New PM, New NHS?

BBC Five Live are having an NHSS day and asking people to fill in their experiences of the NHS today - be it as a patient - GP, Dentist, optician, A&E or outpatient; or staff member - consultant, staff grade doctor, foundation year doctor, medical student, nurse, physio, OT, SLT, cleaner, ambulance-person, manager clerk etc.

Five Live then plan to send these collected experiences in a dossier to Alan Johnson, the new English health secretary, to help inform his decisions.

Many of the contributions are the classic stories of the NHS being there in times of emergency:

I was taken ill on a Sunday a few weeks ago. I rang my Doctor’s number and was put through to an emergency number. The person on the end of the line took all details and told me a nurse would ring me back. The nurse advised me to go to Southmead Primary Care Unit, where I was examined by a doctor. He told me to go to C Ward in Southmead Hospital. I was immediately seen by a nurse who took my blood pressure etc. I then saw a doctor who gave me a thorough examination. She sent me for an X-Ray. Eventually I saw a Consultant who told me I had pneumonia. I was allowed to go home with antibiotics.

or failing in out of hours cases.

My mother suffered abdominal severe pain on Christmas Eve 2004 and through a misdiagnosis at her GP out of hours surgery in Cheshire and a failure to manage her properly she was sent home and later passed away in pain on Christmas Day. All three triage nurses we spoke to on the phone over a 24 hour period were later criticised for having weak skills while several medical staff visited her but left her in pain not taking responsibility for her

The stories from staff of long hours,

We can run a 24 hour service, but there is no 24 hour support - no CT scans, physio, OT, Echocardiograms etc out of hours unless we are talking a dire emergency. Clearly these things shouldn't be done at 2am, but I don't see 7pm as a problem. So we enter a game of negotiation with these clinical areas, trying to get our patients through quicker, while the departments have to prioritise the requests. It takes up an awful lot of time which doesn't truly contribute to patient care.

Everyday I'll stay till about 7pm, and there is always something still not done. Handover is tough as Working Time laws mean people are available and unavailable at random times - I fear for next year with the 48 hour working week because it may be that patients rarely have the same team looking after them. That can't help a sick and scared patient.

I like my job - because I know my patients, because I feel involved, because it is interesting and challenging & I am privileged to play a part in peoples lives. But I am increasingly fatigued, by the moaning in the press, by the moaning on the wards, by the governmental attacks on the profession. I do this job to be a doctor - and know for cetain politicians cannot tell me how to do this.

and the relentless demand for change:

PLease stop CHANGING things. GB said this word 8 times in his first speech. We are sick of changes all the time, moving goalposts and targets. How can we hope to build a stble forward thinking service for our patients with this constant meddling. Leave doctoring to us doctors and stop criticising consultants. We work bloody hard, above our paid hours to serve our patients. Considering it took 13 years of hard work working through nights, doing untold exams, self funding my own training for the essential courses and neglecting family life to get to where I am, I think you are getting us at a bargain price. Especially when you consider the incredibly stressful and skilled work that we do on a daily basis. Leave us alone to get on with it..

The laundry gets a mention as well:

Much has been said and written about infection control in hospitals and much importance has been put on good practice such as hand-washing. However, one vital aspect of infection control is virtually overlooked. This is infected laundry. Hospital laundries are very much 'out of sight, out of mind' and a common misconception is that everything that comes out of a washing machine is clean. Nothing could be further from the truth - infected laundry must be thoroughly disinfected. A long-standing official NHS guideline advises hospitals to disinfect infected laundry by washing at high temperatures.

and the cleaning;

A sufferer of Bowel and Liver Cancer and now very sadly died, he made an unfortunate mess of the toilet bowl and seat which I cleaned up as best as I was able with tissue.
Once I had him back in bed I reported the state of the toilet to a Staff Nurse and advised that it required disinfecting.
In the two and a half hours that my sister and I were present, no attempt was made to clean the toilet despite the assurances that it would be done.

So basically the answer seems to be that the NHS is great in life-threatening emergencies but fiddling around with the staffing structure (MTAS, MMC, Working time Directive), management (more managers, privatised hospitals and ancillary services), and targets seems to have caused the system to once again appear on the brink of collapse.

We should remember however that Alan Johnson is no fool -

...then on to the Education department as higher education minister. He proved a cunning, persuasive and, above all, successful campaigner in the battle to get the back benches to support "top up" university tuition fees. The measure was carried by just five votes, and beforehand the whips were so unsure of victory that Blair discussed the terms of the motion of confidence that would have followed such a major defeat. The orphaned grammar school boy without an O-level to his name cut a more convincing figure among old Labour stalwarts than Charles Clarke, his hectoring, public-school-educated boss. "I was part of the charm offensive with Charles Clarke," Johnson said recently. "I did the charming and he was offensive."

Of course, up here in devolved Scotland things are very different, with only some of the NHS decisions from London actually affecting us.

The NHS up here is now run by Nicola Sturgeon, who has already made an interesting start to the new Executive / Government's programme by reversing hospital re-organisations in Lanarkshire and Ayr, but supporting the previous executive's decisions elsewhere.

The SNP minority government are also opposed to PFI, so we shall have to see if the rate of investment up here is maintained, or whether the NHS is allowed to settle before more upheaval is foisted upon it.

One down

First exam was today - this one had:

• 60 EMQs - like a long MCQ - 5 clinical scenarios on one topic and then 15 possible answers at the bottom - match them up. Seemed to go ok, but there were some nasty results interpretation questions.
• 3 Short notes questions - Rheumatoid/Osteoarthritis comparison; Alcohol misuse - communication issues, treatment and chronic effects; Breast Cancer screening & pathology
  
• 2 Modified Essay Questions - the ones which are a bit like a PBL Scenario - Coeliac disease and osteomalacia; Asthma and COPD.

So it looks like tomorrow will focus on Cariology, Renal, Neurology, Psychiatry...or maybe not.

Hospital teaching

Ok, so this morning was our penultimate hospital teaching session before the OSCE, and we were taking history and examination from patients on the surgical floor. My patient was a nice old guy who had Parkinson's and a history of prostate cancer, cataracts, atrial fibrillation (irregular heart beat) and probable bleeding from his 'back passage' which he was going to have laser'd. So this was all going ok, and I did the examination.

Come feedback time, we were all critiqued for not examining every system, not probing harder, not doing a full systemic enquiry - I don;t know if we have become to OSCE oriented that we try to do all histories in 5 minutes, and have parred each examination to the minimum.

We then had a masterclass on Jugular Venous Pulses (JVP)
starting with the normal pulse, and the items we need to describe about each pulse:

• Rate
• Rhythm
• Strength
• Volume
  
• Character
• Collapsing
• Can you feel the vessel wall?

When it came to JVP, we had to list all the ways to increase the JVP so you can tell that it is the JVP that you are seeing:

• Tilt patient's bed backward so they are lying at nearer 30 degrees than the recommended 45 degrees.
  
• Compare timing of breathing (JVP is higher on expiration)
• Look for bi-phasic nature of pulsation
• Increase pressure my pressing on abdomen over liver
• Check for landmarks - the two heads of sternocleidomastoid, carotid artery, external jugular vein

All in all it was a good session. This afternoon's PBL had a distinct end of term feel about it, with references to Crufts, prostatic discharges and revision avoidance tactics. But hey thats what you get for studying at *****************.

Choose cancer, choose life?

This Scotsman.com article is suggesting that there will be a 3-day course in Edinburgh next week which will try to help people choose not to have cancer or anorexia.

The group says it can help people with a range of illnesses, including cancer, and also those with eating disorders, alcohol and drug addiction. Wolter van Verschuer, a Course in Miracles member, said: "We want to change the way that people think about life. It will make you look in a different way at yourself. It has a complete basis on the teachings of Jesus Christ." The organisation's website includes controversial statements suggesting illnesses such as cancer are a person's own choice. It states: "No-one suffers pain except his choice elects this state for him. No-one can grieve, nor fear, nor think him sick unless these are the outcomes that he wants. And no-one dies without his own consent." Mr van Verschuer admitted this was a tough stance, but he invited people with cancer and other diseases to go to the event, adding: "Sickness is a decision that you have made."

This seems a little at odds with most modern evidence based medicine and current western medical opinion. However, some studies have shown that prayer can improve a patients condition and shorten their hospital news (great news for NHS administrators). It is a well respected 'fact' that a positive attitude from the patient and their close family and friends is beneficial to their condition (for a public recent example, look at Jane Tomlinson), the opposite that people who worry about conditions can 'choose' to get them seems a little far fetched.

The two quotes from representatives of Scottish Charities associated with chronic illness/cancer seem to sum up the situation succinctly:

"Some people do find some help and comfort in their religion, but to say that people choose to have it is ridiculous." "Dementia is an illness and people need help and support to cope with it, not to be taken advantage of by outfits peddling miracle cures."