Past Posts...

Supping With a Short Spoon

Just as there is gold for drug companies in them thar pills, so there is gold for GPs in them thar patients. Historically, GPs were paid chiefly on a patient head-count basis, topped up with item of service fees for ‘extras’ such as vaccinations and contraception. The simplest way for GPs to boost income under this system was to increase list size, sometimes to absurd levels where the GP could not hope to provide adequate care for all the patients on the list. Some even gamed the system, by sneaking ghost patients on their lists. Governments disliked crude head-count based pay, not least because it offered no scope to influence GP activity. Item of service payments were an attempt to change that, but the capitation fee was still paid whatever the doctor did, or didn’t, do. The below par golfing GP trousered the fee in equal measure to his more conscientious colleague on the other side of town.

Big Pharma’s Little Helpers

The idea the there is gold in them thar pills is, one might say, as old as the hills: the book on the left was published in 1975. But it sure is a rum old business. Dr No’s last post highlighted the paradox that, even for drugs that do work, for most patients, most drugs don’t work. This naturally enough in today’s world of evidence based medicine begs the question: why do doctors prescribe, on the industrial scale they do, when the evidence shows most of the time, most drugs don’t work? The answer, Dr No suspects, not necessarily quite so straight forward as at first it may seem, and may even have more to do with blind faith than scientific evidence.

Most Drugs Don’t Work

Just over three years ago, when few had heard of him, Dr No wrote a post called The Collapse of the Probability Function. At its heart lies the troublesome paradox that, while we might know how a group of patients might fare, we have no way of knowing how individual patients will fare. We might know that of a hundred patients, five will die in the next ten years from a heart attack. What we don’t know is who of the hundred will be the five; and the flip side of that is, when as doctors we choose to intervene, as increasingly we do, there are ninety five souls now tangled in our medical web, with all that that entails, be it tests, treatments and general apprehension, who were never going to have a heart attack anyway, let alone die from one in the next ten years. That’s a whole lot of medical intervention without any benefit whatsoever – but what the heck – overall, we might save a handful of lives - or so the hopeful reasoning goes.

The Healthcare Insurance Scam

One of the consequences, most probably intended by David ‘I want…the NHS to be a fantastic business for Britain’ Cameron, of the NHS reforms is a rise in the promotion of healthcare insurance. Against a background of a financially squeezed NHS, junk insurance mailshots have started rising like miasmic bubbles through the financial swamp, and now regularly surface in Dr No’s inbox and on his doormat, where they emit a foul and distasteful odour. The gist of the pitch is usually see a doctor of your choice today for only a few pence a day. Why indeed wait weeks to see one of those nasty mean health service docs when you can get an appointment right away with Dr Nice at Clinics-R-Us? Dr No’s answer is simple: he has already paid for his healthcare, through general taxation, so why on earth would he want to pay twice?

Well, Um

This morning, Yesterday had the Right Honourable Jeremy Richard Streynsham ’Unt, Secretary of State for Health, on the line. He was on to crack up revalidation, Stilton’s pet project to spear ‘under-performing’ doctors. Evidence Based ’Unt is new to health, and it showed, despite being interviewed by Yesterday’s laziest presenter, Justin ‘Um’ Webb. When EBH wasn’t saying well, um too, he squeezed out the usual tired toothpaste of revalidation rhetoric, about the need to ensure doctors were up to speed on the latest advances, and in so doing revealed he hadn’t a clue about Stilton’s real plans. Bored, Um moved on to evidence based abortion limits and evidence based homeopathy. EBH carried on as before, squeezing out colourless, tasteless, um, toothpaste. Yesterday had missed a trick: surely Wingnut, Um’s co-presenter, would have done better. He might even have managed to get evidence based toothpaste with a stripe in it. Instead, we had to put up with evidence based ums.

Coales Hits the Fans

No smoke without a fire, they say, and Hot Burning Coales appears to be doing her best to hot things up, not to mention generate much smoke. Her posts and tweets continue to appear and disappear faster than a Swiss clock cuckoo – a post posted earlier today has already gone - but when in view they tell a story that suggests the Royal College of Caring and Sharing isn’t perhaps quite as caring and sharing as its senior members want us to believe. A report earlier this year in the Telegraph, linked to by HBC, tells how College employees repeatedly taunted another hapless member of staff with xenophobic jests and sexual jibes. She suggests, though Dr No has not been able to find supporting evidence, that the College has upset College candidates and members arriving on the other bus by cosying up to the Sultan of Brunei, who rules over a country infamous for locking up fudge packers (but not, for some reason, crack snackers). She has even all but charged the College with institutional racism, alleging that the lower Clinical Skills Assessment pass rate for international medical graduates stems not from a lower quality of candidates but from a systemic bias by College examiners against our overseas colleagues. And last, but by no means least, she accuses the College of constructive dismissal, insofar as it made her life as a Council member so intolerable that she was forced to resign.

The Chauffeur Must Decide

In Downton Abbey (ITV1), a good many scenettes – most are too brief to be scenes - are set up to climax with the wonderful Maggie Smith delivering a punch line. She has perfected the art of delivering these dénouementettes, which she does with a little shudder, as if a Tantric feather had tickled her G-spot. Last night she delivered a perfect corker: the decision lies with the chauffeur. In just six words, she encompassed a hundred years of medical and social history.

The dramatic tension at the heart of last night’s episode was the ancient clash between the GP and the specialist. It was as high concept as high stakes go: the life of a young mother was at stake. From the early moment a throwaway mention was made of swollen ankles, a pall-bearer of toxaemia, or pre-eclampsia, the obstetrician in Dr No knew it was going to end in tears. Fits would follow, and death was indisputably on the cards. The only question was how Julian Fellowes would deliver not the baby, but the eclampsia.

Nailing Doctors

A hundred years ago, when Britannia ruled the waves, our language was high on a tide of nautical terms. Today, in the age of the automobile, it is to motoring that we turn for our metaphors. The complexities of nutrition are reduced to the simplicities of traffic lights. The rigours of medical regulation – revalidation – are simply MOTs for doctors. Latest on the bandwagon is the Royal College of Caring and Sharing, which has shared, on facebook of course, its Social Media Highway Code. There is, inevitably, a lot of caring, and even more sharing, but, for this reader the wheels started coming off the code when it likened today’s doctors to yesterday’s Wild West cowboys. Are today’s doctors really so feeble that they cannot for themselves work out how to behave online?

Blood Toil Tears and Sweat

The equinox has passed, Monroe is back, and so too is Dr No. It has been a quiet summer for medical bloggers. Hot Burning Coales got herself into hot water lately, implying that the Royal College of Caring and Sharing was a coven of homophobes, xenophobes and gynophobes, and Ben Goldacre has discovered publication bias, and served it up with Bad Pharma sauce, but the big event of the first half of the year, the passing of the Health and Social Bill into law, has given way, as did the outbreak of WWII, to a phoney war. No tanks piloted by Very Willing Cowboys have yet been seen overrunning hospital car parks; nor have any foundation trusts been bombed by even more willing hedge fund managers. It is, for now, as if the Act had not happened. Which is just as well, for now, because there is another big black cloud looming large on the medical horizon: the spectre of revalidation. What, Dr No wonders, would Stilton and his gang of goons make of Monroe?

Savage Life

"Those who, in the confidence of superior capacities or attainments, neglect the common maxims of life, should be reminded that nothing will supply the want of prudence, and that negligence and irregularity, long continued, will make knowledge useless, wit ridiculous, and genius contemptible."

–Samuel Johnson: Life of Savage, 1744

Were it not a hideous truth, the comedically absurd case of the dehydrated patient who dialled 999 from his hospital bed to get a drink of water could have been a scene from Cardiac Arrest, the dark but for those in the know searingly accurate 1990s depiction of life and death on the wards at St Elsewhere’s. By a coincidence, Line of Duty, a police precinct drama in which the leads like Getting Things Done, not in the usual software way, but with hardware, much of it dark blue or grey and involving combustibles, is now running on BBC2. Both were written by Jed Mercurio, and both are about Mercurio’s mojo: the dark and bitter secrets that lie at the heart of two of our biggest institutions: first the NHS, and now the Police. If Cardiac Arrest was Line of Duty with stethoscopes, then Line of Duty is Cardiac Arrest with police badges. Even the protagonists, Andrew Lancel and Martin Compston, look the same.