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La La Land

Posted by Dr No on 14 October 2011

barrage.jpgQuestion Time last night on BBC1 assembled a panel sure to cause fireworks, and fireworks there were, on a military scale. Lansley spent much of the programme looking like a barrage balloon about to explode, Sarah Sands explained to anyone willing to listen why she should be the next editor of the Daily Mail, and Mark Littlewood previewed the bilateral cauliflower ears that all Lib-Dems will sport, once the electorate give them the boxing about the ears that they so sorely deserve at the next election. But the best and most striking bit was the visceral anger of the audience. At one point, they almost rose up as one, as if to tear Lansley limb from limb. Dr No, pacifist that he is, almost wished they had. At least we would have been spared further sight of that blasted barrage balloon.

When he wasn’t looking bloated, Andrew looked disappointed, like a parent let down by unruly offspring. I have done my best for you, these last eight years, the look said, and this is how you repay me. Goaded intolerably at one point by a miscreant Phil Hammond, who had had the cheek to run a word count on the Testament According To Lansley without actually reading it, the wounded patriarch mask all but slipped, with corporal punishment for miscreants back on the menu. But it was not to be. It was Dimber’s turn to look disappointed. A bust up on QT would have done wonders for the ratings.

The take home message was, or rather appeared to be, that, like his boss Cameron, Lansley simply just doesn’t get it. Daily he stares in the face overwhelming public and professional opposition to his reforms, and yet he sees nothing, nor hears a word. It is quite extraordinary, and Dr No can only think of two possible explanations. Either it is denial on a delusional scale – Lansley really does live in La La Land – or - surely not - it is the deliberate steam-rollering of ideological dogma over the expressed will of the people.

Regretfully, Dr No rather fears the latter. Call him a conspiracy theorist, but he can’t help wondering why the CQC’s latest dossier of despair, which Lansley ordered, was released yesterday, the day after the Lords’ second reading of the Bill. More grist to the no-change-in-not-an-option mill? Another hose with which to sprinkle water on dissident reactionary fireworks? Of course, Dr No can’t be sure - but he does wonder.


The expression on Lansley's face when asked by Phil Hammond how many times the word 'competition' appeared in the Bill, then how many times the words co-operation or collaboration appeared was a picture that said far more than the dreary 3 million page slab of bullshit making it's way through the Lords crib?

It was a bit like this ......

Yes, I wondered about the CQC report timing as well. We'll be seeing more of that, not less if the bill gets through. But I have been reading through the transcript of the Lords debate and I think they are going to seriously gut it, esp on the health secretary's duty. I think we should also be asking why QT invited Andrew Lansley on last night and if they are now trying to help stop the bill. It's not over yet.

It is clear that everything ( is planned by the genius: listening game,Lords pretend debate. Fox hunting. PFI. CQC. Immigration. And Baroness William (Dr No spotted it a while back).

Yes, hospitals will close and be sold. But that was by the "independent" Monitor run by McKinsey guy.

NHS is going DENTAL ( no, not MENTAL).

Dear Dr No,

The CQC report was painful reading for anyone involved in the NHS. Nurses, managers and Doctors being interviewed were often very offended, and very defensive. The truth hurts, and the realisation that Sub-prime care is very common in the NHS hurts even a thick-skinned beast like myself. It is not a new phenomenon, scandals about care of the elderly or otherwise vulnerable go back years, and occur in many other countries also. I was a bit disappointed that other bloggers were not interested by our recent health scandals.

The timing was suspicious, with its implication that we need a top down intrusive inspection team such as the CQC (or Monitor?) to maintain standards.

We do though need to aknowledge the systematic failings of the NHS if we are to improve the system. My criticism of the HSCB is not that it is medical armageddon, but that it is a distraction from the real ills of medical practice and health care in Britain. Both DoH and medical profession will be like bald men fighting over a comb.

Dr Phil

Dr Phil,

My Black Cat caught a whiff of the fish too! Nevertheless she is asking herself whether nothing has been learned from Staffordshire. The current report has not passed un-noticed by this witch and most of the other medical bloggers too I imagine - it is just there is so much going on in the medical world just now and if we focus on the report at this moment in time we may be aiding and abetting the fishy coincidence.

However, it might be the case during The Witching Hour tonight that a post from a few years ago on the matter of patient neglect will float to the top of WD blog as if by magic.

"My criticism of the HSCB is not that it is medical armageddon, but that it is a distraction from the real ills of medical practice and health care in Britain" - the biggest single "ill" in health care is an unrealistic level of expectation?
The language of the market (productivity - input/outputs) has contributed in no small measure to this phenomena, especially the relentless propaganda war concerning the performance of the NHS in relation to other health systems, and the tendency to big up every new drug break through or technological development.

Then we have ludicrous media representations - caring, and attentive staff enjoying deep, and unhurried bedside exchanges with adorable grannies - resuscitation that ends with an attractive young man or woman being snatched from the jaws of death - all complete bollocks of course?

Patients in the late stages of life face more and more and intervention for less and less benefit (in the majority of cases) - at least some are finally waking up to the fact dementia is a terminal disease and as the condition progresses should be managed with fewer medical interventions (leaving aside palliation of unpleasant symptoms).
80% of people now die in institutions, yet most of us seem to be in a state of near complete denial about the prospect of a degrading and sometimes brutal loss of function until it's too late.

Surely there needs to be more consideration while we have the intellectual facilities to decide how much medicine we want once we get beyond a certain point?
Perhaps too many people are oblivious to the fact hospital are now more like factories, running at near 100% bed occupancy, with staff finding it nigh on impossible to keep up with the relentless throughput, and from a nursing point of view acting as punch bags for the frustrations of a stream of relatives (either via the endless phone calls, or face to face exchanges) due to failings in the wider system.

I do have one major problem with the clipboard wielding inspectors - they appear to have no ability to contextualise their observations.
The tradition of elder abuse is well established in our culture - for example, many do not even have the wherewithal to eat properly, or heat their home in cold weather.
Isn't this report the same old lament we heard 10 years ago, and 10 years before that - if nothing has substantially changed then one has to assume, however painful it might be for us to accept, oldies are not loved sufficiently to receive the sort of service that would undoubtedly cost a lot more than we are presently paying.

On the other hand we could decide that we can't save everybody, or that the cost of providing existentially questionable care for one means we can't provide better standards for the other?
We really do have to re-think about what death means and whether or not the last few distressing months in hospital is the best place for some people?

A and E Charge Nurse

"and from a nursing point of view acting as punch bags for the frustrations of a stream of relatives (either via the endless phone calls, or face to face exchanges) due to failings in the wider system."

It struck me that the recent proposals to have relatives attending to feeding and toileting patients in hospitals may demand even more of the professional nurses' time since in most cases they will be the only visible punchbag on site carrying any authority as relatives mill around the wards 24 hours a day.

Dr No is as clear as the next person that the dreadful standards in parts of the NHS need fixing, and need fixing fast, but he is also as hot as toast on the certainty that the HSCB and quality of care are related - inversely - and so will prove to be part of the quality problem. By extending the number of 'any qualified providers', which will inevitably (because that is the way of the world) include significant numbers of very willing cowboys, monitoring and maintaining quality of care will inevitably get a whole lot more difficult, for at least two reasons.

The first is that plurality of provision means plurality of - and so simply more - providers to monitor; and that means instead of what are now pretty familiar bog-standard NHS (and occasional structurally similar private provider) set-ups, all manner of blue-sky outside the envelope fanciful arrangements will pop up, like mushrooms in an autumn field. We already know the CQC can't quite cope (unless ordered on a specific tipped off dirt-finding mission by Lansley). How much less able to cope will they be, when faced with mushrooms everywhere, many belonging to species, perhaps of bizarre structure and quite possibly dreadful toxicity, as yet unknown to the no doubt worthy but can't quite cope inspectors?

The second reason is perhaps more unsavoury. At present, those who work in healthcare work largely in the public spirited national health service. Their motives are vocational, not financial, and they provide that deep well of altruism on which the health service draws. As the pool of providers extends, others with less pure motives will enter the water, the Winterbourne Views and Southern Crosses of this world, and for some, such attention as they pay to quality will be not an end in itself, but a means to an end, our old bogey-man profit. And some of those, the more extreme, those with iron hearts drawn most powerfully to the magnet of profit, will very willingingly and deliberately bend the rules and game the system, all in a cloud of obfuscation. In such a setting, the can't quite cope inspectors will stand about as much chance as a packet of iron filings in the face of a powerful magnet.

A&E CN - the debate about the growing trend towards pointless futile and burdensome treatment has yet to be had, but is, Dr No agrees, of great importance. The judgement on 'M', which Dr No has not yet looked at, was handed down a couple of weeks ago, and may have some relevance. From some of the news coverage, it appears it may put some legal formality into 'thou shall not kill, but needst not strive officiously to keep alive'. But fuller consideration will have to wait until the judgement is read - and knowing how efficient the WD's black cat is on these things, she may get there first!

Dear Dr No,

I take your point on the proliferation of providers making inspection difficult. CQC cannot even inspect a fraction of Trusts using these means. It is clear to me that top down inspection systems, whether CQC, Monitor, GMC, Deaneries, SHA cannot microinspect everything because of the coastline paradox that you so eloquently posted on in the past. Inspection needs to be bottom up, by either patient, carer, or patient advocate (often the GP) with whistle blowing celebrated rather than punished.

Any number of providers can be "inspected" this way. Southern Cross is a defunct organisation, at least in part because the market exposed its failings. It was not a central panopticon that did it, but rather a panopticon of the people.

Plurality of General practice and retail pharmacies has not proven to be a quality disaster, why should the secondary care providers be different?

Dr Phil

"why should the secondary care providers be different" - over time competition and profit motive will have a profound effect on services, starting with a bureaucracy that will grow exponentially as the wheeling and dealing becomes ever more complex and opaque (gobbling up >30% of health costs if we look at the experience in the USA).

Dr P - Southern Cross may or may not be defunct because the market exposed its failing - but let us not forget that it failed because of excessive zeal for what the market had to offer in the first place.

Nor is Dr No overly persuaded that a plurality of general practice exists - all said and done, the vast majority of general practice works (albeit with varying degrees of success) on the small business independent contractor status model. But in many ways, despite their legal status, I suspect many individual GPs think of themselves as virtual NHS staff - and that's the crux - they work for the NHS and their patients (even though technically and legally they are working for themselves). They consider themselves part of the NHS family. They are therefore naturally (in most but not all cases) subject to the public service ethos. Those in the corporate private sector, on the other hand, be they any qualified provider, or very willing cowboys, work to the beat of a very different drum, to a rhythm that can all too easily find itself out of step with public service.

A&A CN - Dr No is sure we all agree that the 'tradition of elder abuse is well established in our culture', but is it getting worse? Dr No thinks there may be indirect (and anecdotal) evidence that it is. Too much to post in a comment so new post here (and it covers all patients, not just older patients, although of course most patients are elderly).