an “Aide Memoire” whether it be a reminder such as putting your shoes on the wrong feet, tying a knot of string around your finger, or peering at an algorithm on a computer screen should always, in the case of making a medical diagnosis, be used in conjunction with full medical training and experience. The medical training The Witch Doctor received involved spending time with the whole patient, not just a distant voice. It involved taking a full medical history followed by examination.

This too has crept. It is a rare thing for a doctor nowadays to have enough available time to take a full medical history and do a proper examination.

This is Bad Medicine.

It is very easy, especially when time is limited, to put the tick in the wrong box that leads to a patient embarking on a journey along a path whose destination is disaster. Sure, the qualified medical practitioner may get it badly wrong during a time limited face-to-face consultation but at least, in these circumstances, there is somebody in charge who has professional responsibility for the error or malpractice.

Who exactly would be responsible if a wrong turning is taken by a teenager / student / window-cleaner / nurse employed from April Fool’s day by NHS111?

Nobody of course…….

Just as nobody was responsible for Mid-Staffordshire……….

So, it seems things are now going from bad to worse in England.

HOTLINE TO HEARTBREAK

NHS 111 SERVICE PUTS PATIENTS AT RISK, SAYS BMA

However, The Witch Doctor thinks that the easily remembered single number 111 could be developed in such a way that it has an important function – an information resource only – a function that would not involve triaging patients in an out of hours / emergency situation utilising teenagers and others “trained” to play at being doctors and nurses.

My Black Cat has an idea to enhance such a “111 information only” service. She believes that many patients who own a computer would themselves be able to follow algorithms much more safely than “trained” teenagers or others who are not medically qualified. They would be able to take their time to do so. They would have more of a chance of answering the questions accurately. They would be able to have ongoing observations of their condition that may lead them down a different pathway. Many patients will be far more knowledgeable about many things including their own health issues than those “trained teenagers” and others supposed to be triaging them.

Is it madness having patients triaging themselves or ill relatives by using an algorithm to decide whether it is necessary to see a doctor?

No doubt.

But not nearly as mad as the Creep that is already happening as a result of the demise of medical professionalism carefully orchestrated by Alan Milburn – a previous, and very clever, Secretary of State for Health responsible for offering a huge financial carrot to GPs and consultants leading to a change in contracts. A change that opened the door to healthcare becoming a commodity.

No she’s not!

She is here and very much alive and so is My Black Cat.

It seems there has been a great wringing of hands and gnashing of teeth about what to do about the fact that the song “The Witch is Dead” from the Wizard of Oz has been raging through the charts. It is at Number three right now -apparently it is likely to become Top of the Pops.

Just in time for the funeral of Margaret Thatcher.

It might be extremely unpleasant for the late Lady Thatcher’s relatives and friends to experience the resurrection of this song in the context of the death of a loved one. They may be upset too by the “Death Celebrations” that are going on in small pockets of the country. Or maybe, in their grief, they will just let all the rubbish being generated by The Creeping Humankind to float away into the sewers where it belongs.

The Witch Doctor does not, on balance think the promotion of “political correctness” is a good idea. She can understand fully why people should be prosecuted for uttering malevolence from time to time. In some circumstances it is necessary. But prosecution cannot cover every context.

In her view it is preferable to let people make their deplorable utterances and so let others be aware of what is going on inside the heads of their friends, colleagues, neighbours and enemies. Better have the malevolence out in the open where quiet judgments can be made about the individuals around you. Better to know what is going on inside their heads than not to know. Too much political correctness can push atrocious thoughts underground where they cannot be dealt with.

So The Witch Doctor is of the view that the abusive insults associated with Margaret Thatcher’s death should be allowed as long as they are within the law. It is a barometer by which the minds of individual members of The Humankind and the collective Humankind in a country can be judged. It may serve as a warning. It may also make individual members of the Humankind consider whether their own thoughts are creeping into malevolence and where that Creep might lead.

And so, with the death of Margaret Thatcher, “celebrating” the dead is taking on a whole new meaning.

Take heed “Dying Matters” and “Final Fling,” and all the “celebrants” out there!

There are no “good deaths.”

The term may at times comfort.

But it is just jargon.

And at times, by a few thugs, and others too, the jargon can be mis-interpreted.

The GMC offers advice to anonymous Bloggers, Tweeters and FaceBookers who are medically qualified – shortly after the Leveson Inquiry offered advice to the press.

Today My Black Cat is deeply involved in her Continuing Professional Development into conspiracy theories.

The Witch doctor yawns when she is in this mode because most of what she discovers will not make her a better witch’s cat. And that, of course, is the purpose of her CPD.

However, now and then, while she is immersing herself in the dross, she comes up with something that might turn out to be interesting.

Today she is focussing on The Intertwingled Triplets.

If you have been reading this blog for ages, you will know that the Intertwingled Triplets are Common Purpose, Demos and The Media Standards Trust.

You will also know that “Hacked Off” is a child of the Media Standard’s Trust.

It now seems that she has discovered another Intertwinglement.

It is an outfit called “Full Fact”

Andrew Gilligan had much to say about “Full Fact” in yesterday’s Telegraph.

HOW LEVESON WAS DENIED THE FULL FACTS

“A director of Hacked Off, the campaign against the “lies” of the press, gave false evidence under oath to the Leveson Inquiry, The Sunday Telegraph can disclose.

Will Moy, the head of Full Fact, a “non-partisan” group campaigning against “inaccuracy in the media”, told Lord Justice Leveson that his organisation was “constituted as a charity, and in the process of registering as a charity” and as such operated “under a statutory public benefit obligation”.

Impressed, the judge drew extensively on Full Fact’s evidence in his report, describing it as politically “independent”, its work as “extremely important”, and saying: “I am pleased to recognise that Full Fact can claim to be one of the organisations that does seek to ‘guard the guardians’.”

He said its submissions went to the “very core of what I’ve had to consider”.

In fact, in July 2011, seven months before Mr Moy testified, Full Fact had been refused registration as a charity after another judge heard that it lacked the “requisite objectivity” and was not “established for the public benefit”.

The same Andrew Gilligan had much to say about “Hacked Off” in the 30th March 2013 edition of The Telegraph:

THE TRUTH ABOUT HACKED OFF’S MEDIA COUP

“Who are Hacked Off? And how did Brian Cathcart and a small group of even more obscure allies come from nowhere to write perhaps the most important constitutional change yet of the 21st century?

The royal charter which has just ended 300 years of an unregulated press was, as they boast, “drafted with the help of Hacked Off”. The even more controversial “statutory underpinning,” with its coercive damages and fines, was, as they boast, “a measure suggested by Hacked Off’s chairman”.

The bragging is, if anything, underplayed: Lord Justice Leveson all but cut and pasted their suggestions into his report and the Government has adopted them with relatively few changes.”

And in it, My Black Cat discovered another couple of Intertwinglements that she had never heard of: – CCMR – the Co-ordinating Committee for Media Reform. And “Engage.” No doubt she will explore this spawn from the original Intertwingled Triplets in due course.

“CCMR, which has received virtually no publicity in the mainstream media, is closely intertwined with Hacked Off, sharing key personnel.”

Glory be, The Telegraph has almost but not quite used Witch-speak. We prefer the word “Intertwingle” to “intertwined.”

Don’t we, My Black Cat?

Dumbing down in the NHS might seem a good idea to all of those involved in designing The Skills Escalator.

However, sooner or later, it will become apparent that doctors are required and there are not enough of them

It seems the Law of Supply and Demand is kicking in and some junior doctors are consequently earning a pretty penny.

£2k A DAY FOR TRAINEE DOCTORS AS COSTS SPIRAL OUT OF CONTROL

“Trainee doctors are being paid more than £2,000 a day for locum shifts in NHS hospitals as the bill for agency staff spirals out of control, a Telegraph investigation has found.”

More:

Hospitals spent more than £2 billion on locum doctors in three years – a sum which could have paid the wages of 32,000 junior doctors or 10,000 consultants over the period;

 

 

Jobbing Doctor is due to retire soon and they are looking for his replacement. He reports that there are a couple of good applicants. However, it seems that some of the practices in the leafy suburbs are attracting no applicants at all whereas previously there may have been a hundred or more.

“Both the doctors concerned work in nice areas in the leafy shires, and neither practice had managed to attract a single applicant to apply for the vacancy. I was really surprised (and rather pleased that we had a couple of really good applicants). In the past, these practices would have had 100s of applicants of high calibre looking to join them.”

A post that the Witch Doctor wrote nearly three years ago springs to mind. Here it is:

SHORT MEMORIES

Time was it was normal to do 2 years as a Junior House Officer. The six months in medicine and surgery were compulsory, but after that many young doctors in the UK chose to do a further six months in obstetrics/gyn and a further six months in paediatrics.

As a medical student, The Witch Doctor always wanted to be a General Practitioner. However during her first two house jobs she became unsure. The witch doctor hated obstetrics (very scary specialty when things go quickly wrong) so instead she did six months of locums in general practice to help her make up her mind what to do.

So, The Witch Doctor has exactly six months experience of working in general practice. For several reasons, she decided it was not for her but following her experience she has always held GPs high in her esteem. General Practice is not the easiest of specialties and she found it quite lonely – at that time there were many single handed practices.

This was a very long time ago. No training in general practice was necessary. It was possible to enter general practice directly from house jobs.

You will find this difficult to believe………

One morning, The Witch Doctor appeared in an inner city single handed practice to be met by the receptionist-cum-practice-nurse-of-sorts-cum-clerkess-cum-cleaner. The GP had great difficulty getting time off for a family bereavement. He had great difficulty getting time off for anything. It can be safely assumed that his situation was desperate and he was at the end of his tether because, following the preliminary niceties, the first thing the receptionist said to The Witch Doctor was:

“The doctor wants to know if you would be interested in a permanent job with him”

The GP concerned had never met The Witch Doctor and to my recollection had never even seen her CV! An newly acquired MBChB and 1 years house jobs in medicine and surgery were evidence enough of competence. No further post graduate training, no references, no criminal check, no appraisal, and certainly no revalidation.

That is how dumbing down manifest itself in these days!

Recruitment into General Practice followed the law of supply and demand.

Remember the dumbing down that took place during the recent “flu pandemic” when window-cleaners took calls from patients.

Warning lights are beginning to flash…..

“”We pulled the plug on overseas recruitment far too quickly,” said Professor Derek Gallen, who is postgraduate dean of medical training for Wales.

“[We didn’t] realise what the implications of that action would be two, three or four years down the line,” he added.

“Particularly with the European Working Time Directive [and the] increased feminisation of the workforce. These are things that have made staffing rotas very difficult.”

“The deaneries are looking to recruit in areas such as paediatrics, obstetrics, gynaecology, anaesthesia, as well as accident and emergency.”

“The European Working Time Directive, which was fully introduced into the NHS last August, limits doctors to working no more than 48 hours per week and has left gaps on rotas.

Some district general hospitals have had trouble attracting enough staff to cope with the changes leading, in some cases, to services being cut.

In May, the Victoria Hospital in Kirkcaldy had to close its accident and emergency department overnight for a week due to a shortage of junior doctors.

At Erne hospital in Enniskillen, its obstetric and gynecology service had to be suspended for several weeks for the same reason. “

The Law of Supply and Demand should never be forgotten.

Recently Max Pemberton risked putting his neck on the block by writing this post in the Telegraph.

PART-TIME WOMEN DOCTORS ARE CREATING A TIMEBOMB.

The Witch Doctor has been wittering on about women in medicine since the beginning of this blog in 2007. In fact, she thought the increase in women doctors was one of the (several) reasons behind the MTAS/MMC debacle.

She also thought it was one of the reasons why the then Chief Medical Officer proclaimed in parliament that “the country needs more doctors”.

The Witch Doctor is not yet clear why the number of medical students recruited into medicine nowadays is predominantly female.

She is still not yet clear whether male applicants to medical school are now being discriminated against (no-body will admit to this of course if it is the case.)

She still does not know whether the number of women being admitted to medical school is a reflection of whether:

1. Women are more intelligent than men.

2. Women have better qualifications at school leaving age than men.

3. It is perceived that women make better doctors than men.

4. Men are avoiding becoming doctors (some might say in the NHS post April Fool’s day 2013, that this would indicate high intelligence).

It would be good if some university don in some medical faculty somewhere who has researched the recruiting of medical students could answer these questions.

In the meantime it seems timely that the witch doctor reads through what she has previously written on women doctors and related matters. Heaven knows what she said over the years! That is what me and My Black Cat will be reading during The Witching Hour.

It’s all here in a feed searching this blog for the term “women doctors”

Please note: Since the Witch Doctor writes anonymously or rather conceals using pseudonyms and Witch Speak she may be pulling the wool over your eyes that she is an old hag of a doctor of the female variety. She may be male, female, both or other. She might be a feminist or a male chauvinist pig. She might neither even be old nor a hag! But she is definitely a registered medical practitioner.

And when does art become child abuse?

The Witch Doctor made this comment on 9 November 2012:

“There is no doubt that Graham Ovenden is a very talented artist. When art becomes pornography can be difficult. Presumably in the case of a child, it is to do with whether a child is used as a model and if so in what circumstances. It’s late. Will sleep on this!”

The Witch Doctor has slept on this dilemma and she is pleased to report that she now has a view on the matter.

However, her view is not the purpose of this post.

Rather it is to report that the child painter and photographer Graham Ovenden, whose artistic ability is not in doubt, has been convicted of child sex offences.

ARTIST GRAHAM OVENDEN CONVICTED OF HISTORIC CHILD SEX OFFENCES

GRAHAM OVENDEN : ARTIST THRIVED AMONG 1970S SELF–CONSCIOUS DECADENCE

My Black Cat is reminding me that they brought in people like window-cleaners to man the ‘flu helpline a few years ago.

The Witch Doctor thought this was ridiculous at the time but supposed there was a bit of a panic and they had either run out of qualified people to do the job or they were not prepared to pay a professional wage.

The new NHS111 service is due to be rolled out on April Fool’s Day. Who on Earth would be witless enough to roll out a new service like this over the Easter Holiday weekend? That speaks volumes.

According to Jobbing Doctor, those triaging patients are likely to be “trained” teenagers employed on low wages.

“Lets have a single number that can be used and services can be channelled through this. We don’t need expensive nurses to run it any more, we can now have barely trained teenagers to do it on the minimum wage. National standards, uniform quality, cost effective: what’s not to like?

The answer is just about everything. At least the nurses had a modicum of training in medicine to fall back on: the teenagers won’t. There will be a culture of covering your a*** in this system where any departure from the easiest algorithm will be met by “Call an Ambulance” or “Visit your doctor within 6 hours”

The Witch Doctor totally and utterly disapproves of doctors participating in telephone consultations apart from in circumstances that are well-defined and exceptional. It should never be considered best practice. In the past she herself has initiated a telephone consultation service in such well-defined and exceptional circumstances and so she knows a little about the advantages and limitations of such a venture. She can, however, think of no circumstances when it would be safe to use a routine telephone consultation in an emergency or out of hours setting. That means she does not approve of NHS Direct, NHS 24 nor any similar service manned by medical staff, nurses, or lay persons. These services up till now have been telephone consultations that generally do not in the first instance involve a doctor although the conversation with a nurse may well direct the patient towards seeing a doctor in a face-to-face consultation.

But doctors creep.

The General Medical Council creeps.

The government creeps.

It has gradually become OK with doctors, the GMC and government to employ “others,” untrained in medicine, to follow algorithms in order to make a diagnosis without seeing the patient. However, algorithms, although useful in certain circumstances as a type of personal “Aide Memoire” are really only a way of propelling a patient down a “pathway” which takes them on a “journey” which may or may not lead them to a proper face to face consultation with a medical practitioner. It may or may not lead them to an accurate diagnosis. In this witch’s view, an “Aide Memoire” whether it be a reminder such as putting your shoes on the wrong feet, tying a knot of string around your finger, or peering at an algorithm on a computer screen should always, in the case of making a medical diagnosis, be used in conjunction with full medical training and experience. The medical training The Witch Doctor received involved spending time with the whole patient, not just a distant voice. It involved taking a full medical history followed by examination.

This too has crept. It is a rare thing for a doctor nowadays to have enough available time to take a full medical history and do a proper examination.

This is Bad Medicine.

It is very easy, especially when time is limited, to put the tick in the wrong box that leads to a patient embarking on a journey along a path whose destination is disaster. Sure, the qualified medical practitioner may get it badly wrong during a time limited face-to-face consultation but at least, in these circumstances, there is somebody in charge who has professional responsibility for the error or malpractice.

Who exactly would be responsible if a wrong turning is taken by a teenager / student / window-cleaner / nurse employed from April Fool’s day by NHS111?

Nobody of course…….

Just as nobody was responsible for Mid-Staffordshire……….

So, it seems things are now going from bad to worse in England.

HOTLINE TO HEARTBREAK

NHS 111 SERVICE PUTS PATIENTS AT RISK, SAYS BMA

However, The Witch Doctor thinks that the easily remembered single number 111 could be developed in such a way that it has an important function – an information resource only – a function that would not involve triaging patients in an out of hours / emergency situation utilising teenagers and others “trained” to play at being doctors and nurses.

My Black Cat has an idea to enhance such a “111 information only” service. She believes that many patients who own a computer would themselves be able to follow algorithms much more safely than “trained” teenagers or others who are not medically qualified. They would be able to take their time to do so. They would have more of a chance of answering the questions accurately. They would be able to have ongoing observations of their condition that may lead them down a different pathway. Many patients will be far more knowledgeable about many things including their own health issues than those “trained teenagers” and others supposed to be triaging them.

Is it madness having patients triaging themselves or ill relatives by using an algorithm to decide whether it is necessary to see a doctor?

No doubt.

But not nearly as mad as the Creep that is already happening as a result of the demise of medical professionalism carefully orchestrated by Alan Milburn – a previous, and very clever, Secretary of State for Health responsible for offering a huge financial carrot to GPs and consultants leading to a change in contracts. A change that opened the door to healthcare becoming a commodity.

It appears that the Duty of Candour recommended in the Francis Report on Mid-Staffordshire is now kicking in elsewhere

WAR OF WORDS FOLLOWS CLOSURE OF LEEDS CHILD HEART UNIT

“It was 8am on Thursday morning when Sir Bruce Keogh, NHS medical director, and two colleagues marched into the office of Maggie Boyle, chief executive of Leeds Teaching Hospitals, and ordered her to suspend heart surgery on children.

Mr Keogh had been shown preliminary data on Wednesday by the former Government heart tsar, Sir Roger Boyle, who now leads the national clinical audit of heart surgery, indicating that the children’s heart surgery unit at Leeds General Infirmary had a mortality rate for 2010-12 that was at least twice the average.”

“Mr Keogh, a former heart surgeon who pioneered the publication of comparative death rates for adult cardiac surgery a decade ago, said there had been “rumblings” in the cardiac surgical community for some time that “all was not well with Leeds”.

The Witch Doctor has not yet made up her mind about the pros and cons of the Duty of Candour except that she anticipates as well as the pros it will cause a lot of work, pain, disagreement and expense.

Being easily bamboozled by statistics, she has also often wondered whether there are enough good statisticians around who also have an expert knowledge of the vagaries of biology and medicine.

This article (quite long) is worth a read:

RIGGING THE DEATH RATE

“The statistics presented in the Francis Report suggest that at Mid-Staffs hundreds of patients died who might well have lived had they been treated in a good, or even an average hospital. Some newspapers have consistently claimed that 1200 patients died unnecessarily. It isn’t quite clear how they arrived at this total, and it matters, because the mortality statistics and their reliability are crucial to any assessment of what happened. The method used to arrive at the figures in the Francis Report is complicated, and has its critics. Its origins can be traced back to the inquiry into an earlier scandal, concerning the deaths of children who underwent heart surgery at the Bristol Royal Infirmary between 1991 and 1995.”

Every now and then there is so much going on in the world that The Witch Doctor becomes catatonic. So does My Black Cat. Currently we are lost for words about many things but that does not mean we are also lost for thoughts. However, we need to break our silence for a moment.

The General Medical Council wise as ever, on 25 March 2013 produced a document that will come into effect on 22 April 2013. It has important and intrusive implications for freedom of speech among the medical profession and so My Black Cat insists that we regurgitate what we once said in this blog regarding the anonymity of medical bloggers. It was part of a conversation with Dr Grumble way back in 2008

“The Witch Doctor had no such qualms. Indeed she even uses Witch Speak to scramble her writing style. This is because, hidden away in many managerial filing cabinets in her corner of the world, are many letters written in her hand that might give the game away.

So, for The Witch Doctor, a Nom-de-Plume and Witch Speak it is.

And so it will remain.

This is what she said during her conversation with Dr Grumble:

“Good to see you back Dr Grumble.

On the subject of anonymity: “But in a way I don’t feel that is quite proper.”

While acknowledging the concept of “if you have something to say, then stand up and be counted” The Witch Doctor has no problem with anonymity for the following reasons:

1. When The Witch Doctor graduated many millenniums ago, “advertising” ones wares in medicine was extremely frowned upon and this is deeply rooted in The Witch Doctor’s psyche. Intentionally using one’s professional name in a blog might lead to patient interest and could be construed as a form of advertising. This is quite a different situation from one where readers guess the identity.

2. If something controversial has to be said, and there is a chance that an employer/government/individual will not like it, then they only have to wait for the writer to make a “faux pas” the legality of which could then be challenged in order to silence the doctor. Since the occasional slip of the pen is likely from time to time anonymity offers some protection. Lie low. It is better not to be silenced than to be silenced.

3. It is all good fun – anonymity is a mischievous game. And what’s wrong with that?

The Witch Doctor “scrambles” some things a bit so that his/her/their identity is not easily revealed. Even My Black Cat does this. It’s a game. However, The Witch Doctor would not want his/her/their colleagues to know about the blog, because the interest/advice/criticism that it might generate might turn into another of life’s hassles. There is no time for more hassles.

Having said this, before starting to blog, The Witch Doctor considered the consequences of writing a post that offended the establishment.

What would The Witch Doctor do if someone from the General Witching Council knocked on his/her/their door (lets just say “her” since most witches are female)? Nowadays it would be relatively easy to identify a blogger. The Witch Doctor is not a wealthy witch but she is not poor either. She did some sums. She decided she could still afford to buy the mince if her job ended tomorrow. She also decided that she had no ambition but to do the job she was trained to do – she has no need to seek extra reward for anything. Threats do not rattle The Witch Doctor in any way, indeed they make her chuckle – she regards them as a battle of wits.

Once a senior colleague who is now dead, gave The Witch Doctor good advice – “To thyself be true. It is good to care about what people think, but not too much.”

So all in all, The Witch Doctor decided she was in a good position to start blogging. There was probably nothing to lose. And there was much needed to be said. But it would be anonymous. She would use a ‘Nom de Plume”

And that is the way it will stay even after 22 April 2013, when, all being well, we will return to the blogosphere. We will remain Witch Doctor and My Black Cat.

Won’t we My Black Cat?

Are you hard-wired to be a follower rather than a leader?

Are you susceptible to Creep?

“My parents took the view that the Germans are easily led. I take the same view. But I differ in that I think we are all easily led. Humans are built to be led. It’s what enables us to operate in societies instead of just squabbling with each other for scarce resources.

Since the time of Hitler, the way we are controlled has changed. We are told there’s a democracy. And many of us may believe that. But the reality is that we have very limited choice at election time and the main political parties have a stranglehold on the process. In parliament your MP is told strictly how to vote. He’s not his own man. Only rarely can a well-meaning independent reach the Commons.

But it’s worse than this. The policies of the main parties are not really determined by the wishes of the electorate. We all know of the strong support for the NHS. But the Coalition has changed the basis of the NHS without any public support. And before them Labour was intent on heading the same way.

It might not be so bad if our masters were acting in our best interests but they are not. They are acting in the best interests of themselves and their paymasters. At least when Hitler was in charge there was a visible unequivocal villain. Now the corridors of power are controlled by a more insidious evil of which few of us are much aware. That evil takes the form of the lobbying industry. Ironically this scandal-in-the-waiting was recognised by the prime minister himself. Judge for yourself whether he has met his promise to stop the lobbyists from influencing government policy.”

What will you do when the NHS is as dead as a dodo?

For pities sake, read these links, you stupid, lazy, blinkered, creeping humankind!!!!

THE WHITE ROSE

THE LAST NAIL IN THE NHS COFFIN

URGENT NEW THREAT TO THE NHS – 5 WAYS YOU CAN HELP

They may well be feeding disgusting burgers to children in Scottish schools.

Horse meat has been found in a burger intended for school dinners. No doubt that will disgust most Scots children and their parents. They are used to seeing cows and sheep in fields for slaughter, but not horses. Last Sunday on the Andrew Marr show a famous lawyer (Baroness Helena Kennedy), born in the land of the Oldest Sage Witch’s Highland Granny, muttered that one of the problems with horse meat being discovered in cheap meat containing prodcuts was that it came from “scabby old horses.” HK must have eaten a horse or two that was neither scabby nor old in the past because she says it tastes delicious – rather like prosciutto. Does she really want to have them breed foals in the land of her birth only to slaughter them when they are so young and beautiful? That will go down like a ton of bricks in Dame Helena’s homeland! Won’t it My Black Cat!?

Anyway, it is a fact of life that The Witch Doctor would not dream of eating a burger unless it was home made. She fears cheap meatburgers could easily become the repository of parts of animals (including horses), that we witches would find so unsavoury that even thinking about these things would make us vomit.

However, disregarding horse meat, why are our schools feeding cheap burgers to children?

After all, they are again targeting school children’s unhealthy packed lunches that contain neither horse meat nor the unmentionables that would make a witch vomit.

This annoyed the Witch Doctor in Jan 2010.  This is what she said then. Her opinion has not changed much.

CHIPS WITH CHOCOLATE

As an act of rebellion, tonight The Witch Doctor had a big dinner plate of chips cooked in dripping and sprinkled with a huge bar of grated Cadbury’s melting milk chocolate.

And a big mug of tea with milk and 4 spoonfuls of sugar. Ugh – The Witch Doctor hates tea with sugar!

All because of THIS

Let’s talk about fruit and vegetables.

Over the years, The Witch Doctor has come across patients at her clinic who have never tasted a cherry, not a single one. Others wouldn’t know a gooseberry if they saw one. Many have never eaten peas shelled straight from the garden. Children nowadays think strawberries are a crunchy and tasteless fruit to be avoided at all costs and that pears and turnips come from the same family.

Almost no young person who has ever attended my clinic has tasted a Black Hamburg grape with stones. It is just as well, because they wouldn’t know what to do with the stones – because all the grapes they have ever tasted are cloned seedless. Yet they have never tasted the wonderful old sweet seedless sultana grapes.

And plums. Where are the dark skinned sweet juicy Santa Rosa plums? They have been replaced with horrible hard atrocities that are only fit for stewing. And what about the sweet, juicy seasonal Victoria plums that grow so well in the UK? Most youngsters have never tasted them.

Apples? How many youngsters know the UK is an excellent apple growing country and could have thousands of varieties to choose from (although probably many are now extinct.)

Ayrshire potatoes? You can barely find them even in Ayrshire. They are called “Ayrshires” of course. They are not. A true Ayrshire potato has to be grown in sandy soil that is fertilised with two different types of seaweed at particular times of the year. Pembroke’s and Jersey Royals are the nearest but are not a patch on the real Ayrshire potato properly grown.

No young people today have ever had the pleasure of eating a plate of Ayrshire potatoes smothered in butter. Yes, butter – the nasty stuff!

It makes me weep!

Ladies and Gentlemen who are trying to change the eating habits of our children, please listen to this witch.

You are getting it wrong!

Wrong!

Instead of poking your nose into school children’s packed lunches and giving them hang-ups that their parents are not feeding them properly, why don’t you tackle the supermarkets and tell them to sell local produce when in season. Then there might be some kind of incentive for local farmers to grow decent fruit and vegetables.

There are many reasons why parents may not feed their children properly. Some of them are very complex.

Why don’t you ensure that every school has a garden and the children are taught about fruit and vegetable growing every year. Let them take their fresh produce home for a good meal at night. It would be a superb investment. Gardening is an experience that will last a lifetime. It also makes many people happy and can help them through difficult times in their lives. It’ll probably keep the young tearaways out of trouble too!

And the exercise will keep them fit and slim.

In fact, why don’t all you busy-bodies get out your wellies and spades and volunteer as gardening supervisors at your local school!

If The Witch Doctor is an expert in anything it is in fruit and vegetables. She might even be a world authority! She is not a vegetarian but she eats more raw fruit than anyone she has ever met. She always has and she always will. In fact she has many stories she could tell you about fruit and vegetables. Perhaps some day she will.

What she would never do, however, is comment on the contents of a child’s lunch box unless she was specifically asked by a parent to do so. She would regard it as an intrusion into the life of a family.

Just as she regards this sort of thing as an intrusion also.

We witches are very contrary beings!

If you poke your nose into any lunch box belonging to A Witch Child, something with many legs and teeth will jump out and bite it off and then then crawl all over you!

a red apple ……………………

The Witch Doctor – Link to a random page

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LINK TO UK MISSING KIDS WEBSITE

LINK TO MISSING PERSONS WEBSITE

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© Dlundin | Dreamstime.com

There are the usual expected mutterings that more leadership is required within the NHS to change the culture, and so prevent the recurrence of what has been diagnosed as the systemic failures of Mid-Staffordshire NHS Foundation Trust.

For pities sake, the NHS is dripping with “leaders!” Leadership courses are rife. So rife are these away-day, role-playing, blethering, bonding junkets, that the public should insist they are told how much of their money is spent within the NHS trying to develop these so-called leaders.

It doesn’t work. True leaders emerge when it is necessary without any training whatsoever. Leaders always have their fingers on the pulse. They do not Creep. They do not follow. They know when and how to say “no.” Mid-Staffordshires do not happen when there are true leaders about.

Take for example three names closely associated with Mid-Staffordshire:

Sir David Nicholson:
Chief Executive of the National Health Service in England. Acted as interim Chief Executive of the SHA overseeing the Mid Staffs NHS Trust for a period when death rates were found to be high.

Cynthia Bower :
Former Chief Executive of West Midlands SHA with responsibility for Stafford Hospital Chief until she was promoted to Chief Executive of the Care Quality Commission. She resigned from that position a year ago.

Julie Bailey:
Daughter of Bella Bailey who died in Mid-Staffordshire General Hospital. Founder of “Cure the NHS.”

It would be interesting to know how many leadership courses each one of these people attended.

The Witch Doctor suspects the one that she regards as a true leader has never attended such a course. She could be wrong, of course, but we witches are seldom wrong on matters of leadership.

In the meantime, The Witch Doctor, is now firmly addicted to “Pinterest” It gives her some light relief from NHS matters. She much prefers it to Twitter and Facebook – social media that she regards as a bit trivial, voyeuristic, insulting and at times depressing. Pinterest is different. There she doesn’t need to think much, she just looks and marvels. She also comes across a remarkable number of things that she considers to be “Twee.”

Generally witches do not do “Twee,” although The Witch Doctor often “pins” Twee things on to her board to help her to escape into an imaginary world far removed from the life she knows.

Today she found this:

On thinking it over, she came to the conclusion it was not “Twee” at all.

The wording could easily be changed to:

“Every patient in your ward is, or was, someone’s whole world”

However the patients in your care are not YOUR whole world. They never can be. You have your own world that causes you love, happiness, pain and grief.

So, forget about Loving, Caring, and Leadership.

These are all modern utterances of fashionable jargon – a sort of “Twee” health-speak. Each word has lost its true meaning and should be ditched within the healthcare setting.

Professionalism, empathy, and the willingness to help every patient as an individual are the words associated with the true language of healthcare.

Only when this language, plus a consultant delivered service, and a clear system of professional accountability is reinstated, will the lesser “Mid-Staffordshires” throughout the NHS be healed.

You look confused, My Black Cat…..

You want to know who is responsible for Mid-Staffordshire?

Well, My Black Cat, it is not as complicated as many seem to think. The “Pathway of Accountability” starts with the consultant medical practitioner and his or her individual patients.

The Witch Doctor holds the view that Mid – Staffordshire happened because :

a) Consultant Medical practitioners were over-worked and demoralised, or
b) Consultant Medical practitioners responded to carrots and / or sticks, or
c) Consultant Medical practitioners allowed themselves to Creep, or
d) There was no “Consultant medical practitioner delivered service”
d) A combination of all of these.

Notice The Witch Doctor blames medical practitioners. She uses this term in preference to “doctor” because there are many doctors around the NHS who are not medical practitioners.

That is not to say that others were not to blame. Indeed it is likely there were many who were not doctors who were very much to blame. More than any other group, however, it is medical practitioners who hold the power to change things quickly. They do this by saying “no.” They can say “no” because of their professional accountability and medical ethics that must always stay outwith state control.

Unfortunately, in The Witch Doctor’s opinion, a jail sentence is one thing, perhaps the only thing, that will be a wake up call to all UK medical staff that they must never again creep into becoming the obedient servants of the state. Sometimes the state, with good intentions, cannot grasp the complexities of the patient – doctor relationship. Sometimes when the state tries to save the taxpayers money in one way, in so doing it wastes more in other ways. Sometimes benevolent states creep into evil.  Managers on the other hand, by nature of their contracts, ARE obedient servants of the state and  so if they act out any views that they hold that are contrary to the will of the state it is likely they will be sacked. In the past, but possibly no longer, these dissenters on being sacked may have agreed to a gagging clause using the benevolent carrot of cash.

Doctors who become part of the formal management system put themselves into a conundrum – sometimes they are servants of the state, at other times not. They should be aware of this before they take on these posts and weigh their vulnerability against any financial incentives there might be as a result of  becoming clinical directors, medical directors, or chief executives. Doctors acting professionally and ethically in the interests of individual patients in their care will not be sacked if they deal with the system in a certain way. This “certain way” will be different in each situation. There are various ways of saying “no,” if those “leaders” in the NHS do not understand the simple articulation of that word.

Apparently, under health and safety laws, convictions may lead to unlimited fines or up to two years in jail.

The Telegraph reports that The Health and Safety Executive is considering launching an investigation into one particular patient who died in Mid-Staffordshire.

MID STAFFS ; HEALTH AND SAFETY CHARGES CONSIDERED

No one will agree with the Witch Doctor’s views on these matters, My Black Cat.

The are too straightforward for todays “leaders” of the NHS to grasp. They like lots of complexity.

Just look at this list!

It is no wonder that The Witch Doctor has sought out some respite by becoming an addict to the only kind of social media (apart from blogs) that she finds agreeable.

Her addiction, that is well on the way to becoming madness, is a welcome relief from wading through this diary of events taken from The Mid Staffordshire NHS Foundation Trust Public Inquiry.

What does it take to alert the “Leaders” of the NHS that Mid- Staffordshire was going off the rails and that there must have been consequences regarding patient care.

In particular, note the entries that My Black Cat has highlighted in purple.

No doubt we will have more to say sometime about the names “David Nicholson” and “Dr Turner” mentioned below.

MID STAFFORDSHIRE : TIMELINE OF THE WARNING SIGNS

Aug 2001
PCG concerns re the Trust shared with NHS Executive West Midlands

Jan 2002
CHI report on the Trust sets out concerns

Jul 2003
First peer review of the Trust children’s services published; concerns sent to SHA and PCT

Jul 2004
The Trust’s star rating reduced to zero

Sep 2004
Minister briefed by the SHA on the Trust’s star rating and concerns

Jan 2005
The Trust produces financial recovery plan, with staff cuts; PCT informed

Aug 2005
Report of cancer peer review visit; concerns shared with the SHA (Mar 05) and PCTs (Aug 05)

Aug 2005
Barry Report carried out for the Trust on whistleblowing complaints by two nurses

Aug 2005
Health Scrutiny Committee raises concerns about Trust culture

Oct 2005
David Nicholson and Antony Sumara meet Martin Yeates and Toni Brisby re progress at the Trust and finances

Dec 2005
FT diagnostic: The SHA Committee hold Trust board-to-board meeting; Trust deemed two years away from FT status

Apr 2006
Trust writes to the SHA with details of CRES programme (savings and staff cuts)

May 2006
The Trust writes to the SHA requesting £1 million for redundancies

May 2006
Auditors express serious concerns to the Trust about its management and assurance systems

Jun 2006
Report published of second peer review of children’s services; concerns had been shared with the Trust and SHA in Jan 06

Jul 2006
The Trust writes again to SHA requesting £1 million for redundancies

Aug 2006
The new SHA briefed on peer reviews

Aug 2006
The HCC publishes results of national peer review of children’s services

Sep 2006
Bentley Jennison Report highlights clinical coding concerns to the Trust

Oct 2006
National cancer peer review published; concerns had been shared with the Trust and Cancer Network Director (Jul), SHA (Oct), PCTs (Nov)

Oct 2006
Internal audit criticises accuracy and reliability of Trust’s compliance with HCC standards

Oct 2006
The HCC publishes national review of medicines management, Trust rated ‘weak’

Nov 2006
The Trust writes to the SHA Chief Executive re progress on cost savings

Jan 2007
CHKS audit find 20% error rate in the Trust’s coding

Apr 2007
Dr Foster Report on mortality rates published; the Trust second worst outlier in the country

Apr 2007
SHA receives SUI of Gillian Astbury’s death, after failure to administer insulin

May 2007
The Trust Board told inpatient survey results; Trust in worst 20% in country

Jul 2007
The SHA risk assessment of Trust; Trust deemed high risk on quality and safety

Sep 2007
Helen Moss raises concerns about nurse staffing with the SHA

Oct 2007
The Trust solicitor’s report on death of Mrs Astbury shows serious concerns re quality of care

Oct 2007
Nurse Donnelly lodges whistleblowing complaint re A and E

Oct 2007
Royal College of Surgeons report describes surgical department as dysfunctional

Jan 2008
The HCC inform the SHA it is considering investigation into the Trust

1 Feb 2008
The Trust awarded FT status

5 Feb 2008
The HCC informs Monitor of its interest in the Trust and asks for any information

19 Mar 2008
The HCC launches investigation into the Trust

Mar 2008
The Trust Board receives report of skill mix review

Mar 2008
The Trust Board given 2007 inpatient survey results; the Trust among worst 20% on several points

Apr 2008
The Trust report to the PCT sets out serious concerns re A&E

23 May 2008
The HCC writes to the Trust with concerns about A&E

May 2008
Dr Turner first raises concerns about A&E with the SHA Deanery

7 Jul 2008
The HCC writes to Trust re concerns about basic nursing care

Jul 2008
Audit Commission report finds inaccuracies in Trust coding

Jul 2008
The HPA raises concerns about handling of C. difficile cases by the Trust

Sep 2008
The Trust receives report of external review of A&E by Heart of England NHS FT; confirms several deficiencies

1 Oct 2008
The PCT sends the Trust formal performance notice re A&E target; copied to Monitor

15 Oct 2008
The HCC writes to the Trust with concerns about unsafe care; copy also sent to the SHA, the PCT, Monitor and the DH

Oct 2008
Third peer review on children’s services; concerns had been shared with the PCT (July) and the SHA (Oct)

4 Nov 2008
The PCT issues second performance notice to Trust

Mar 2009
The HPA peer review of C. difficile outbreak at Trust shows failure to institute effective measures

Sadly, The Witch Doctor has discovered she is an addict.

Sad.

Very sad.

The Public Inquiry on Mid-Staffordshire has been published.

Niall Dickson, Chief Executive of the General Medical Council and an expert in Tony Blair’s politics of the “Third Way” (see links below) responded on behalf of the GMC to the publication of Robert Francis’s report into the failings at Mid-Staffordshire NHS Foundation Trust.

WELL, DID YOU SPOT THE INTERTWINGLEMENT?

TONY 1 AND TONY 2

As expected, revalidation of the medical profession features in the response:

“Niall Dickson, Chief Executive of the General Medical Council, said:

‘Today’s report makes it clear that the system which was meant to protect patients let them down very badly.
‘Robert Francis QC exposes fundamental failings that allowed poor care to go unchecked and a culture to develop which led to catastrophic results.

‘Professional regulation on its own cannot prevent another Mid-Staffs, but by working with patients, employers and other organisations, we can play a part in helping to create a culture which encourages openness, which learns from mistakes and which supports front-line staff to deliver high quality safe care.

‘Anyone who has met and listened to the patients and their families – as we have- knows that what happened to them was inexcusable – their accounts are heart-breaking and should remind all of us involved with the health service that the culture must change.

‘Today’s report will make us redouble our efforts to achieve that goal. This means working more closely with colleagues on the ground, listening to those providing and receiving care and improved information sharing with other key players such as the Care Quality Commission.

‘We now have teams working with hospitals and patient groups throughout the country – but the system as a whole needs to get much better at spotting problems and intervening earlier to protect patients from harm and we are determined to play a part in that.

‘For us, the new system of checks on doctors, known as revalidation – which started at the end of last year – will enhance our ability to improve the quality of medical practice as a whole. It will mean that, for the first time, every doctor practising in the UK is required to demonstrate on an ongoing basis that they are competent and fit to do their job. It will take time to bed in, but we believe it will help create a safer service for patients across the country.

‘We also need to do more to make sure doctors and other professionals feel they can speak out. Last year we issued detailed guidance to all doctors on what they need to do whenever they have concerns about patient safety. We also recently launched a confidential helpline for doctors who are worried about patient safety so they can get advice and help when they need it. Any doctor can call the helpline and speak to us in confidence.

‘Taking responsibility, not just for the patient being treated but for all patients in the clinical environment, is at the heart of medical professionalism – working with others we are determined to do everything we can to promote it. Changing culture will not be achieved overnight – it requires commitment from all levels of the healthcare system, but if we are to avoid more tragedies we need to tackle this problem now.

‘In its response to the report, the Government has asked us about the action we have taken in relation to the individual doctors involved. We have investigated 42 doctors from Mid-Staffs and have sought to keep the inquiry updated on the progress of these cases. Twenty-two of the doctors have received formal letters from us advising them about their future conduct, one has accepted restrictions on their practice, and a further eight are subject to ongoing active investigation; four of whom are due to appear shortly before a public hearing. If they are found guilty, there will be sanctions including the possible loss of their registration.

‘In the last year, we have established the Medical Practitioners Tribunal Service, led by a senior judge who is in charge of overseeing the decisions of panels on doctors’ cases. This reform is an important step towards ensuring the public has confidence in the system. We have made progress but there is still more to do.

‘Today’s report welcomes a number of the steps taken by the GMC including our investment in information systems and recommends that other regulators follow some of our reforms, such as revalidation and the introduction of local employer teams. The report also sets out a number of key recommendations. We will study them carefully and be ready to lead where necessary and work with others to bring about the changes that are needed if all patients are to receive the care they deserve.’

The Witch Doctor doubts if revalidation will create a safer service for patients across the country.

However, she has an idea flitting through her head at the moment that, using revalidation in a rather different way from that intended that it might, just might, make healthcare safer.

She might even get round to gradually put her thoughts on paper on how revalidation may be put to good use.

By turning it on its head,

Upside down.

For the benefit of patients.

In the meantime, here is a reminder that there will be many Business Intelligence Specialists waiting in the wings to profit from the revalidation process no doubt spurred on by the Mid-Staffordshire Scandal. It is always worth following where the taxpayers’ money goes when new initiatives are introduced into the NHS.

These are some of The Witch Doctor’s thoughts on revalidation in 2010?

REVALIDATION CREEP : BARKIS IS WILLING

Do you suppose her views have changed, My Black Cat?

The Public Inquiry on Mid-Staffordshire has been published.

Apparently Jeremy Hunt has said it was “absolutely outrageous” that no-one has been brought to account for the premature deaths of up to 1,200 people in Mid Staffordshire.

The Witch Doctor agrees. After all, in Mid Staffordshire it is likely that mal-practice accounted for more un-necessary or premature deaths of UK patients than the combined total of UK troops killed in Iraq (179) and Afghanistan (440 to date).

The diagnosis of “Systemic Failure” or even “Corporate Manslaughter” is just not good enough. The accountability of the individuals concerned in the death and suffering of each patient is essential, not only to give closure to relatives but to protect other patients and to change the whole culture of the NHS to something that, in the future, is not only safe but world class.

It may well be that the overall neglect and mal-practice on this scale was driven by some type of corporate / systemic / cultural failure, but for every individual patient there will be a pathway of accountability. Sometimes, these “pathways” may lead to the very top of the NHS organisation and even to government. But you can be sure of this : a “pathway” there will be for each and every patient who died and the many more who suffered un-necessarily. The “pathway” will be different for each patient and so different individuals will be involved. It is likely though, that the same names will begin to appear the further along the “pathway” is travelled as those, whose job it is to hold overall accountablity, emerge.

After all, “pathway” is part of the current jargon in the NHS just now. There are “pathways” for everything. Sometimes these pathways are helpful. Sometimes they are stupid. Sometimes they are downright dangerous.

However, it seems to the Witch Doctor that the “Pathway of Accountability” is the most important of all. This Pathway is being fudged now and this has been the case within the NHS for many years. Little by little the `Pathway of Accountability” has become overgrown – first with weeds like nettles, dandelions and fireweed followed by fast growing bushes and ultimately towering trees. This Pathway of Accountability is now unrecognisable and many patients and staff no longer know it ever existed.

The seeds of these weeds were sown intentionally by governments along the course of “The Pathway of Accountability” They were allowed to germinate, become saplings and slowly grow over many years – so slowly that few noticed. However, Black Cats and Witches have beady eyes. They noticed the beginnings of the gradual overgrowth  way back in 1984.

It is time the most important pathway of all (indeed perhaps the only necessary pathway) was tackled. What is now turning into a forest needs to be hacked down and this, “The Pathway of Accountability,” cleared.

In order the expose “The Pathway of Accountability” the police need to investigate the deaths of these individual patients.

It will be a huge task, it will be expensive, and there will be much anguish, but it has to be done.

Yesterday the Public Inquiry on Mid-Staffordshire was published.

And yesterday My Black Cat fished out part of an article that had been published in the Wall Street Journal two days before.

She thought it was relevant to the problems at Mid-Staffordshire and elsewhere in the NHS. But it was really about the Iraq War and the muddle regarding weapons of mass destruction (WMD).

“In 2002 and 2003 some very smart people with access to the most sophisticated data and imagery available made a convincing case that Iraq was in possession of weapons of mass destruction. One invasion later, and the truth was revealed: the suspected WMD stockpiles did not exist. I spent several months in 2003 as a member of the CIA’s WMD search team in Iraq, and the stark contrast between the data I studied before arriving and the reality on the ground was shocking. Simply showing up and asking the right people the right questions told a very different story from the imagery, the intercepts, and the analysis. Human intelligence, in this case, made a mockery of the spreadsheets. This isn’t always so, of course. But an overreliance on metrics, spreadsheets, and forecasts can leave number-driven executives blind to the ground truth”.

With Stafford it took a long time for the data to come up with anything and when it did it was too late. People had already suffered and many (perhaps over 1000) had needlessly died.

It should not take Dr Foster, governments, other data collecting agencies and local spreadsheet lovers to tell when there is neglect in a hospital. Mid Staffordshire is a hospital where clerical staff were triaging A and E patients, where patients were lying unwashed in their own excrements, where relatives were cleaning the toilets, where pain relief was not given, where patients were not being fed, where confused patients were so thirsty they are drinking out of flower vases and much more.

All of this is so basic that it should have been picked up by Chief Executives, Chairs, Medical Directors, Clinical Directors because they should have got their backsides off their comfy ergonomic chairs and walked around the place informally and frequently and as they did talk to staff, patients and relatives. Then they would have seen the stark reality for themselves.

Simple.

Not rocket science.

Neither spreadsheets nor data collection is required.

Just simple observation.

You can easily guess what The Witch Doctor, My Black Cat and many others will be doing soon.

We will be reading the Public Inquiry on Mid-Staffordshire released today, of course.

As we read this long report we will be trawling the pages mainly concerning ourselves about what they are saying about the medical staff there. We are also very interested in whether the report draws attention to the need for a Consultant Delivered Service, rather than a Consultant Led Service or any other kind of “led” service because we feel that A Consultant Delivered Service driven by professional ethics would have had the clout to have helped prevent at least some of the problems of Mid Staffordshire, and similar problems in other parts of the NHS nationwide.

In the meantime, this is a post from March last year.

FOUNDATION TRUSTS, MID-STAFFORDSHIRE AND A CONSULTANT DELIVERED SERVICE

This isn’t really such a long post – most of it is an important article reproduced in full.

The government is hell bent on allowing Foundation Trusts to earn up to 49% of their income from private patients.

Only Heaven and The Government know what that really means. In fact, probably only Heaven knows and HMG doesn’t have a clue.

Only Heaven and Black Cats know the unintended consequences.

There is a discussion going over at Bad Med just now regarding the HSCB that is trundling its way through parliament, Foundation Trusts, and the Mid Staffordshire situation.

Having worked in the NHS for what seems like centuries, The Witch Doctor can fully understand how the level of basic care in some parts of some hospitals, some of the time, can slowly degenerate and creep un-noticed into NHS pockets of killing fields.

There have been previous inquiries re Mid Staffordshire, that was awarded Foundation Trust status on1 February 2008. The current and most comprehensive inquiry is The Mid Staffordshire NHS Foundation Trust Public Inquiry that completed its hearings in December 2011. The Chairman is currently writing his report.

In the meantime, here is copy of an article that was written by one of the consultants at Mid Staffordshire NHS Foundation Trust. It is extracted from “Hospital Doctor” but originates from the Royal College of Physicians journal “Clinical Medicine.”

The Witch Doctor has fished it out again because she is particularly interested by the reference to a “consultant delivered” rather than a “consultant led” service, highlighted in coloured text. She has been wittering on about the importance of this since the early days of this blog. Indeed she feels so strongly about it that she believes the problems with basic care in Stafford and other hospitals simply could not happen with a PROPER consultant delivered service operating.

A consultant led service is an airy-fairy term that can mean a lot or nothing at all.

A consultant delivered service is more concise and less open to a plethora of interpretations.

Patients seen or admitted to hospital should expect nothing less, because it lets them know clearly that a fully trained doctor with experience is responsible for their care, and exactly whom that doctor is.

DOCTORS AND MANAGERS MUST NOT FORGET THE LESSONS OF STAFFORD

By Dr Paul Woodmansey, consultant cardiologist at Mid Staffordshire NHS Foundation Trust – 23rd February 2011

This article first appeared in a recent issue of the RCP’s Clinical Medicine.

Stafford Hospital, or as it is more usually referred to in the press, the ‘beleaguered’, ‘troubled’ or ‘scandal hit’ Stafford Hospital, is a medium-sized district general hospital sited near the centre of a small town surrounded by beautiful countryside and a handful of small market towns. It is generally considered to be a pleasant place to live and bring up a family, lying in a rural oasis between the urban sprawls of the Black Country to the south and the Potteries to the north.

When the Healthcare Commission published its report in March 2009, this modest hospital was catapulted onto the front pages of national newspapers and politicians queued up to express their disgust on television and the radio. There has been much discussion within the hospital and local papers as to whether some accounts of poor care were exaggerated, the use of hospital standardised mortality rate (HSMR) has been strongly questioned and many colleagues elsewhere have expressed relief that it was our hospital not theirs which had received such in-depth scrutiny.

It soon became clear that the real position of the hospital in the national league of awfulness did not matter. What did matter was that many patients had received poor care and, for some, their treatment was appalling.

The reason for this has been picked over at length but it essentially boiled down to poor managerial and clinical leadership in some areas, lack of clinical staff, particularly nurses, with inevitable low morale and, to some extent, lack of equipment.

What kind of hospital is Stafford at the time of writing in October 2010?

Certainly not perfect, but by many measures vastly improved. There are more consultant posts in the emergency department and the number of consultants in acute medicine has increased. There has been a review of surgical specialties and a significant increase in nursing numbers.

For the staff, it remains a work in progress and much is still to be done to regain the confidence of the local population.

While many poor judgements were made and the need to blame is entirely understandable, it is important to recognise that nobody who worked at Mid Staffordshire Foundation Trust came to work with the intention to do harm. However, the entire senior management team has since been replaced, many by short-term appointments. This has been necessary and helpful, but also unsettling.

How did we let it happen?

No doubt all the consultants in Stafford have asked themselves this question. There were certainly times when consultants raised serious concerns and it seems that ‘the management’ did not listen or did not act. We understood the very difficult financial situation and most of the time we did as many in the health service do, and got on with our daily jobs working very hard to make the best of difficult circumstances.

It is important to understand that in most parts of Stafford Hospital patients were receiving good treatment, but it is sobering to realise how one can get used to such poor standards in other areas. In retrospect more of us should have made it clear that there were unacceptable staffing levels and practices in emergency care.

New way of working

If a hospital’s performance was measured by the number of visiting agencies visiting the place, Stafford would be by far the best hospital in the country. Of particular value to the consultant physicians was the help offered by Dr Ian Sturgess and Russell Emeny of the interim management and support team and Professor Sir George Alberti.

It seemed that this terrible situation could be turned into an opportunity to make genuine improvements. A small group led by myself and Dr Shaun Nakash in acute medicine realised that consultant input was the key to better and more efficient patient care.

We practised the old model of the acute medical take which was run by a specialist registrar with a morning consultant-led post-take ward round the following day. In the summer of 2009, a few of us informally trialled a ‘new way of working’ in which all patients referred to medicine would be seen by the on-call consultant as soon as possible, ideally within two hours of referral. The assessment was recorded by a junior doctor on a specially designed page in the emergency care pathway which prompted the consultant to make a clear problem/diagnostic list, management plan and to estimate the date and time of discharge, whether venous thromboembolism prophylaxis was required and the most appropriate ward for the patient, or if community care was possible.

After what seemed to be a successful trial, the entire consultant physician body accepted the new way of working and it was formalised from July 2009. The acute medical consultants manage the weekdays between 0800 and 1600 after which the on-call physician takes over and is present on the ‘shop floor’ from 1700 to 2030. A post-take ward round for all the night patients is carried out at 0800 the following morning.

This is consistent with the guidelines produced by the Royal College of Physicians for managing non-elective care.

In December 2007, we introduced a Saturday morning ‘trouble-shooting’ round in which the on-call consultant visited all the medical wards to see any sick patients and to aid weekend discharges. More recently a similar Sunday morning ward round has been introduced. The ‘new way of working’ at the weekends involves the attendance of the on-call physician in the afternoons and into the evening in addition to the Saturday and Sunday morning post-take rounds.

We do not claim that this approach is unique, but it has led to an increase in early discharges and appears to have coincided with a reduction in mortality including at the weekend. What has struck me particularly is the relative ease in which this major change to our working lives was introduced.

So, how did it come about? Consultants proposed the change and tried it and their colleagues quickly accepted that it was good for patient care.

Work in progress

Having made some progress with the first 48-hours of acute medicine, we are currently focusing on care on the specialty medical wards. Perhaps the greatest challenge to consultant physicians (and our managers) is the recognition that a consultant delivered – not led – service is required. I suspect that most people accept the principle, but the practice tends to be more difficult.

It is necessary for patient safety and because of the pace of life in a modern hospital, including the need to reduce length of stay and our inability to rely on junior doctors means that our patients need senior input every day.

It should involve seeing all new patients on the ward, all sick ones and some of those planned for home. Many timetables (including mine) are set up in such a way as to make this difficult. However, daily review is best practice. I believe that we need to remember that the reason we have hospitals is to care for the acutely ill and while outpatient activity is very important, the relative priorities, including financial ones, have become distorted.

A patient with stable angina can wait a while with little risk. When a patient with an acute cardiac condition, severe enough to be in hospital, is admitted to my ward on Monday afternoon after my ward round, it is simply wrong for them to have to wait to see me until my next planned round on Thursday. I and my colleagues therefore squeeze in ward reviews and in-patient referrals in between other activities, but we are now working in job planning to make this core activity.

A personal view

In my opinion a major underlying cause of the ‘Stafford scandal’ was that most of us, including politicians and healthcare professionals, had lost sight of the fundamental priority of a national health service. That is to provide excellent and immediate care to those who become suddenly very unwell. There have been tremendous improvements in many areas such as cardiac, cancer and orthopaedic care.

However, the importance of the care of sick elderly patients who make up the bulk of our medical ‘takes’ have only rarely grabbed the headlines. Care of these patients is expensive in staff time and resources, it is often difficult and tiring and can only be delivered in a high-quality way by departments which are equipped appropriately, are well staffed by motivated individuals and led by enthusiastic consultants.

What are the lessons to learn?

It might be comforting to imagine, but no one should fool themselves into thinking, that the problems which occurred in Stafford were unique. Our hospital did not have the worst HSMR in the country during the period under investigation. Delivery of good healthcare is difficult, particularly in the pressured environment of emergency care.

Much as I would love to return to the relative anonymity of old, politicians, healthcare mangers and clinical staff must not forget the lessons of Stafford. What does it say about this still rich country if we cannot fund sufficient nurses and doctors to look after our sick and elderly when they most need it? As consultants we are the ones who need to lead change and we are the most powerful advocates for our patients and sometimes have to muster the courage to state loudly and clearly when ‘care’ is simply not good enough.”

The Witch Doctor has a few unread medical books on her shelves that are not text-books. The other day she found one that is now out of print. She decided she will now read it slowly and in so doing try to imagine what the old GP would think of today’s changes in the healthcare system. If still alive he would be 112 by now.

The book is called “Gorbals Doctor” This was the name given to Dr George Gladstone Robertson who spent his whole life working in what was considered the toughest part of Glasgow. He saw The Gorbals slowly change from an area of large flats inhabited by “the well to do” into one of the filthiest slums in Europe, the eruption of gang-land, and finally the slum clearances – the demolition of buildings, friends and neighbours as families were moved into utilitarian housing schemes built on farm land some miles away or into local high flats.

He was still working full time into his 70s and at that age drove a white MGBGT around the toughest streets in Glasgow. He never locked his small but conspicuous car when he did his visits. It wasn’t necessary. Everyone knew it was “The Doctor’s car.” No one would enter it or steal it. A kind of loyalty existed among the Gorbals folk. Perhaps he was considered in this environment to be some kind of demi-god.

So WD and My Black Cat might be quiet for a while as we savour his memories. On the other hand if we find something in the book that takes our fancy, we might share it with you.

If we can be bothered……

In the meantime, we will have in mind the post below that we first published nearly five years ago as we compare the life of the “Gorbals Doctor” to what we see developing today.

THE WHEELIE-BIN DOCTORS

Doing a dentist:

You know, My Black Cat, The Witch Doctor remembers well the time most dentists came out of the NHS. It was a scenario carefully orchestrated by the government, and The Witch Doctor is of the opinion that it all went according to “The Big Government Plan” at the time.

Toothache, so what!

(Have you ever had toothache?)

Fillings, so what!

Orthodontics, so what!

DOING A DENTIST

“Doing a Dentist” would not lead to increased patient mortality.

Would it?

Or if it did, it would not be easily apparent to the punters (patients and clients) that the lack of dental facilities was to blame.

Now we see huge queues when a new dentist, who is prepared to do NHS work, opens.

And dentists are flown in from Poland on occasion to “fill the gap.”

Mark you, some say the dentists did OK out of it, because the marketplace dictated a demand for dentists.

Beautiful teeth are a cosmetic blessing.

(And toothache is a terrible thing).

Greedy dentists!

Anyway, that’s all in the past, the medical establishment didn’t take too much interest then. Doctors were different. Patients die without doctors. This could never happen to GP’s.

Really?

Another huge tidal wave of “The Big Government Plan” is about to engulf the GPs.

More difficult for the government this time, though. This is not about toothache, fillings, and orthodontics. Without doctors, patients will die and this will be apparent to all. Big court cases. So there has to be a fallback position.

The fallback position is an excellent one.

THE FALL-BACK POSITION

It will boost the economy – our economy, and the US economy.

So that makes it altruistic.

The punters’ (patients and clients) taxes will be diverted into multi-national companies who will provide health care.

Free health care – now, but not always.

The multi-national healthcare companies will want a ROTUND clientele but a LEAN workforce.

That’s why we’re all hearing about Toyota-style LEAN-NESS.

Better health care.

Better health care – because the patients will be seen in interior designed surroundings with fresh flowers, well nourished pot plants, and music in the toilets. Local artists will be encouraged to display their original paintings on the walls. No tacky prints here!

Staff will all have excellent communication skills. They will smile a stage smile and will never forget to remind you to “have a nice day” – or the up-market London equivalent, or the up-market Yorkshire equivalent, or the up-market Liverpool equivalent. Staff will not chew gum. This is because they are following the “smile” and the “nice day” protocol. This protocol does not allow chewing gum. They hold certificates for these protocols. The certificates will be proudly and elegantly framed and hung on the wall. These “Competent Clinical Decision Makers”*** who are not doctors will have many certificates displayed on the wall of their rooms: for they will have sat lots of little tests for lots of little skills. And passed them all. The degree in handwashing. The certificate of “niceness.” The “empathy” diploma. The punters (patients and clients) will be impressed.

BETTER, LOVING, HEALTH CARE

The more gregarious doctors might have one or two certificates on the walls. The little unimpressive one that says “MB ChB” will go un-noticed by the punters (patients and clients). The more reticent doctors will keep their unimpressive certificates somewhere in a suitcase in the attic. This is just as well, because soon there will be no wall available for doctors’ certificates because there will be no doctor’s rooms. Doctors will become the “Wheelie-Bins” of the new NHS. Wheeled into the elegant rooms of “The Competent Clinical Decision Makers” when the diagnosis and treatment is forming the shape of a pear. The doctors will do salaried part time work on a sessional basis. There will be many young women doctors working two, three or four sessions per week. With some exceptions, these women doctors will be more malleable than the full-time men. They will be wheeled about from branch to branch of the big multi-nationals to cover sick leave and maternity leave. These “Wheelie-Bin Doctors” will not know their patients from Adam. But the “punters” (clients) won’t care. Some other “punters” (patients) will.

A GP’S OFFICE IN THE NEW GLOBAL NHS

That’s the way it will be.

Won’t it, My Black Cat?

“The Competent Clinical Decision Maker” is coming of age.

***N.B. The term “The Competent Clinical Decision Maker” was first noticed by The Witch Doctor in October 2007.

You think it was a term introduced by the government?

Wrong!

By the National Practitioners?

Wrong!

By the nurses?

Wrong!

By the pharmacists?

Wrong!

By Skills for Health”

Wrong!

It was introduced by The Royal College of Physicians in London in October 2007.

“ACUTE MEDICAL CARE – THE RIGHT PERSON, IN THE RIGHT SETTING – FIRST TIME”
Report of the Acute Medicine Task Force
October 2007

Yes, the term “Competent Clinical Decision Maker” was introduced by doctors – senior doctors, although the term seems to originate from Iran.

Introduced by senior physicians working under the aegis of The Royal College of Physicians in London, at a time the country was on the brink of massive unemployment of junior doctors.

Now there’s a thing to chew over.

Eh, My Black Cat?

a red apple ……………………

The Witch Doctor – Link to a random page

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LINK TO UK MISSING KIDS WEBSITE

LINK TO MISSING PERSONS WEBSITE

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